Cancer

Cervical Cancer Screening:
Not Screened and Why?

Who

Is

Linda C. Harlarn PhD, Amy B. Bemnstein, ScD, and Larry G. Kessler, ScD

Intodudion
Although cervical cancer is a readily
curable disease if diagnosed and treated
early, survival rates have not continued to
improve over the mid-1970s and early
1980s.I Although these static survival
rates may be related to better survivorsbeing diagnosed in the in situ stage while
women with poorer survival potential are
diagnosed later, improved screening and
early detection could increase survival
rates and lower mortality. In addition,
while overall rates of Pap smear screening
are reasonably high, a significant number
of women are not being screened.
Using the 1973 and 1985 National
Health Interview Survey (NHIS),Makuc,
et al, described changes in use of Pap
smears by United States women.2 They
reported that poor women were less likely
to use preventive services than nonpoor.
They also found that between 1973 and
1985 Black women had substantially increased their use of Pap smears with rates
exceeding those of White women. Older
women also increased their screening
rates, but their rates continued tobe lower
than younger women.
Using data from a telephone survey,
Hayward, et al, found, in a multiple regression analysis, age was inversely related to the use of Pap smears.3 Having
health insurance, a higher level of education, being employed, and Black race
(compared to Whites and Hispanics combined) were positively related to the use of
Pap smears.
In a study conducted by 15 statehealth departments and the District of Columbia, Parker reported that 72 percent of
the female participants had a Pap smear
within the last year.4 Rates decreased with
increasing age, were higher in Blacks than
in non-Hispanic Whites, and rose with in-

creasing income. In this study, only 1 percent of the women had never had a Pap
smear and 0.2 percent had never heard of
the test. Theknowledge and previous
screening rates are much higher than other
published rates.2,3
In a case-control study of cervical
cancer patients, Celentano found that
cases were significantly less likely than
controls to have ever had a Pap smear or
to have had regular Pap smears.5 Cases
were also older at the first Pap smear and
more frequently reported not being informed that they should have routinePap
smears.
In England, a general medical practice studied women overdue for Pap
smears.6 Of the 118 women personally
contacted, 47 percent said they had no
major objection to the test, but it was of
low priority. Another 24 percent gave reasons for not having the procedure which
were based on incorrect information and
29 percent had strong objections to the test
and would probably neverconsent to having a Pap smear.
Although research suggests Pap
smear screening is relatively common,
there are subgroups which remain resistant to screening efforts. The literature
does not detail the underlying reasons for
this failure. The 1987 National Health Interview Survey (NHIS) data offers an opportunity to explore these reasons. This
paper will identify subgroups failing to utilizeappropriate screening, as well as their
underlying rationale.
From the National Cancer Institute. Address
reprint requests to Linda C. Harlan, PhD, National Cancer Institute, Executive Plaza North,
Room 313, 9000 Rockville Pike, Bethesda, MD
20892. This paper, submitted to the Journal
May 31, 1990, was revised and accepted for
publication January 8, 1991.

American Journal of Public Health885

Harlan et al.

ommended as the appropriate interval,
was chosen for the purpose of these analyses.7
Reasons for non-compliance were
categorized into seven groups: 1) put off
(the woman thought the Pap smear was
unnecessary; she was simply putting it off
or she had no problems and therefore did
not have the test); 2) hysterectomy (the
woman states she had a hysterectomy and...