Breast and Cervical Cancer Screening: Impact of Health Insurance Status, Ethnicity, and Nativity of Latinas

INTRODUCTION

Cancer is the second leading cause of death in the United States.¹ Tragically, Latinas in the United States have greater proportions of later stage breast cancer diagnoses,^2–3 later initiation of treatment, and worse breast cancer survival outcomes.^4,5 Latinas also experience twice the incidence of cervical cancer compared with non-Latina whites.⁶ These disparities stem in part from infrequent screening practices for these cancers. Previous studies suggest that Latinas face added challenges in gaining access to needed preventive health services compared with non-Latina whites because they are less educated,^7–9 have lower incomes,^7–9 have lower rates of health insurance coverage,^9–14 and have limited English proficiency.¹⁵ Studies that examined utilization of cancer screening services by nativity suggest that immigrants are less likely to receive a Papanicolaou (Pap) smear.^16,17 Other studies, however, either suggest that birthplace is not a significant predictor of cancer screening utilization^18–20 or that foreign-born status increases the chances of cancer screening utilization.²¹ The conflicting conclusions among these studies may be accounted for by differences in definitions of screening, lack of adjustments for predictive variables, and inclusion of heterogeneous Latina groups.

In addition, ethnicity, nativity, and health insurance status may interact in complex ways to influence access to appropriate preventive services. Understanding the mechanisms of these interactions will help inform interventions to reduce disparities in health care by increasing screening rates for breast and cervical cancer among Latinas. The Institute of Medicine has also recommended that data collection include subpopulations within ethnic populations, because these data will provide a better understanding on variations in care based on race and ethnicity.²² Latinas are one of the largest and fastest growing populations in the United States; efforts to reduce disparities in screening rates for cancer among Latinas may be more effective if we more fully understand how overlapping characteristics may contribute to subgroups that are less likely to be screened. We conducted this study to help fill our knowledge gap about subpopulations of Latinas, those born in and outside the United States, by examining the relationship between rates of cancer screening utilization and health insurance coverage among foreign- and US-born Latinas compared with non-Latina whites using a statewide population-based California database.

METHODS

RESULTS

DISCUSSION

Closing the gap in ethnic disparities for access and health outcomes is a top priority for this nation. This study found significant disparities in unadjusted rates of breast and cervical cancer screening across ethnicity and nativity. Foreign-born Latinas had the highest rates of never being screened with mammography, clinical breast examinations, and Pap smears when compared with US-born Latinas and non-Latina whites. Additionally, foreign-born Latinas had the lowest rates of recent breast cancer screening among all 3 groups. This underscores the importance of examining Latino subgroups to better understand the role of ethnicity in preventive health services utilization.²² Furthermore, it shows that foreign-born Latinas are a group that may benefit from public health efforts tailored to improve utilization of cancer screening services.

As expected, our results also showed the vital roles that health insurance and socioeconomic status play in cancer screening for breast and cervical cancer. When stratifying by insurance status, all ethnic and native groups showed an 11% to 48% decrease in the percentage of uninsured women receiving timely screenings. Because a greater proportion of foreign-born Latinas are uninsured compared with the other subgroups, they are at greater risk of lacking timely cancer screening. This study mirrors national surveys suggesting that those who are poor,^7,8 less educated,^8,23 and uninsured^7,24 are at a greater risk for underutilization of services that screen for breast and cervical cancer. Although increased Latina cancer screening rates have been reported in the past decade, ²⁵ this study shows that Latinas still remain at risk of underutilizing preventive screening services, and foreign-born Latinas are at an even greater risk for substandard utilization of breast and cervical cancer screening services. Lack of health insurance remains a serious obstacle that needs to be addressed to improve utilization of cancer screening services for all uninsured women. Given the disproportionate rates of uninsurance, low income, and low educational attainment among foreign-born Latinas, culturally and linguistically appropriate screening interventions for this population may help reduce ethnic health disparities as well.

This study contributes new knowledge on the impact of ethnicity and nativity as a predictor of cancer screening utilization. Among Latinos in Texas and California, higher levels of acculturation were associated with more timely utilization of cervical and breast cancer screening.^16,26,27 Studies that included both socioeconomic factors and ethnicity as explanatory variables reported that socioeconomic factors, such as poverty, educational attainment, and health insurance status, predicted utilization rates to a much greater extent than ethnicity.^9,17,23,26 Nevertheless, in one study foreign-born status was still predictive of underutilization for cancer screening.¹⁹ While our study confirms the association between socioeconomic status and utilization rates, a surprising finding was that foreign-born status was positively associated with screening in the model of Pap smear and mammography utilization after adjusting for confounding variables. The difference in results between our study and previous studies may be attributed to our focus on the Latinas in California, which decreased the heterogeneity and increased the likelihood of finding differences.

The findings in this study are also consistent with literature showing that foreign-born women have better than expected outcomes in a variety of areas when compared with non-Latina whites after adjusting for socioeconomic status. Despite limitations in accessing health care, immigrants to the United States have lower all-cause and cause-specific mortality rates.²⁸ In the year 2000, California foreign-born Latinas had a life expectancy of 84.3 years, whereas US-born Latinas had a life expectancy of 82.6 years, and overall female life expectancy for non-Latina whites was 80.1 years.²⁹ Similarly, Latinas give birth to relatively fewer low–birth-weight babies compared with white non-Latinas despite socioeconomic disadvantages and lower rates of prenatal care.^30–31 It has been suggested that minority women may experience increased access to screening services through programs linked to income and a lack of health insurance coverage.⁷ In a previous study conducted by Pérez-Stable et al, birthplace was not a significant predictor of obtaining cancer screening tests. This finding suggests that being involved in a health care plan may diminish differences in preventive services utilization for foreign-born Latinas.¹⁸ This study is consistent with our findings that show, when adjusted for insurance status and other variables, foreign-born Latinas were actually more likely to report cancer screening utilization. Nevertheless, delays in breast cancer diagnosis among Latinas² and higher rates of cervical cancer⁶ suggest that screening levels remain inadequate. These data provide support for additional research on Latino subpopulations to identify resiliency factors that may benefit other groups, as well as provide support for policy efforts to cover all US residents with health insurance, regardless of legal status.

Although foreign-born Latinas were more likely to receive mammography and Pap smear screenings after adjusting for insurance status and other socioeconomic factors, US-born Latinas were not. Some literature suggests that having strong traditional ethnic belief systems may explain the differences observed between nativity groups. For example, Mexican-American women who held strong traditional Mexican family values were more likely to receive mammograms.²⁷ Foreign-born Latinas may hold stronger beliefs in their susceptibility to and in the seriousness of breast cancer³¹ and thus may be more motivated to receive breast cancer screenings. In contrast, foreign-born women may also have more fatalistic views toward health, which could discourage them from seeking preventive services.^16,32 To prevent misconceptions stemming from identification of Latinos as a homogeneous group regarding preventive health care behavior,³³ more work is needed to investigate the factors motivating foreign-born Latinas to obtain screenings. Diverse public health strategies will likely be needed to improve utilization rates for screening services among Latinas.

This study has several limitations. Telephone surveys exclude households that lack telephone service; therefore, this limitation may have disproportionately affected those foreign-born Latinas, functionally impaired persons, and residents of rural areas who are more likely to lack a telephone.²¹ Telephone surveying may also overrepresent women living in large households. This characteristic may be associated with ethnicity, nativity, and socioeconomic status factors found to be significant in this study. In addition, self-reported answers are subject to recall and social-desirability bias, which may lead to higher estimates of screening; however, overestimates in self-reported screening rates do not appear to differ much by Latino ethnicity.^34,35 Also, the sensitive nature of nativity may exacerbate misclassification bias and reduce completion and response rates. Misclassification of birthplace can bias results to the null, resulting in underestimation of the actual differences found in the study.

The unequal burden of breast and cervical cancer among Latinas is an important dilemma and challenge for our nation. The high uninsurance rates among foreign-born Latinas may explain some of the disparity. The results of this study suggest that if we improve access to care for foreign-born Latinas, they will use cancer screening services appropriately. The outcomes also illustrate the heterogeneity of Latinas and the importance of including nativity when conducting analysis of immigrant groups, because these women have an unequal burden of factors to be addressed before utilization of cancer screening services can improve. Specific programs that may help include culturally and linguistically appropriate delivery of care, as well as public health messages to increase awareness of publicly funded programs to prevent cancer. These findings also provide new insight into the needs of poor, uninsured non-Latina white women. Recent trends in health policy that curtail state and national funding of social services for the medically underserved in an attempt to reduce budget deficits may adversely affect access for all women. It is important to advocate for policies that ensure access to high-quality cancer screening and treatment for all patients.