Linguistic and Ethnic Disparities in Breast and Cervical Cancer Screening and Health Risk Behaviors Among Latina and Asian American Women

Introduction

Regular cancer screening examinations can lead to the detection and removal of precancerous growths and the diagnosis of cancer at an early stage. For example, mammograms, breast self-examinations, and clinical breast examinations can detect breast cancer early in its development. Cervical cancer can also be easily prevented and is highly treatable and curable because the Papanicolaou (Pap) or human papilloma virus (HPV) test can effectively, safely, and cheaply detect cellular changes even before cancer develops. ¹ As a result, the 5-year survival rates for women diagnosed with localized breast and cervical cancer are 98% and 92%, respectively, reflecting the effectiveness of breast and cervical cancer screenings. ^2,3 This suggests that the implementation of screening programs is a secondary prevention strategy that is instrumental in reducing breast and cervical cancer incidence and mortality rates in the 21st century. ⁴

However, whereas the rate of breast cancer incidence among European Americans is high compared with the rates of some ethnic minorities, minority populations are typically diagnosed at later stages of the disease compared with European Americans. ^2,5 Additionally, incidence and death rates are generally higher in minority populations than among European Americans for cancer of the uterine cervix. ^3,5 Given the fact that ethnic minority groups are the fastest-growing populations in the United States and that ethnic minority women have a lower 5-year survival rate, ^2,4 extra attention should be paid to prevention and medical outcomes among these high-risk groups. Recent reports suggest that ethnic minorities and underserved populations suffer an increased cancer burden. ^{4,6 –8} Many women may fall through the net of care because health practitioners or researchers have not addressed the risk factors for poor use of care among ethnic minority and underserved women in the United States. Specifically, language barriers may be potentially important contributors to disparities in breast and cervical cancer among Latina and Asian American women. ^{9 –11} Several studies report that language problems can impede access to healthcare, ^{12 –14} diminish the quality of care, ^{15 –17} and cause dissatisfaction with care. ¹⁸ Nevertheless, few studies address the effects of linguistic barriers on health outcomes and healthcare access, especially in relation to cancer screening. ¹ Thus, this study focuses on ethnic and linguistic disparities in cancer screening among Latina and Asian American women.

Disparities in the receipt of health services and outcomes may exist primarily because demographic indicators of low socioeconomic status (SES), such as low educational attainment, ¹⁹ high unemployment, low income, ^20,21 and lack of health insurance coverage. ^{22 –24} For example, lack of health insurance coverage and low SES status may restrict access to healthcare services, including the prevention, treatment, and management of conditions that are related to cancer. Indeed, it is well documented that SES impacts healthcare access and outcomes that are relevant to cancer control. ^25,26 Several studies found that lower income, educational attainment, and job status are negatively related to access to care. ^27,28 Unfortunately, ethnic minorities and underserved populations disproportionately experience lower SES, ^29,30 so demographic factors, including SES indicators, should be considered in research that includes ethnic minority populations.

Health risk behaviors may be associated with the likelihood of undergoing breast and cervical cancer screenings, especially in the context of the practice of appropriate health behaviors, such as prevention activities. ³¹ Generally, health risk behaviors, such as smoking, drinking, diet, and exercise, are sustained in daily practice, whereas cancer screening methods, such as medical checkups, mammography, and Pap smear tests, are health service dependent. ³² Some studies report that health risk behaviors may influence a greater variety of prevalent health conditions and delay incidental health conditions, such as cancer. ^33,34 However, few studies have addressed the association between health risk behaviors and cancer screening among Latina and Asian American women. Further knowledge about health risk behaviors among ethnic minority populations may be helpful to understand their cancer screening patterns and, ultimately, facilitate timely and appropriate screening through culturally and contextually rooted strategies.

This study aims to (1) describe breast and cervical cancer screening patterns and health risk behaviors among Latina and Asian American women, with consideration for their language, and (2) investigate the impact of health risk behaviors on breast and cervical cancer screening, after controlling for language and demographic characteristics. The following hypotheses were formulated:

Asian Americans will show better outcomes in breast and cervical cancer screening and health risk behaviors than Latinas.

Materials and Methods

Results

Discussion

This study focused on describing breast and cervical cancer screening patterns and health risk behaviors among Latina and Asian American women and investigating the impact of health risk behaviors on cancer screening, after controlling for demographic characteristics and language. The study findings suggest that (1) Asian Americans had better outcomes in health risk behaviors, such as smoking habits, BMI, and binge drinking, but Latinas were more likely than Asian Americans to use the breast and cervical cancer screening tests, (2) English-speaking Latinas and Asian Americans showed better outcomes in cancer screening and health risk behaviors, but there were different patterns in BMI according to language, and (3) unhealthy risk behaviors were related to low screening rates, except for BMI and drinking among Latina women. Therefore, the research hypotheses were partially confirmed in the current study.

The current study is novel because the study sample included a large portion of Latinas and Asian Americans who were identified by language proficiency. Previous studies have shown that Asian American women have the lowest breast and cervical cancer screening rates among all ethnic groups. ³⁶ Several studies have also reported that Latinas are less likely than European American and African American women to obtain cervical cancer screening. ^{37 –39} However, no study based on the CHIS 2007 has investigated the differences in cancer screening behaviors between Latina and Asian American women taking language into consideration. This study demonstrated that Latinas are more likely than Asian Americans to receive mammograms and Pap smears. Moreover, the CHIS 2007 data confirm once more that Asian Americans may still have the lowest breast and cervical cancer screening rates. For Asian American women specifically, language proficiency influenced the low rate of cervical cancer screening, indicating that English-speaking Asian American women are more likely to undergo cervical cancer screening. Nevertheless, the overall cervical cancer screening rate for Latinas was higher than that for Asian Americans. Although the findings demonstrated that income and educational levels were higher among Asian Americans than among Latinas, this study cannot assume the usual relationship between higher SES and higher cancer screening rates. Rather, unique cultural beliefs and attitudes, acculturation, and access to culturally competent, in-language, and ethnic-specific services should be considered to further understand screening patterns among ethnic minority populations.

With regard to health risk behaviors, Latina and Asian American women showed similar patterns by language. First, English-speaking and bilingual women were more likely than non-English native language-speaking women to be involved in regular physical activity. With regard to drinking and smoking patterns, English-speaking women were more likely to be binge drinkers or current smokers. These findings are consistent with those of previous studies. ^{40 –42} In fact, such results seem to reflect acculturation patterns toward a Westernized lifestyle and its adoption among ethnic minority populations. The English language may also provide additional influences, exposing women to a greater number of positive messages about exercise via work and school environments and through English-language mass media. ⁴³ Additionally, changes in cultural values and beliefs associated with the acculturation process might result in changes in drinking and smoking patterns among women specifically.

Meanwhile, unique patterns in BMI emerged between Latinas and Asians by language. For example, among Latinas, Spanish-speaking women were more likely to be obese, whereas among Asian Americans, English-speaking women were more likely to be obese. Previous research has indicated that the level of acculturation may play an important role in the development of obesity within ethnic minority and immigrant populations because immigrants tend to follow the trend of native-born Americans toward more sedentary behavior, the consumption of more calorie-rich foods, and a higher reliance on private cars rather than public transportation. ^44,45 In this study, however, only the Asian American women seemed to follow that trend. In fact, the obesity risk in immigrant populations not only is related to acculturation but also is affected by the interplay of sociocultural and income changes, ⁴⁶ which means that other factors, such as SES, poor eating habits (inexpensive, energy-dense foods that are high in sugar and fat), and demographic characteristics, need to be considered with acculturation.

In terms of demographic characteristics, marital status was a key factor influencing mammogram and Pap smear testing. This finding is consistent with the results of previous research. ³⁶ According to the American Cancer Society (ACS), yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health. ACS also recommends that all women should begin cervical cancer screening about 3 years after they begin having vaginal intercourse but no later than 21 years of age. Given that marital status is significantly related to an intimate relationship with a partner, body image, and sexual intercourse, this finding is understandable. Nevertheless, it would be important to encourage unmarried women from all ethnic groups to obtain mammograms and Pap smears. Additionally, as indicated in Table 4, Latina and Asian American women showed different patterns in Pap smear testing with regard to age. Latina women aged between 18 and 39 years were more likely to receive a Pap smear than older Latinas, whereas middle-aged Asian American women were more likely than their younger counterparts to receive a Pap smear. These differences may be due to different cultural beliefs about sexual relationships and exposure, the level of social openness, or a lack of knowledge about cervical cancer screening. Therefore, this finding suggests that different strategies regarding cervical cancer screening should take different cultural contexts into account.

In the current study, health risk behaviors were included as factors that could influence breast and cervical cancer screening patterns. In fact, both health risk behaviors and cancer screening are considered to be prevention activities. Thus, health risk behaviors may be important factors that can predict cancer screening patterns. Given that health risk behaviors are sustained in daily practice, investigations about the relationship between health risk behaviors and cancer screening may provide a cue to effectively deliver a message about cancer screening. In the current study, for example, Latina women who reported current smoking and underweight Asian American women were less likely to obtain a Pap smear. These findings suggest that it may be important to develop culturally tailored preventive activity programs that include smoking, diet, and cervical cancer screening. There is, therefore, an urgent need to investigate the dynamic relationships and patterns between health risk behaviors and cancer screening in order to further understand the relationships between these factors and develop effective and efficient preventive interventions for ethnic minority populations.

Unlike prior studies, ^{47 –50} this study found that obese Latina women are more likely than normal weight Latinas to receive breast and cervical cancer screenings. Several national surveys have suggested that obese women are less likely to undergo breast or cervical cancer screening, potentially placing these women at a higher risk for advanced disease. ^51,52 Unfortunately, however, most of these studies were conducted among primarily European American women and not among ethnic minority populations. Thus, these findings might reflect skewed results by not considering ethnic minorities. An example is represented by a recent study ⁵⁰ that suggested that obesity is a barrier to cancer screening among European American women but not Latinas. Additionally, Latina women showed similar patterns in the relationship between binge drinking and cervical cancer screening, indicating that Latina binge drinkers are more likely to receive a Pap smear. Thus, there is an urgent need to include ethnic minority populations in studies in order to further understand the relationship between health risk behaviors and cancer screening. We should not overlook the fact that overweight and obese women may overestimate their height and underestimate their weight in self-reported data. Furthermore, in reality, this study may suggest that Latina women use cancer screening services appropriately when they have access to care.

The present study had several limitations. First, this study aggregated subgroups of Latina and Asian American women based on a social definition of race recognized in the United States. ⁵³ However, the findings may be different according to subgroups. Further study is needed to investigate the relationship between health risk behaviors and cancer screening among Latina and Asian American ethnic subgroups. Second, the data were self-reported. Several studies suggest that patients tend to overreport the use of screening and underreport the time elapsed since their last screening. ^36,54 Third, the CHIS 2007 data did not include questions about breast and cervical cancer screening tests that are conducted for diagnostic purposes, which may influence the results. In addition, the findings from this sample set may not be generalizable to all populations, even though the sample is population based. Nevertheless, this study provides meaningful, new knowledge about cancer screening, health risk behaviors, and health status for Latina and Asian American women. CHIS has been shown to be a valuable resource, as it was the first population-based survey of several groups with limited English proficiency.

There are several clinical and research implications. This study reveals unique ethnic and linguistic patterns that are relevant to health risk behaviors and cancer screening and that influence overall health outcomes. These findings suggest that health risk behaviors and cancer screening for ethnic minority and underserved populations may be framed by a cultural context that includes language, cultural beliefs, and gender roles. In addition, the current study demonstrated the relationship between health risk behaviors and cancer screening among Latina and Asian American women. Thus, intervention strategies designed to promote healthy lifestyles and cancer screening may have greater sustainable benefits if socioecological and cultural contexts are considered. Finally, there is a tremendous need for population-based research to assess the health risk behaviors and cancer screening patterns of ethnic minority populations. Thus, future study is essential to tailoring appropriate and effective outreach and education programs for Latina and Asian American women.