We found that Hispanic women with high English proficiency were more likely to report having a Pap smear in the past 3 years as compared to women who spoke only or mostly Spanish. In addition to English language proficiency, access factors such as household annual income, having a usual source of care, and health insurance also increased the likelihood of having a Pap smear in the past 3 years among Hispanics.
Low English proficiency has been associated with low use of Pap smears in previous studies,9,11–13
including two reports using data from national surveys.9,13
However, despite a trend in the same direction as previous reports, a study using pooled 1990 and 1992 NHIS data found no significant difference.17
Misclassification of low proficient as high proficient may explain the inconsistency. While the 1990–1992 study assessed language proficiency with language of interview, the other studies used self-reported language use. Answering a questionnaire like NHIS in English does not necessarily imply high command of the English language. The fact that only 21% of participants in the 1990–1992 NHIS study were considered to have low English proficiency as compared to 44% in our study and over a third in the others supports this notion.
Low English proficiency can impact use of Pap smears among Hispanics in several ways. Language barriers limit access to general and preventive health care. Even after accounting for factors such as health insurance and usual source of care, less English-proficient Hispanics are less likely to use health services.18
According to a recent survey among Spanish speakers in the United States, nearly one in five delayed or refused needed medical care because of language barriers with an English-speaking physician.19
Once access is achieved, language barriers may interfere with the physician's ability to describe the benefits of screening, and some may opt for postponing or omitting a recommendation for a Pap smear. Even if Pap smear is recommended, language barriers may impede adherence among the low proficient.
Currently, 28 million residents in the United States speak Spanish at home and about one third of them speak English “not well” or “not at all.”14
This number is expected to increase according to Census projections.14
Our findings suggest that despite successful outreach programs and media strategies targeting low English-proficient Hispanics, increased efforts are needed to improve cervical cancer screening among these numerous groups.
There are several limitations to our study. NHIS data are based on self-report; participants may have provided socially desirable answers, or may have misrepresented their English proficiency. Previous studies have shown that self-report, rather than decreasing Pap smear use rates, can substantially overestimate them, especially among low-income, ethnic women.20
We could not assess the impact of physician characteristics or use of interpreters on Pap smear use and recommendation of Pap smear by health care providers because the database did not include items on those topics. Although we adjusted for the most relevant sociodemographic and access factors, our results may have been influenced by residual confounding by income, educational attainment, health insurance status, and self-reported health status or by factors not included in the analysis, such as geographic location.
Our findings may help guide future research and assist in the design of interventions to improve cervical cancer screening among low English-proficient Hispanics. Interventions aimed at improving communication between health care provider and patients, such as the use of interpreters, cultural competency training, and provision of culturally appropriate education materials, may improve Pap smear use rates in this population
Our findings suggest that low English proficiency is a barrier to cervical cancer screening among Hispanics. Increased efforts are needed to improve Pap smear use rates in this sizable group with elevated cervical cancer burden.