Editorial Board:
Editor:
George H. Conklin,
 North Carolina
 Central University

Board:
Rebecca Adams,
 UNC-Greensboro

Bob Davis,
 North Carolina
 Agricultural and
 Technical State
 University

Catherine Harris,
 Wake Forest
 University

Ella Keller,
 Fayetteville
 State University

Ken Land,
 Duke University

Miles Simpson,
 North Carolina
 Central University

Ron Wimberley,
 N.C. State University

Robert Wortham,
 North Carolina
 Central University

Editorial Assistants

John W.M. Russell,
 Technical
 Consultant

Austin W. Ashe,
 Duke University

® 

Volume 9, Number 1

Spring/Summer 2011
 

Health Status and Cancer Screening in Hispanic Women: A Sample from Cumberland County, North Carolina*

by

 Heather Griffiths

and

Sharmila Udyavar

Fayetteville State University
 

Introduction

    The Hispanic population in the United States is increasing rapidly and is projected to rise to 11 percent by the turn of the century and constitute 23 percent by the year 2050 (U.S. Census Bureau 2010, Bean and Tienda 1990).  Despite the recent decrease in the number of uninsured Hispanics, as a partial consequence of its relatively high poverty rate (25.3 percent in 2009) this population faces a number of serious health problems (DeNavas-Walt, Proctor, and Smith 2008).  The current study seeks to add to the literature on health in Hispanic populations by analyzing factors that influence wellness among Hispanic women; specifically variables that influence breast and cervical cancer screenings. 

    Hispanics perceive themselves as having separate and distinct cultures and lifestyle based on their country of origin rather than a single culture as Hispanics or Latinas/Latinos (Kaiser Family Foundation 2002).  Since this category tends to serve as an undifferentiated category for a variety of distinct groups, one major contribution of this study is examining within group differences between Hispanics who identify as Mexican, Central American, South American, and Caribbean Americans.  Thus, the study focuses on the screening habits of Hispanic women in Cumberland County North Carolina in order to provide both a general picture of breast and cervical cancer screening behavior of this generalized population as well as a comparison of within group differences between the general health experiences of Mexicans, Central Americans, South Americans, and Caribbean Americans.  Local statistical data is compared to National Institute of Health data for White women and a national sample of Hispanic women.  Since qualitative responses add depth and clarity to statistical analyses, another contribution of the current study is the incorporation of both mixed methodology and local data, an important component of current Health Disparities research. 

Hispanic Population Overview:

    Since Census 2000, the Hispanic population in the United States increased considerably.  In 2000 approximately 13 percent of the population identified as Hispanic (Grieco and Cassidy 2001); the Census 2010 identified 16.3 percent of the total population as Hispanic (Census 2010).  By 2050, an estimated 23 percent of the population will identify as Hispanic (Census 2010). 

    According to the American Community Survey "In 2008, Mexicans were 66 percent of all Hispanics, Puerto Ricans were 9 percent Cubans were 3.4 percent, 3.4 percent Salvadorean and 2.8 percent Dominican. The remaining consisted of other Central and South American and Hispanic origins."  (U.S. Census Bureau 2008)

    This population is relatively young, and in 2010 36.24 percent of Hispanics were less than age 18 compared to 23.6 percent of the U.S. population (Census 2010).  The Hispanic population of the United States experiences higher rates of asthma, respiratory disease, obesity, and HIV/AIDS (Center for Disease Control 2007).  In 2002, the leading causes of death for Hispanics included heart disease and cancer (National Center for Health Statistics 2004). 
    According to the U.S. Census Bureau (2010), 8.4 percent of the North Carolina population claims a Hispanic identity, up from 5 percent in 2000 and 1.25 percent in 1990.  These numbers will continue to increase at both the local and national level, requiring increased attention to health concerns prevalent among the Hispanic population. 

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Health Disparities, Hispanic Women, and Breast/Cervical Cancer:

    There are significant gender-based health disparities in America (Matteo 1993; Hoffman 1995).  Even though women tend to live longer than men, they also experience higher rates of illness and disability.  But examining gender alone is not enough to explain women's experiences with health disparities.  Despite advances in reducing race and sex based health disparities; gender, race, and class continue to influence health outcomes (Mullings and Schulz 2006; Jackson and Williams 2006; Geiger 2006).  Some of the many varying explanations for existing race/gender/class health disparities include: socioeconomic status, geographic variation, exposure to occupational hazards, segregation, discrimination, and lifestyle choices (Geiger 2006; Hofrichter 2003; Kawachi, Kennedy, and Wilkinson 1999).

    Nationally, gender intersects with race to influence how individual women experience health disparities.  A Kaiser Foundation Study (2004) found that almost 20 percent of Black women and almost 30 percent of Latinas described their health status as only "fair" or "poor" compared to a mere 13 percent of White women.  This study reported, among other disparities, that almost twice as many Latinas (17 percent) had diabetes compared to White women (9 percent).

   A plethora of studies focusing on Black/White female health disparities serve as the basis for focusing on health disparities experienced by Latinas (American Medical Association 1990; Bach, Pham, Schrag, Tate, and Hargreaves 2004; Bloche 2001).  At this time there is a lack of data available for specific ethnicities within the general grouping of nationalities that make up the socially constructed category "Hispanic," which the current study attempts to address. 

    During a time of national decline, recent research has indicated that the cervical cancer incidence for Hispanic women over the age of 30 years is twice that for non-Hispanic women.  In addition, Hispanic women are more likely than women of other races to be diagnosed at an advanced stage.  (American Cancer Society 2006).  As a group, in addition to early detection barriers faced by all women (financial constraint, lack of regular doctor's visits, failure to obtain annual mammograms), Hispanic women face additional barriers to obtaining preventative care, including: lacking a regular source of care more often than other ethnic groups (Aday 1980; Anderson, Lewis, Giachello, Aday, and Chiu 1981; Roberts and Lee 1980), more likely than Whites to use public health facilities (Lieu, Newacheck, and McManus 1993), more likely than other ethnic groups to lack insurance, a shortage of Latino/Latina health professionals, immigration status, and English proficiency (Molina and Molina 1994). 

    Breast cancer tends to affect younger Hispanic women. Not only that, when compared to non-Hispanic women the tumors are often larger and more advanced.  The incidence of breast cancer is highest among White women; however, it is still the leading cause of cancer death among Hispanic women. When diagnosed with the same stage tumor at the same age Hispanic women are more likely to die of breast cancer than white women (American Cancer Society 2006). 

Both breast and cervical cancer are preventable.  Evidence shows that mortality due to breast cancer is significantly reduced (up to 45%) by screening for lumps and other changes. This screening could include self breast exam, mammogram and clinical breast exam (CBE).

    Unfortunately, a study conducted in 2000 finds significant ethnic disparities in breast cancer screening in the United States.  Hispanic women had lower odds of having had screening mammographies than non-Hispanic women (Coughlin et al. 2004).  In addition, though regular pap smears (an annual screening that identifies cervical dysplasia, a pre-cancerous condition) can help prevent invasive cervical cancer, relatively few Hispanic women get one annually.  (American Cancer Society 2006). 

    The current study takes a cue from the assertion, made by many social science researchers, that there is no pan-ethnic Hispanic experience (de la Garza, Garcia, Garcia, and Falcon 1992, Arvizu and Garcia 1996, Uhlaner 2002).  Among other examples, the Latino Political Survey demonstrates clear differences in socioeconomic status and opinions on important issues among Mexican, Peurto Rican, and Cuban populations (de la Garza, et al 1992).  In order to maximize the variety of Hispanic ethnicities included as respondents in the current study, it is necessary to sample the population in such a way that representation of a variety of groups is ensured.

    One means of ensuring a variety of within group respondents representing the various ethnicities and cultures that form the group "Hispanic" is to utilize the community stores (Tiendas) that serve as the primary source for Hispanic oriented food and other groceries.  A Tienda is (1) a convenience OR grocery store that caters to a Latina/Hispanic clientele, which contains (2) an assortment of Latino/Hispanic food products, AND (3) offers a variety of media in Spanish. 

    While there is certainly a difference in cuisine, the effort to stock Spanish language labeled products and hire Spanish speaking employees ensures that the clientele will serve as representative of all Hispanic groups in the immediate area.  Several other studies have demonstrated the importance of the  Tienda to a variety of groups within the Hispanic community, including Bolivian (Coen, Ross, and Turner 2008), Mexican (Delapa, Mayer, Candelaria, Hammond, Peplinski, De Moor, Talavera, and Elder 1990), and Latin American (Ayala 2005).  The current research attempts to utilize the Tienda as a point of contact with the variety of groups that compose the socially constructed category Hispanic as suggested by these, and many other, studies. 

    While Hispanics as a group experience higher rates of asthma, respiratory disease, obesity, and HIV/AIDS, and more Hispanic women describe their health as "fair" or "poor" compared to White women, research on health suggests the existence of a so-called "Hispanic Mortality Paradox."  This research demonstrates that as a group, Hispanics in the United States have lower adult mortality rates than non-Hispanic Whites (Sorlie, Backlund,  Johnson, and Rogot 1993; Hummer, Rogers, Amir, Forbes, and Frisbie 2000; Palloni and Morenoff 2001).  Follow-up studies suggest that the benefits inherent in this Hispanic paradox is limited to foreign-born Hispanics, not including Cubans or Puerto Ricans (Palloni and Arias 2004), providing yet more support for research that focuses on between ethnic group differences in health and health screening behavior.

    The current research is a mixed methodology study that focuses on antecedents of breast and cervical cancer screening behavior for Hispanic women living in Cumberland County North Carolina, as well as collecting more general qualitative responses on specific issues that Hispanic women have with regards to health care. Both quantitative survey distribution and qualitative interviews were utilized in order to provide substantial baseline data for the Hispanic female population in the areas of breast and cervical cancer screening, family health history, specific health experiences and health concerns. 

    The population of interest for this study included all Hispanic female adults residing in Cumberland County, North Carolina during data collection.  Since Tienda's play an important role within the Hispanic community (as a place to meet, socialize, exchange information about resources, and purchase commonly consumed foods), these local stores served as a natural contact point for the population (Ayala et. al, 2005).  Bilingual research assistants first surveyed, and then interviewed Hispanic women in Tiendas and a larger Hispanic grocery called Compare Foods Supermarkets (which also fit our definition of a Tienda) catering to the Hispanic population of Cumberland County.  From the approximately 160 tiendas in Cumberland County, we acquired a sample of 160 quantitative surveys and 43 semi-structured interviews from this population.

    The survey instruments used for the Hispanic Women's Health Project (HWH) developed from the National Health Interview Survey (NHIS), which is available from the National Center for Health Statistics (NCHS), Center for Disease Control and Prevention (CDC).  Conducted annually, the NHIS administered by the CDC supplies health data.  Following the collection of survey data, researchers asked Phase One participants to participate in semi-structured interviews.

    We compared the HWH data to the 2005 NHIS Data.  This data included a supplementary Cancer Control Module consisting of six sections covering diet\nutrition, physical activity, tobacco, cancer screening, genetic testing and family history. Those respondents who served as sample adults for each household also participated in the Cancer Control Module. The total sample size of this module was 31,428 respondents (13,762 males and 17,666 females). We merged this file and the person file to include other variables of interest (i.e. self-rated health status). 

    After selecting for non-Hispanic white females and Hispanic females, we created a separate file that included 11,298 records for non-Hispanic white females and 3,052 records for Hispanic women. The merged files included all the variables of interest involving self-rated health status and cancer screening history. This file served as the basis for comparing the differences (if any) among women at the national level as compared to  behavior of Hispanic women in a Southern county. 

Variables used from the HWH included:
 

• Self-rated health status recoded into two categories (good and fair)
• Self-identified mammogram history
• Self-identified Pap Smear history
• Socio-demographic variables (including age, income, and educational status)
• Self-identified ethnicity recoded into four categories (Mexican, Central American, South American and Caribbean)

Quantitative Findings:

    Table 2 shows rates of breast and cervical cancer for the national population of White and Hispanic females.  breast and cervical cancer rates for the North Carolina female appear as well. 

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    North Carolina rates for breast cancer are higher than the national rate, while the rates for cervix and ovarian cancer are similar. Uterine cancer is higher at the national level than it is in Cumberland County. 

    Table 3 shows the breast and cervical cancer screening history of Cumberland County Hispanic females as compared to U.S. non-Hispanic whites and Hispanic females. A higher percentage of Cumberland County females undergo CBE's as compared to both U.S. White and Hispanic groups. Fewer of them undergo mammographies as compared to the U.S. White population. More Cumberland County Hispanic females undergo Pap Smears than the other two groups. 

    From the three groups being utilized for this study, there appears to be significant intra-group variation with regard to age and education. In the HWH dataset, the Cumberland County Hispanic group, 43.3% of the respondents are below the age of 30 years. In the U.S. non-Hispanic white group, 16.6% of the respondents are below the age of 30 years; and among the U.S. Hispanic group, 30.8% of the respondents are below the age of 30 years. With regard to education, the U.S., in the non-Hispanic white group 41.2% have a High School Diploma or less; 70.2% of the U.S. Hispanic women have a High School Diploma or less and 52.8% of the Cumberland County Hispanic females have a High School Diploma or less. 

    This demonstrates that the U.S. Hispanic sample is more educated than the HWH sample. From the cross tabulation shown below in Table Three, one can infer that the higher percentage of women in Cumberland County with greater education  can explain the higher level of health screening behavior in Cumberland County. 

    Tables 4 and 5 show the bivariate analysis of the education variable from both the HWH and NIHIS files, as well as the self reported ethnicity variable from the HWH file. The tables also show the impact of these independent variables on self reported health status, mammogram, and pap smear history based on cross tabulations and Chi Square. 

    In Table 4, it is observed that self-rated health behavior impacts education both positively and significantly.  With higher level of education, the likelihood of a better self-rated health status for all three groups is greater. Within the local data, it appears that Central Americans experience the largest percentage of respondents with good health; however the impact of ethnicity is not significant. 

Table 5 is a cross tabulation showing the impact of education and ethnicity on choosing to undergo mammograms and pap smears at some time during their lifetime. Education appears to enact a positive impact on screening history and there is greater screening with more education. This impact is significant for mammograms among Cumberland County Hispanic females and U.S. non-Hispanic White females. It is also significant for pap smears among the U.S. white and Hispanic females. 

    Among the ethnic groups, South Americans from Peru, Brazil, Argentina, and Colombia as well as other South American countries show the greatest percentage of women undergoing mammograms as compared to the other 3 groups and the impact of ethnicity on this screening behavior is significant. It also appears that greater numbers of women from all four ethnic groups have screening for cervical and uterine cancer than breast cancer, but the impact on this behavior is not significant.

Qualitative Findings:

    Following completion of the quantitative survey, we invited respondents to participate in a short interview.  Analysis of interview data pinpoints the language barrier as the number one concern for our respondents, with eighteen of the forty-three indicating that they share this concern:
 

"Sometimes we go to doctors here and either I don't understand them or its bad communication and all that causes more problems…I have gone to Mexico to be treated because here no one, because here I do not feel satisfied."  (Mexican, 43)

"I have found the problem, they do not have interpreters…I had to change clinics so that I would get some that spoke the same language."  (El Salvador 33)

"When I came here we have to work immediately and there is no time to learn English and then there are people that will not go to a doctor…because there is no one to help them or understand them."  (Guatemalan, 60). 

    As shown below, in some cases, women neglected to request the translation they needed in an effort to avoid annoying the doctor:
 

"Those that interpret don't interpret right, or we don't understand each other right, but I am not satisfied.  That is my problem, leaving me with doubt and worry, and I leave with the same problems and I don't even know what to think…We are wrongly informed a lot.  Sometime we just stay quiet and don't say anything because then they try to interpret and we ask for one and it is as if it annoys them.  So, better not to annoy. [It would be] that they put more Mexican Hispanics to interpret so that we can understand better...that there would be more Mexican doctors."  (Mexican 43)

    Another issue is the lack of available Spanish/English translators:
 

 "Us as Hispanics see some that speak very little English and some do not speak English, but the majority will get assistance in English not a lot in Spanish.  No[body] bothers or worries about us Hispanics...I would like there to be more attention for the Hispanic language and community…that someone could translate and I could understand…because sometimes you go to the clinic and they you I speak Spanish but I speak very little Spanish and they don't understand you and you don't understand them."  (Mexican, 30). 

    For those women who do not mention have any problems personally, they make plain the reason they have avoided difficulty, either specifying that they have no problems because they speak English or noting they only see Hispanic (Spanish speaking) doctors.  Another six women discussed their ability to avoid difficulty, either by speaking English during the exam or only using Spanish speaking doctors:
 

"Honestly, I have not had any problems because I speak English very well." (Dominican, 27)

Q: What has been your experience when you talk to your doctor?
"No problems…No, none.  For me, I always get a Hispanic doctor."  (Dominican, 65)

    Eleven of the forty-three women noted that lack of insurance combined with high cost presented a barrier to seeking health care:
 

"We don't have insurance.  Those of us that have children worry that our children also need insurance for emergencies."  (Mexican, 30)

"I'm diabetic and problems with blood pressure…when I don't feel good I worry because I don't have insurance."  (Dominican, 65)

"Sometimes it is hard because it is expensive and sometimes there is not enough [money] for health services…the cost of it, it is at times expensive." (Mexico, 27A)

    Despite the relatively high mortality rate experienced by Hispanic women, only five of forty-three interviews involved the discussion of breast cancer as a health concern,
 

Q: Do you have any health concerns?
A: "Well, just the average concerns about…breast cancer." (Puerto Rican, 30)

"The everyday worries like breast cancer, even though is not in the generation of our mothers or grandmothers, there can be possibilities."  (Puerto Rico, 30A)

Two women mentioned racism in the health care system as a concern for them, and it is possible that more in-depth interviewing would reveal further issues in this area:
 

"On health services there are lots that don't treat you very well but there are others that do, in some clinics there is racism and you got to deal with it because we are immigrants." (Mexico, 31A)

"Racism they treat you with it, not the doctor, but the nurses."  (Puerto Rico, 28A)

    The current study indicates that the language barrier ranks as the number one concern among Hispanic women living in Cumberland County.  Inasmuch as the current sample reflects the national population, we can speculate that Hispanic women who speak little to no English (irregardless of specific ethnic identity), all share this concern.

    Lack of insurance, combined with the high cost of health care also generated a number of responses during interviews.

    Results from this research report will assist in eliminating ethnic disparities in health status and health screening behaviors that exist in the United States. Preliminary analysis shows that while a higher rate of breast cancer exists in North Carolina, only about 40% of Hispanic women in Cumberland County undergo mammographies as compared to 61% of non-Hispanic white female population in the United States.   When compared to national figures, there is a higher rate of uterine cancer in North Carolina as well.  When comparing the Cumberland County sample to national data, comparable rates of pap smears exist.

    This report further assessed the impact of ethnicity and education on cancer screening behaviors as well as self reported health status. A higher level of education correlated to better self rated health as well as better screening behaviors. While a variation in screening behavior existed among the ethnic groups, with the Puerto Rican/Caribbean and South Americans showing the highest rates of screening and Mexicans the lowest, education did not appear to have a significant impact on any ethnic group. 

    As nationally, the Hispanic population in North Carolina is very young.  Considering the incidence of breast, cervical, and uterine cancers in this population, there might be a need for more awareness and education imparted through intervention programs that promote screening for these cancers.  Given the concerns expressed by respondents during interviews, any education and awareness programs should take appear in culturally sensitive Spanish, with an effort to target specific cultural/linguistic groups rather than using a single Spanish translation across all ethnic groups. 

    The current study finds support or contacting specific ethnic groups within the socially constructed category "Hispanic" at Tiendas.  Our research was able to connect with Latinas from a variety of Hispanic ethnicities, and the advantage of using the local Hispanic grocery stores is clearly demonstrated by our data set.  The success of this methodology suggests using the Tiendas as a point of contact for this population when setting up public health clinics or health issue awareness campaigns.

    The findings demonstrate that there is a clear perception among Hispanic women that they are grouped together into a homogenous pan-ethnic group.  Women referred to the lack of a same-ethnicity translator when they sought health care as a serious issue.  As suggested by the literature on Hispanic identity, it is not enough to have a Spanish speaking translator—it is also necessary to address the need for cultural sensitivity.  In other words, patients from one Hispanic ethnicity may perceive prejudice in the unexplained use of a different Hispanic ethnicity for translation. For example, Mexican Spanish may have different nuances than Cuban Spanish, and to act as if these differences are nonexistent implies a lack of cultural sensitivity that will be perceived as prejudicial. 

    Also demonstrated by the qualitative findings, there are two main areas that health care professionals should focus on.  First, emphasis on training more Spanish language interpreters for emergency rooms, public care facilities, and private specialists would greatly reduce the perception among Hispanic women that the health care system does not pay attention to their needs.  Second, training in cultural sensitivity would greatly reduce the perception that health care providers view all Hispanics as the same and that health care providers do not appreciate the between ethnic group differences, especially the between group ethnic differences in dialect and linguistics.

*Support for this research was provided by grant P20 MD001089-01 from the National Institution of Health, NCMHD, and Department of Health and Human Services.

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