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1 Cervical cancer screening among foreign-born versus US-born women by birthplace and length of time in the US: Meheret Endeshaw, MPH CDC/ASPPH Fellow Division Cancer Prevention and Control Office of International Cancer Control Atlanta, Georgia, USA Co-Authors: Tainya Clarke, PhD, MPH Virginia Senkomago, PhD, MPH Mona Saraiya, MD, MPH

2 Disclosures No financial relationships or conflict of interest to disclose

3 Cervical cancer in the United States (US) Incidence Decreased from 14.8 in 1975 to 6.4 in 2013 Deaths Decreased from 5.6 in 1975 to 2.3 in 2013 Decrease due to cervical cancer screening with a Papanicolau (Pap) test SEER 9 Incidence & U.S. Mortality , All Races, Females. Rates are Age-Adjusted. National Institutes of Health. Cervical Cancer. NIH Consensus Statement. 1996;14(1):1 38.

4 Cervical Cancer Disparities in the US Incidence and mortality rates of cervical cancer differ by many factors such as racial/ethnic groups place of birth Differences could be due to different participation rates in screening and access to health services including treatment Human papillomavirus associated cancers United States, Cervical cancer screening among foreign-born women by birthplace and duration in the United States Cervical cancer mortality among foreign-born women living in the United States, 1985 to 1996 Froment MA, Gomez SL, Roux A, DeRouen MC, Kidd EA. Impact of socioeconomic status and ethnic enclave on cervical cancer incidence among Hispanics and Asians in California. Nativity disparities in late-stage diagnosis and cause-specific survival among Hispanic women with invasive cervical cancer: an analysis of Surveillance, Epidemiology, and End Results data

5 Foreign born population in the US: 2014 Africa & Middle East, 7.8% Europe, 11.5% Elsewhere, 2.5% Mexico, 27.7% Foreign born population: 42.2 million people or 13.3% of the total US population 52% of the total foreign born population is from Latin America Asia, 26.6% Caribbean, 9.5% South America, 6.7% Central America, 7.8% 78.3% of the total foreign population is from Latin America and Asia 16.2 million American children under the age of 18 have at least one immigrant parent Projections of the Size and Composition of the U.S. Population: 2014 to 2060: Population Estimates and Projections In: Current Population Reports: United States Census Bureau American Community Survey data

6 Study objective To examine differences in Pap test screening among US-born and foreign-born women

7 Analysis Combined four years of National Health Interview Survey (NHIS) cancer supplement data (2005, 2008, 2010, 2013, 2015) to conduct cross-sectional analyses on cervical cancer screening behavior Analyses were age-standardized to the 2000 U.S. population, weighted for national estimates Results are representative of the U.S. civilian noninstitutionalized population All statistical analyses were conducted using SAS-callable SUDAAN version

8 Analysis Indicator variables: 1.) Birthplace: Foreign-born vs. US-born 2.) % of Life Spent in US: Time in US/Age (<25% vs. 25%) 4.) Region of Origin 3.) Demographic, Health care access factors Screening outcomes 1.) Ever vs. Never had a Pap test

9 Study sample: NHIS years 2005, 2008, 2013, 2010, % 4.9% 3.6% 7.7% U.S. born (50,542) 83.3% Foreign Born (11,791) 16.7% 7.2% 8.2% 11.5% 33.6% 10.3% 7.5% 1.6% 2.2% Mexico Caribbean Island Central America South America Africa Western Asia (Middle East) South Asia (Indian SubCnt) Central Asia Southeast Asia Europe Eastern Europe (Russia) Elsewhere

10 Never screening among foreign-born & US born women Women who are 18+ Without a hysterectomy 62,333 Total foreign-born 11,791 Total US-born 50,542 Never screened foreign-born from sample 1,976 Never screened US-born from sample 3,225 Weighted never screened total for foreign-born population 2,580,272 Weighted never screed total for US-born population 5,626,724

11 Never screening by demographic factors Characteristic N Foreign Born Women Weighted N % (95% CI) N US Born Women Weighted N % (95% CI) Total never screened 1,976 2,580, ( ) 3,225 5,626, ( ) Race/Ethnicity Hispanic 946 1,120, ( ) , ( ) Non-Hispanic White , ( ) 1,849 3,613, ( ) Non-Hispanic Black , ( ) , ( ) Non-Hispanic Asian , ( ) , ( ) Education <High School , ( ) 612 1,049, ( ) High School graduate/ged , ( ) 953 1,651, ( ) Some college , ( ) 1,180 2,176, ( ) College Degree , ( ) , ( ) Household Income <100 % of poverty level , ( ) 1,011 1,305, ( ) 100% - 199% of poverty level , ( ) 813 1,296, ( ) 200% - 399% of poverty level , ( ) 864 1,685, ( ) 400 % of poverty level , ( ) 537 1,340, ( ) Age Adjusted weighted percentages of women who are 18 years and older and never screened with Pap test. National Interview Survey 2005, 2008, 2010, 2013, 2015.

12 Never screening by health care access factors Characteristic N Foreign Born Women Weighted N % (95% CI) N US Born Women Weighted N % (95% CI) Insurance None 791 1,042, ( ) 610 1,074, ( ) Private , ( ) 1,741 3,223, ( ) Public , ( ) 853 1,277, ( ) Usual source of care None , ( ) 701 1,204, ( ) Clinic or health center , ( ) 755 1,203, ( ) Doctor's office or HMO , ( ) 1,650 3,017, ( ) Hospital outpatient 25 25, ( ) 41 69, ( ) Other Place 17 23, ( ) 43 71, ( ) Visits to health provider (past 12 months) none 822 1,048, ( ) 890 1,528, ( ) , ( ) 632 1,075, ( ) 2 to , ( ) 761 1,380, ( ) 4 or more , ( ) 927 1,618, ( ) Age Adjusted weighted percentages of women who are 18 years and older and never screened with Pap test. National Interview Survey 2005, 2008, 2010, 2013, 2015.

13 Percent Never Screened Never screening by place of birth and length of time in the US Total 7.4 US born Mexico Caribbean Islands Central America South America Europe Eastern Europe (Russia) Africa Middle East Central Asia Southeast & East Asia South Asia 25% < 25% Place of Birth by Percent of Lifetime in the U.S Age Adjusted weighted percentages of women who are 18 years and older and never screened with Pap test. National Interview Survey 2005, 2008, 2010, 2013, 2015.

14 Percent never screened Never screening by length of time in the US adjusted for sociodemographic and access to care variables 25% 20% 20.1% 15% 12.8% 10% 7.7% 5% 0% US born Foreign born 25% Foreign born <25% Adjusted for age, race and ethnicity, marital status, income, region of current residence, education, self-reported health status, health insurance coverage, usual place for medical care and number of doctor visits in the past twelve months. National Interview Survey 2005, 2008, 2010, 2013, 2015

15 Never screening by length of time in the US adjusted for sociodemographic and access to care variables Southeast & East Asia 1x 13.7% 2x 3x Central Asia 21.2% South Asia Middle East 23.7% 25.0% Africa Eastern Europe 27.8% 28.1% Europe 16.4% South America 12.6% Central America 8.9% Caribbean 14.6% Mexico 9.8% United States 7.7% 0% 5% 10% 15% 20% 25% 30% Adjusted for age, race and ethnicity, marital status, income, region of current residence, education, self-reported health status, health insurance coverage, usual place for medical care and number of doctor visits in the past twelve months. National Interview Survey 2005, 2008, 2010, 2013, 2015

16 Discussion Foreign-born women have lower cervical cancer screening rates compared to US born women within all demographic and health care access categories Percent of time spent in the US and place of birth were important factors that contributed to differences for never screening among foreign-born. A higher proportion of never-screened women were born in Africa, Asia and immigrated recently Screening rates have improved for foreign born women from some Latin American regions/countries (Mexico and central America) compared to a previous study

17 Future implication Screening differences based on place of birth demonstrate the heterogeneity of foreign born National and local screening programs should target foreign-born women who are likely to have never been screened

18 Limitations and Strength Limitation Self-reported data No over sampling for other minority groups aside from Latinos and Blacks Strength Data are from a nationally representative sample of women in the US The large sample size allows for estimation of the receipt of a Pap test by a wide variety of population subgroups

19 Acknowledgments Division Cancer Prevention and Control National Center for Health Statistics Association of Schools and Programs of Public Health The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

20 Thank you! Contact Information: Meheret Endeshaw (404)

21 Screening guidelines in the US since 2012 USPSTF ACS ACOG ASCCP? Begin screening at 21 years, regardless of age at first sex. From 21 to 29 years, screen every 3 years (cytology alone) From 30 to 65 years, screen every 3 years (cytology) or every 5 years (cytology and human papilloma virus test [co-testing]). Women Older than 65, who have had adequate prior screening should not be screened The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer US Preventive Services Task Force Cervical Cancer: Screening American Congress of Obstetricians and Gynecologists Cervical Cancer Screening Yang, D.X., et al., Impact of Widespread Cervical Cancer Screening: Number of Cancers Prevented and Changes in Race-specific Incidence. Am J Clin Oncol, Simard, E.P., et al., Age-specific trends in black-white disparities in cervical cancer incidence in the United States: Gynecol Oncol, (3): p

22 Study objectives Compare Pap test screening in the US compare among United States (US) born and foreign-born women How do the rates of never-screening for cervical cancer compare among United States (US) born and foreign-born women? Do never-screening rates differ by region of origin among foreign born women? Do never-screening rates differ by length of time in the U.S. among foreign born women?

23 Methods All statistical analyses were conducted using SAS-callable SUDAAN version Estimates are age adjusted to the year 2000 U.S. standard population Two-sided t tests were conducted and 95% confidence intervals and p- values were obtained Adjusted prevalence for never-screening by place of birth are presented as predictive margins from the logistic regression models

24 Never screening by demographic factors Characteristic Sample n Weighted total for frequencies Foreign Born Women % never screened US Born Women (95% CI) Sample n weighted total for never screened % never screened (95% CI) Age , ( ) 1,024 2,432, ( ) , ( ) 925 1,656, ( ) , ( ) , ( ) , ( ) , ( ) , ( ) , ( ) , ( ) , ( ) , ( ) , ( ) Marital Status Never Married , ( ) 2,049 4,025, ( ) Currently Married/ 950 1,355,899 ( ) 589 1,057,090 Living as Married ( ) Formerly Married , ( ) , ( ) Region of Current Residence Northeast , ( ) , ( ) Midwest , ( ) 692 1,300, ( ) South , ( ,163 2,011, ( ) West , ( ) 808 1,325, ( ) Table 2. Age Adjusted weighted percentages of women never screened with Pap smear by birthplace.

25 Percent never screened Never screening by length of time in the US 30% 25% 25.3% 20% 16.3% 15% 10% 7.4% 5% 0% US-born Foreign-born 25% Foreign-born <25% Age Adjusted weighted percentages of women who are 18 years and older and never screened with Pap test. National Interview Survey 2005, 2008, 2010, 2013, 2015.

26 Percent never screened Never screening by region of birth 35% 30% 30.1% 25.8% 25% 23.1% 21.6% 21.3% 21.2% 20% 15% 17.3% 14.6% 16.4% 14.7% 15.3% 10% 7.4% 5% 0% US Mexico Central America Caribbean Islands South America Europe Eastern Europe Africa Middle East Central Asia Southeast & Eastern Asia Southern Asia Age Adjusted weighted percentages of women who are 18 years and older and never screened with Pap test. National Interview Survey 2005, 2008, 2010, 2013, 2015.

27 Foreign-born sample: combined NHIS years 2005, 2008, 2013, 2010, 2015 Characteristic Sample n Weighted total for frequencies % never screened (95% CI) Country of Birth Mexico , ( ) Central America , ( ) Caribbean Islands , ( ) South America , ( ) Europe , ( ) Eastern Europe (Russia) 36 82, ( ) Africa , ( ) Western Asia (Middle East) 43 91, ( ) Central Asia , ( ) Southeast and Eastern Asia , ( ) Southern Asia (Indian subcontinent) , ( ) Lifetime in US <25% 826 1,051, ( ) 25% 1,146 1,525, ( ) Age at migration 18 years ( ) years ( ) years ( ) >50 years ( ) Citizenship Status Naturalized ( ) Non-Citizen ( )

28 Percent never screened Never screening by age of migration 35% 32.7% 30% 25% 20% 17.2% 16.3% 15% 13.7% 10% 5% 0% 18 YEARS YEARS YEARS >50 YEARS

29 Percent never screened Never screening by citizenship status 25% 22.9% 20% 15% 10% 10.8% 5% 0% Naturalized Non-Citizen

30 Adjusted results by place of birth and length of time in the US Predictive margins (%) 95% Confidence Intervals p value Place of birth and % time in the US US born 7.7 ( ) Foreign born <25% 20.1 ( ) <0.001 Foreign born 25% 12.8 ( ) <0.001 Country/region United States 7.7 ( ) Mexico 9.8 ( ) <0.01 Caribbean 14.6 ( ) <0.001 Central America 8.9 ( ) South America 12.6 ( ) <0.01 Europe 16.4 ( ) <0.001 Eastern Europe 28.1 ( ) <0.001 Africa 27.8 ( ) <0.001 Western Asia (Middle East) 25.0 ( ) <0.001 South Asia (Indian subcontinent) 23.7 ( ) <0.001 Central Asia 21.2 ( ) <0.001 South East Asia 13.7 ( ) <0.001 Elsewhere 6.0 ( ) Adjusted for sociodemographic and access to care variables. National Interview Survey 2005, 2008, 2010, 2013, 2015

31 Non-adherence to screening recommendations Predictive margins (%) 95% Confidence Intervals p value Place of birth and % time in the US US born 17.2% ( ) Foreign born <25% 26.2% ( ) <0.001 Foreign born 25% 19.9% ( ) <0.001 Country/region of birth United States 17.2% ( ) Mexico 15.3% ( ) Caribbean 20.7% ( ) <0.05 Central America 16.2% ( ) South America 15.7% ( ) Europe 22.7% ( ) <0.05 Eastern Europe 35.3% ( ) <0.001 Africa 35.7% ( ) <0.001 Western Asia (Middle East) 30.8% ( ) <0.01 South Asia (Indian subcontinent) 34.1% ( ) <0.001 Central Asia 29.9% ( ) <0.001 South East Asia 21.0% ( ) Elsewhere b 23.2% ( ) Adjusted for sociodemographic and access to care variables. National Interview Survey 2005, 2008, 2010, 2013, 2015

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