To our knowledge, this is the first study to compare unmarried women who partner with women or with both women and men with comparably aged women who partner exclusively with men on adherence to multiple cancer screening practices. We assessed experiences with breast, cervical, and colorectal cancer screenings and classified each woman as being on-schedule or not. We also developed a measure of comprehensive screening based on each woman's adherence to all three types of cancer screenings for which she was eligible.
We did not find significant differences by partner gender for any of the measures of on-schedule screening after controlling for important differences in demographic characteristics, health behaviors, and cancer-related experiences. To our knowledge, there are no other studies with an equivalent sample of unmarried women aged 40–75 years with which to compare our results. Based on results of other studies that included heterosexual and sexual minority women,7,8
we hypothesized that WPW and WPWM would be less likely than WPM to be on-schedule for breast, cervical, and colorectal screenings. There are at least two reasons that may explain why we did not find that WPW/WPWM were less likely than WPM to receive recommended screenings. First, Rhode Island is one of only a few states in the United States to have nondiscriminatory policies toward sexual minorities. Therefore, within the political and social context, women in Rhode Island may have better experiences with healthcare than have women in other parts of the country. Second, the relatively small sample size of WPW and WPWM may have limited our ability to detect important differences based on partner gender. However, all the odds ratios for the relationships between partner gender and the screening variables were very close to 1.0. It is, therefore, not likely that increased sample sizes would change the conclusions substantially. As a result, we encourage other investigators to replicate our methods to determine the generalizability of the findings.
Overall, 75% of women in our sample reported being on-schedule for breast and cervical cancer screenings, and 66% reported being on-schedule for colorectal screening. On the other hand, slightly more than half of all women were on-schedule for comprehensive screening. Our finding that 75% of women reported on-schedule mammography screening is only slightly higher than the 72% of women who reported repeat, on-schedule screening in a national level survey conducted in 2002–2003.25
Our rates may be somewhat inflated for at least three reasons. First, to ensure sufficient numbers of sexual minority women, we used nonprobability-based sampling methods. As a result, our sample was highly educated, predominantly white, and had relatively higher incomes, all characteristics previously shown to be associated with increased screening rates.25,26
Second, in 2002, Rhode Island had the highest percentage of women in the United States who reported recent mammography and ranked in the top seven states for reports of recent sigmoidoscopy and fecal occult blood tests.27
However, among women who participated in the 2004 Rhode Island Behavioral Risk Factor Surveillance Survey, rates of screening were 83% for mammography within the previous 2 years, 91% for Pap test within the previous 3 years, 31% for FOBT within the past 2 years, and 55% for sigmoidoscopy or colonoscopy within the previous 10 years. Assuming relative consistency in screening patterns, this translates to repeat, on-schedule screening rates of about 68% (i.e., 83%*83%) for breast and 81% (i.e., 91%*91%) for cervix. Finally, our results may have been affected by question wording and the definitions used for on-schedule status. In a previous review of repeat mammography screening, we found that rates varied substantially across studies based on the items used to define repeat screening.28
The absence of effects as a result of recruitment source and data collection mode suggest that if there is a bias toward higher rates, it is likely due to the items used to define on-schedule screening.
As expected, we found that women with more barriers to screening were more likely to report being off-schedule for screenings. In addition, there were specific barriers associated with being off-schedule for one or more screening examinations. There were no differences by partner gender, however, in the number of reported barriers, the specific types of barriers reported, or the effect of barriers on the likelihood of on-schedule screening.
In the total sample, 6% of respondents reported they had put off, avoided, or changed the place they went for cancer screenings because of their sexual orientation. These women were significantly more likely to be off-schedule for comprehensive screening as well as breast screening specifically. We did not find significant differences by partner gender; 5% (18 of 395) of WPM/NPP and 7% (15 of 203) of WPW/WPWM reported barriers associated with sexual orientation. We have no data to describe the circumstances involving the reported experiences associated with sexual orientation. However, in focus group and cognitive interview phases of the CSPW, WPM reported incidents of sexual harassment and unwanted advances by healthcare providers during cancer screenings, and WPW reported experiences of verbal and behavioral discrimination based on their sexual minority status. Therefore, although they may have had different types of experiences based on sexual orientation, it appears that for a small percentage of both WPW and WPM, these negative encounters with healthcare providers affected their willingness to undergo routine screenings at recommended intervals.
We found that concern about body image was one of the most frequently reported specific barriers to cancer screenings regardless of sexual orientation; 21% of WPM and 23% of WPW reported they had put off, avoided, or changed the place they went for cancer screenings because of concerns about body image, and these body image concerns were associated with lower likelihood of screening. Other investigators found that obese women were less likely than normal weight women to have had recent screenings,29,30
and in a recent study, Zhu et al.31
found that both obese and underweight women were less likely to have had a recent screening. We did not ask questions to calculate body mass index (BMI) and, therefore, cannot determine characteristics of women who reported barriers due to body image. Although BMI was not associated with Pap testing for African American and Hispanic women, Wee et al.29
found that a higher proportion of obese white women than normal weight white women cited embarrassment or discomfort as the primary reason for not undergoing screening. Obese women may have poor self-image related to body weight, and underweight women may be afraid of questions about low weight. As a result, women may delay preventive screenings because of actual or perceived negative attitudes or judgmental behaviors from health professionals. Thus, strategies are needed to address women's reservations about undergoing screening. These strategies could include sensitivity training for providers about patient-provider interactions for delivering recommendations for screening and for actually performing the tests. Other strategies could include addressing contextual features of screening that may reduce body image concerns, including private changing areas, adequately sized gowns, and accessible examination tables.
Previous studies have generally found that employed women are more likely than unemployed women to be on-schedule for screening.32,33
In our sample, women who specifically reported problems taking time off from work were more likely to be off-schedule for breast, colorectal, and comprehensive screening but not cervical screening. To obtain a mammogram, sigmoidoscopy, or colonoscopy, women generally must schedule an appointment separate from a general medical visit. Threats of lost income or actual job loss because of taking time from work for multiple medical visits may be particularly relevant for unmarried women who are more likely than married women to depend solely on their own employment for financial security. Therefore, unmarried women, regardless of sexual orientation, may benefit from screening providers who offer evening and weekend appointments or opportunities to obtain multiple cancer screenings (i.e., mammogram and Pap test) during the same medical visit.
Our study had a number of strengths. First, although the ideal approach would have been to draw a representative, population-based sample, it is particularly difficult to sample sufficiently large numbers of sexual minority women using these methods. Therefore, we used principles of targeted34,35
sampling that were comparable for recruiting WPW/WPWM and WPM. Furthermore, we controlled for recruitment source in all our analyses. Next, our sample included diverse groups of women including 25% women of color and 44% with household incomes <$30,000. Finally, we had a high study completion rate; 95% of women who were eligible and agreed to participate completed the baseline questionnaire.
There are also a number of study limitations. Unfortunately, because sexual orientation is not asked of all individuals in the census or on any large statewide population-based survey, we do not have data to compare our sample to the eligible Rhode Island population. Second, this study was based on self-reported behaviors. Although other investigators have found both underestimation36
in self-reported cancer screening data, concordance with medical record documentation has been generally satisfactory.38–40
Third, we determined on-schedule screening status based on intervals recommended by the National Cancer Institute and American Cancer Society, although controversies remain about screening, including age to begin screening and frequency with which screenings should be obtained.41,44
Fourth, we were unable to interpret the causal relationship between cancer screening adherence and other factors because of the cross-sectional nature of the study design. Finally, because our sample included only unmarried women, we are not able to address differences in rates of comprehensive cancer screenings between unmarried and married women.