970496332415J Low Genit Tract DisJ Low Genit Tract DisJournal of lower genital tract disease1089-25911526-097630063576666430210.1097/LGT.0000000000000422HHSPA1043267ArticleCervical Cancer Screening Among Women by Birthplace and Percent of Lifetime Living in the United StatesEndeshawMeheretMPH1ClarkeTainyaPhD, MPH2SenkomagoVirginiaPhD, MPH1SaraiyaMonaMD, MPH1Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA;Division of Health Interview Statistics, Centers for Disease Control and Prevention, National Center for Health Statistics, Atlanta, GACorrespondence to: Mona Saraiya, MD, MPH, Division of Cancer Prevention and Control CDC/NCCDPHP, 4770 Buford Hwy, NE, Mailstop F76, Atlanta, GA 30341. yzs2@cdc.gov257201910201801102019224280287Objective:

The aim of the study was to provide national estimates of Pap test receipt, by birthplace, and percent of lifetime in the United States (US).

Materials and Methods:

Pooled nationally representative data (2005, 2008, 2013, 2015) from the National Health Interview Survey were used to examine differences in Pap test receipt among adult US women by birthplace and percent of lifetime in the US. Descriptive estimates were age-adjusted. Regression models were adjusted for selected sociodemographic and healthcare access and utilization factors and presented as predicted margins.

Results:

Foreign-born women 18 years and older were more than twice as likely to have never received a Pap test compared with US-born women(18.6% vs 6.8%). Regression models showed that foreign-born women from Mexico (9.8%), South America (12.6%), Caribbean (14.6%), Southeast Asia (13.7%), Central Asia (20.4%), South Asia (22.9%), Middle East (25.0%), Africa (27.8%), Europe (16.4%), and Former Soviet Union (28.2%) were more likely to be unscreened compared with US-born women (7.6%). Foreign-born women who spent less than 25% of their life in the US had higher prevalence of never having a Pap test (20%) compared with foreign-born who spent more than 25% of their life in the US (12.7%).

Conclusions:

Using national survey, we found that where a woman is born and the percent of her lifetime spent residing in the US do impact whether she gets screened at least once in her lifetime.

Impact:

These findings may inform cervical cancer screening efforts targeting foreign-born women.

papanicolaucancer screeningforeign bornimmigrantsbirthplace

Globally, cervical cancer is the fourth most common cancer in women and the seventh most common among all cancers overall, with an estimated 528,000 new cases in 2012.1 The Pap smear (Pap test) is a screening method used to detect potentially precancerous and cancerous processes in the cervix (opening of the uterus or womb). Since the introduction and widespread use of the Pap test in the 1950s, cervical cancer incidence and mortality rates in the United States (US) have decreased by more than 70%.2 Still, 11% of US women aged 21 to 65 years have never been screened for cervical cancer.3 From 1995 to 2000, more than half of all new cervical cancer cases occurred among women who were rarely or never screened.4 Cervical cancer incidence rates are higher among foreign-born women living in the US compared with US-born women,5 yet foreign-born women are less likely to receive cervical cancer screening compared with US-born women.6 This disparity is partially attributed to birthplace, race, and social disparities.6–8

Thirteen percent of the US population is foreign-born, and this proportion is expected to grow to 20% in the next 40 years.9,10 With high cervical cancer incidence rates among this subgroup, and foreign-born females constituting 51% of the foreign-born population,9 it is important to understand the cervical cancer screening disparities these women face. This article uses periodic cancer supplements for recent years from the National Health Interview Survey (NHIS) to gain a better understanding of the use of Pap tests for cervical cancer screening in the US. We examine lifetime receipt of a Pap test for all women 18 years and older and adherence to US Preventive Services Task Force (USPSTF) recommendations for cervical cancer screening for women aged 21 to 65 years11 by birthplace and percent of lifetime spent in the US.

MATERIALS AND METHODSData Source

The NHIS is a multipurpose, cross-sectional health survey of the US civilian noninstitutionalized population based on a stratified multistage sampling design of households and group quarters (e.g., college dormitories).12 The NHIS data are publicly available with some exceptions; some demographic characteristics and geographic variables such as country of birth must be accessed through the National Center for Health Statistics (NCHS) Research Data Centers. The NHIS does not collect data on immigration status.

Combined 2005, 2008, 2010, 2013, and 2015 NHIS data were used for this report. We examined lifetime receipt of a Pap test among women aged 18 years and older without a history of hysterectomy (n = 62,333). Worldwide differences in recommended age of first Pap test precluded use of other age ranges. We further examined adherence to the USPSTF recommendations for cervical cancer screening in women aged 21 to 65 years without a history of hysterectomy (n = 49,233). The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology (Pap test) alone in women ages 21 to 29 years and either screening every 3 years with Pap test alone or every 5 years with high-risk human papillomavirus (HPV) testing alone in women ages 30 to 65 years.11 The use of high-risk HPV was not included in analyses because HPV screening data were not available on the NHIS for all years used for this analysis.

Study Variables

Women born in the US, a US territory or born abroad to a US citizen, were categorized as US-born, and all others were considered foreign-born. Among foreign-born women, birthplace was categorized using a modification of NHIS’ geographic region variable. Mexico, Central America, and the Caribbean were separated because of the larger number of immigrants relative to those from the other regions (South America, Southeast Asia, Central Asia, South Asia [Indian Subcontinent], Middle East [Western Asia], Africa, The Former Soviet Union [FSU], and Europe [excludes FSU]) included in the study. Because of small sample sizes and representation in the overall study population (<1% of study population), we assigned foreign-born women from all other regions/countries not listed, to the “Elsewhere” category. However, the diverse sociodemographic, economic, and varied geographies preclude this category from comparison as a uniformed statistical unit for the purposes of this report.

Percent of lifetime living in the US is commonly used as a proxy measure for acculturation. Similar to Tsui et al.,6 we calculated percent of lifetime in the US by dividing the number of years living in the US by age at interview and then dichotomized into less than 25% and 25% or more. Lifetime Pap test receipt was determined by a “yes/no” response to the question “Have you ever had a Pap smear or Pap test?” Women who responded “no” were categorized as never screened. Those who responded “yes” were asked “When did you have your most recent Pap test?” Age at interview and response to time of most recent Pap test were used to calculate the percentage of women who did not meet the USPSTF recommendations for cervical cancer screening with Pap test alone.

Demographic characteristics presented in this report include age, ethnicity, race, highest level of education, poverty status, birthplace, and percent of lifetime in the US. Selected health, healthcare access, and utilization variables include health status, health insurance coverage at the time of interview, usual place of medical care, and number of doctors’ visits in the past 12 months. Using the imputed income files, poverty status was calculated from poverty thresholds predefined by the US Census Bureau using a specific ratio of income as a percentage of the poverty threshold. Health insurance was categorized into 3 mutually exclusive categories; persons with more than 1 type of health insurance were assigned to their primary insurance category in the following hierarchy: private then public. Uninsured included persons who had no coverage as well as those who had only Indian Health Service coverage or had only a private plan that paid for 1 type of service such as accidents or dental care.

Statistical Analyses

Estimates were calculated using the sample adult sampling weights (adjusted for the number of survey years combined in the analysis) and are representative of the civilian, noninstitutionalized population of US women 18 years and older and 21 to 65 years. Unless otherwise indicated, estimates were age-adjusted using the 2000 projected US population.13 Detailed population tables are available from the US Census Bureau. Respondents with missing information on healthcare utilization, Pap test receipt (5.6%), birthplace (0.1%), and other sociodemographic factors were excluded from the relevant analysis. Point estimates and estimates of their variances were calculated using SAS-callable SUDAAN Version 11.0.0 (RTI International, 2013, Durham, NC), a software package that accounts for the complex sample design of NHIS. Estimates were compared using two-sided t tests at the 0.05 level and assuming independence.

Prevalence estimates for Pap test receipt by birthplace were adjusted for selected socioeconomic and health care access and utilization factors, and these were presented as predicted margins from logistic regression models. The predictive margin for a given group is the average predicted value for a population. Comparisons of Pap test receipt by birthplace and percent of lifetime in the US were made as though women in those population subgroups had the same sociodemographic characteristics, health status, and selected indicators of health care access and utilization. Thus, resulting estimates reflect differences by birthplace and length of lifetime in the US only. Statistical comparisons of the differences between estimated differences of lifetime Pap test receipt and receipt in the past 3 years between selected subpopulations compared with US-born women were also made. Age-adjusted estimates in associated tables may differ from other age-adjusted estimates based on the same data presented elsewhere if different age groups were used in the adjustment procedure.

RESULTSSociodemographic Characteristics

Foreign-born women represented 16.7% of the study population (see Table 1). Women born in Mexico (28.7%), Central and South American countries and the Caribbean (23.4%), and Asian countries (27.9%) accounted for most foreign-born women. Nearly half of the foreign-born participants identified as Hispanic, whereas 3 quarters of the US-born women identified as non-Hispanic white. A larger percentage of foreign-born women (30.7%) had less than high school education compared with US-born women (10.2%). Preliminary analyses indicated differences in educational attainment by region of birth among foreign-born women (data not shown). Compared with their US-born counterparts, foreign-born women were more likely to not have health insurance (27.4% vs 11.7%), a usual place of care (19.9% vs 11.2%), and reported no visits to a healthcare provider within the past 12 months (21.7% vs 12.0%). Most foreign-born women (72.9%) had spent 25% or more of their life in the US.

Pap Test ScreeningEstimates Adjusted for Age Only.

Foreign-born women were more than twice as likely to have never received a Pap test (18.6% vs 6.8%) as US-born women (see Table 2). Among foreign-born women, those who spent less than 25% of their life in the US were more likely to be unscreened compared with those who spent 25% or more of their life in the US (25.3% vs 16.3%). For each sociodemographic characteristic examined, foreign-born women were more likely to have never received a Pap test compared with US-born women. Differences in Pap test receipt also existed by region of birth and percent of lifetime in the US (see Figure 1).

Estimates Adjusted for Sociodemographic Characteristics, Health Status, and Health Care Access and Utilization.

The relationship between place of birth and never receiving a Pap test is attenuated but remains significant for most regions when adjusting for selected sociodemographic and healthcare access and utilization characteristics (see Figure 1, Table 3). Among women aged 18 years and older, foreign-born women who had spent less than 25% of their lifetime in the US were more than twice as likely be unscreened (20.0%) compared with US-born women (7.6%) (see Table 3). Foreign-born women who had spent 25% or more of their lifetime in the US (12.7%) were also more likely to be unscreened compared with US-born women. Women from Mexico (9.8%), South America (12.6%), the Caribbean (14.6%), and Southeast Asia (13.1%) were more likely to never have a Pap test compared with US-born women. Women born in Europe (16.4%) and Central Asia (20.4%) were more than twice as likely as their US-born peers to never have a Pap test, whereas those born in FSU (28.2%), Africa (27.8%), Middle East (25.0%), and South Asia (22.9%) were more than 3 times as likely to be unscreened. There was no significant difference in never having a Pap test between women born in Central America (8.9%) and US-born women. Note that preliminary analysis (not shown) showed no interaction between survey year and foreign-born status for lifetime Pap receipt (p = .23) or recommended screening (p = .38).

Even after adjusting for sociodemographic and health care access and utilization characteristics, among women aged 21 and 65 years; foreign-born women who spent less than 25% of their lifetime in the US and those who spent 25% or more of their lifetime in the US were more likely to not have a Pap test in the past 3 years (26.2% and 21.2%, respectively) compared with US-born women (18.9%) (see Table 3). Women from the Caribbean (23.3%), Europe (24.9%), FSU (42.8%), Africa (36.8%), Middle East (35.1%), Central Asia (28.7%), and South Asia (33.5%) were more likely to not have a Pap test in the past 3 years compared US-born women. Conversely, women from Mexico (15.8%) and Central America (15.5%) were less likely to not have a Pap test in the past 3 years compared with US-born women. There was no significant difference between US-born women and foreign-born women from South America (18.8%) and South East Asia (19.3%) in meeting recommended USPSTF cervical cancer screening guidelines.

DISCUSSION

Health disparities between foreign- and US-born persons are often attributed to socioeconomic differences and dissimilarities in healthcare access and utilization.5,7 In this study, even after controlling for those factors, foreign-born women from most regions examined were more likely to have never received a Pap test compared with US-born women. With regard to meeting the USPSTF cervical cancer screening recommendation, foreign-born women from most regions, with the exception of Mexico, Central and South America, and Southeast Asia, were more likely to not have had a Pap test in the past 3 years compared with US-born women. The proportion of women who had never received a Pap test as well as those who had not been screened in the past 3 years was greater for foreign-born women who spent less than 25% than those who spent more than 25% of their lifetime in US and was also greater for women who spent more than 25% of their lifetime in comparison with US-born women.

Tsui et al.6 published a study in 2007 using NHIS data from 2003 and earlier and conducted analyses that closely paralleled the current study, where they divided foreign-born women based on birthplace as well as percent of time in the US and adjusted for sociodemographic and health care utilization factors. Tsui et al.6 reported that foreign-born women were more likely to never have a Pap test compared with US-born women, regardless of birthplace and percent of time in the US. They also found that differences in Pap test screening rates in the past 3 years, between foreign-born and US-born women, were similar to those seen for women who never received a Pap test.

Contrary to Tsui et al.,6 we found no significant difference between US-born women and foreign-born women from Central America with regard to lifetime Pap test receipt. Contrary to Tsui et al.,6 when examining the percentage of women who did not meet USPSTF recommendations for cervical cancer screening, we found that women from Mexico, Central and South America, and Southeast Asia were more likely or as likely as US-born women to have received a Pap test in the past 3 years. This could suggest that in more recent years, the likelihood of getting a Pap test in the past 3 years among foreign-born women from these countries has increased.

Some of our findings are also consistent with studies conducted outside of the US. Researchers in Canada and Norway have shown that foreign-born women were more likely to have never received cervical cancer screening compared with native-born women.14,15 The likelihood of screening for foreign-born women also varied by percentage of lifetime in their host country.14,15 In addition, the Norway study found variations in cervical cancer screening coverage based on birthplace for some immigrant groups.15

Researchers have provided some explanations for the cervical cancer screening disparity observed in foreign-born women. Documented barriers to screening among foreign-born women include language, lack of knowledge about preventive care and safety net programs, misconceptions about screening and the cause of cervical cancer, fear, embarrassment, previous negative experiences, lack of time, and financial concerns related to missing work.16–20 Some barriers such as language, lack of knowledge of cervical cancer prevention and cause, as well as characteristics tied to culture may be more pronounced in women who have spent a smaller percentage of their lifetime in the host country.21 The use and incorporation of the Pap test into population-based cervical cancer screening programs have not been fully realized in many parts of the world.22 Improvement in or stagnation in availability of national cervical cancer prevention and control programs using the Pap test or other screening modalities in country of origin may influence observed differences based on birthplace.23,24

In the US, Hispanics account for the largest group of immigrants. Therefore, verbal and written translation for health-related materials are more common for the Spanish language.25 Consequently, Hispanic women have access to more targeted health services and cervical cancer screening programs with culturally appropriate bilingual information.26 This may further explain differences in Pap test receipt among foreign-born women from Mexico, South America, and Central America compared with foreign-born women from non-Spanish speaking countries.

Systematic reviews have found that culturally appropriate, targeted interventions are effective at increasing cancer screening rates.27,28 Common elements among these interventions include using language-based disease specific materials, involving patient navigators, providing cultural awareness training for health care providers, and removing barriers to screening. Research is underway for novel ideals such as providing self-sampling test kits to make screening convenient for people, including foreign-born persons.29 Further research could examine barriers to interventions to increase cervical cancer screening among the foreign-born population.

The NHIS is a cross-sectional survey where current and historical information are collected at 1 point in time. Data are based on self-report, which may be limited by respondents’ willingness to provide information, inaccuracy in recall, inflating self-assessment, question comprehension, and cultural differences.30 To increase the precision of estimates of Pap test receipt at detailed levels, we combined data from 5 periodic cancer supplements spanning 11 years. Although there are significant reductions in sampling errors by combining data across years, there are also limitations associated with this estimation procedure in that it only provides an average across the years and does not represent a particular point in time. However, preliminary analyses using Joinpoint (National Cancer Institute, 2017, Bethesda, MD) software showed that there was no significant trend in ever having a Pap test across the survey years within the study. A major strength of these analyses is that the data are from a nationally representative sample of US women, thus allowing for population estimates. The large sample size allows for estimation of receipt of a Pap test by several population subgroups and other self-reported health characteristics collected in NHIS.

CONCLUSIONS

Where a woman is born and the percent of her lifetime residing in the US may play a role in whether she receives a Pap test at least once in her lifetime and if she is likely to be screened regularly. Foreign-born women have a higher incidence of cervical cancer5 yet are less likely to receive a Pap test compared with US-born women. These findings may inform cervical cancer screening efforts targeting foreign-born women.

The authors have declared they have no conflicts of interest.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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Age-adjusted estimates of never having a Pap test by birthplace and percent of lifetime in the United States, women 18 years or older: National Health Interview Survey 2005, 2008, 2010, 2013, and 2015. Note: The denominator used for analysis is US women 18 years or older, who never had a hysterectomy. Percents shown are age adjusted using the projected 2000 US population as the standard population and using the following age groups: 18–20, 21–29, 30–39, 40–49, 50–59, 60–64, and ≥65 years. Percents were weighted using the sample adult weight adjusted for 5 years of data. Birthplace is mutually exclusive. aSignificantly different from US-born (p < .05). bSignificantly different from ≥25% of lifetime in the United States (p < .05).

Age-Adjusted Demographic and Healthcare Access Characteristics of Women 18 y and Older, by Birthplace: NHIS 2005, 2008, 2010, 2013, and 2015

CharacteristicsForeign-born womenUS-born women
Sample size, nDistribution, %Standard errorSample size, nDistribution, %Standard error
All womena11,79116.7%50,54283.3%
Age, yb
 18–203003.5%0.262,2756.8%0.19
 21–291,95717.2%0.529,44120.2%0.27
 30–393,20125.6%0.5110,01719.0%0.22
 40–492,49122.4%0.518,78018.3%0.23
 50–591,59914.8%0.457,87016.0%0.21
 60–645734.9%0.253,3046.0%0.13
 65+1,67011.6%0.388,85513.8%0.22
Race/ethnicityb
 Hispanicc6,47546.2%1.005,5128.0%0.24
 Non-Hispanic white1,60520.5%0.7134,25475.5%0.40
 Non-Hispanic black9237.9%0.488,68112.8%0.31
 Non-Hispanic Asian2,71824.8%0.778151.4%0.13
Marital statusb
 Never married2,01015.9%0.3913,14821.5%0.22
 Currently married/living with a partner6,90865.3%0.5523,03457.8%0.30
 Formerly married2,83418.8%0.4014,21320.7%0.21
Current US region of residency
 Northeast2,16020.8%1.118,79318.7%1.11
 Midwestb1,19111.2%0.9712,12025.4%0.84
 Southb3,74230.6%1.5218,45436.2%0.86
 Westb4,69837.4%1.9711,17519.7%0.81
Educationb
 Less than High School4,02730.7%0.765,69510.2%0.19
 High School graduate/GEDd2,43221.8%0.5512,90125.7%0.30
 Some college2,24819.8%0.5217,00933.6%0.29
 College Degree2,95227.7%0.6814,76330.5%0.35
Family incomeb,e
 <100% of poverty level3,25021.9%0.598,87612.7%0.24
 100%−199% of poverty level3,17125.2%0.5910,27218.1%0.26
 200%−399% of poverty level2,93227.6%0.7214,94730.3%0.30
 ≥400% of poverty level2,43825.3%0.6716,44739.0%0.44
Health statusb
 Excellent/very good6,59757.1%0.6630,90663.4%0.32
 Good3,57029.5%0.5613,15425.3%0.25
 Fair/poor1,61913.5%0.446,45811.4%0.19
Insuranceb (at time of interview)
 None3,61527.4%0.646,26711.7%0.22
 Private5,10047.6%0.7832,24368.3%0.37
 Public3,02925.0%0.5411,87920.1%0.28
Usual place of care
 Noneb2,54719.9%0.515,99011.2%0.22
 Clinic or health centerb3,20623.9%0.6610,02917.0%0.41
 Doctor’s office or HMOb5,61153.9%0.8033,36070.3%0.44
 Hospital outpatientb2271.6%0.154850.8%0.06
 Other place850.8%0.134230.8%0.05
Visits to health providerb (in past 12 mo)
 None2,74121.7%0.536,25612.0%0.21
 12,20318.9%0.517,74415.2%0.23
 2–33,00826.0%0.5414,01428.1%0.27
 ≥43,80033.4%0.5822,33644.7%0.33
Ever had a Pap testb
 Yes9,67781.4%0.4747,10793.2%0.15
 No1,97618.6%0.473,2256.8%0.15
Country of birth
 Mexico3,95228.7%1.04NANA
 Central America9646.7%0.34NANA
 South America8446.8%0.38NANA
 Caribbean Islands1,3549.9%0.78NANA
 Southeast Asia1,21010.8%0.48NANA
 Central Asia9098.0%0.41NANA
 South Asia (Indian Subcontinent)5796.1%0.35NANA
 Middle East1973.0%0.33NANA
 Africa4294.0%0.28NANA
 Europe87811.0%0.58NANA
 FSU1932.5%0.27NANA
Lifetime in USNANA
 <25%3,23227.1%0.58NANA
 ≥25%8,53472.9%0.58NANA

Estimates are based on household interviews of a sample of the civilian noninstitutionalized population. Estimates were weighted using the sample adult weight adjusted for 5 y of data. Unless indicated, unknowns for the columns were not included in the denominators when calculating percentages, but they were included in the “All Women” row. Percentages may not add to totals because of rounding. Estimates are age-adjusted (except age-specific results) using the projected 2000 US population as the standard population and using age groups: 18–20, 21–29, 30–39, 40–49, 50–59, 60–64, and 65 y and older.

Adapted from NCHS, National Health Interview Survey (NHIS) Sample Adult Cancer Supplements 2005, 2008, 2010, 2013, and 2015.

US women 18 y and older, who never had a hysterectomy.

Significantly different by foreign-born vs US-born status (p < .05).

Hispanic refers to persons who are of Hispanic or Latino origin and may be of any race or combination of races.

GED is general educational development high school equivalency diploma.

Based on family income and family size using the US Census Bureau poverty thresholds for 2004, 2007, 2009, 2012, and 2014.

FSU indicates Former Soviet Union; GED, general educational development; HMO, Health Maintenance Organization; NA, not applicable; US, United States.

Age-Adjusted Prevalence of Women 18 y and Older Who Never Had a Pap Test, by Birthplace: NHIS 2005, 2008, 2010, 2013, and 2015

CharacteristicsForeign-born womenUS-born women
Sample size, nNever screened, %Standard errorSample size, nNever screened, %Standard error
Total never screeneda,b1,97618.6%0.473,2256.8%0.15
Age, yb
 18–2020274.2%3.141,02447.3%1.37
 21–2952628.4%1.3892510.8%0.48
 30–3943712.9%0.742482.4%0.19
 40–4927710.0%0.742102.1%0.19
 50–5917610.5%1.031601.5%0.15
 60–646411.1%1.54892.3%0.31
 65+29417.1%1.145696.0%0.34
Race/ethnicityb
 Hispanicc94616.7%0.6661410.1%0.56
 Non-Hispanic white18915.0%1.041,8496.3%0.18
 Non-Hispanic black15718.9%1.475576.7%0.40
 Non-Hispanic Asian67525.6%0.9512311.9%1.11
Marital statusb
 Never married64527.4%1.432,04911.0%0.45
 Currently married/living with partner65015.4%0.755893.3%0.21
 Formerly married37614.1%1.335784.0%0.60
US region of current residenceb
 Northeast35718.8%1.025627.3%0.39
 Midwest24619.9%1.386925.9%0.26
 South62217.9%0.761,1636.7%0.26
 West75118.6%0.818087.5%0.34
Educationb
 < High school77121.6%0.906129.6%0.48
 High school graduate/GED43119.9%1.029537.4%0.30
 Some college34315.8%0.881,1806.2%0.22
 College degree40414.8%1.904645.6%1.46
Family incomeb
 < 100% of poverty level71823.2%1.061,0119.1%0.41
 100%−199% of poverty level57820.3%0.938137.8%0.35
 200%−399% of poverty level43018.5%0.928646.8%0.28
 ≥400% of poverty level25014.7%0.995375.7%0.27
Health statusb
 Excellent/very good1,14717.6%0.562,0266.4%0.18
 Good60319.5%0.957906.7%0.28
 Fair/poor22617.4%1.464088.5%0.59
Insuranceb (at time of interview)
 None79126.2%1.4361010.9%1.43
 Private64915.5%0.651,7416.3%0.18
 Public52518.3%1.028537.1%0.33
Usual place of careb
 None68528.0%1.3870111.6%0.69
 Clinic or health center49717.9%0.967557.0%0.30
 Doctor’s office or HMO71416.0%0.641,6506.0%0.18
 Hospital outpatient2511.4%2.84418.8%1.60
 Other place1719.3%4.47439.2%1.60
Visits to health provider (past 12 mo)b
 None82231.1%1.3089014.5%0.60
 135818.1%0.956327.9%0.39
 2–335014.6%0.827615.9%0.23
 ≥443813.0%0.709274.8%0.20
Lifetime in USb,d
 <25%82625.3%1.03NANANA
 ≥25%1,14616.3%0.52NANANA

Estimates are based on household interviews of a sample of the civilian noninstitutionalized population. Estimates were weighted using the Sample Adult weight adjusted for 5 y of data. Unless indicated, unknowns for the columns were not included in the denominators when calculating percentages, but they were included in the “Total never screened” row. Percentages may not add to totals due to rounding. All estimates are age-adjusted (except age-specific results) using the projected 2000 US population as the standard population and using age groups: 18–20, 21–29, 30–39, 40–49, 50–59, 60–64, and 65 y and older.

Adapted from NCHS, National Health Interview Survey (NHIS) Sample Adult Cancer Supplements 2005, 2008, 2010, 2013, and 2015.

US women 18 y and older, who never had a hysterectomy and responded “no” to the question “Have you ever had a pap smear or pap test?”

Significantly different by foreign-born vs US-born status at all levels (p < .05).

Hispanic refers to persons who are of Hispanic or Latino origin and may be of any race or combination of races.

Significantly different by lifetime in the US (p < .05).

US indicates United States; GED, general education; NA, not applicable.

Predicted Margins of Adult Women by Birthplace and Percent of Lifetime in the US: NHIS 2005, 2008, 2010, 2013, and 2015

Never had a Pap test (age ≥18 y)aNo Pap test in the past 3 y (age 21–65 y)b
Predicted margins, %cStandard errorpPredicted margins, %cStandard errorp
Birthplace and % of lifetime in the US
 US-born7.6%0.1918.9%0.29
 Foreign-born <25%20.0%1.01d,e26.6%1.16d,e
 Foreign-born ≥25%12.7%0.56d21.2%0.75d
Country/region of birth
 United States7.6%0.1918.9%0.29
 Mexico9.8%0.66d15.8%0.85d
 Central America8.9%1.0115.5%1.34d
 South America12.6%1.50d18.8%1.81
 Caribbean14.6%1.38d23.3%1.89d
 Southeast Asia13.1%1.42d19.3%1.85
 Central Asia20.4%2.09d28.7%2.54d
 South Asia (Indian Subcontinent)22.9%2.36d33.5%3.02d
 Middle East25.0%3.56d35.1%4.49d
 Africa27.8%2.58d36.8%2.83d
 Europe16.4%1.66d24.9%2.08d
 FSU28.2%4.02d42.8%4.19d

Adapted from NCHS, National Health Interview Survey (NHIS) Sample Adult Cancer Supplements 2005, 2008, 2010, 2013, and 2015.

The denominator used for analysis is the number of US women 18 y and older without a hysterectomy. Estimates are based on household interviews of a sample of the civilian noninstitutionalized population.

The denominator used for analysis is the number of US women 21–65 y without a hysterectomy. Estimates are based on household interviews of a sample of the civilian noninstitutionalized population.

Adjusted for age, race and ethnicity, marital status, income, region of current residence, education, health status, health insurance coverage, usual place for medical care, and number of doctor visits in the past 12 mo.

Significantly different from US-born (p < .05).

Significantly different from ≥25% of lifetime in the US.

US indicates United States; FSU, Former Soviet Union.