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Identifying factors influencing utilization of cervical cancer screening among immigrant women in Canada Chang, Su-Jin 2002

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IDENTIFYING FACTORS INFLUENCING  UTILIZATION OF C E R V I C A L  CANCER SCREENING A M O N G IMMIGRANT W O M E N IN C A N A D A by SU-JIN C H A N G  B . S . N . , Chonnam University, 1996  A THESIS S U B M I T T E D IN P A R T I A L F U L F I L M E N T O F THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in T H E F A C U L T Y OF G R A D U A T E STUDIES School of Nursing We accept this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH C O L U M B I A M a y 2002 © Su-Jin Chang, 2002  UBC  Rare Books and S p e c i a l C o l l e c t i o n s  - Thesis Authorisation  Form  Page 1 of 1  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed wi thout my wr i tten permission.  Department The University of B r i t i s h Columbia Vancouver, Canada  http://www.library.ubc.ca/spcoll/thesauth.html  5/13/02  11  ABSTRACT Cervical cancer screening using the Papanicolaou (Pap) smear test has had a significant effect on early detection of invasive cervical cancer. However, the risk of cervical cancer remains high among immigrant women in Canada. The objective of this study was to explore factors influencing the utilization of cervical cancer screening among immigrant women 15-69 years of age in Canada. Data from the 1996-1997 National Population Health Survey were used to conduct a secondary analysis, with logistic regression analysis, of factors associated with use of Pap testing. The findings indicated that 27% of immigrant women in Canada have either never had Pap testing or have had Pap testing completed more than three years ago. With regression analysis, factors significantly related to ever having had Pap testing among immigrant women between 25-69 years of age included: residing 10 years or more in Canada, having a regular doctor, speaking English or French, completion of some post-secondary education, aged 25-39 years, being widowed/divorced/separated, and having been born in US/Europe/Australia. Several interesting interaction effects were noted between income and education, between length of residence in Canada and having a regular doctor, and between education and language use. Being younger and having a regular physician were significantly related to having Pap testing within the past three years. O f these women, the most frequently reported reason for the use of Pap testing was that it was part of a regular check-up. Only a few women experienced problems obtaining Pap testing. A m o n g women who never had a Pap test or had no Pap testing within the last three years, the most common reason for non-use of Pap testing was thinking that it was not necessary. The findings provide direction for identifying immigrant women at risk for not having regular Pap tests. Nurses can help to increase the uptake of Pap testing by providing information about the importance of this relatively simple, life-saving test to immigrant women and by  promoting routine physical checkups with a family doctor. Offering women alternative and convenient ways to obtain Pap testing in settings that employ female health-care providers and provide language services may be among the best strategies for improving uptake and regular participation in cervical cancer screening for Canadian immigrant women.  iv TABLE OF CONTENTS  Abstract  ii  List of Tables  vii  Acknowledgements  viii  Dedication  ix  CHAPTER I  INTRODUCTION  1.1  Introduction  1  1.2  Framework  3  1.3  Purpose  3  C H A P T E R II  2.1  LITERATURE  REVIEW  Patient-Related Factors 2.1.1 Sociodemographic Characteristics 2.1.2 Having a Regul ar Medical Doctor 2.1.3 Sexual History 2.1.4 Acculturation 2.1.5  Attitudes and Knowledge about Cervical Cancer Screening  4 4 6 6 7 9  2.2  Health-Care System Barriers  9  2.3  Summary  12  C H A P T E R III  METHODS  3.1  Purpose of the Study  13  3.2  Research Design  14  3.3  Sample 3.3.1  Survey Sample  14 14  Sample Selection  15  3.3.2 3.4  Data Collection  15  3.5  Conceptual and Operational Definition  15  3.5.1 3.5.2 3.5.3  Definition of Immigrant Sociodemographic Characteristics Having a Regular Physician  16 16 17  V  3.5.4 3.5.5 3.5.6 3.5.7 3.5.2  Sexual History Acculturation Attitudes and Knowledge about Cervical Cancer Screening Health-Care System Barriers Use of Cervical Cancer Screening  18 18 18 19 19  3.6  Data Quality  20  3.7  Data Analysis  20  3.8  Ethics Approval  22  C H A P T E R IV  RESULTS  4.1  Characteristics of the Sample  23  4.2  Factors Related to Pap Testing Participation  27  4.3  Reasons for the Use and Non-use of Pap Testing  33  4.4  Health-Care System Barriers  34  4.5  Conclusion  35  CHAPTER V  DISCUSSION  5.1  Significance of the Findings  37  5.2  Factors Related to Individual Women and Pap Testing  38  5.2.1 A g e 5.2.2 Marital Status 5.2.3 Language and Education 5.2.4 Interaction Between Language and Education 5.2.5 Interaction Between Education and Income 5.2.6 Culture 5.2.7 Attitudes and Knowledge about Cervical Cancer Screening 5.2.8 Country of Birth 5.2.9 Having a Regular Doctor 5.2.10 Acculturation 5.2.11 Interaction Between Acculturation and Having a Regular Doctor  38 39 39 40 40 41 42 43 43 44 45  5.3  Health-Care System Factors  46  5.4  Implications for Practice and Research 5.4.1 Practice 5.4.2 Research Recommendations  46 46 47  vi 5.5  Limitations of the Study  48  5.6  Conclusion  50  REFERENCES  53  Appendix A  60  Appendix B  68  Appendix C  69  List of Tables Table 1. Characteristics of Immigrant Women 15-69 in the Study Sample  25  Table 2. Bivariate Relationships Between Patient-Related Variables and Participation in Pap Testing A m o n g Women 15-69  28  Table 3. Logistic Regression Analysis of the Variables Associated with Ever H a d Pap Testing A m o n g Women 25-69  31  Table 4. Reasons for the Use and Non-use of Pap Testing  34  Table 5. Problems Getting Pap Testing  35  Vlll  ACKNOWLEDGEMENTS I would like to express my gratitude to a number of people who have been extremely helpful in conducting this thesis project. Professor Joan Bottorff, my thesis chair and patient guide through this project deserves a great deal of thanks for an enormous amount of help. Professor Joy Johnson likewise has lent much support and expertise throughout this project. Thanks are extended as well to Professor Pamela Ratner for kindly agreeing to serve as third reader. This thesis committee has been o f great value in m y learning experience. I am indebted to my trusted friend A l l a i n Lebreton who has been a much-appreciated source of strength and encouragement. I would like to thank my friends and colleagues Cheryl Segaric, Peggy Wyatt, and Chris Richardson for their support and advice through different phases of the project. M y good friend W i l - l i e Chen deserves additional thanks for her ability to give well-timed, much needed encouragement. Finally, thanks are in order for M a r y Luebbe, data librarian for University of British Columbia Library. M a r y has a wonderful ability to make a very difficult job seem quite easy as she kindly and cheerfully helped me extract the necessary data, without which this study would never have been possible.  ix D E D I C A T I O N  For the sacrifices they have made for me and my studies, this thesis is dedicated to my parents Sam-Gyu Chang and Jung-Ae Kim.  1 C H A P T E R 1: I N T R O D U C T I O N  Cervical cancer screening using the Papanicolaou (Pap) smear test has had a significant effect on the early detection of invasive cervical cancer (Hislop, Guninder, & Yelland, 1995; Miller, 1999). Since the Pap test was implemented in Canada in the 1970s, both the mortality and incidence rates of invasive cervical cancer have declined significantly (Anderson, Benedet, Le Riche, Matisic, & Thompson, 1992; Parboosingh, 1999). According to The Canadian Task Force on Periodic Health Examination (1994), the current Canadian guidelines on regular Pap testing recommend screening at three-year intervals for women who are sexually active or between the ages of 18 and 69 years after two initial smear results are normal. The American Cancer Society (1993) guidelines for cervical cancer screening recommend that all women who are sexually active or the age of 18 years and older should be screened annually. However, there are discrepancies regarding recommendations for the age of initiation and discontinuation of Pap smears as well as for screening intervals across Canada. For example, the program in British Columbia (BC) currently recommends that women who are sexually active should be screened every two years after three normal Pap smears at one-year intervals until age 69 (BC Cancer Agency, 1998). Despite the dramatic reduction in invasive cervical cancer mortality and incidence rates, and recommendations for routine Pap testing, cervical screening remains underutilized by some groups. These groups include First Nations, ethnic minorities, recent immigrants, the elderly, and the poor (Anderson et al., 1992; Harlan, Bernstein, & Kessler, 1991; Hislop et al., 1995; Jennings-Dozier, 1999; Kim et al., 1999; Lee, 2000; Sent, Ballem, Paluck, Yelland, &Vogel, 1998). Specifically, in 1996-1998, the Pap test utilization rate was found to be 56% among Chinese women in BC compared to 67% for all women in BC aged 20 to 69 years (Hislop, Teh, Lai, Labo, & Taylor, 2000). Lower Pap testing participation rates of women aged 25 to 64 years  2 who were born outside Canada and only spoke languages other than English were found in the 1996-1997 National Population Health Survey ( N P H S ) (Maxwell, Bancej, Snider, & V i k , 2001). According to Statistics Canada, in 1996, over five million people in Canada were immigrants, representing 17.4% of the Canadian population. O f these, over one million arrived between 1991 and 1996. This group is usually referred to as 'recent immigrants' (Statistics Canada, 1997). Historically, the main sources of immigrants for Canada have been the United Kingdom, the United States, and Europe. However, this trend has changed in recent years with increasing numbers arriving from Asia, the Middle East, Africa, and Central and South America (Statistics Canada). The age-standardized cervical cancer mortality rates are 2 to 8 times greater in most countries in Africa, South-Eastern and South-Central Asia, and Central and South America than in Canada (Globocan 2000, 2001). Most of Canada's recent immigrants come from these countries. Following immigration, high rates of cervical cancer are reported among immigrant ethnic groups despite the availability of Pap testing. For example, the incidence rate of cervical cancer in Chinese women aged 15 years and older in B C was twice greater than that of Caucasians between 1985 and 1988 (Archibald, Coldman, Wong, Band, & Gallagher, 1993). A n d the age-standardized incidence rate for invasive cervical cancer in South Asian women aged 15 years and older was 1.8 times higher than that for all women in B C between 1989 and 1993 (Hislop et al., 1995). Incidence rates of invasive cervical cancer among immigrant ethnic minority groups have been observed to be higher than the general population in Canada. Although Pap testing is available to all women through publicly funded health care in Canada, there is evidence that Pap testing use among women born outside Canada is lower than Canadian born women. With routine Pap testing use, the morbidity and mortality associated with cervical cancer can be reduced significantly. Therefore, there is an urgent need to explore the factors that influence utilization of cervical cancer screening following immigration.  3 Studies have highlighted specific factors influencing the frequency of cervical cancer screening among general populations and some ethno-cultural groups in the United States (Harlan et al., 1991; K i m et al., 1999; Lee, 2000; Mandelblatt et al., 1999; Wismer et al., 1998). Although there has been an increase in research to identify factors related to underutilization of Pap testing for cervical cancer, few studies have examined the Pap testing behavior of immigrants residing in Canada.  Framework The underlying framework for this study is derived from Anderson and associates' recent work on the delivery of culturally-sensitive gender-related health care for immigrants in Canada (Anderson & Kirkham, 1998; Anderson, Waxier-Morrison, Richardson, Herbert, & Murphy, 1990). These researchers suggested that factors influencing the health beliefs and practices of immigrant populations are socioeconomic status, level of education, language skills, place of residence in their country of origin, cultural beliefs and ethnicity, structure of the health-care system, and availability of resources.  Purpose The purpose of this study was to explore patient-related factors and health-care system barriers influencing the utilization of cervical cancer screening among immigrants in Canada using the 1996-1997 N P H S . To increase rates of participation in Pap test screening it is crucial to identify factors influencing the utilization of cervical cancer screening. Once these factors are identified, nurses can identify women who are not likely to be screened and target education efforts to improve participation in regular Pap testing. Further, nurses can utilize the information in the development of intervention programs or health policies that w i l l enhance prevention and early detection of cervical cancer among immigrants in Canada.  4 C H A P T E R 2: L I T E R A T U R E R E V I E W Considerable research effort has been devoted to identifying factors associated with cervical cancer screening utilization. A search for literature published between 1991 and 2001 on factors affecting the participation of immigrant or minority women in cervical cancer screening was conducted using the C I N A H L , M E D L I N E , P S Y C H O I N F O , and W E B O F S C I E N C E S databases, and from reference lists of the literature acquired. The search terms used included "cervical neoplasms," "cervical smears," "vaginal smears," "immigrants," "minority groups," and "emigration and immigration." The articles selected addressed sociodemographical, psychological, cultural, and structural issues related to participation in cervical cancer screening among immigrants or ethnic minority groups. The literature reviewed points to a number of variables that may be significant in Pap testing utilization. These variables are categorized into two main groups: 1) patient-related factors and 2) health-care system barriers. Patient-related Factors Patient-related factors that influence the frequency of Pap testing among immigrant women include sociodemographic characteristics, having a regular physician, sexual history, acculturation, and attitudes and knowledge toward Pap testing. Sociodemographic Characteristics Sociodemographic variables such as age, education, income, marital status, and country of birth have been associated with the use of Pap testing. Studies of immigrant women have shown that Pap test utilization is higher among younger women, married women, and women with higher education and higher incomes (Harlan et al., 1991; K i m et al., 1999; Tang, Solomon, Y e h , & Worden, 1999; Wismer et al., 1998; Y i , 1998). In a study of barriers to breast and cervical cancer among 645 Vietnamese-American women in California, McPhee, B i r d , et al.  5 (1997) reported that women who had less than 7 years of education and who never married were less likely than other Vietnamese-American women with more education and who were married to have received Pap testing. Juon, Choi and K i m ' s (2000) study of cancer screening behavior among Korean-Americans demonstrated that women aged less than 50 years old were more likely than women aged 50 years and older to have Pap testing. Jennings-Dozier and Lawrence (2000) explored sociodemographic predictors of annual Pap testing adherence in 204 Black and Hispanic women residing in the United States. The authors found that age and place of birth (born in the United States vs. outside the mainland United States) were significant predictors for Hispanics. More specifically, Hispanic women younger than 40 years and born in the United States were twice more likely to be screened than Hispanics older than 40 years and born outside the mainland United States. Some Canadian studies have shown an association between sociodemographic variables and the use of Pap testing among immigrant women. In a study of cervical cancer screening behavior among 776 Chinese women residing in B C , Hislop et al. (2000) reported that women who were married, had relatively higher incomes, and had higher education were more likely than other women to have been screened. Their results also showed that Chinese women born in North America, Taiwan, and Hong K o n g were more likely to have been screened than women born in Southeast A s i a and Mainland China. M a x w e l l et al. (2001) identified that Canadian women, aged between 25 and 64 years, who never had a Pap test were more likely to have been born in A s i a than other continents including North America, Europe and Australia. Matuk (1996) examined Pap testing practices among recent immigrants in a sample of 234 participants enrolled in a descriptive study in Windsor, Ontario, in 1991. The results showed that women who had not been screened were less likely to have a secondary or postsecondary school education, and had relatively lower incomes. In contrast, Schulmeister and Lifsey's (1999) American study of the use of Pap testing among 96 Vietnamese immigrants to the United States suggested that age and  6 marital status were significantly related to Pap test utilization, while there were no significant relationships between education, having a regular doctor and number of years in the United States and utilization rates. Having A Regular Medical Doctor Having a regular doctor or consistent source of care has also been demonstrated to be related to the likelihood of obtaining Pap testing. O ' M a l l e y , Mandelblatt, Gold, Cagney, and Kerner (1997) examined the relationship between the continuity of care and the use of cancer screening services in 1,420 American Black and Hispanic women. Controlling for age, ethnicity, education, marital status, income, insurance, health status, and acculturation, women with a consistent source of care were more likely to have Pap testing than women who did not. McPhee, Bird, et al. (1997) also identified that not having a regular physician was a negative predictor of obtaining Pap testing among Vietnamese women. Other U S researchers studying Korean American have reached similar conclusions ( K i m et al., 1999). Sexual History Matuk's (1996) study identified sexual activity variables including age at first sexual intercourse and number of partners as factors associated with Pap testing practices among immigrants in Canada. The findings showed that immigrant women who initiated sexual intercourse at the age of 18 or older reported to be more likely to have been screened than those who had intercourse before the age of 18 years. Her study also revealed that women who had one sexual partner were more likely to have been screened than either women with no sexual partners or women with more than two sexual partners. Cervical cancer appears to be more common among heterosexual women than homosexual women because women who have sexual intercourse with men in their early years are most likely to be infected with the human papillomavirus ( H P V ) , which is known to cause cervical cancer (White & Levinson, 1993). Recent studies have indicated, however, that cervical  7  smear abnormalities were found even among women who were exclusively homosexual (Bailey, Kavanagh, Owen, M c L e a n , & Skinner, 2000; Marrazzo, 2000). Nonetheless, these women were less likely than heterosexual women to receive Pap testing. Acculturation Acculturation has been examined as a factor influencing the use of Pap testing among immigrant women. Acculturation has been described as a multidimensional process in which individuals change their beliefs, attitudes, values, and behaviors from their native culture to dominant cultural systems (Clark & Hofsess, 1998). W i t h acculturation, women change their attitudes and health practices to more closely match those of mainstream society. Acculturated women are, therefore, more likely to accept the need for Pap testing and to participate in screening. Although acculturation measures have not been used consistently by researchers, commonly used items have included length of residence in the host country, English proficiency, English use, ethnic identification, and sociocultural interaction with the mainstream society (Juon et al., 2000; O ' M a l l e y , Kerner, Johnson, & Mandelblatt, 1999; Suarez, 1994; Y i , 1998). Y i ' s (1992) study of the relationship between acculturation and breast and cervical cancer screening behavior in Vietnamese American women showed that length of stay in the United States was the strongest acculturation predictor of Pap testing use. Later, Y i (1994) examined cervical cancer screening behavior in a sample of 141 Vietnamese American women. The results showed that women who resided longer in the United States were most likely to have obtained a Pap smear. Further support for using length of residence in a measure of acculturation is demonstrated by Y i (1998). In an examination of the effect of acculturation on cervical screening practices among Vietnamese women in the United States, Y i used a modified version of the Suinn-Lew Asian Self-Identify Acculturation Scale, which includes items such as language use and preference, ethnic identification, and sociocultural preferences. In addition, length of residence was measured. The results revealed that highly acculturated women, as measured by  8 the Self-Identity Acculturation Scale, were more likely to have received a Pap test than less acculturated women. Length of residence in the United States was also significantly related to Pap testing and was positively correlated with acculturation. These results support the use of length of residence in the host country as a proxy measure of acculturation. In a recent study of Korean American women aged 18 years and older in Maryland, Juon et al. (2000) found that cultural and linguistic aspects of acculturation (operationalized as proportion of life spent in the United States and spoken English proficiency) were significant predictors of adherence to cancer screening. Although one study has shown no association between length of residence in the United States and the use of Pap testing among Vietnamese immigrants (Schulmeister & Lifsey, 1999), other studies have indicated that the likelihood of receiving Pap testing increases as length of stay increases among Filipino, Korean, Cambodian, and Hispanic Americans (Mandelblatt et al., 1999; M a x w e l l , Bastani, & Warda, 2000; McPhee, Bird, et al., 1997; McPhee, Stewart, et al., 1997; Tang et al., 1999; Taylor et al., 1999; Wismer et al., 1998). In a Canadian study of the influence of acculturation, Hislop et al. (2000) reported that Chinese women with shorter lengths of stay in Canada were less likely to have received a Pap smear. In a recent study examining the role of education and acculturation on cervical cancer screening among 124 South Asian women in Canada (Gupta, Kumar, & Stewart, 2002), acculturation was measured with five indicators including language usage, cultural identity, movie preference, involvement in cultural celebrations/traditions, and value systems regarding marriage, dating, and lifestyle. The results showed that highly acculturated women were more likely than less acculturated women to report that they received Pap testing. Although several American researchers have examined the effect of acculturation on the utilization of Pap testing among immigrants, little is known about the relationship between acculturation and the use of Pap testing among Canadian immigrant women.  9 Attitudes and Knowledge about Cervical Cancer Screening Researchers have highlighted that a number of factors influence women's decisions about screening (Harlan et al., 1991; K i m et al., 1999; Lee, 2000; Schulmeister & Lifsey, 1999). In a study of the cervical screening knowledge and practices of 159 Korean American women in Chicago, K i m et al. identified both an absence of symptoms and procrastination as reasons why women had not had Pap testing within the last three years. Harlan et al. also examined factors related to compliance with Pap testing in a sample of 12,868 White, Black, and Hispanic women in the United States. The analysis revealed that women tended to delay because of their knowledge or attitudes related to Pap testing. Commonly reported reasons for not obtaining a recent Pap test were procrastination, not believing the test was necessary, and an absence of problems. N o significant difference was found across racial groups. Several authors have reported that the use of Pap testing might be negatively linked with cultural beliefs such as fatalism, faith in G o d and modesty among Chinese Canadian, Korean, Vietnamese, African, and Hispanic American women (Lee, 2000; Sent et al., 1998; Taylor et al., 1999; Womeodu & Bailey, 1996). Further studies have shown that cultural factors such as women's background and socialization, lack of knowledge about cervical screening, and previous screening practices in their country of origin would affect Pap testing practice in their host country (Schulmeister & Lifsey, 1999; Shin, 1994; Suarez, 1994). Although American researchers have tended to focus on reasons for not obtaining Pap testing and ignored reasons for obtaining Pap testing in immigrant groups, no population based study has been conducted in Canada to identifying factors that facilitate or discourage immigrant populations from obtaining cervical cancer screening. Health-Care System Barriers System barriers to health care have contributed to inadequate participation of immigrant populations in cervical screening. Wismer et al. (1998) examined correlates of Pap testing in a  10 sample of 1,090 Korean immigrants in the United States. In their study, barriers to Pap testing in the previous two years were cost, long waiting times in waiting rooms, and language barriers. Lee (2000) conducted a qualitative study with eight focus groups involving 102 Korean immigrants in N e w York. The findings showed that major barriers to having Pap testing were cost, lack of time, language barriers, and lack of familiarity in the use of preventive health services. Other researchers have reported different barriers to Pap testing among other ethnic groups. Schulmeister and Lifsey (1999) found in their study of cervical cancer screening behavior among 96 Vietnamese immigrants in the United States that frequently mentioned reasons for never having had Pap testing included not having a gynecologist, not having a regular doctor, and not having a female doctor. A similar study by Taylor et al. (1999) examined Pap testing behavior among Cambodian immigrants residing in Seattle. Their analyses showed that having a female doctor and having a doctor's recommendation were significantly associated with obtaining Pap testing. Further, in a qualitative study of factors associated with the use of Pap smear in African and Latina women in the United States, Jennings (1997) found that the doctor's gender (male) was the most frequently cited reason inhibiting women from obtaining Pap smear screening. There are reports that ethnic women prefer to visit physicians with a similar ethnocultural background for general check-ups and that women prefer physicians from outside their communities for Pap testing (McPhee, Stewart et al., 1997; Sent et al., 1998). Researchers have observed that some ethnic physicians are uncomfortable providing or even discussing Pap testing with their patients (Lee, Lee, Stewart, & McPhee, 1999). Physicians' frequently identified reasons for not providing Pap testing included: 1) the patient's embarrassment; 2) a belief that the test was unnecessary because the patient was healthy; 3) inconvenience because patients did not have time; and 4) inadequate knowledge and conflicting guidelines for Pap testing.  11 Canadian researchers have also identified structural barriers that influence Pap test utilization (Fitch, Greenberg, Cava, Spaner, & Taylor, 1998; Ffislop et al., 1995). Fitch et al. conducted a qualitative study of barriers to cervical screening in an urban Canadian setting with 110 focus group participants. O f these, approximately 25% were recent immigrants from Sri Lanka and the West Indies. Cited barriers to access to Pap testing were limited clinic hours, childcare problems, transportation difficulties, long waiting times, hurried explanations, rushed appointment times, loss of privacy, and inadequate explanations from physicians. Although the participants were socioeconomically disadvantaged, cost, which is one of the frequently mentioned reasons in U S studies, was not identified in this study. This is not unexpected because Pap test screening in Canada is provided through publicly funded health care. Other barriers have been identified such as language difficulties, limited availability of interpretive services, lack of familiarity with the location of services and the health care system in general, limited hours of service, and transportation difficulties (Flislop et al., 1995; Mailloux & M u l v i h i l l , 2000). Although these researchers included immigrant women as well as the general population in their study samples, their findings suggested that recent immigrants were less likely than the general population to be screened because of structural barriers. Language barriers have been commonly identified as an important factor influencing access to health care. Since English and French are the official languages in Canada, women who speak other languages have reported to be less likely to be screened (Goel, 1994; Flislop et al., 2000; Matuk, 1996; M a x w e l l et al., 2001; Sent et al., 1998). A similar conclusion has been reached in U S studies among Flispanics, Koreans and Cambodians (Harlan et al., 1991; K i m et al., 1999; Lee, 200; Taylor et al., 1999). Consequently, language barriers limit the appropriate use of Pap testing.  12  Summary Factors contributing to the use of cervical cancer screening in immigrant or minority populations have been discussed. Significant factors that contribute to the use of Pap testing have been highlighted. There is still relatively little research on cervical cancer screening use among Canadian immigrant women. The studies reviewed suggest that certain factors may affect the frequency of obtaining Pap testing and that these variables are categorized into two main categories: patient-related factors (sociodemographic characteristics, having a regular physician, sexual history, acculturation, and attitudes and knowledge about Pap testing) and health-care system barriers. The literature relevant to these domains is often inconsistent because Pap testing practice is complex and no single factor stands out as a major independent variable. Additionally, because Canada's health insurance coverage is different from that available i n the United States, findings from most studies conducted in the United States may not be applicable to immigrants within a Canadian context. Therefore, it is crucial to identify factors influencing the use of Pap testing among immigrant women in Canada.  13  C H A P T E R 3: M E T H O D S A N D P R O C E D U R E Purpose of the Study The purpose of this study was to use the 1996-1997 National Population Health Survey (Statistics Canada, 1998) to address the question, "What factors influence the use of Pap testing among immigrant populations in Canada?" The use of secondary analysis constrained the specific questions that could be addressed. Sub-group analysis to compare Pap testing use among immigrants regarding their origin of country was limited because of data restrictions imposed by Statistics Canada. Despite these constraints, valuable information could be obtained through existing data to address the research questions. The specific research questions included: 1) What are the sociodemographic factors influencing the use of Pap testing among immigrant women? More specifically: i)  A r e age, education, income, and marital status related to the use of Pap testing among immigrant populations?  ii)  Is country of birth related to the use of Pap testing in these populations?  iii)  Is having a regular physician related to the use of Pap testing?  iv)  Is sexual history related to the use of Pap testing?  v)  Is acculturation related to the use of Pap testing?  2) What are the frequently identified reasons for the use of Pap testing among immigrant women? 3) What are the frequently identified reasons for the non-use of Pap testing among immigrant women?  14 4) Are health-care system barriers, such as availability of Pap testing in an area, waiting time, transportation, language, and cost associated with having Pap testing? 5) What patient-related factors have the strongest relationships with the use of Pap testing by immigrant women? Research Design This study used Cycle II cross-sectional data from the National Population Health Survey ( N P H S ) conducted by Statistics Canada between 1996 and 1997. Cycle I data were initially collected between June 1994 and June 1995. Cycle II was completed between June 1996 and August 1997, using some of the same sample as Cycle I for longitudinal analytical purposes, and some new respondents for cross-sectional purposes. This cycle specifically focused on women's health. Questions about frequency, reasons for use or non-use, and barriers to preventive tests were asked. Although Cycle III (1999-2000) data were currently available, the data set did not include detailed questions regarding Pap testing. Sample Survey Sample The target population for the survey included household residents aged 0 years and older throughout Canada except persons living on Native Indian Reserves, Canadian Forces Bases and in some remote areas in Ontario and Quebec. For the purpose of this longitudinal study, 20,725 households were randomly selected in Cycle I. O f these, 17,626 respondents aged 12 years or older provided in-depth health information. These respondents were re-interviewed for general and in-depth health questions in Cycle II, resulting in a sample of 16,168 respondents or 93.6% response rate. O f the randomly selected 392,181 respondents selected for cross-sectional purposes in Cycle II, 210,377 respondents provided the general health information, and 81,804 provided in-depth health information.  15 Sample Selection The sample for this study was derived from the 81,804 randomly selected respondents who participated in the Cycle II in depth health survey of N P H S 1996-1997. The inclusion criteria for this study limited the subjects to the following: women aged between 15 years and 69 years, who were sexually active, who were immigrants, and for whom data related to Pap testing were available ( N = 3,806 immigrants). Data Collection The N P H S questions were developed for computer-assisted interviewing (CAI), and the questions were programmed for the survey. Interviewers were hired on a part-time basis and trained to carry out surveys using the C A I method. Over 95% of respondents were interviewed by telephone. The rest of the interviews were done on the basis of personal visits. The survey was administered in languages that respondents selected. These languages include the following: 1) English; 2) French; 3) Arabic; 4) Chinese; 5) Cree; 6) German; 7) Greek; 8) Hungarian; 9) Italian; 10) Korean; 11) Persian (Farsi); 12) Polish; 13) Portuguese; 14) Punjabi; 15) Spanish; 16) Tagalog (Filipino); 17) Ukrainian; and 18) Vietnamese. Data collection and entry occurred immediately during the telephone interview, and the C A I application was programmed to correct when an invalid entry was recorded. The survey encompassed a general component and a health component. The health component included questions about health status, use of health services, risk factors and demographic and socioeconomic status. Conceptual and Operational Definitions The variables identified in the questions were operationalised to answer the research questions. Some recoding was done to collapse categories where responses were limited. For details, refer to the Appendices A and B .  16 Definition of Immigrant A n immigrant refers to "a person who has been granted the right to live in Canada permanently by immigration authorities" (Statistics Canada, 1997). Whether a respondent was an immigrant was determined by using a variable created by Statistics Canada. The variable indicating that the respondent was an immigrant was created on the basis of two sociodemographic variables - country of birth and the year the respondent came to Canada. If respondents did not answer 'born in Canada' to the question, "In what country were you born?" they were asked: "In what year did you first come to Canada to live?" The year was coded from 1902 to 1997. Sociodemographic Characteristics The sociodemographic characteristics examined included the following variables: age, education, marital status, and income. Age was measured by using a variable reporting grouped data. Responses were coded as: 6) 15 to 19 years; 7) 20 to 24 years; 8) 25 to 29 years; 9) 30 to 34 years; 10) 35 to 39 years; 11) 40 to 44 years; 12) 45 to 49 years; 13) 50 to 54 years; 14) 55 to 59 years; 15) 60 to 64 years; 16) 65 to 69 years; 17) 70 to 74 years; 18) 75 to 79 years; and 19) 80 years or older. Responses were recoded to correspond with the inclusion criteria as followings: 1) 15 to 20 years old; 2) 20 to 29 years; 3) 30 to 39 years; 4) 40 to 49 years; 5) 50 to 59 years; and 6) 60 to 69 years. Education was measured by using a derived variable, which was measured with the following questions: "1) excluding kindergarten, how many years of elementary and high school have you successfully completed? 2) have you graduated from high school? 3) have you ever attended any other kind of school such as university, community college, business school, trade or vocational school, C E G E P or other post-secondary institution? and 4) what is the highest level of education that you have attained?" A derived variable reported grouped data in seven levels of highest attained education. The levels were as follows: 1) no schooling / elementary / some secondary; 2) secondary school graduation; 3) other post-secondary/ some  17 trade or college; 4) diploma / certification from college or trade; 5) some university; 6) bachelor degree; and 7) master, Ph.D., medical degree. For this study, this variable was re-coded as: 1) less than secondary; 2) completed secondary; 3) some post-secondary; and 4) completed university. Marital status was measured by using a variable that was coded: 1) single (never married); 2) married / common-law / partner; and 3) widowed / separated / divorced. Income was measured by using a derived income adequacy variable that reported data based on total household income and the size of the respondent's household. The level of income was adjusted by the size of household, which was classified as: 1) 1 or 2 people; 2) 3 or 4 people; and 3) 5 or more people. For details, see Appendix B - the documentation on derived variables in the 199697 N P H S Public Use Microdata Documentation (Statistics Canada, 1998). Respondents were asked, "What is your best estimate of the total income, before taxes and deductions, of all household members from all sources in the past 12 months?" The derived income adequacy variable was coded with five categories: 1) lowest income quintile; 2) lower middle income quintile; 3) middle income quintile; 4) upper middle income quintile; and 5) highest income quintile. Country of birth was measured by a derived variable created by Statistics Canada. Respondents were asked the question, "In what country were you born?" Responses were then coded to the following: 1) Canada; 2) U S A , Europe, Australia, M e x i c o ; 3) A s i a (including the Middle East); and 4) other (including South and Central America, Caribbean, and Africa). For this study, responses were re-coded as: 1) U S A , Europe, or Australia; 2) A s i a ; and 3) Other. (See Appendix A for the items l a - le.) Having a Regular Physician Having a regular physician was measured with the question, " D o you have a regular medical doctor?" The responses were coded: 1) yes or 2) no. (See Appendix A for the item If.)  18 Sexual History Sexual history included age at first sexual intercourse and number of sexual partners. The question, " H o w old were you when you first had sexual intercourse?" was used. Responses were coded as: 1) under 18 years; 2) 19 to 30 years; and 3) 31 years and older. The variable 'number of sexual partners' was measured by asking respondents, " W i t h how many partners?" Responses were coded: 1) one partner; 2) two partners; 3) three partners; and 4) four or more partners. (See Appendix A for the items l g - lh.) Questions related to sexual history are highly sensitive. Therefore, some respondents refused to answer the question or probably provided incorrect information. Older respondents may not have accurately recalled their history (e.g., questions that ask age at first sexual intercourse and number of sexual partners). Acculturation Acculturation is the process by which native cultural traditions are changed due to adaptation to the cultural systems in a host country (Clark & Hofsess, 1998). This process is dynamic and multidimensional and involves the adoption of beliefs, values, and practices of the dominant culture as a function of length of time individuals spend in their host country. Acculturation was measured by using a derived variable of length of time in Canada obtained in response to the question, "In what year did you first come to Canada to live?" Since a continuous variable was not available in the public data set, grouped data were used and were reported as: 1) 0 to 4 years; 2) 5 to 9 years; and 3) 10 years or more. (See Appendix A for the item 2a.) Attitudes and Knowledge towards Cervical Cancer Screening Reasons for the use of Pap testing were measured with an item that asked subjects, " W h y did you have a Pap smear test?" The responses were coded as: 1) part of regular check-up / routine screening; 2) high-risk group; 3) follow-up of previous problem; 4) abnormal bleeding /  19 other symptoms; 5) sexually active; 6) on birth control p i l l ; 7) pregnant/ after delivery; 8) on hormone replacement therapy; and 9) other. The reasons were not read by the interviewers and all those that were reported were recorded. Each possible reason was coded for each respondent as: 1) yes or 2) no. (See Appendix A for the items 3a - 3i.) Reasons for the non-use of Pap testing were measured with an item that asked subjects: " W h y have you not had a Pap smear test in the past 3 years?" The responses included: 1) have not gotten around to it and 2) respondent did not think it was necessary. Reasons were recorded for each respondent as: 1) yes or 2) no. (See Appendix A for the items 4a -4b.) Health-Care System Barriers Health-care system barriers were measured with the question, "What were the problems obtaining a Pap smear test?" The responses included: 1) not available when required; 2) not available in area; 3) waiting time too long; 4) transportation; 5) language; and 6) cost. Reasons were recorded for each respondent as: 1) yes or 2) no. The influence of language barriers was measured with a derived variable that reports grouped data obtained in response to the question: "In which languages can you conduct a conversation?" Responses were coded as: 1) English only; 2) French only; 3) English and French only; and 4) Other. F o r this study, the responses were recoded as: 1) English or French and 2) other. (See Appendix A for the items 5a - 5g.) Use of Cervical Cancer Screening The use of Pap testing is the dependent variable and was measured using two variables. The first variable determined whether a woman had ever had Pap testing. Respondents were asked: "Have you ever had a Pap smear test?" Responses were coded: 1) yes or 2) no. The second variable measured whether respondents had recently been screened based on their age and their adherence to Canadian programmatic guidelines for routine screening (Parboosingh et al., 1996). T o determine their adherence to Pap testing guidelines, respondents were asked: "When was the last time you had a Pap smear test?" Responses were then coded: 1) less than 6  20 months ago; 2) 6 months to less than 1 year ago; 3) 1 year to less than 3 years ago; 4) 3 years to less than 5 years ago; and 5) 5 or more years ago. A recent Pap smear test was defined as having been screened within the last three years. For this study, two groups were created as follows: 1) compliants who had Pap testing in the last three years and 2) non-compliants who had no Pap testing done in the last three years including never having had Pap testing. (See Appendix A for the items 6a - 6c.) The responses to the questions regarding use of Pap testing may have had some inaccuracy. For example, i f physicians had given inadequate explanations, some women might have not known whether they received Pap testing, especially Non-English speaking minority women, facing language barriers. Data Quality Statistics Canada puts every effort into eliminating any potential systematic error or random error in its survey data collection procedures. Data editing was performed on-line in the C A I application to minimize random error. Invalid value and flow errors were controlled through the use o f C A I . Further, Statistics Canada implemented quality assurance measures for data collection and processing cycles to monitor the quality of data. The measures involved the use of highly skilled interviewers who were extensively trained regarding survey procedures and in administration of the questionnaire, and the observation of interviewers to detect problems and to minimize data collection errors. D a t a Analysis The N P H S data were weighted to reflect sampling design, non-response adjustment, and post-stratification adjustment by Statistics Canada. Weight adjustments were calculated by Statistics Canada to account for non-response bias. F o r detailed information, see Appendix C . The variables for this study were weighted to take full advantage of the sample design and thereby avoid some non-response bias and to produce better estimates of the general population. To obtain accurate population point estimates, the weighted data were used. In order to ensure  21 the sample size was not inflated, the weights were standardized by multiplying the sampling weight by the unweighted sample size and divided by the weighted sample size. The calculated weights were used in all statistical analysis using SPSS Version 10. In this study sample, women aged 15 to 59 years who reported that they had never had sexual intercourse (n = 357) were disqualified from the analysis. Since the information on whether women between 60 and 69 years old ever had sexual intercourse was not available, women in this age group who reported that they were single (n = 38) were considered to have no sexual activity, and also were excluded from the analysis. Descriptive statistics were used to examine the distribution of independent variables (e.g., age, education, marital status, income, country of birth, having a regular doctor, sexual behavior, acculturation, and language use) in the study sample. Then, cross-tabulations and chi-square tests were performed to examine the statistical significance of bivariate relationships between the use of Pap testing and those variables. Logistic regression analysis was conducted to estimate the odds ratios of patient-related predictors and to identify predictors with the strongest relationships with the use of Pap testing - never had the test vs. recently had the test. The goodness of fit of the logistic regression models was assessed with the Hosmer-Lemeshow test (Hosmer & Lemeshow, 1989). Descriptive statistics were estimated to identify reasons for the use of Pap testing among women who recently had a Pap test as well as reasons for the non-use of a Pap test among women who never had Pap testing or had not had Pap testing in the past three years. Descriptive analyses were also conducted to examine health-care system barriers reported by women who had Pap testing in the past three years and who have ever had problems obtaining a Pap test.  22 Ethics A p p r o v a l Since this study was a secondary analysis of data that were presented anonymously for public use, there was no requirement for an ethical review. The data were provided on microdata C D - R O M with no identifying characteristics, and the anonymity of the subjects was therefore guaranteed.  23 C H A P T E R 4: R E S U L T S The purpose of this chapter is to present the analysis and findings of a study related to utilization of Pap testing among immigrant women in Canada. First, the characteristics of immigrant women in the study sample are described. Second, the relationships between patientrelated factors and Pap test participation are reported, and the variables that were found to be statistically significant are identified. Third, the factors associated with whether the women recently had Pap testing or ever had Pap testing are highlighted. Fourth, reasons for the use as well as non-use of Pap testing are illustrated. Finally, the various problems that immigrant women report in obtaining Pap testing are summarized. In the analyses where weighted data were used, the sample size varies because some questions were not asked for certain age groups and some respondents refused to respond to certain items. Therefore, the total number of respondents for each statistical test is provided. Characteristics of the Sample A s illustrated in Table 1, the characteristics of the study sample indicate that the majority of the respondents were between 25 and 39 years of age (34.6%) and 40 to 54 years of age (35.3%). Most of the respondents (72.8%) were partnered, that is they were either married or in a common-law relationship. The majority of the respondents had at least secondary education with only 18.6% indicating less than secondary education. Over h a l f of the sample (64.8%) reported an income between middle income quintile and upper middle income quintile. A m o n g the sample respondents, 91.4% indicated that they had a regular medical doctor. In relation to country of birth, 59.7% (n = 2,248) of the sample reported that they were born in the United States, Europe, and Australia, 25.7% (n = 970) reported being born in Asia, and 14.6% (n = 550) indicated that they were born in other countries or continents such as Guyana, Jamaica, South and Central America, Caribbean, and Africa. The majority of the sample (75.9%) had been residents of Canada for 10 or more years. Sixty percent of the respondents spoke languages other  24 than English or French. Some of these respondents may have also been to conduct conversations in English and/or French although this could not be determined because of the constraints of the data provided by Statistics Canada. A m o n g the respondents between 15 and 59 years of age, 44% had their first sexual intercourse between the ages of 19 and 30 years, and most of them (96.5%) reported having only one sexual partner. However, about one third of the respondents did not answer the question regarding the number of sexual partner. Because questions related sexual history are highly sensitive, some respondents may have refused to respond the question. W i t h regard to Pap smear testing, 84% (n = 3,080) of the women indicated that they had at least one prior Pap test. O f the 3,080 who reported, 73% (n = 2,675) reported obtaining a Pap smear within the past three years. In terms of Pap test use, twenty-seven percent (n = 987) of the women reported that either they had not received a Pap test within the last three years or never had a Pap test, and as such were considered as non-compliant in following accepted recommendations for Pap test screening.  25 Table 1. Characteristics of Immigrant Women 15-69 in the Study Sample (N=3,806)  Characteristic  Frequency (%)  Sociodemographic Age 15-24 years 25-39 years 40-54 years 55-69 years  ,  206 (5.4) 1316(34.6) 1345 (35.3) 939 (24.7)  Marital Status" Single" Married/common-law/partner Widowed/separated/divorced  484 (12.7) 2767 (72.8) 552 (14.5)  Education Less than secondary Completed secondary Some post secondary Completed university  701 746 1683 646  Income Adequacy Lowest income quintile Lower middle income quintile M i d d l e income quintile Upper middle income quintile Highest income quintile  203 (6.5) 404 (12.9) 871 (27.8) 1160 (37.0) 499 (15.9)  Country of B i r t h US/Europe/Australia Asia Other  2248 (59.7) 970 (25.7) 550 (14.6)  c  (18.6) (19.8) (44.6) (17.0)  d  6  Have a Regular Medical Doctor Yes No Sexual History " Age at First Sexual Intercourse Under 18 years 19 to 30 years 31 years to 59 years  f  3476(91.4) 328 (8.6)  1  1068 (28.1) 1675 (44.0) 1062 (27.9)  26 Number of Sexual Partners One partner T w o partners or more  8  2359(96.5) 85 (3.5)  Acculturation Length of Time in Canada 0 to 4 years 5 to 9 years 10 years or more  317(8.3) 601 (15.8) 2888 (75.9)  Language Use English or French Other  1520 (39.9) 2286(60.1)  Pap Test Participation Ever H a d Pap Testing Never had Ever had  586 (16.0) 3080(84.0)  Last Time H a d Pap Testing' More than 3 years ago Within the last 3 years  401 (13.0) 2675 (87.0)  Pap Test Use Non-compliant Compliant  987 (27.0) 2675 (73.0)  11  1  1  k  3 missing cases includes women 15-59 years of age because only this group of women was asked to respond to questions related to sexual history 30 missing cases 669 missing cases 3 8 missing cases 1 missing case 1 3 6 2 missing cases 140 missing cases 7 3 0 missing cases 144 missing cases includes women who never had Pap testing or had Pap testing more than three years ago includes women who recently had Pap testing a  b  c  d  e  f  8  h  1  j  k  1  27 Factors Related to Pap Testing Participation T o examine factors related to Pap testing, cross-tabulations and chi-square analyses were conducted. In these analyses, some variable categories (e.g., income) were regrouped and certain responses (e.g., not stated, don't know, refused, and not applicable) were treated as missing cases. Women who had Pap testing in the last three years were compared to those who had never had Pap testing or had no Pap testing in the last three years on key predictor variables (see Table 2). Significant differences on the use of Pap testing between the two groups were found in relation to age, education, income adequacy, country of birth, having a regular doctor, age at first sexual intercourse, number of sexual partners, length of stay in Canada, and language use. Marital status did not differ significantly in relation to the use of Pap testing. More specifically, women 55-69 years of age reported lower participation rates in Pap testing within the last three years than those 15-54 years old. Factors including less than secondary education, low household income, countries of birth in Asia, less than 10 years of residence in Canada, and language proficiency in other than English or French were negatively associated with the likelihood of ever having received Pap test within the last three years. In relation to sexual history variables, women under the age of 59 years who had their first sexual intercourse at the age of 31 years or older and had two or more sexual partners, reported lower cervical cancer screening rates than those who had their first sexual intercourse when they were less than 30 years old and had one sexual partner.  28 Table 2. Bivariate Relationships Between Patient-Related Variables And Participation in Pap Testing Among Women 15-69  No Pap Testing in last 3 years  Pap Testing in last 3 years  Sociodemographic Age 15-24 years 25-39 years 40-54 years 55-69 years  (N=987) 44 (24.9%) 328 (25.6%) 303 (22.7%) 312(35.8%)  (N=2675) 133 (75.1%) 953 (74.4%) 1029 (77.3%) 560 (64.2%)  Marital Status Single MarrieoVcommon-law/partner Widowed/separateoVdivorced  (N=988) 133 (29.1%) 695 (26.0%) 160 (30.4%)  (N=2672) 324(70.9%) 1981 (74.0%) 367 (69.6%)  Education Less than secondary Completed secondary Some post secondary Completed university  (N=985) 233 (37.6%) 199 (27.3%) 416 (25.0%) 137 (27.1%)  (N=2655) 386 (62.4%) 529 (72.7%) 1246 (75.0%) 494 (72.9%)  Income Adequacy Low Moderate High  (N=821) 215 (37.3%) 507 (25.6%) 99 (20.3%)  (N=2222) 362 (62.7%) 1471 (74.4%) 389 (79.7%)  Country of Birth US/Europe/Australia Asia Other  (N=976) 496 (22.4%) 367 (41.5%) 113(21.4%)  (N=2647) 1714 (77.6%) 517 (58.5%) 416 (78.6%)  Have a Regular Medical Doctor Yes No  (N=986) 812 (24.2%) 174 (57.2%)  (N=2675) 2545 (75.8%) 130 (42.8%)  Sexual History Age at First Sexual Intercourse Under 18 years 19 to 30 years 31 years or older  (N=987) 252 (24.7%) 422 (25.5%) 313(31.8%)  (N=2674) 770 (75.3%) 1232 (74.5%) 672 (18.4%)  Variables  1  48.0*  5.5  47.8  43.8  126.5*  154.7  16.1'  29 Number of Sexual Partners One partner 2 partners or more  (N=564) 533 (23.2%) 31 (39.7%)  (N=1808) 1761 (76.8%) 47 (60.3%)  Acculturation Length of Time in Canada 0 to 4 years 5 to 9 years 10 years or more  (N=987) 150 (49.8%) 218 (39.0%) 619 (22.1%)  (N=2674) 151 (50.2%) 341(61.0%) 2801 (77.9%)  Language Use English or French Other  (N=988) 324 (21.7%) 664 (30.6%)  (N=2674) 1166 (78.3%) 1508 (69.4%)  11.3  154.7  34.9  ** Significant at alpha level < 0.01 *** Significant at alpha level < 0.001 includes women who never had Pap testing includes women 15-59 years of age 1  2  To examine the contribution of the predictor variables in relation to group differences (ever had/never had Pap testing), a logistic regression analysis was conducted. Table 3 summarizes the results of a logistic regression model indicating how factors related to participation in Pap testing among women aged 25 to 69 years. For purposes of analysis, women who were 15 to 24 years of age were excluded from the model because o f small sample size and concerns about the stability of estimates on particular predictors such as education and income. Further, sexual history variables (i.e., age at first sexual intercourse and number of sexual partners) were excluded from the model because only women between the ages of 15 to 59 years were asked to respond to questions related to sexual history. The model contained the following explanatory variables: age, income, education, marital status, country of birth, having a regular doctor, length of time in Canada and language use. The explanatory variables in this model were all entered together. The Hosmer-Lemeshow test of the goodness of fit indicated that the model fit the data (Chi-square = 13.762, p> 0.088). The model predicted correctly 97.5% of the ever had Pap  30 testing group but only 35.6% of the never had pap testing group; the overall prediction was 87.7% correct. Age, education, marital status, country of birth, having a regular doctor, and length of residence in Canada were significant predictors. Income showed little evidence of an effect, given the other variables in the model. Women were more likely to have had Pap testing i f they: 1) had lived 10 years or more in Canada; 2) had a regular doctor; 3) had some post secondary education; 4) spoke English or French; 5) were between 25 and 39 years of age; 6) were widowed/separated/divorced; and 7) were born in the United States, Europe, or Australia. In terms of the acculturation variable, however, the confidence interval on 10 years or more residence in Canada is large. This may be related to the number of cases in other years of residence categories (e.g., 0 to 4 years (n = 130) and 5 to 9 years (n = 332)) compared to the number of cases in the category of 10 or more years (n = 2492) among the respondents who reported that they received a Pap test at least once in their life. Significant interaction effects were identified between education and income, education and language, and length of stay in Canada and having a regular medical doctor. The most significant interaction effect observed was that women who have completed secondary education and have an annual household income between $15,000 and $59,000 were three times more likely to obtain Pap testing than those with less than secondary education and an annual household income of less than $15,000. In contrast, the interaction between education and language, and between length of stay in Canada and having a regular medical doctor had a negative effect on ever use of Pap testing. For instance, women who had less than secondary education and spoke languages other than English or French were more likely to receive Pap testing than those who had secondary education or more and spoke English or French. Furthermore, women who lived in Canada 10 years or more and had a regular medical doctor  31 were less likely to obtain Pap testing than those who lived i n Canada less than 5 years with no regular medical doctor. Table 3. Logistic Regression Analysis of the Variables Associated with Ever Had Pap Testing Among Women 25-69  Variables Sociodemographic A PP. Age 25-39 years 40-54 years 55-69 years (ref) Marital Status Single (ref) Married/common -law/partner Widowed/ separated/divorced  B  1.17 0.79  Wald  39.96 22.14 41.43  Odds Ratio (95% CI)  3.24(2.24-4.66) 2.20(1.58-3.06)' 1.00  8.72  1.00  0.31  2.04  1.36(0.89-2.09)  0.79  8.14  2.19(1.28-3.77)**  -0.11 1.55 1.50  31.15 0.09 18.17 9.46  1.00 0 . 8 9 ( 0 . 4 4 - 1.82) 4.97 (2.31 -9.56)** 4 . 5 0 ( 1 . 7 3 - 11.74)*  -0.57 1.89  4.41 1.62 1.91  1.00 0 . 5 6 ( 0 . 2 3 - 1.37) 6.65 ( 0 . 4 5 - 9 7 . 8 3 )  -1.21 -0.07  73.26 67.46 0.09  1.00 0.29(0.22-0.39)** 0.94(0.62- 1.41)  Education Less than secondary (ref) Completed secondary Some post secondary Completed university Income Adequacy L o w (ref) Moderate High Country of Birth US/Europe/Australia (ref) Asia Other  Have a regular medical doctor Yes 1.61 N o (ref)  9.47  5.00 (1.79 - 13.94) ** 1.00  32 Acculturation Length of Time in Canada 0 to 4 years (ref) 5 to 9 years 10 years or more Language use English or French Other (ref)  1.21 3.69  63.04 4.56 49.88  1.24  4.99  Education x Language use Less than secondary x Other (ref) Completed secondary -1.37 x English or French Some post secondary -1.56 x English or French Completed university -1.77 x English or French  1.00 3.35 (1.11 - 10.14)* 4 0 . 0 7 ( 1 4 . 3 9 - 111.59)***  3.46 (1.17 - 10.29) ** 1.00  1  Education x Income Less than secondary x L o w income (ref) Completed secondary x M e d i u m income Completed university x L o w income  13.49  1.00  7.48  0.25 (0.09 - 0.67)**  12.42  0.21 (0.09 - 0.50)***  9.02  0.17(0.05-0.54)**  1  30.03  1.00  1.21  8.50  3.35 (1.49 - 7.57)**  1.10  3.94  3.010(1.01 -8.93)*  Length of stay in Canada x Having a regular doctor 0 to 4 years x N o (ref) 10 years or more x Yes -1.45  8.28 7.22  1.00 0.23 (0.08-0.68)  1  * Significant at alpha level < 0.05 ** Significant at alpha level < 0.01 *** Significant at alpha level < 0.001 x Interaction effect Interaction effects between each category of the two factors were included in the analysis. However, only significant effects are displayed in the table. 1  Similar to the logistic regression analysis on ever used Pap testing, another logistic regression analysis was conducted to predict factors associated with recent use of Pap testing among immigrant women between the age of 25 and 69 years. The same patient-related variables used in the previous logistic regression model were included in this model and were entered  33 simultaneously. The Hosmer-Lemeshow test of the goodness of fit showed that the model fit the data (Chi-square = 10.667, p> 0.221). The model predicted correctly 99.2% of having had a Pap test within the past three years but only 14.5% of having had a Pap test more than three years ago; the overall prediction was 87.8% correct. Unlike the findings for ever used Pap testing (Table 3), only the variables of age and having a regular doctor were significantly related to having had Pap testing within the last three years. Further, interactions between education and income, between education and language, between income and having a regular medical doctor, and between length of stay in Canada and having a regular medical doctor were examined in relation to recent use of Pap testing. N o significant interaction effects were identified. Women between 25 and 39 years of age were five times more likely to have recent Pap tests than women between 55 and 69 years of age (CI: 3.58 - 8.08). Moreover, women between 40 and 54 years of age were 1.8 times more likely to have had recent Pap testing than women between 55 and 69 years of age (CI: 1.33 - 2.44). Women who had a regular medical doctor were 22 times more likely to have had recent Pap testing than women who did not have a regular medical doctor (CI: 1.83 - 264.53). The confidence interval for this predictor is extremely large. This likely occurred because of the frequency of having (n = 2,545) and not having (n = 130) a regular physician among the respondents who reported having a Pap test within the last three years. Reasons for the Use and Non-use of Pap Testing O f the 2,749 women reporting that they had Pap tests within the past three years, the most frequently mentioned reason for participating in Pap testing was that it was part of a regular check-up or routine screening (91.2%). The least frequently reported reasons for obtaining Pap testing were being in a high-risk group, taking birth control pills, being on hormone replacement therapy, and being sexually active.  34 The women who reported not having had a Pap test in the past three years or who have never had a Pap test cited two reasons: 1) they "did not think it was necessary" (49.6%) and 2) they "had not gotten around to it" (21.9%). The reader should note that more than one response was permitted for each reason. Table 5 presents the reported reasons for Pap testing participation and non-participation. Table 4. Reasons for the Use and Non-use of Pap testing  Reason  Frequency (%)*  Use of Pap Testing Part of check up Pregnant/ after delivery Follow-up of previous problem Abnormal bleeding/ other symptoms High risk group On birth control pill On hormone replacement therapy Sexually active 2  Non-use of Pap Testing Respondent did not think it was necessary H a d not "gotten around to it" 3  (N=2749) 2506 (91.2%) 155 (5.6%) 61 (2.2%) 28 (1.0%) 17 (0.6%) 14 (0.5%) 13 (0.5%) 10 (0.4%) (N=921) 427 (49.6%) 202 (21.9%)  multiple responses permitted includes only women reporting that they had Pap testing in the past 3 years includes women reported that they never had Pap testing or they had no Pap testing in the past 3 years.  2  3  Health-Care System Barriers A small number of women (n = 19) who obtained a Pap test in the past three years reported that they had problems in obtaining the test (Table 5). Some women described the problems they encountered. These included "not available when required," "waiting time too long," "not available in area," and "cost."  35 Table 5. Problems Getting Pap Testing  Reason  Frequency  Not available when required Waiting time too long Not available in area Cost  2  2  8 5 3 1  includes only women who reported that they had Pap testing in the past 3 years More than one response permitted  Conclusion In conclusion, women (25-69 years of age) were more likely to have had a Pap test i f they: 1) were residents in Canada for 10 or more years; 2) had a regular medical doctor; 3) completed some post-secondary education; 4) spoke English or French; 5) were 25-39 years old; 6) were widowed/divorced/separated; and 7) were born in the United States/Europe/ Australia. However, among women with low annual household income, women who completed university education were more likely than women who had less than secondary education to have received a Pap test. Further, women who lived in Canada 10 years or more and had a regular physician were less likely than women who lived in Canada zero to four years and did not have a regular physician to have had a Pap test. Moreover, women who completed secondary or higher education and spoke English or French were less likely than women who had less than secondary education and spoke other than English or French to have had a Pap test. Women who had Pap testing within the past three years were more likely to be young (25-34 years of age) and to have a regular medical doctor. O f these women, the most frequently reported reason for participating in a Pap test was that it was part of a regular check up. Further, a few experienced problems in obtaining the test. Finally, women who never had Pap testing or  36 had no Pap testing within the past three years reported two reasons for not obtaining Pap testing, which included: they " d i d not think the test was necessary" and "had not gotten around to it".  37 C H A P T E R 5: D I S C U S S I O N A s previously discussed, there is evidence that the rate of Pap smear use in immigrant populations in Canada is significantly lower than Canadian-born populations. In spite of this finding, few studies have explored the factors or characteristics that influence participation in Pap testing in immigrant populations across Canada. T o increase the utilization rates of Pap testing in this population, it is important to identify factors influencing Pap test use. The purpose of this research project was to examine the determinants of Pap smear use among immigrant women in Canada. A significant outcome of the study has been the identification of specific determinants of Pap smear use among immigrant women in Canada including patient-related factors, attitudes and knowledge about cervical cancer screening, and health care barriers. The purpose of this final chapter is to provide a more thorough examination of these key findings. Moreover, the limitations of the study are presented and the implications of the findings for use in nursing practice, health education, and future research are discussed. Significance of the F i n d i n g s A substantial number of immigrant women in Canada are at risk for invasive cervical cancer because they are not being screened on a regular basis. Based on the results of the 19961997 National Population Health Survey, the majority of women between the ages of 15 and 69 years reported that they received at least one Pap test in their lifetime. O f the women in this group, most (73%) reported having received a Pap smear within the last three years. Most importantly, however, the remaining (27%) women indicated that they never had Pap testing or had not received Pap testing within the last three years. In light of the fact that any mortality resulting from cervical cancer is entirely preventable, the fact that a full 27% of Canadian immigrant women are not being screened for this disease is worthy of attention.  38 Factors Related to Individual Women and Pap Testing It is likely that there are a variety of reasons related to individual women and to the health-care system that explain why 27% of immigrant women are not being screened for cervical cancer. In this study, individual factors associated with ever having Pap testing among women 25-69 years of age included: being 25-39 years old, having some post-secondary education, being widowed/separated/divorced, reporting their country of birth as the United States, Europe, or Australia, speaking either English or French, having a regular physician, and having resided in Canada for more than 10 years. Moreover, there were significant interaction effects between factors that involved education, language spoken, having a regular doctor and length of stay in Canada. Although some variation in the reported association between sociodemograhic characteristics such as age, marital status, education, language, country of origin, and Pap test use is evident across other studies, the findings of this study do not differ greatly from what has been reported in the published literature. F o r example, previous studies have shown that younger immigrant women (18-50 years old) were more likely to be screened than those who were older than 50 years (Juon et al., 2000; Wismer et al., 1998). Based on the findings in this study, women aged 25-54 years were more likely than those aged 55-69 years to have ever obtained a Pap test and to have received Pap testing within the last three years. Age Contrary to other reports (McPhee, Bird, et al., 1997; Schulmeister & Lifsey, 1999), based on the current data, women 15-24 years of age reported a significantly higher proportion of Pap test use in the last 3 years when compared with women 55-69 years of age. Although at the moment there is no locatable confirming data, the most logical explanation for this finding is that these young immigrant women have had more opportunities to receive preventive health education at school because they were more likely to be engaged in the education system. Because of the small sample size and the instability of estimates of education and income  39 variables, the younger women aged 15-24 were excluded from the logistic regression analysis. Consequently, it is not possible to consider how Pap testing uptake by younger women aged 1524 effects Pap testing for immigrant women as a whole based on the current data. Marital Status The effect of marital status on Pap testing has been examined in previous studies. Some researchers have reported that being married increases the likelihood of receiving Pap smears (Tang et al., 1999; Y i , 1994). The results of this study, however, indicate that widowed/separated/divorced women were more likely than either single or married women were to obtain Pap smears. In contrast, it has been reported that single or unmarried immigrant women are less likely to obtain Pap testing because they may believe that Pap testing is more important for married women than single women (Schulmeister & Lifsey, 1999). Previous researchers have suggested that married immigrant women may be more afraid of receiving positive results from Pap testing than widowed/separated/divorced women (Lee et al., 1999; Taylor et al., 1999). The thinking has been that married immigrant women may be more concerned about the potential negative effect a positive Pap result would have on their responsibility as family caregivers. The findings presented here provide further support for the significance of these beliefs related to Pap testing. Language and Education Other individual factors related to Pap testing include language and education. Previous studies have shown that better educated, English speaking women were more likely to have Pap screening (Hislop et al., 2000; Matuk, 1996; M a x w e l l et al., 2001), and these findings are supported by the current data. Women who spoke languages other than English or French were found to be at greater risk for never having had Pap testing. Perhaps because of the need to read and understand signs in health facilities and informational materials, and to communicate with health care providers and comprehend their instructions, women less proficient with English or  40 French seem to be less able to access preventive health services such as Pap testing. This is a concern particularly for elderly female immigrant populations who are most likely to have limited language skills, be less knowledgeable about cervical cancer and preventive measures, and therefore at greater risk for inadequate screening (Goel, 1994; Taylor et al., 1999). Interaction Between Language and Education Interaction effects were examined in this study with some interesting results. Immigrant women who had not completed secondary education and who spoke a language other than English or French were more likely to obtain Pap testing than those who completed secondary education or higher and spoke English or French. There are a few possible explanations for this finding. Language proficiency may provide an explanation for the interesting interaction findings. Immigrant women with less than secondary education who speak a language other than English or French may be more compliant when Pap tests are offered by physicians. This may be due to communication barriers such as an inability to ask detailed questions related to Pap tests or about the procedure. There is support from other researchers that women in some ethnocultural groups do not want male physicians to do Pap tests and avoid having them for this reason (Bottorff et al., 2001; Lee, 2000; Schulmeister & Lifsey, 1999; Womeodu & Bailey, 1996). It is possible that immigrant women who are more educated and able to speak English or French can better assert themselves and are more likely to decline offers of Pap testing from male physicians more often than those who are less educated and do not speak English or French. Interaction Between Education and Income The finding in relation to the interaction between education and income provides an important and surprising result. A m o n g women with low annual household income, women who completed university education were more likely to have ever had a Pap test than those with less than secondary education. This suggests that highly educated women tend to participate in Pap  41 testing regardless of their income level. McPhee, Bird, et al. (1997) support this finding. They suggest that highly educated women may be more likely to understand the importance of preventive health care when explanations are provided by health care providers. Culture Cultural health practices and beliefs may provide another explanation for the varying uptake of Pap testing. Recent published studies have identified significant cultural barriers to cervical screening (Schulmeister & Lifsey, 1999; Womeodu & Bailey, 1996). The cultural barriers include embarrassment related to the physical exam, cultural constraints related to being touched by a stranger, particularly a male doctor or a male doctor with a similar ethnic background, and the belief that cancer cannot be treated. Unfortunately, this study was constrained in its ability to examine cultural factors related to Pap testing practice because of the lack of available data in the N P H S . With this data set it was not possible to determine the cultural backgrounds of the study participants. Culture may provide further clues as to why participation in Pap testing varies. In their examination of Pap testing use among First Nations women, Clarke et al. (1998) found evidence that health care providers' offers of Pap testing did not necessarily involve informed consent of women. These First Nations women reported that they did not receive any information about the purpose of Pap testing until after their first test. Although the need for the test was provided, they "felt caught" and thus submitted to Pap testing. These women reported feeling they had to accept Pap testing because of physician authority and their need to respect authority. These findings may not provide sufficient explanation why less educated immigrant women who spoke other languages than English or French were more likely than more educated counterparts to have ever received a Pap test. This raises questions pertaining to the influence of cultural factors.  42 Attitudes and Knowledge about Cervical Cancer Screening It is thought that attitudes and knowledge about Pap smears are important factors that influence women's decisions about cervical cancer screening. This study identifies the reported reasons for the use of Pap testing among immigrant women who had Pap testing within the past 3 years. Ninety-one percent of the women cited that the primary reason for participating in Pap testing was that it was a part of regular check-up or routine screening. Other reasons noted for obtaining Pap testing included being pregnant or after delivery, as a follow-up to a previous problem, and having abnormal bleeding or other symptoms. Having regular check ups and/or having a consistent source of health care (e.g., a family physician) have been reported by other researchers to be important catalysts for immigrant women to obtain Pap testing (Juon et al., 2000; O ' M a l l e y et al., 1997). It is recommended that all women who are sexually active be screened regularly with Pap testing for cervical cancer. This has to do with the sexually transmitted virus, H P V , that is associated with cervical cancer (Marrazzo, 2000). The current Canadian guidelines on regular Pap testing recommend that women who are sexually active or between the ages of 18 and 69 years be screened at three-year intervals after two initial smear results are normal (Canadian Task Force on the Periodic Health Examination, 1994). However, in this study, being sexually active was the least frequently reported reason (0.4%) for obtaining Pap testing. Educative efforts targeted toward the most vulnerable in our population are important in helping increase the uptake of Pap testing. Women who lack knowledge about cervical cancer screening and who are not used to receiving Pap testing in their country of origin may be less likely to participate in Pap testing in their host country. Reasons for non-use of Pap testing among the immigrant women in this study reporting never having had a Pap test or having no Pap test in the past 3 years included: thinking the test was not necessary and not having "gotten around to it." This is consistent with previous findings (Shin, 1994; Suarez, 1994). Researchers  43 have identified that immigrant women who are sexually active without adequate knowledge of cervical cancer screening tend to be reluctant to obtain Pap smears. This may be due to beliefs such as faith in G o d and fatalism, and modesty among Chinese, Korean, Vietnamese, African and Hispanic women in North America (Chavez, Hubbell, Mishra, & Valdez, 1997; Lee, 2000; Sent et al., 1998; Taylor et al., 1999). Because little is known about the reasons for participating in Pap testing among immigrant women in Canada, the findings in this study pertaining to the reported reasons for use of Pap testing may provide useful information that can be used to enhance participation in cervical cancer screening. Country of Birth Consistent with other studies was the finding that country of birth was a significant predictor of whether not women ever used Pap testing (Jennings-Dozier & Lawrence, 2000; M a x w e l l et al., 2001). Women from countries with more highly developed cervical cancer screening programs would likely have higher rates of Pap testing. W i t h the data analyzed for this study, women born in the United States, Europe, and Australia were more likely than those born in A s i a and other countries to have ever received Pap testing. This may be related to the existence of screening programs in these countries. Women's previous Pap test experience in their country of origin would be associated with Pap testing practices in the host country following immigration (Shin, 1994; Suarez, 1994). W o m e n from countries with more highly developed screening programs would therefore be more likely to have ever received a Pap test. A detailed exploration of a woman's country of origin in relation to Pap testing is needed to better understand how country of origin relates to Pap testing for Canadian immigrants. Having a Regular Medical Doctor Having a regular doctor has been reported to improve the uptake of Pap testing (McPhee, B i r d , et al., 1997; K i m et al., 1999; O ' M a l l e y et al., 1997). When other variables were controlled, women in this study with a regular medical doctor were also more likely to have ever had Pap  44 testing and to have had a Pap test in the past three years. Perhaps by encouraging immigrant women to seek and maintain a relationship with a regular medical doctor the uptake of Pap testing could be improved further. Acculturation The length of time spent in Canada or acculturation to the new country appears to be important in considering uptake of Pap testing. When controlling for the other variables in the model, however, the proxy measure of acculturation (in this study length of stay in Canada) was a stronger predictor of ever having had Pap testing, than of having Pap testing within the last three years. Women who lived in Canada less than five years were less likely to have ever received Pap testing than those who have lived in Canada for 10 years or more. In other words, with each additional year o f residence in Canada, women were more likely to have received Pap smears. For immigrant women, acculturation may affect the uptake of Pap testing. A s women remain in Canada for longer periods, they are more likely to adapt to Canadian culture and gain proficiency in one of the official languages. Using length of residency in the new country as a measure of acculturation, a number of researchers have found a positive effect of acculturation on Pap testing. A m o n g Chinese, Filipino, Korean, Cambodian, and Hispanic Americans (Hislop et al., 2000; Juon et a l , 2000; Mandeblatt et al., 1999; McPhee, Stewart, et al., 1997; Tang et al., 1999; Wismer et al., 1998), acculturation appears to explain uptake of Pap testing. Only one research team reported that the effect of acculturation on Pap testing use among Vietnamese immigrants was not significant (Schulmeister & Lifsey, 1999). Perhaps, as Schulmeister and Lifsey suggest, the reason for this lies in the cultural practices of Vietnamese persons and their ability to maintain long-standing traditions in spite of having emigrated from their homeland to the United States.  45 The conceptualization and operationalization of a variable such as acculturation requires a great deal of consideration in interpreting research results. The main problem in understanding the effect of acculturation on Pap testing is that researchers have not used acculturation measures consistently. This makes interpretation difficult at best and for this reason a number of studies are not comparable with the present study. Researchers have demonstrated that acculturation positively affects the uptake of Pap testing (Gupta et al., 2002; Suarez, 1994; Y i , 1998), however, each of these studies used a different measure for acculturation. M a n y variables were factored into the various measures used in each study including language use, ethnic identification, sociocultural preferences, movie preference, involvement in cultural celebrations and interaction with mainstream society. It could be argued that language usage is a better predictor of Pap testing among immigrant women (Suarez, 1994), however, given the wide variety of acculturation measures it is difficult to interpret these findings. A l l considered, it is reasonable to believe that women living in Canada for longer duration have had more time to become familiar with the health care system and thereby have greater likelihood of receiving Pap testing. Nonetheless, further investigation is needed to fully understand the influence of acculturation on uptake as well as continued participation in Pap testing. Interaction Between Acculturation and Having a Regular Doctor In this study the effect of length of stay in Canada on Pap testing varied in relation to having a regular doctor. Women having lived 10 years or more i n Canada and who had a regular doctor were significantly less likely than women who lived 0 to 4 years in Canada and did not have a regular doctor to have ever received Pap testing. This may reflect the influence of patientphysician relationships on the use of Pap testing. It has been observed that women who develop long-standing relationships with their male physicians report feeling uncomfortable and embarrassed discussing Pap testing (Bottorff et al., 2001). These women would be more likely to decline offers from their physicians for Pap testing. While the number of female physicians has  46 increased, the majority of family physicians continue to be males (Canadian Institute for Health Information, 2000). It would be useful to explore the effect of the relationships between immigrant women and their physicians on Pap testing participation. Health-Care System Factors Factors within the health-care system could be barriers that may help explain some of the findings in the current analysis. This study found that problems related to obtaining Pap testing in the last three years included the lack of available services in the area, that testing services were not available when required, waiting time was too long, and the cost was too high. With this study it is not entirely clear what was implied by respondents' reports that Pap testing was "not available when required" or "not available in area". These responses may be associated with unfamiliarity with the location of services, limited clinic hours, or transportation difficulties. Physician-related barriers may provide another explanation. A m o n g Cambodian, Vietnamese, Latina, and African women, studies have shown that lack of a physician or gynecologist, having a physician with a similar ethnic background, and lack of a female physician were reasons for never having had pap testing (Jennings, 1997; Schulmeister & Lifsey, 1999; Sent et al., 1998; Taylor et al., 1999). W h i l e cost was frequently cited as a reason for not getting Pap testing in the United States, only one respondent in the present analysis reported cost as a barrier. This is likely due to the fact that in Canada, cervical cancer screening is provided through publicly funded health care. Implications for Practice and Research Practice This study provides several findings that can be used by nurses to help prevent some of the hardships caused by cervical cancer. Because having a regular physician was associated with having had a Pap test in the past three years, educational efforts aimed at encouraging women to have a regular medical doctor are recommended. Nurses can contribute to helping improve Pap  47 testing uptake by encouraging immigrant women to maintain a regular family doctor who can assist in encouraging Pap testing. Providing information to nurses and other health care providers on the importance of offering Pap testing to immigrant women is equally important. Nurses in their everyday interactions with immigrant women can help to spread the message that Pap testing is an important test that can detect cancer early when treatment is most successful. Women who have been in Canada long enough to be considered acculturated to Canadian society, who have a family doctor and who still are not being screened for cervical cancer are of particular concern. It w i l l be necessary to devise strategies aimed at increasing Pap testing among these women. Using media campaigns, while perhaps expensive would be one way to reinforce the importance of Pap testing (Sent et al., 1998). Another strategy would be to target community settings such as churches, community centers and local organizations serving the most vulnerable of these immigrant women. Nurses could be strategically placed to visit the areas frequented by these immigrant women to provide information and encouragement regarding Pap testing. For these women who are reluctant to have Pap testing completed by male physicians, it w i l l be important to offer testing provided by female doctors or nurses. Ensuring appropriate language services are provided when Pap tests are offered has been shown to be important for some groups of immigrant women (Bottorff et al., 2001; Sent et al., 1998) Research Recommendations Acculturation status measured by the length of residence in Canada was related to the use of Pap testing although the effect varies depending on whether women have a regular doctor. Therefore, nurses and other health care providers need to develop culturally appropriate intervention programs or health policies about cervical cancer screening for less acculturated and recent immigrants, particularly those without family doctors. The effect of acculturation has been shown to be significant on access to health care and preventive health practices including cervical screening. However, the measures of acculturation vary considerably resulting in poor  48 consistency across research reports. A well-developed and consistently used conceptualization of acculturation is needed to guide future research. Because most countries in Asia, the Middle East, Africa, and Central and South America have reported higher incidence and mortality rates of cervical cancer than Canada, future research should focus on particular subgroups. In recent years, an increasing number of immigrants have arrived in Canada from these countries (Statistics Canada, 1997). In this study, women who were born in A s i a were less likely than women born in the United States, Europe, and Australia to be screened although it was not possible to identify their specific countries of origin. Therefore, future research is required to address utilization of Pap testing among subgroups of immigrant women, particularly of Asian descent. L i m i t a t i o n s of the Study Limiting this study were those constraints associated with a secondary analysis of data. The data as provided by Statistics Canada had immigrant women categorized by country of birth with those originating from the United States, Europe and Australia in one category. A s shown in Table 1, chapter four, roughly 60% of this sample of immigrant women originated from the United States, Europe and Australia were grouped in this category. Certainly large numbers of immigrant women from these countries would be English speaking and white, thus not readily identifiable in Canadian society as 'foreigners'. W i t h this study it was not possible to sort out the sample according to language proficiency or cultural background hence, making interpretation of findings difficult. Statistics Canada (1998) reported that as many as 18 different languages were used to interview the women surveyed for this study. Further, complicating the analysis of this data is that women who reported ever having had a Pap test may not necessarily have received this test in Canada. A n undetermined number of these women surveyed could have received Pap testing elsewhere. Future research should include these important questions to better understand how Pap testing is utilized by women following immigration.  49 There are other study limitations that should be considered i n interpreting the findings of this study. The Pap smear utilization was measured by self-report and was not validated with medical records. Because the N P H S data were collected using telephone survey methods by Health Canada, validation of Pap smear utilization was not possible. There is evidence that women's self-reports of Pap smears represent overestimates when compared to the actual prevalence of screening (Mammon, Taylor, Morrell, Vain, & Moore, 2001; Suarez, Goldman, & Weiss, 1995). Additionally, there is evidence that Pap test participation rates differ across diverse ethnic groups (Hislop et al., 2000; Jennings-Dozier & Lawrence, 2000; O'Malley et al., 1997). However, sub-group analysis to compare the use of Pap tests among immigrants based on country of origin was constrained because of data restrictions imposed by Statistics Canada. This data set did not allow for the examination of study participants by country of origin. The influence of ethnicity on women's attitudes, beliefs, and knowledge about cervical cancer screening was limited by lack of available data. The literature reviewed in this study highlighted acculturation as a strong predictor of Pap smear screening in immigrant populations. Various measures of acculturation have been developed and used in studies of Hispanic (Suarez, 1994), South Asian ( Y i , 1998), and South Asian women (Gupta et al., 2002). The most common indicators of acculturation are English proficiency, English use, length of residence in the host country, ethnic identification, and interpersonal network composition. A limitation of the N P H S (Statistics Canada, 1998), however, is that all these indicators to measure acculturation could not be included because of the lack of available data. It is possible, therefore, that the influence o f acculturation on Pap smear utilization is not fully captured in this study. Pap testing use was significantly associated with sexual history such as age at first sexual intercourse and number of sexual partners. These variables were not analyzed in the logistic  50 regression model because women aged 55-69 were excluded from the questions pertaining to sexual history questions in the N P H S . Future studies should include questions on sexual history for all women, regardless of age. Sensitive approaches to asking those questions w i l l be important. Finally, because this research study was conducted as a secondary analysis, all relevant factors and measurements related to the research question were not available. This lack of information is an issue in this study because the research question of this study was restricted to the data available from the original study. Conclusion The risk of cervical cancer remains high among immigrant women in Canada. Because mortality due to invasive cervical cancer is entirely preventable and because a full 27% of Canadian immigrant women are not being screened for this disease, more attention must be aimed towards immigrant women and increasing their participation in Pap testing. In an attempt to better understand utilization of Pap testing among these women, a major goal of this secondary data analysis was to identify factors related to Pap test use in immigrant women 15-69 years of age in Canada using the 1996-1997 N P H S data. T o promote increased participation in cervical cancer screening, it was postulated that this knowledge might provide direction for nurses and other health care professionals to identify immigrant women at risk for not having regular Pap tests. A number of factors influencing the uptake o f Pap testing for immigrant women have been identified with this study. Education, income, length of stay in Canada, and having a regular doctor interact to influence the uptake of Pap testing. The results of this study indicate that women who reported that they have ever had Pap testing were more likely to be young, to have completed post-secondary education, to have been widowed, separated, or divorced, to speak English or French, and to be born in the United States, Europe, and Australia.  51 Additionally, these women were more likely to have lived in Canada for 10 years or more, and to have a regular physician. Perhaps the most important category of women to study would be those who have undergone Pap testing within the past three years. Unlike those women who had ever had Pap testing, age and having a regular family doctor were the only statistically significant variables related to having a recent (within three years) Pap test. A regular check-up or routine screening was the most frequently reported reason for obtaining Pap testing. The identified problems in obtaining Pap testing were that it was not available when required or services were not located in the area, and waiting time was too long. A m o n g women who had no Pap testing in the past three years or who never had Pap testing, reasons for not obtaining Pap testing included thinking it was unnecessary or not having "gotten around to it." In spite of the acknowledged limitations of this study, the results contribute to the body of knowledge related to Pap test use among immigrant women in Canada. Further research is needed to better understand attitudes and knowledge about cervical screening among immigrant women in Canada. It would help greatly i f the concept of acculturation were more fully and consistently operationalized to allow for better comparisons of studies pertaining to immigrant women and their uptake of Pap testing. Additionally, examining country of birth and ethnicity may help provide better direction for interventions in future studies. Nurses can help to increase the uptake of Pap testing by spreading the word to those we serve in our daily practice about the importance of this relatively simple, life- saving test. Unfortunately nurses alone w i l l probably not be able to effect the amount of change needed to reach the 27% of immigrant women who are not being screened for cervical cancer. 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Acculturation and Pap smear screening practices among college-aged Vietnamese women in the United States. Cancer Nursing, 21, 335-341.  APPENDIX A Coding of Variables and Questionnaire Items  Value 1 Yes 2 No 99 Not stated  Concept Inclusion Criteria - Immigrant  Variable Name SDC6FIMM  Question Description Flag indicating that the respondent is an immigrant  - Age: 15-69  DHC6GAGE  Age-grouped  Year of Birth  - Sexual activity: Ever had sexual intercourse  SHS6_1  Ever had sexual intercourse  Have you ever had 1 Yes sexual intercourse? 2 No 7 Don't know 8 Refusal 9 Not stated  DHC6GAGE  Age-grouped  Year of birth  6 15 to 19 years 7 20 to 24 years 8 25 to 29 years 9 30 to 34 years 10 35 to 39 years 11 40 to 44 years 12 45 to 49 years 13 50 to 54 years 14 55 to 59 years 15 60 to 64 years 16 65 to 69 years  Patient-related Factors  Sociodemographic Characteristics la: Age  6 15 to 19 years 7 20 to 24 years 8 25 to 29 years 9 30 to 34 years 10 35 to 39 years 11 40 to 44 years 12 45 to 49 years 13 50 to 54 years 14 55 to 59 years 15 60 to 64 years 16 65 to 69 years Recoded as: 1 15-24 years 2 25 to 39 years 3 40 to 54 years 4 55 to 69 years  lb: Education  EDC6G7  Derived highest level of education - 7 levels grouped  1) Excluding kindergarten, how many years of elementary and high school have you successfully completed? 2) Have you graduated from high school? 3) Have you ever attended any other kind of school such as university, community college, business school, trade or vocational school, CEGEP or other postsecondary institution?  1 No schooling/ Elementary/ Some secondary 2 Secondary school graduation 3 Other postsecondary/some trade or college 4 Dipl. / Cert. College, Trade, CEGEP. 5 Some university 6 Bachelor degree 7 Master, PhD, Medicine degree 96 Not applicable 99 not stated Recoded as: 1 less than secondary 2 completed secondary 3 some postsecondary 4 completed university  4) What is the highest level of education that you have attained? lc: Income Adequacy  INC6DIA5  Derived income adequacy  1) What is your best estimate of the total income, before taxes and deductions, of all household members form all sources in the past 12 months?  1 Lowest income quintile 2 Lower middle income quintile 3 Middle income quintile 4 Upper middle income quintile 5 Highest income quintile 9 Not stated  Recoded as: 2) The size of the 1 Low household 2 Moderate 3 High  Id: Marital status  DHC6GMAR  Marital status grouped  Marital status  1 Married 2 Common-Law 3 Living with a partner 4 Single (Never married) 5 Widowed 6 Separated 7 Divorced Recoded as: 1 Single 2 Married / common-law / partner 3 Widowed / separated / divorced 4 Not stated  le: Country of Birth  Having a regular medical doctor If  SDC6CB  TWC6_5  Country of birth  Has regular medical doctor  In what country were you born? 1 Canada 2 China 3 France 4 Germany 5 Greece 6 Guyana 7 Hong Kong 8 Hungary 9 India 10 Italy 11 Jamaica 12 Netherlands / Holland 13 Philippines 14 Poland 15 Portugal 16 United Kingdoms 17 United States 18 Vietnam 19 Other (Specify)  1 Canada 2 U.S., Europe, Australia 3 Asia 4 Other 99 Not stated  Do you have a regular medical doctor?  1 Yes 2 No 7 Don't Know 8 Refusal  Recoded as: 1U.S., Europe, Australia 2 Asia 3 Other  Sexual history lg: Age at first sexual intercourse  SHS6G2  Age at first sexual How old were you 1 10 to 11 years intercourse when youfirsthad 2 12 to 14 years grouped sexual intercourse? 3 15 to 17 years 4 18 to 19 years 5 20 to 24 years 6 25 to 29 years 7 30 to 34 years 8 34 to 39 years 9 40 years and older 96 Not applicable 99 Not stated Recoded as: 1 under 18 years 2 19 to 30 years 3 31 years to 59 years  lh: Number of sexual partners  SHS6_4  Number of partners (sexual intercourse)  With how many partners?  1 one partner 2 two partners 3 three partners 4 four or more partners 6 Not applicable 7 Don't know 8 Refusal 9 Not stated Recoded as: 1 one partner 2 two partners or more  SDC6DRES  Derived length of time in Canada grouped  In what year did youfirstcome to Canada to live?  1 0 to 4 years 2 5 to 9 years 3 10 years or more 6 Not applicable 9 Not stated  WHC6_23A Attitudes and knowledge about cervical cancer screening Reasons for the use of Pap testing  Had Pap smear Part of check-up  Why did you have a PAP smear test? - Part of check-up / routine screening  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  Had Pap smearHigh risk group  Why did you have 1 Yes a PAP smear test? 2 No - High risk group 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  Acculturation: Length of time in Canada 2a  3a 3b  WHC6_23B  3c  WHC6_23C  Had Pap smear Follow-up of previous problem  Why did you have a PAP smear test? - Follow-up of previous problem  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  3d  WHC6_23D  Had Pap smear - Why did you have Abnormal bleeding a Pap smear test? / other symptoms - Abnormal bleeding / other symptoms  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  3e  WHC6_23E  Had Pap smear Sexually active  Why did you have 1 Yes a Pap smear test? 2 No 6 Not applicable - Sexually active 7 Don't know 8 Refusal 9 Not stated  3f  WHC6_23F  Had Pap smear On birth control pill  Why did you have 1 Yes a Pap smear test? 2 No - On birth control 6 Not applicable pill 7 Don't know 8 Refusal 9 Not stated  3g  WHC6_23G  Had Pap smear Pregnant / after delivery  Why did you have 1 Yes a Pap smear test? 2 No 6 Not applicable - Pregnant / after delivery 7 Don't know 8 Refusal 9 Not stated  3h  WHC6_23H  Had Pap smear On hormone replacement therapy  Why did you have a Pap smear test? - On hormone replacement therapy  3i  WHC6_23I  Had Pap smear Other  Why did you have 1 Yes a Pap smear test? 2 No - Other 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  Reasons for the non-use of Pap testing 4a  WHC6_26A  No PAP smear have not gotten around to it  Why have you not had a PAP smear test in the past 3 years? - Have not gotten around to it  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  WHC6_26B  No PAP smear Respondent did not think it was necessary  Why have you not had a PAP smear test in the past 3 years? Respondent did not think it was necessary  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  Health care system barriers 5a  WHC6_25A  Problem getting PAP smear - Not available when required  What were the problems obtaining a PAP smear test? - Not available when required  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  5b  WHC6_25B  Problem getting PAP smear - Not available in area  What were the problems obtaining a PAP smear test? - Not available in area  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  5c  WHC6_25C  Problem getting PAP smear Waiting time too long  What were the problems obtaining a PAP smear test? - Waiting time too long  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  5d  WHC6_25D  Problem getting PAP smear Transportation  What were the problems obtaining a PAP smear test? - Transportation  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  5e  WHC6_25E  Problem getting PAP smear Language  What were the problems obtaining a PAP smear test? - Language  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  5f  WHC6_25F  What were the Problem getting PAP smear - Cost problems obtaining a PAP smear test? - Cost  1 Yes 2 No 6 Not applicable 7 Don't know 8 Refusal 9 Not stated  4b  Health Care System Barriers  Language use 5g  SDC6GLG4  Derived language respondent can conduct conversation in grouped  In which language 1 English only can you conduct a 2 French only conversation? 3 English and French only 4 Other 99 Not stated Recoded as: 1 English or French 2 Other  WHC6_20 Dependent variable - Pap test participation  Had PAP smear test  Have you ever had 1 Yes a PAP smear test? 2 No 6 Not applicable 7 Refusal 9 Not stated  Last time PAP smear test was done  When was the last 1 Less than 6 time you had a months ago PAP smear test? 2 6 months to less than 1 year ago 3 1 year to less than 3 years ago 4 3 years to less than 5 years ago 5 5 or more years ago 6 Not applicable 7 Don't know 9 Not stated  6a: Ever had Pap testing 6b: Last time had WHC6_22 Pap testing  Recoded as: 1 More than 3 years ago 2 Within the last 3 years 6c : Pap test use  DV-Based on 6a and 6b  Use of cervical cancer screening  1 Non-compliant: Never had Pap testing or Had Pap testing more than 3 years ago 2 Compliant: Had Pap testing within the last 3 years  68  APPENDIX B  INC6DIA5  Income adequacy in 5 discrete categories  This variable is based on household income and the size of the household. INC6DIA5 = 1  DESCRIPTION Lowest income  2  Lower middle income  3  Middle income  4  Upper middle income  5  Highest income  9  Unknown  INCOME Less than $10,000 Less than $15,000 $10,000 to $14,999 $10,000 to $19,999 $15,000 to $29,999 $15,000 to $29,999 $20,000 to $39,999 $30,000 to $59,999 $30,000 to $59,999 $40,000 to $79,999 $60,000 to $79,999 $60,000 or more $80,000 or more Not stated  HHSIZE 1 to 4 persons 5 or more persons 1 or 2 persons 3 or 4 persons 5 or more persons 1 or 2 persons 3 or 4 persons 5 or more persons 1 or 2 persons 3 or 4 persons 5 or more persons 1 or 2 persons 3 persons or more Not applicable  Statistics Canada. (1998). National Population Health Survey 1996-1997: Household Component User's Guide for the Public Use Microdata Files (Catalogue. No. 82M0009GPE). Ottawa: Ministry of Industry.  69  APPENDIX C 1996-97 NPHS PUBLIC USE MICRODATA  DOCUMENTATION  11.1 Cross-sectional Weighting for the 1996-97 NPHS—Core Household Sample This section describes the 1996-97 weighting procedures for selected members and all members of their households in the continuing (core) N P H S sample. A complete description of the additional weighting procedures necessary in the buyin provinces (Ontario, Manitoba, and Alberta) is found in Section 11.2. 11.1.1 Stripped Weights A s described in Sections 11.3 and 11.4, the starting point of the 1996-97 weighting procedure is the "stripped" weight, based upon the original sample design of 1994-95. Once these weights are obtained, the following weight adjustments are performed. 11.1.2 Weight Adjustments for Household Members Adjustment 1A: Household Non-response Adjustment The definition of a non-responding household encompasses any of the following situations: refusal, special circumstance, language barrier, no one at home, temporarily absent or computer problem. There are also cases where it was determined that the selected member being followed-up in 1996-97 was dead, institutionalized, had moved to the Y u k o n or Northwest Territories, or out of the country. For cross-sectional weighting purposes, these households are included as responding households at this stage, but are subsequently dropped from further calculations. These units do not appear on the cross-sectional microdata file but do appear on the longitudinal file. T o adjust for cases of entire households that did not respond to the 1996-97 survey, the following adjustment is made: sum of weights for responding and non & responding households within weighting class sum of weights for responding households within weighting class  Weighting classes consist of groupings of units (or households) that share the same propensity to respond to the survey. Characteristics from cycle 1, available for cycle 2 respondents and non-respondents alike, are used to define membership in the weighting classes. Classes are formed using a clustering algorithm that arranges the sample units into a tree structure by successively splitting the data set into "branches" based on the units' characteristics.  Statistics Canada. (1998). National Population Health Survey 1996-1997: Household Component User's Guide for the Public Use Microdata Files (Catalogue. No. 82M0009GPE). Ottawa: Ministry of Industry.  

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