Sociodemographic and Health Care System Factors Influencing Cervical Cancer Screening among Young American Indian Women

Age-adjusted cervical cancer mortality rates (Indian Health Service 1997) are higher for women in the Oklahoma Indian Health Service (IHS) area (3.3 per 100,000) than for the general U.S. female population (2.5 per 100,000). But reported rates may not provide a complete picture of the problem due to underreporting of Indian race on death certificates (ibid.). With an adjustment for misclassification, the rate increases to 4.9 per 100,000, almost twice that of the general U.S. female population.

Through Papanicolaou (Pap) test screening and appropriate treatment, virtually 100% of those deaths could be prevented. Women in the United States least likely to receive screenings are generally poor, elderly, and/or of ethnic minorities. They are generally over the age of 50 and no longer seeking gynecological care. However, data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program indicate that the incidence of invasive cervical cancer in white women under age 50, reversing its previous downward trend, has been increasing about 3% a year since 1986 (Larsen 1994). The cervical cancer incidence rate for white women under 50 was 5.9 per 100,000 in 1990 compared to 5.4 per 100,000 in 1986. Some believe the increase is due to an increase in Human Papilloma Virus (HPV) infection among young women, particularly sexually active college-age women. HPV is transmitted through sexual intercourse, with a peak prevalence of infection in women in the 22 to 25 age group (NIH 1996). The increasing incidence of cervical dysplasia in young women, the link between HPV and cervical cancer, and the establishment of sexual activity in late adolescent and early adult years strongly suggest that, to help prevent disease, health educators need to learn about the behavior of young women and their attitudes toward obtaining regular Pap tests.

Older, nonwhite, unmarried, low-income, and less-educated women are less likely to receive Pap tests regularly (Hayward et al. 1988). Having a regular primary caregiver (Dietrich et al. 1989), getting an annual checkup (Wilcox and Mosher 1993), using medical and preventive care services (Franks and Clancy 1993), using an obstetrician-gynecologist (CDC 1993), and having a female provider (Nielsen 1990) have been found to be significant predictors of cervical cancer screening. Having a gynecologist as the primary care physician is linked with a greater chance of receiving regular pelvic examinations and Pap tests (ibid.); a physician's advice to get a Pap test (Peters, Bear, and Thomas 1989) has also been associated with screening behavior. Belief in the benefits of screening (Dignan et al. 1994), perceived susceptibility to cancer (Sharp et al. 1990; Davis et al. 1994), and having a social support network have also been found to facilitate screening (Kang, Bloom, and Romano 1994; Strickland et al. 1996; Gottlieb et al. 1993).

While numerous studies have been conducted on the barriers and facilitators to cervical cancer screening, few are specific to American Indian women (Strickland et al. 1996; Hislop et al. 1996; Minhas 1992; Welty 1994) or to young women (Wilcox and Mosher 1993; Sharp et al. 1990). None are specific to American Indian women in northeast Oklahoma. This region of the state is primarily rural. American Indian women receive health care from tribal clinics operating in their community or from Indian Health Service hospitals in the region. To receive care, women must be enrolled members of a recognized tribe.

The aim of this study was to describe screening practices for cervical cancer among American Indian women age 18 to 40 living in northeast Oklahoma and to examine the association of selected sociodemographic, access, and cognitive variables with screening practices. The sociodemographic variables included age, marital status, number of children...