Older Hispanic Women,Health Literacy,and Cervical Cancer Screening

Abstract

Approximately 90 million people in the United States lack basic literacy skills, which affect health behaviors. Cervical cancer is preventable and treatable, yet few older Hispanic women seek screening and continue to be a high-risk group for cervical cancer. A literature review was conducted to address the relationship between cervical cancer screening, health literacy, and older Hispanic women. Eighty studies were reviewed, and nine addressed health literacy and Hispanic women. One study addressed the association between functional health literacy and Pap smear screening among older Hispanic women. Few studies have explored the association between preventive cervical cancer screening and health literacy among older Hispanic women. Nurses must assess health literacy and be prepared to provide care, which is culturally, and linguistically appropriate to improve health outcomes. Further research is needed to be inclusive of all populations including older Hispanic women.

Keywords

Hispanic women health literacy cervical cancer screening

Background and Significance

Cancer is now the leading cause of death among Hispanics (American Cancer Society [ACS], 2012, p. 2). Screening and vaccination prevent cervical cancer (ACS, 2012). However, many new cases (11,000) are expected each year in the United States (Jemal et al., 2008). Cervical cancer is a leading cause of cancer among women (Kamangar, Dores, & Anderson, 2006) and Hispanic women have a higher prevalence (ACS, 2012). In addition, cervical cancer screening among older Hispanic women is seldom obtained (Ramirez, Suarez, Laufman, Barroso, & Chalela, 2000).

Cervical Cancer Screening

In the United States, yearly Pap smear screening recommendations were based on routine practice; it is now evident that certain high-grade types of human papilloma virus (HPV) cause most cervical cancers (O’Connor, 2007; Waxman, 2005). The Pap test is an effective and a low-cost tool in prevention of cervical cancer if repeated over time (Waxman, 2005),yet not for underserved women in the United States (Scarinci et al., 2010). Low rates of screening have been found among low-income women, low education, those older than 44, and born outside of the United States (Hewitt, Devesa, & Breen, 2004). A woman’s risk factors, in conjunction with correctly interpreting Pap test results, are crucial components of screening (Warren, Gullett, & King, 2009). Increased risk factors for cervical cancer include inadequate screening, early age at first intercourse, multiple partners, tobacco use, and infection with HPV (Reynolds, 2004). At highest risk for cervical cancer (1 in 359) are older women ages 40 to 59 (Jemal et al., 2008), and those not previously screened (Bernstein, DeJoseph, & Buchanan, 2010). Hispanic women are diagnosed with invasive cervical cancer (ICC) at an age of 65 to 74, have a higher incidence of ICC compared to non-Hispanic/Whites and are least screened (Barnholtz-Sloan et al., 2009). For these reasons, it is recommended that minority women continue to be screened beyond the current recommendations (Barnholtz-Sloan et al., 2009). Low health literacy may be a contributing factor to inadequate screening rates (Lindau et al., 2002). The purpose of this literature review was to address the relationship between cervical cancer screening, health literacy, and older Hispanic women.

Literacy and Health Literacy

In the United States, close to 90 million people lack basic literacy skills (Nielsen-Bohlman, Panzer, & Kindig, 2004). Literacy is described as “an individual’s ability to read, write, and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential” (National Literacy Act, 1991, Sec 3). People older than 65 years of age had the lowest literacy score, Below Basic, in the 2003 National Assessment of Adult Literacy (NAAL). Hispanics surveyed had low literacy scores; 44% scored Below Basic as compared to 7% of Whites. Most Hispanics were of Mexican origin, and, of those surveyed, 3% were nonliterate in English (Kutner et al., 2007).

Literacy is the building block to health literacy which is most often defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate heath decisions” (Ratzan & Parker, 2000, p. v). Health literacy skills are needed to make informed health decisions, maintain health, and improve overall “quality of life” (Zarcadoolas, Pleasant, & Greer, 2005, p. 196; Ratzan & Parker, 2000). Low literacy skills have been associated with poor health (Berkman et al., 2004) and poor health outcomes (DeWalt, Berkman, Sheridan, Lohr, & Pignone, 2004). Similarly, low health literacy has been associated with worse physical and mental health (Wolf, Gazmararian, & Baker, 2005) and higher mortality rates (Baker et al., 2007; Sudore et al., 2006). Therefore, it is possible that people with low literacy also have low health literacy skills (Nielsen-Bohlman et al., 2004).

Race and Ethnicity

Hispanic, Latino, or Spanish may be of any race; ethnicity is based on social group characteristics (Bulatao & Anderson, 2004). People whose ancestry or origins are from a Spanish-speaking country are designated with the term Hispanic. Their origin can be traced to Mexico, Puerto Rico, Cuba, and Spanish-speaking countries, and the designation originates from the use of a language (Cafferty & Engstrom, 2006). In 2010, there were 50.5 million Hispanics in the United States, or 13% of the total population, (U.S. Census Bureau, 2010). In the United States, Hispanics come from three major groups: Mexican (64%), Puerto Rican (9%), and Cuban (3.4%), (U.S. Census Bureau, 2006).

Cervical Cancer Screening and Hispanic Women

The literature review related to cervical cancer screening and Hispanic women (Flores, 2009) revealed areas, which negatively impact Hispanic women’s screening practices. These areas of negative impact included cultural beliefs, limited knowledge, and age.

Cultural Beliefs

Cultural beliefs of some Hispanic women include the belief that cervical cancer is related to immoral or promiscuous sexual behavior (Chavez, McMullin, Mishra, & Hubbell, 2001; Guilfoyle, Franco, & Gorin, 2007). Immigrant Hispanic women believe that cervical cancer is caused by physical trauma, rough sex, stress, or birth control (Chavez et al., 2001). Many Hispanic women believe that sexuality is a private concern (Hubbell, Chavez, Shiraz, & Valdez, 1996), and do not talk about it. These beliefs make it difficult for Hispanic women to discuss their concerns with a health care provider (Guilfoyle et al., 2007). In addition, fatalism (fear of cancer) was a Hispanic cultural belief noted in several articles (Arredondo, Pollak, & Costanzo, 2008; Guilfoyle et al., 2007). Latinas were less likely to have had a Pap smear within the last 3 years as compared to non-Hispanic White women and expressed more fatalistic ideas in regard to cervical cancer (Chavez, Hubbell, Mishra, & Valdez, 1997). In addition, to health beliefs, preferred language spoken (English vs. Spanish) has been reported in the literature as an indicator of cervical cancer screening practices among Hispanic women. Speaking Spanish, a predominant cultural aspect of Hispanics living in the United States (Cafferty & Engstrom, 2006) may be negatively related to Pap smear screening, although mix findings have been reported. One study reported that Hispanic women competent in English language have higher rates of cervical cancer screening as compared to those with low English competency (Arredondo et al., 2008; Jacobs, Karavalos, Rathouz, Ferris, & Powell, 2005). Research investigating acculturation, measured by language spoken at home, have shown that less acculturated Hispanic women were found to have less Pap smear screening (Shah, Zhu, Wu, & Potter, 2005), while other researchers have found that acculturation did not show a statistically significant difference between those who spoke Spanish and those who spoke English on recent Pap smear screening (Abraido-Lanza, Chao, & Gates, 2005).

Limited Knowledge

Limited knowledge of cervical cancer and prevention among Hispanic women were negatively correlated with Pap smear use (Arredondo et al., 2008; Scarinci, Beech, Kovach, & Bailey, 2003). Knowledge of cervical cancer screening and screening compliance was found lowest among older Hispanic women (Coughlin, Uhler, Richards, & Wilson, 2003). Scarinci et al. (2003) reported decreased use of cervical cancer screening among less educated Hispanic women. Furthermore, Hispanic women believe that a Pap smear is an all-encompassing exam, which can detect other gynecological problems (Cooper, Polonec, & Gelb, 2011; Flores & Volker, 2011).

Age

Few studies have addressed cervical cancer screening and older Hispanic women. Reports have shown that older Hispanic women are the least likely to be screened and have less knowledge of cervical cancer than younger women (Coughlin et al., 2003; Ramirez et al., 2000). In addition, older age and Mexican ethnicity were related to lower rates of Pap smear screening (Fernández-Esquer, Espinoza, Ramirez, & McAlister, 2003). Many factors contribute to decreased use of cervical cancer screening among Hispanic women, but few studies have addressed health literacy among older Hispanic women. Therefore, this literature review examined the relationship between cervical cancer screening, health literacy, and older Hispanic women.

Method

A computerized database search used the Cumulative Index of Nursing and Allied Health (CINAHL plus), Ovid Medline, Pub Med, and Education Resources Information Center (ERIC). An initial systematic review of both quantitative and qualitative research was conducted using the following search terms: cervical smear+, Hispanic+, health literacy, and literacy, delimited to 1990 to 2010. Multiple combinations of these terms were used to find articles for the review. The search strategy was later updated in 2011.

For inclusion in this integrated review, research articles met the following inclusion criteria: quantitative and qualitative research design study, research conducted in the United States and written in English, participants aged 18 and older, cervical cancer screening without a hysterectomy that included health literacy, and publication of the study between 1990 and 2010, later updated to 2011.

Exclusion criteria for this review were research reports related to pregnancy, adolescents, self-collection and HPV vaccine reports addressing follow-up care after abnormal results or invasive carcinoma; those not published; and those conducted outside of the United States. Eighty articles were reviewed by title to determine inclusion criteria; if needed, the abstract was reviewed. Thirty research articles addressed health literacy, 19-addressed health literacy and Hispanics; of those, nine articles addressed health literacy, and Hispanic women. One article addressed health literacy and cervical cancer screening among older (> 40) Hispanic women.

Findings

Health Literacy

Low health literacy is associated with older age, ethnicity (non-White), and level of education (Baker et al., 2004; Gazmararian et al., 1999; Paasche-Orlow, Parker, Gazmararian, Nielsen-Bohlman, & Rudd, 2005). Poor health outcomes, higher mortality rates (DeWalt et al., 2004) and worse mental, and physical function (Wolf, Gazmararian, & Baker, 2005) have been associated with low health literacy. Furthermore, those with low health literacy are more likely to have a hospital admission (Baker et al., 2002) and higher hospital costs (Howard, Gazmararian, & Parker, 2005). Mortality and cause-specific mortality such as cancer was associated with inadequate health literacy (Baker et al., 2007). Furthermore, a two-fold increase in mortality was associated with limited heath literacy (Sudore et al., 2006). Poor health outcomes and higher mortality rates could be related to less knowledge and use of preventive care.

Preventive Care and Health Literacy

Underutilization of preventive care services such as cancer screenings, including Papanicolaou smear, has been associated with low health literacy (Bennett, Chen, Soroui, & White, 2009; Guerra, Krumholz, & Shea, 2005; Scott, Gazmararian, Williams, & Baker, 2002; White, Chen, & Atchison, 2008). Authors reported in a cross-sectional study that decreased use of preventive health services, including mammograms, was associated with low health literacy and older age (White et al., 2008). Having a Pap smear was related to higher heath literacy (White et al., 2008). Women with inadequate health literacy were more likely never to have had a Papanicolaou smear (10% vs. 5%) or a mammogram (24% vs. 17%; Scott et al., 2002), and were found to hold more negative feelings about mammography, such as embarrassment (Davis et al., 1996).

In a study to explore Latinas’ functional health literacy and mammography, Guerra et al. (2005) reported that functional health literacy was associated with greater odds of having a mammogram. Authors concluded that 70% of Latinas surveyed (N = 97) scored inadequate or marginal health literacy test, which continues to be a problem for the Latina community (Guerra et al., 2005). Similar to other reported findings, the authors recommended continued research efforts to increase the rates of screening for low health-literate populations. Bennett et al. (2009) reported an association between increased health literacy and use of preventive health services including mammography, and dental care. Few studies have explored the association between health literacy and preventive health among Hispanics.

Health Literacy and Hispanics

Researchers noted the association between education levels and health literacy. Sarfaty, Turner, and Damotta (2005) found educational levels of Hispanics to be low: less than a fourth grade education (60%), fifth to eight grade (19%), and less than an eighth grade education (79%). Many researchers reported that non-Hispanic Whites consistently score significantly higher than Spanish-speaking Hispanics on health literacy tests (Brice et al., 2008; Britigan, Muran, & Rojsa-Guyler, 2009; Sarkar et al., 2010). The literature shows a gap in that strategies are needed to improve health-literacy scores of Hispanic patients; however, only a few intervention studies have been conducted with Hispanic subjects. Van Servellen et al. (2005) conducted a pilot study aimed at improving health literacy regarding HIV among Spanish-speaking Latinos. Participants were assigned to two groups, intervention (n = 43) and control (n = 42). The authors reported no statistically significant differences were noted between the groups. However, they did report improved provider communication for the intervention group at 6 weeks (t = − 2.06, p = .04) and 6 months (t = − 4.54, p < .0001) and improved underrating of HIV terms at 6 weeks (t = −2.97, p < .0001) and 6 months (t = −3.16, p < .0001). Health literacy was assessed with a modified Rapid Estimate of Adult Literacy in Medicine (REALM). Olney, Warner, Reyna, Wood, and Siegel (2007) studied the use of MedlinePlus training by promotoras, and the researchers identified, analyzed, and coded 157 promotora stories, concluding that promotoras helped residents find health information and decreased anxiety.

Health Literacy and Hispanic Women

Gender and health-literacy findings have been mixed. Aguirre, Ebrahim, and Shea (2005) evaluated the Test of Functional Heath Literacy (S-TOFHLA) in English and Spanish-speaking participants. Findings showed that women scored better than men. Gazmararian et al. (1999) found no significant differences in health literacy scores of men and women.

Mexican ethnicity, educational attainment less than high school, and being older have been associated with lower scores of health literacy in Hispanic women (Bennett, Culhane, & Elo, 2007; Guerra et al., 2005). In addition, Bennett et al. (2007) found higher depression scores in pregnant Latina women with limited English proficiency. Similarly, those participants with lower scores on health literacy were also more likely to experience depressive symptoms as compared to women with adequate health literacy. Guerra et al. (2005) found that inadequate knowledge of mammography screening was associated with lower health literacy among Hispanic women. Hawley et al. (2008) in a multiethnic sample (N = 1,224) found that Spanish-speaking Latinas (n = 196) reported 8.7 times greater dissatisfaction and 9.4 times greater regret (p < .01) related to breast cancer treatments and decision making (p. 368) in comparison to Caucasian women. Furthermore, the authors reported that women with low health literary were more likely to report dissatisfaction (OR: 5.6; 95% CI 2.9-11.1) and regret (OR: 3.5; 95% CI 1.8-7.1) compared to those with high literacy. In a study to examine the effects of health literacy and physician communication (N = 771), Sudore et al. (2009) found that Spanish-speaking and low health literacy participants had the lowest rated or poor patient–physician communication compared to English-speaking adequate health literacy participants (p < .001). Although authors Hawley et al. (2008) and Sudore et al. (2009) concluded that health literacy, ethnicity, language, and communication style is very important, few studies were found to address health literacy and cervical cancer screening in Hispanic women.

Health Literacy, Cervical Cancer Screening, and Hispanic Women

Research on health literacy and cervical cancer screening among Hispanic women is extremely limited. Functional health literacy, Pap smear screening, and Hispanic women older than 40 years were studied by Garbers and Chiasson (2004). The researchers found that participants with low health literacy scores were less likely to have ever had a Pap smear (OR, 0.12; 95% [CI], 0.04-0.37), and were 16.7 times less likely to have had a Pap test than those participants with adequate or marginal health literacy. After controlling for the variables age, insurance, education, and ethnicity, those participants scoring higher on health literacy were much more likely to obtain a Pap test (Garbers & Chiasson, 2004).

Lindau et al. (2002) studied English-speaking women older than 18 years of age (N = 529), including African American (58%), Hispanic (18%), non-Hispanic White (15%), and other (10%). Authors reported that 39% of participants scored below adequate literacy on the REALM, a health literacy tool. The study also showed that only five women had obtained a Pap smear test and only 13% could articulate the purpose of the Pap smear. Additional findings showed that health literacy was a predictor for cervical cancer screening; however, ethnicity did not predict cervical cancer screening.

It is important to note that the instruments used to measure health literacy are often diverse, making comparisons more difficult. Garbers and Chiasson (2004) used the Spanish version of the Test of Functional Literacy for Adults (TOFHLA), while Lindau et al. (2002) used the REALM.

Summary

Years of empirical research show that proper screening through Pap smear testing can prevent death from cervical cancer. Unfortunately, this literature review shows that lack of knowledge; cultural beliefs, language and low health literacy are deterrents to proper cervical cancer screening behavior. The review showed that (4/9, 45%) of studies related to health literacy and Hispanic women were conducted in both English and Spanish, (4/9, 45%) were conducted in Spanish only and (1/9, 10%) were conducted in English only. A number of variables including language of interview and health literacy instrument used make contrast and comparisons among studies difficult. Similarly, a literature review examining health literacy among U.S. Hispanics found that of 27 studies, only 10 focused on Hispanics and three on female subjects (Koskan, Friedman, & Messias, 2010).

It is important to conduct studies exclusive to Hispanic women, given the expected Hispanic population growth, to assess how all the above variables influence cervical cancer screening behavior. In addition, health literacy needs to be evaluated using valid, reliable, culturally and linguistically appropriate measures so that results can be compared to non-Hispanic samples. Lastly, few studies specifically addressed women older than 40; thus additional studies aimed at older Hispanic women are needed in order to fully address health literacy needs of this population.

Limitations

Limitations of the study include a limited database, search terms and publication time frame. Articles written in Spanish and those conducted outside of the United States were excluded from this review. Additional research is needed to include articles written in Spanish and conducted outside of the United States.

Implications for Practice

It is very important for nurses to be aware of the health literacy needs of older Hispanic women because nurses often spend more one-on-one time with patients. In addition, nurses have unique opportunities to make health literacy assessments and to convey important health-related information. Health screening practices, particularly cervical cancer screening, cannot be improved without utilizing evidence to support culturally appropriate strategies aimed at improving health literacy and health behavior. An example of this is through the National Standards for Culturally and Linguistically Appropriate Services (CLAS) that stresses patients must receive respectful care congruent with their culture and preferred language (U.S. Department of Health and Human Services, 2001). Nurses must continue to provide holistic care, which recognizes an individual’s age, culture, beliefs, and health literacy. Additional research is necessary to address, older women, health disparities and be inclusive of all populations

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Bertha E. Flores received support in part from the John A. Hartford Foundation.

Author Biographies

Bertha E. Flores is a clinical assistant professor at the University of Texas Health Science Center at San Antonio, PhD in nursing from The University of Texas at Austin School of Nursing, Austin, Texas. Her research focus is on older adults, health literacy, culture and language. 2009-2011 John A. Harford Foundation Building Academic Geriatric Nursing Capacity Scholar.

Gayle J. Acton is an associate professor of adult health nursing at the University of Texas at Austin School of Nursing, Austin, Texas. Her research focus is on older adults, caregivers and health promotion.

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