Papanicolaou ( Pap) Screening among Hispanic Mothers: Influence of Years Living in the United States, Language and Depre

1. Papanicolaou ( Pap) Screening among Hispanic Mothers:Influence of Years Living in the United States, Language and Depressive Symptoms Lisa R. Fortuna, MD, MPH Whitney P. Witt, PhD, MPH Ninth Annual Maternal and Child Health Epidemiology Conference December 11, 2003

2. Structure of Talk • Background • Methods • Results • Summary conclusions • Strengths and limitations • Policy implications

3. Background (1) • Disproportionate percentage of Hispanic women are at risk of being unscreened for cervical cancer. • Both cultural (e.g. language, acculturation) and socioeconomic barriers ( e.g. insurance status) have been implicated as barriers to preventative care for Hispanic women. • Mental health problems have been associated with poor medical care and follow-up for women.

4. Background (2) • However the use of Pap screening by Hispanic mothers has not been well examined in the context of psychological distress and/or depression. • The impact of acculturation on preventive healthcare practices and service use among Hispanic mothers is not yet well understood.

5. Specific Aims • This study aims to understand the relationship between depressive symptoms, years living in the US, language and use of pap screening among Hispanic mothers.

6. Primary Hypotheses • Less time living in the United States and Spanish language dominance will be associated with never having a pap screen. • Hispanic mothers with depressive symptoms will be more likely to report never having had pap screening.

7. Insurance Status Time in the United States Usual Source of Care Latina Mothers (Ethnicity) Pap smear Language & Cultural Barriers Mental Health Status Conceptual Framework

8. Methods

9. Sample and Data Source • Sample consists of 5,825 mothers between the ages of 18-49 • 1998 National Health Interview Survey (NHIS), Adult Prevention Module

10. Independent Variables (1) Maternal Race /Ethnicity • Hispanic • Black/African American ( Non-Hispanic) • Other ( Non-Hispanic) Reference/Comparison • White non-Hispanic Language • Spanish or English Interview

11. Independent Variables (2) • Maternal psychological distress/ depressive symptoms • Maternal depressive symptoms were measured by a six-item distress battery known to be correlated with DSM-IV defined depression • Mothers with mild-moderate psychological distress were considered to have psychological distress score of 7 out of a possible 24 ( Kessler, 2002)

12. Independent Variables (3) • Years living in the US • Measure of acculturation, and access ( Coughlin, 2003; Austin, 2002) • Divided into: • Born in US • less than 5 years • 5-10 years • greater than 10 years

13. Independent Variables (4) • Health insurance status • Examined whether mothers had any health insurance versus none • Usual source of care • Two level variable • Has usual source of care and gets care from clinic, health center, doctor's office, HMO, hospital outpatient department or some other place • Does not have usual source of care

14. Dependent Variable • Maternal use of Pap screening • Never had a Pap Screen • Delayed Receipt of Pap Screen ( More than 2 years) • Appropriate Use of Pap Screen ( less than 1 year but not more than 2 years)

15. Dependent Variable • Modeled the odds of mothers never having had a pap screen • Against mothers who received a pap screen as recently as a year ago or less, but not more than 2 years and mothers with delayed screening.

16. Control Variables • Maternal age • Education • Live birth within past 5 years • Single parent status • Poverty threshold level • Region of family residence

17. Results

18. Sample Characteristics • 5,825 mothers between the ages of 18-49 • Sample consisted of • 70% White-non-Hispanics • 14% Black-non-Hispanic • 12% Hispanics • 4% Other-non-Hispanics • Hispanic sub sample consisted of Mexican-Americans, Mexican-origin, Puerto Rican, Cuban and other Latinos.

19. Sample Ethnicity Characteristics% by Pap Screen status

20. Hispanic Mothers Not Receiving Pap by Depression/Distress Status Hisp % Not Receiving Pap Screening Other *p-value <0.05

21. Odds* of Never Having Pap Screen by Time Living in US *Controlling for maternal age, language, education, live births, single parent status, poverty threshold level, and region of family residence

22. Odds of Not Having a Pap Screen: Staged Model p-value <0.05

23. Odds of Never Having a Pap Screen: Full Model *White, Non-Hispanic as comparison and controlling for maternal age, education, live births, single parent status, poverty threshold level, and region of family residence

24. Summary Conclusions (1) • After controlling for potential confounders, less time living in the United States was highly associated with never having Pap screening among mothers. • Mothers living in the U.S less than 5 years are 15 times more likely to never have had a pap screen than those born in the U.S. • Psychological distress was associated with not ever having Pap screening among Hispanic mothers.

25. Summary Conclusions (2) • Women who were interviewed in Spanish were less likely to report that they have never had a Pap screen. • Language has been implicated as a barrier to preventative care for Hispanic women. • May have a differential impact for different groups. • Variations in health care/help seeking, health care resources, social networks, and complex cultural factors may contribute to this variation.

26. Limitations & Strengths Limitations • Cross-sectional data/ only correlations examined • Imprecise measure of English language proficiency and sociocultural factors Strengths • Nationally representative data of mothers and Hispanic mothers. • Validated measure of psychological distress in this representative sample.

27. Policy Implications • Promote and ensure access to a usual source of care and health care coverage soon after immigration to the US. • Provide culturally appropriate education/outreach, especially among recent immigrant mothers. • Address mental health as a correlate of non-use of Pap screening among mothers.

28. Policy Implications • There is a need for nationally representative-ethnic specific research, and advancement of measures and data collection for this purpose.