Characteristics of blacks obtaining papanicolaou smears

CHARACTERISTICS OF BLACKS OBTAINING PAPANICOLAOU SMEARS

RICHARD B. WARNECKE, PHD,* AND SAXON GRAHAM, PHD+

An understanding of the characteristics of women who do not obtain cervickl cytology may shed light on procediues which can be instituted by physicians and public health workers to increase use of screening. Of patticular interest are women at high risk of cervical cancer. We interviewed a random sample of about 700 blacks living in central Buffalo cenaus tracts in regard to their past use of pelvic examinations as well as circumatances surrounding auch use or non-use. We employed only data on screening which was verified ih records. We found that there was decreasing use with increasing age and lack of contact with physicians, clinics, or hospitals. The relationship between increasing use and increasing education was found to be a function of the fact that women with more education are likely to be younger. There was clear evidence that making such examinations part of the contact women have with physicians or hospitals for any purpose, including childbirth, would increase the proportions screened.

Cancer 972015-2025, 1976.

TUDIES OF POPULATIONS AT HIGH RISK FOR S cancer of the cervix have generally con- cluded that if continued over a long period, mass screening may be effective in substantially reducing the incidence of invasive disease. Longitudinal data from these studies have shown a decrease in cases of invasive disease and an increased number of cases diag- nosed as in situ.3~4~17 Recently published statis- tics on morbidity and mortality from cancer of the cervix among various populations have shown trends compatible with what would be expected if cervical cytology and early treatment of positives were expanding among the general population.lJ5 For example, cases of cancer of the cervix reported to the California Tumor Registry between 1942 and 1968

Supported by Research Program in Epidemiology and Prevention of Cancer, State University of New York at Buffalo, under National Cancer Institute Grant CA11535.

+ Associate Professor of Sociology and Associate Di- rector, Survey Research Laboratory, University of Illinois (Chicago Circle). Formerly Research Associate, Program in Social Epidemiology and the Prevention of Cancer, State University of New York a t Buffalo.

t Professor, Departments of Sociology and Social and Preventive Medicine, State University of New York a t Buffalo. Principal Cancer Scientist, Roswell Park Memorial Institute, Buffalo, New York.

Address for reprints: Dr. Saxon Graham, Room 56, 4224 Ridge Lea Road, Amherst. New York 14226.

Received for publication February 6, 1975.

showed a consistent decline in those advanced beyond stage 1, and a concomitant increase in the number of cases found in situ.1 Moke- over, there was reduction in mortality of about 10% per year, which could have been partly related to improvement in the levels of participation in screening programs.

Studies of the epidemiology of cancer of the cervix continue to show high risk of the disease among low socioeconomic groups, non- whites, and older segments of the population.C8,10J3-15 This is lamentable in view of the results of our own research and that of others which suggest that if cervical carcinoma could be found and treated at stage 0, the death rate from this disease could be reduced to almost n0thing.12J482~

Unfortunately, studies also continue to show that those at high risk are least likely to participate in mass screenings or to obtain regular cytological examinations from their physiciahs. Yet a few inquiries have found that, given adequate information and opportunity via programs of mass persuasion, high risk groups can be induced to participate at levels equalling or surpassing those at less

Research is needed to enlarge our understanding of participation and to identify the patterns of organization of medical care facili- ties which would be most likely to increase it.

risk.4,7,8,1823

2015

2016 CANCER April 1976 VOl. 37

TABLE 1. Disposition of Interviews

Disposition Number Percent

Refusals 119 11

Not-at-home 271 25

Terminations 11 1 Completions 696 63

Total households contacted 1097 100

The present study attempts to investigate these questions among a sample of black women living in low socioeconomic districts of Buffalo. New York.

METHODS

Sampling procedures for this study are de- scribed el~ewhere.2~ T h e data were obtained via personal interviews with a random sample of black, female residents in predominantly black, inner-city census tracts, stratified ac- cording to whether the respondents live in a model neighborhood or an adjacent area. Interviews were attempted a t 1097 households. Their disposition is shown in Table 1.

Table 2 shows actual sample size and data weighted to reflect the probabilities of selec- tion within each stratum of the sampling frame, and among households at given ad- dresses. In all remaining tables only weighted data are presented.

Persons were defined as having received regular Pap smears, if there was a record of at least one within the 2 years immediately preceding the verification date, and at least one additional examination within the three years before that. When an individual had a

TABLE 2. Verification and Classification of Pap Smear Experience

Unweighted Weighted Percent

Total sample 696 1144 100

(hysterectomies) 115 177 15 Ineligible

Eligible 58 1 967 85

1. Regular 121 217 22

2. Sporadic 192 327 34

(unverifiable) 268 423 44

Pap smear of eligible respondents:

3 . No record

TOTAL 581 967 100

record of a smear within 5 years but it was impossible to determine the precise number received, or the time period within which they were received, or where the frequency did not meet the criteria established for regularity, the respondent was classified as having received cytology sporadically.

Possible Sources of Unreliability Znteruiewer turnover: Reliability of these

data may be limited due to the large number of interviewers required to complete this study. All interviewers were female and black; they were trained and supervised by the Sur- vey Research Center of the State University of New York at Buffalo. Large turnover was experienced in this staff despite careful re- cruitment and training. The factors respon- sible for this turnover have not been fully identified, but similar problems have been encountered in other studies of such populations.18JlJ5 Despite careful quality control, maintained by telephone reinterviews with 10% of the sample, it is difficult to assess the effects of this high turnover.

Completion rate: A second likely source of unreliability follows from the 63% completion rate on this study. T h e direct refusal rate of 11% was well below that experienced in studies of similar populations.l8*21 There were substantial numbers of respondents reported not at home, including many truly not at home plus an undetermined number of tacit refusals or vacant apartments. Although low completion rates are not uncommon in studies of Model Neighborhood Areas in other parts of the country,18,21j26 the exclu- sions represent a sizeable proportion of the population about whom we have no information.

Interview data: Data reported in interviews relating to preventive behavior, such as obtaining Papanicolaou smears or chest x-rays, have been found of questionable reliability when compared with medical records.1l TO determine the reliability of reports of having obtained cervical smears, interviewers asked each respondent whether she had ever received a pap smear, with what regularity, and where it had been obtained. The listed source, usually a private physician, outpatient clinic, or a planned parenthood clinic, was then contacted and information was requested about the dates on which the cytology had been done, and the precise number of times within the preceding 5-year period.

No. 4 PAP SMEARS Warnecke and Graham 2017

Where we could not verify the reported pattern the individual was classified as having no record of receiving the examination. Ulti- mately 44% of the respondents were so classified (Table 2), roughly one quarter of these because we were unable to secure cooperation necessary to complete the verification, and the remainder because the source, although co- operative, had no record of having seen the respondent. Probably some of those for whom we could not verify cytology were in fact users. As verification proceeded, numerous in-

stances of inaccurate interview information about the source of the Pap smear became apparent. Therefore, we undertook to search records in the three major gynecologic outpatient clinics in the sampling area for names of persons who had designated other or no sources at interview. We were unable to search all possible sources for names of our no record interviewees and thus, others were un- doubtedly misclassified. The various verification measures we applied indicated consider- able discrepancy between interview response and content of records. For example, 11% of the subjects had more cytology in records than they cited in interviews (Table 3). Thus, percentages reported as receiving examinations are at best conservative estimates of the actual behavior of the respondents. Since we had no way of estimating error, we employed conservative criteria for classification.

In spite of these limitations, there are patterns in the data which are of interest to those concerned with increasing the use of cytological screening for detecting cancer of the cervix among high risk groups. Moreover, for many parameters studied here there were con- sistencies with data from earlier inquiries which lend credence to our results.

FINDINGS

Frequency of Obtaining Pap Smears The data presented in Table 2 indicate that

85% of the sample had not had a hysterectomy and could have benefitted from a Papani- colaou smear. Of these, 56% had some record of at least one examination in the 5-year period prior to the survey. Twenty-two percent could be classified as having received regular cytology; among the other 34% some record of a smear was present, but these did not meet our criteria of regularity.

TABLE 3. Accuracy of Self-reported Pap Smear Experience by Number of Children Under 6 Years

in the Household

No. of children under 6 years in the household

Two Verification on a or Total report None One more No. Yo Greater number verified than

Number verified was identical with number reported 37 40 41 364 38

Verification revealed fewer smears than reported 53 53 38 492 51

TOTAL 661 186 111 958 100

reported 10% 770 2170 102 11

Correlates of Obtaining a Pap Smear

Age: Most previous studies have found that increasing age is related to declining use of the Pap smear.*.3.*J7J~ Our data (Table 4) are consistent with these findings. It is note- worthy that the largest proportion of women in high risk age groups had no protection.

Medically related experiences: Recent studies suggest that some, particularly older women with little education, may resist having a Pap smear because of modesty or ignor- ance of its importance.8.16 Nevertheless, it seemed likely that although some may not have actively sought a smear they might have received an examination during treatment for a chronic ailment or during recent hospitalization.

The association between treatment for a chronic condition and having a record of cytology is presented in Table 5. In general, as age increased, the likelihood that the in-

TARLE 4. Frequency of Receiving Pap Smears by Age

Frequency of Pap Smear Total

Age None Sporadic ReKular No. % 0-24 2570 36% 3970 182 100

25-34 28 31 41 196 100

31 20 216 100 3 5 4 4 49 45-54 54 35 1 1 162 100

39 1 109 100 55-64 60 Over 65 61 36 3 89 100

CANCER April 1976 VOl. 97

dividual had been treated for a chronic condition also increased. Among those respondents in the youngest and oldest age categories, there was a positive association between having been treated and receiving at least one cytologic examination. However, older women, regardless of their treatment experience, still had least protection.

New York State Law and local hospital policy require that any woman over 20 years of age who is hospitalized must be offered the opportunity to have a pelvic examination if she has not had a hysterectomy or a recent smear elsewhere. Our interviewers inquired about hospitalization in the year immediately prior to the time of the interview. The data in Table 6 indicate that among those respondents over 44 years of age, recent hospitalization was associated with having received at least one Pap smear. This relationship was not present for the younger age groups. The most consistent pattern apparent in the data presented in Tables 5 and 6 indicates an inverse relationship between age and receiving a Papanicolaou smear. But there was a slight and consistent improvement in experience among older respondents recently treated or hospitalized.

Pregnancy: Regular pre-natal care should include cytology. Therefore, a positive relationship between number of pregnancies and frequency of Pap smears was anticipated. As an index of this, the number of children under 6 years of age present in the household was examined in terms of the regularity of cytology (Table 7).

When the relationship between the presence of children under age 6 and regularity of receiving a Pap smear was examined by age, after age 44 there were too few respondents with children under 6 years of age to permit analysis. However, there is the suggestion in Table 8 of independent relationships with age and pregnancy. The percentages in each age category who received a Pap smear were higher among thsse with children under 6 years. Among those respondents under 35 years of age, the data show that even those without young children were more likely to have had regular cytology than those respondents in the older age categories.

Socioeconomic strata mad education: Studies of the rates at which various segments of the population are likely to obtain cervical cytology have generally shown that those from the lower socioeconomic strata are least likely to

PAP SMEARS * Warnecke and Graham 2019

TABLE 7. Frequency of Pap Smear by Presence of Children Under 6 Years of Age in the Home

Frequency of Pap smear Presence of Spor- TOTAL

Children None adic Regular No. % No children 350/, 36y0 9% 319 100.0 Children 6 years and over 48 31 21 347 100.0 One child under 6 31 36 33 187 100.0 T w o or more children under 6 24 3 1 45 115 100.0

obtain a regular Pap smear without special efforts on the part of public health agen- cies.2,4.15,17.19.22-25 In this study, two often- used indices of socioeconomic status, occupation and source of income, were found to be unrelated to the number and/or recency of Pap smear examinations.

Table 9 elucidates the association with a related variable, education. In previous studies, increased education has been associated with acceptance of new behavior .8~~~ In this case, those with at least a ninth grade education were more likely to have obtained a regular Pap smear than those with less than 9 years of education. Almost two-thirds of those with less than 9 years of education had no record of having received any Pap smear; only 10% had received a regular Pap smear. In contrast, 41% of those with 9-11 years of education and 36y0 of those with 12 years or more of education had no record of having received a Pap smear, and more than one- quarter in each of these categories had a record of receiving regular Pap smears.

Age has often been found in the past to be inversely related to education2 and the relationship was present for the population studied here. Among those under 35 years of age, Sly0 had completed high school in contrast with only ISYO of those over 44 years of age (Table 10). Similarly, virtually all the respondents under 35 had at least completed the ninth grade, but only half of those over 44. Table 10 examines the possibility that the relationship between education and cytoIogy observed in Table 9 was a product of this strong association between age and education: Within each age group, education seems unrelated to frequency of examination.

I t has already been shown that regularly receiving a Pap smear was positively associated

2020 CANCER April 1976 Vol. 37

TABLE 8. Frequency of Receiving Pap Smears by Presence of Children Under 6 Years of Age in the Home by Subject's Age

~~

Age IJnder 35 Age 35-44 Frequency of Pap smear

Presence of - Total - Total children None Sporadic Regular No. % None Sporadic Regular No. % No children 31% 33% 36% 44 100.0 64% 32% 4% 51 100.0

Children 6 and under 34 34 32 87 100.0 47 27 26 126 100.0

One child under 6 27 34 39 143 100.0 30 50 20 32 100.0

2 or more children under 6 20 32 48 105 100.0 * * * 8 100.0

* Cell sizes are too small to compute meaningful percentages.

with number of children under 6 years of age living at home. Thus, the unexpected lack of relationship between education and cytology could be accounted for by the presence of more children in homes of women with less education. T h e marginal percentages in Table 11 indicate that those with less education were indeed more likely to have had more children during the 5-year period preceding the study than were those with more education. Twenty-four percent of those with 12 years or more of education as compared with 36% of those with less education had two or more children under 6 years .of age in the home. However, among women with no, one, and two or more children at home, there appeared no greater use of cytology among the better educated. Thus, although a super- ficial examination shows greater cytology use among the better educated, this would appear to be more likely a product of the fact that young women have more education and more recent pregnancies, during the care for which they receive cytology.

Source of Pap smear: Table 12 indicates that more women who received cytology obtained the examination from clinics than from private physicians. Moreover, clinic patients were more likely to receive them regularly

TABLE 9. Frequency of Receiving a Pap Smear, by Years of Education

~

Frequency of Pap Smear Years of Spor- Total

Education None adic Regular No. % 0-8 61% 29% 10% 234 100.0 9-1 1 41 32 27 338 100.0

12-21 36 39 25 386 100.0

than patients of private physicians. I t is difficult to ascertain the reasons for this dis- parity. A review of the intake and treatment procedures at each of the gynecological clinics mentioned as a source of smears indicated that smears were routinely given to all new patients as part of the admitting procedures, regular patients received them routinely, and all patients attending for prenatal care routinely received cytology. Whether these procedures were also followed by private physi- sians on a routine basis is unclear, although the evidence suggests that they probably were not. It is also possible that the variation in frequency was partly an artifact of our verification procedure and resulted from the possibility that clinics provided more complete information than did private physicians.

The summary at the bottom of Table 12 indicates some variation in the use of private physicians by education. Among those with 9-11 years of education, only a very small percentage reported private physicians as their source of Pap smears. In contrast, among those with 12 or more years of education, 32% reported private physicians as their source of smears, perhaps reflecting greater affluence among the more highly educated. Note that most of the variation in frequency was associated with the source from which the smear was received rather than with number of children. In fact, better educated users of clinics received more frequent examinations whether or not they had children.

DISCUSSION

Cervical cytology in the population under study seems to be more .frequent among younger women, those who have been recently

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No. 4 PAP SMEARS Warneclte and Graham 2023 pregnant, and those experiencing recent treat- TABLE 15. Comparison of Buffalo Pap Smear ment or hospitalization. Variables such as education, occupation, and income were unrelated.

Experience (Reported and Verified) with American Cancer Society

(Reported Only)

Our finding (Table 4) regarding age is consistent with those of other studies. Table 13 compares frequencies of cytology by age in this and four other st~dies.~.8-".*9 Compari- sons of these data should be made cautiously. There are inconsistencies both in the form in which they are presented and in the manner by which they were obtained which make rigorous comparison perilous. T h e age categories are not strictly comparable and the form of the published data made recomputa- tion impossible. In addition, the other studies were completed at least 10 years prior to the time of this present study utilizing different study designs and geographic areas of inquiry. comparability is also limited by the fact that the Dade and Memphis-Shelby County data were obtained as part of mass screening programs where concerted efforts were made to attract participation. In contrast, the data for the Buffalo, Alameda County, and national surveys were collected as part of general health surveys. Despite these inconsistencies, the findings on age for Buffalo are generally reminiscent of the earlier results.

There is evidence that black respondents used cytology somewhat more in Buffalo than in the earlier inquiries. Almost three-quarters of those under 35 in the Buffalo sample reported at least sporadic Pap smears in the 5-year period preceding the study. In contrast, a decade earlier in Dade County, only one-third of the black respondents in this age group reported even sporadic use.

T h e data in Table 13 refer to having had one pelvic examination. They do not describe the more desirable condition of adoption of periodic Pap smear at annual or biannual intervals. Table 14 presents comparisons of

Age 21-34 Age 35-49 Age SO+ No. % No. % No. %

A.C.S.. 19749 402 89 372 85 545 66 Buffalo. 1972

Reported 318 94 298 86 278 59 Verified 318 63 298 51 278 41

life-time cytology among various populations. In Alameda County, 60% of the sample had been screened, most of these only once. Even in the Memphis-Shelby data, where respondents with negative smears were stringly en- couraged to return for a second smear, the percentages were similar. Sixty percent were screened, the majority receiving only one smear. Data for Buffalo were similar; however, 22% had regular cytology.

The most recent national data available on Pap smear experience, obtained for the American Cancer Society, are shown in comparison with the Buffalo findings in Table 15.8 Here agaiin, in this national sample of both races, we see decreased cytology with increasing age. These data are also consistent with our finding that exposure to obstetrical services increases the probability of receiving a Pap smear.

T h e survey indicates that a substantially larger percentage reported having received a Pap smear than we were able to verify among the Buffalo sample. But the data 'base on reports in interviews in the two populations are very similar. It is possible that, had the national study attempted to verify their findings, these results, as well, would 'be similar to ours, in spite of the regional and racial differences in the two groups. These data clearly suggest that more effort needs to be

TABLE 14. 1,ifetime Screening, in Percents

1960 1964 1965 1972 Frequency of smear Memphis-Shelby Alameda Co. Na t io rial Buffalo

Never 40% 50 % 60 % 44% Once 35 31 32 30 More than once 2 5 29 8 4

Regularly not studied not studied nnt stiidied 22

TOTAL 100% 100% 100% 100%

2024 CANCER Apri l 1976 VOl. 37

expended toward verification of preventive health practices, on the one hand, and study of segments of the population, on the other.

We found that contact with medical or- ganizations for therapy is related to examinations among older respondents. This increased participation may 'be a result of the New York State policy offering all new hospital admissions cervical cytology. Tha t policy may also account in part for increased used by younger women (who are more likely to be hospitalized for childbirth).

There is further evidence that making cytology part of the contact patients have with medical organization may be an impor- tant factor in increased acceptance. We found that women obtaining smears were much more likely to have gotten them from clinics than from private physicians. Among those with 12 or more years of education, who received examinations from private physicians, no more than 24% could be verified as having received regular Pap smears: whereas among those who obtained cytology from clinics, 61% had verifiable records of having received regular Pap smears. These data suggest the possibility that private physicians do smears less routinely (or keep poorer records of it) than public clinics.

The implications of declining cytology with increasing age, as shown in Tables 13-15, are serious. However, our data suggest that attempts to increase the percentages of indi- viduals who receive regular Pap smears might profitable focus on the sources of general health care. For example, it would increase the numbers who receive regular Pap smears if general practitioners and others who see female patients could be persuaded to offer pelvic examinations routinely.

Such a program would only reach part of the population. Those least likely to receive even sporadic Pap smears in this inquiry were of middle age, perhaps because they were least likely to have any contact with a medical organization or practitioner. Institution- alization of screening would only be effective if patients were regularly required to see a physician. This is not unlike the situation encountered by Lambert and Freeman. They found that when an institutionalized provi- sion for dental care for low socioeconomic groups was no longer available, those who formerly received regular care did not continue.20 This may have been partly because the attitudes of former users were not positive enough regarding such care to cause them to obtain it when i t was not easily available. I t is clear that institutionalization must be supplemented by intensive educational cam- paigns which could make such screening a habitual routine among women in the high risk groups. Under present circumstances when there is no need for a physician there is little motivation to obtain a Pap smear.

In short, we would urge regular adoption of cervical cytology by physicians, especially general practitioners, clinics, and hospitals. Experiments using other loci of institutionalization, such as industries, churches, settle- ment houses, and community centers, should also be mounted. These should be supplemented by educational programs and by the personal persuasion by change agents, such as health guides,24 among women in high risk categories. Hopefully, such efforts would be assessed by careful research techniques on a more elaborate scale than has been possible here.

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Documents

Characteristics of blacks obtaining papanicolaou smears