Objective
To determine whether the level of cultural adaptation (acculturation) of Hispanic women is associated with increased sexual risk behaviors and cervical cytological abnormalities.
Study Design
Hispanic women 18-55 years of age (mean, 30.5 ± 8.32 years) underwent routine Papanicoulaou testing and completed a comprehensive survey (n = 3149). Acculturation (cultural adaptation) was measured using the Short Acculturation Scale for Hispanics. Structural equation modeling was used to test a mediation model.
Results
Highly acculturated women engaged in a greater number of sexual risk behaviors and were more likely to have an abnormal Papanicoulaou test when compared to less acculturated Hispanic women ( P < .001).
Conclusion
Acculturation is related to sexual risk taking and abnormal cervical cytology. Determination of acculturation level as part of culturally competent health care will aid in tailoring patient communication and counseling on the prevention of cervical cancer among Hispanic women.
Hispanic women have one of the highest incidences of cervical cancer in the United States. The age-adjusted incidence of cervical cancer for Hispanic women is 12.7 per 100,000, which is approximately 1.5 times the overall cervical cancer incidence for all U.S. women (8.2 per 100,000). As cervical cancer can be prevented by early detection and treatment, this is an alarming and unacceptable rate.
Paradoxically, although Hispanic women have a higher incidence of cervical cancer, they engage in fewer of the sexual risk behaviors that predict cervical cancer. For example, a study comparing sexual behaviors in Hispanics and non-Hispanic whites found that Hispanic women had fewer lifetime sexual partners and a lower rate of sexually transmitted infections (STI). Another study of women in New Mexico found that the incidence of human papillomavirus (HPV) infection, the causative agent of cervical cancer, was 9.7% in Hispanic women compared with 13.7% in white women. To attempt to understand this paradox, we need to understand the differences within the Hispanic population.
Cultural adaptation, or acculturation, describes the extent to which an individual from a nondominant ethnic group, namely, Hispanic, adopts aspects of the culture of the dominant ethnic group, namely, white. A highly acculturated individual is someone who has adopted many of the values, beliefs, and traditions—including language—of the dominant culture, whereas an individual with a low level of acculturation has not, or has done so to a lesser degree. Whether high acculturation is positive or negative depends on the behavior in question. Research has shown that Hispanic women who are more highly acculturated are more likely to engage in risky sexual behaviors. Kasirye et al found that moderately and highly acculturated Hispanic women were more likely to have multiple sexual partners than those who were less acculturated. Other studies looking at human immunodeficiency virus (HIV) risk and acculturation have found that higher acculturation predicts increased sexual risk taking behavior.
In the current study, we examine the relationship between sexual risk behaviors and acculturation as related to cervical cytology. We predict that acculturation mediates the relationship between sexual risk behaviors and having an abnormal Papanicoulaou (Pap) test result. Specifically, highly acculturated Hispanic women are more likely to have an abnormal Pap test result because they engage in more risky sexual behavior than less acculturated Hispanic women.
Materials and Methods
Data for the current study were collected between June 1, 2006, and May 29, 2009, as part of an ongoing randomized clinical trial addressing cancer prevention. Women between 18 and 55 years who were patients in 1 of 5 University of Texas Medical Branch (UTMB) regional clinics in southeast Texas were screened for eligibility for the main study. Pregnant women, those currently undergoing treatment for cervical cancer, women who were under the age of 18 years or over the age of 55 years, or women unable to understand English or Spanish were excluded from participation. During the recruitment period captured in the current study, approximately 80% of those meeting eligibility criteria agreed to participate and provided written informed consent for the study. From available refusal data, women who refused to participate did not differ by age or ethnicity ( P = .35 and .82, respectively) from participants. Women were reimbursed $5 for their time. All procedures and measures were approved by the UTMB Institutional Review Board.
Women who presented to 1 of the clinics for a routine visit in which it was anticipated that a Pap test would be performed were asked to complete a comprehensive survey. A total of 4582 women completed the comprehensive survey; of those, 4500 (98%) underwent Pap screening. The most common reasons for not receiving a Pap test were proximity of the visit to the previous Pap test and current heavy vaginal bleeding. In this investigation, 7 women were excluded from analysis secondary to a history of HIV infection and 89 were excluded secondary to a personal history of cervical cancer. One additional subject was excluded because of inconsistencies within her survey answers. Because this paper focused on Hispanic women, we excluded 1254 women who did not self-identify as Hispanic or indicated their country of birth as outside the United States, Mexico, or another Central American country. The final sample included 3149 women.
Each subject was asked demographic questions, including age, ethnicity, birth country, marital status, education level, number of pregnancies, and number of children. Sexual history information was obtained including age at first sexual intercourse, number of sexual partners in the past year and in her lifetime, history of an abnormal Pap test, and history of sexually transmitted infections, specifically genital warts, gonorrhea, Trichomonas , Chlamydia , syphilis, and herpes.
Four items from the language portion of the widely used Short Acculturation Scale for Hispanics measured acculturation. The items assessed were language spoken as a child, language spoken at home, language thought in, and language spoken with friends. The reliability of the scale for our sample was α = .96. The response metric ranged from Only Spanish (1) to Only English (5). These items were summed to create an acculturation score with a possible range of 4 to 20. Higher scores indicated higher levels of acculturation.
All participants underwent liquid-based Pap screening (SurePath; BD, Franklin Lakes, NJ) and pelvic examination by a practitioner at 1 of the UTMB clinics. Cytology was reviewed per routine by the UTMB pathology department, with the exception of 1 clinic, which used LabCorp (San Antonio, TX). All results were read as satisfactory; any result not indicating “negative for intraepithelial lesion or malignancy” was classified as abnormal. In this sample, abnormal results encompassed the following cytologic classifications: abnormal squamous cells of undetermined significance, abnormal glandular cells of undetermined significance, low-grade intraepithelial lesion, and high-grade intraepithelial lesion. Patients were clinically managed as per UTMB guidelines.
Statistical analysis
All preliminary data analyses were conducted using SPSS version 15.0 (SPSS, Inc, Chicago, IL). In general, missing data were between 1-5% with the exception of household income, where 15% of the data were missing. Means, standard deviations, skewness, and kurtosis indices were examined for each variable. In addition, correlation coefficients and indices of reliability were computed. All subsequent analyses were conducted using structural equation modeling (SEM) and the software program Mplus version 5.1 (Muthén & Muthén; Los Angeles, CA). To better simulate the interaction of risk factors and psychosocial concepts, mediation modeling was used to examine the indirect effects of sexual risk behaviors (through acculturation) on cervical cytologic results.
Bootstrap estimation analysis with the variance-adjusted least squares estimator (WLSM) was used to test the mediation model. The model fit indices and Sobel tests results were examined to determine the statistical significance of the mediation paths. The fit of the model was evaluated through the examination of several fit indices: (1) χ 2 (low value and nonsignificant P value is desired), (2) the comparative fit index (CFI; values >0.90 indicate good fit), (3) the weighted root mean square residual (WRMR; values <0.90 indicate good fit), and (4) the root-mean-square residual (RMSEA; values ≤0.05 indicate good fit).
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