ETHNIC DIFFERENCES IN PATIENT REQUESTS FOR PREGNANCY TESTING Daniel Bluestein, MD, MS, and Jeffrey S. Levin, PhD, MPH Norfolk, Virginia
This study identifies a black-white difference in pregnancy test requests and in factors predicting such requests among 324 women tested at an academic family practice in 1986. Data were obtained from encounter sheets filled out by clinicians at the time tests were ordered. Analysis of variance revealed that blacks requested fewer pregnancy tests than whites, and that this finding remained significant (P < .01) after controlling for the effects of gestational status and other clinical and sociodemographic factors. Blacks were less likely to be married or possess health insurance, but more likely to have been pregnant before. Logistic regressions indicated that factors predicting test requests differed by ethnicity, with symptoms and age predicting test requests among whites, and pregnancy the only significant predictor among blacks. Explanations consistent with these findings include possible ethnic differences in reactions to symptoms and economic factors. Further refinement of these hypotheses and consideration of other alternatives will advance understanding of ethnicity as a factor in testrequesting behavior, and enable clinicians to communicate with and care for b'ack women more effectively. (J Nati Med Assoc. 1 992;84:403-407.) Key words * pregnancy tests * ethnic variation From the Department of Family and Community Medicine, Eastern Virginia Medical School, Norfolk, Virginia. Requests for reprints should be addressed to Dr Daniel Bluestein, Dept of Family and Community Medicine, Eastern Virginia Medical School, PO Box 1980, Norfolk, VA 23501. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
Pregnancy tests are often ordered at patients' requests and failure to make such requests may contribute to misdiagnosis.' In these circumstances, teratogenic and iatrogenic misadventures may occur more frequently, and counselling regarding pregnancy disposition may be delayed.2 Patients may have less time to make difficult choices about abortion and, for those who carry the pregnancy, late initiation of prenatal care may increase the likelihood of an adverse pregnancy outcome.3 Understanding why patients do or do not request pregnancy tests may therefore improve doctor-patient communication and result in better quality of care. Pregnancy test requests are determined in part by clinical variables such as symptoms, contraceptive practices, parity, menstrual regularity, and desire for pregnancy.4 Requests may also be shaped by sociodemographic factors that predict health-care utilization in general. Ethnicity is one such factor,5 and the study of ethnic differences in health and health-care utilization is a crucial issue in primary care research.6 For both planners and providers of care, it is essential to verify whether black patients use services differently than whites, and, if so, which services and why. The current study considers whether black women request pregnancy tests less frequently than whites. The authors have found that black women more often received provider-initiated rather than patient-initiated pregnancy tests (P < .05) in a study based on a small sample and low-order analyses.2 The authors now examine ethnic differences in the requesting of pregnancy tests in a large sample using multivariable methods. Specific objectives are 1) to confirm that black women are less likely to request pregnancy tests, 2) to identify ethnic differences both in sample characteristics and in factors predicting test requests, and 3) to generate explanatory hypotheses based on these differences. 403
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Variable Requested testt Pregnant Symptoms score Duration of amenorrhea Desires pregnancy Menstrual regularity Contraceptive use Prior pregnancy* Age Marital statust Employed lnsuredt
TABLE 1. ETHNIC DIFFERENCES IN STUDY VARIABLES Blacks Whites x (SD) n x (SD) 0.40 (0.49) 154 0.54 (0.50) 0.36 (0.48) 154 0.33 (0.47) 1.44 1.28 134 (0.98) (0.99) 144 54.3 52.4 (55.6) (34.9) 0.19 (0.40) 139 0.28 (0.45) 0.73 (0.44) 153 0.65 (0.48) 147 0.50 0.49 (0.50) (0.50) 0.72 (0.45) 151 0.59 (0.49) 26.2 (6.47) 153 25.6 (5.49) 0.29 (0.46) 150 0.52 (0.50) 0.60 (0.49) 150 0.83 (0.38) 0.72 0.58 (0.49) 153 (0.45)
n 155 155 145 149 138 154 153 152 155 154 149 154
*P < .05. tP < .01. tP < .001.
METHODS The Study Subjects were drawn from the population of 324 women undergoing a pregnancy test at an academic primary care practice during 1986. Eleven women were excluded because data on whether or not they requested a pregnancy test were unavailable, leaving a sample of 313 individuals (107 pregnant; 206 nonpregnant). There were 146 women (82 pregnant; 64 nonpregnant) who requested a pregnancy test and 167 (25 pregnant; 142 nonpregnant) who did not. Additional information on this study's sample can be found elsewhere.2
uninsured, 1 = insured). Symptoms considered are those typically associated with normal pregnancy (amenorrhea, breast tenderness, morning sickness),8 and are combined as a summary score (coded: 0 to 3) for the 279 subjects among whom data on the presence or absence of all three symptoms were available. Other clinical variables include duration of amenorrhea (in days), contraceptive use (coded: 0 = no, 1 = yes), gravidity (coded: 0 = no prior pregnancy, 1 = one or more prior pregnancies), menstrual regularity (coded: 0 = irregular, 1 = regular), and desire for pregnancy (coded: 0 = unwanted, 1 = wanted).
Variables
Data Analysis
The pregnancy test used throughout, the Tandem ICON (Hybritech Inc, San Diego, California), detects hCG (human chorionic gonadotropin) concentrations between 20 and 50 IU/L, and because of this high analytic sensitivity, pregnancy status was defined according to test results.7 Data were supplied by a questionnaire filled out by providers ordering these tests who specified whether or not the patient requested the test and whether or not pregnancy was desired. Data were also obtained on ethnicity (coded: 0 = white, 1 = black) and other clinical and sociodemographic variables known to affect the perceived likelihood of pregnancy,4 and thus the likelihood of requesting a pregnancy test. Sociodemographic variables include age (in years), marital status (coded: 0 = unmarried, 1 = married), employment status (coded: 0 = unemployed, 1 = employed), and insurance coverage (coded: 0 =
In order to identify and describe possible ethnic differences in requests for pregnancy tests, sample characteristics, and relevant clinical variables, two analyses were conducted. First, analyses of variance (ANOVAs) were run to test for ethnic differences (black versus white) in these variables. Analyses were run using GLM in mainframe version 5.18 of the SAS software package for statistical analysis.9 Analyses of variance were also conducted separately by pregnancy status in order to determine if potential differences in such requests differed by whether or not one was actually pregnant. An analysis of covariance (ANCOVA) was run to assess the significance of black-white differences in test requests controlling for the effects of all 11 study variables. Second, pregnancy test request status (0 = test not requested, 1 = test requested) was logistically regressed onto the clinical and sociodemographic varia-
404
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TABLE 2. PREDICTORS OF REQUESTING A PREGNANCY TEST, BY ETHNICITY Whites(N = 125) Blacks (N = 110) b (1) (1) se b Variable 1.84 0.60 -0.05 (-0.01) Pregnant (0.50)* (0.81)t 1.47 0.34 0.58 (0.32) Symptoms score (-0.05) -0.00 0.01 0.01 (0.10) Duration of amenorrhea (0.37) 1.51 0.72 0.27 (0.06) Desires pregnancy 0.50 0.62 0.85 (0.21) (0.13) Menstrual regularity 0.12 0.55 0.15 (0.03) (0.04) Contraceptive use (0.07) 0.27 0.70 1.14 (0.29) Prior pregnancy 0.16 0.05 (-0.19) -0.05 (0.50)* Age (0.00) 0.01 0.68 (-0.20) -0.83 Marital status (-0.21) -1.02 0.70 0.60 (0.16) Employed (-0.04) -0.20 0.64 0.68 (0.18) Insured
se 0.70 0.37 0.01 0.82 0.57 0.59 0.52 0.05 0.58 0.82 0.65
*P < .01.
tP < .001. bles identified earlier. Logistic regressions were conducted separately by ethnicity in order to identify potential black-white differences in the patterns of predictors of requesting a pregnancy test. These analyses were run using LOGIST in the SUGI supplement to SAS mainframe version 5.
RESULTS Table 1 presents ANOVA results for ethnic differences in pregnancy-test requests and other study variables. These findings reveal statistically significant ethnic differences in requesting a test and in prior pregnancy, marital status, and insurance status. Specifically, black women were less likely than white women to request a pregnancy test, be married, or be insured, but more likely to have had a prior pregnancy. These differences persisted upon stratification for pregnancy status, and results of an ANCOVA (not reported in Table 1) revealed that the black-white difference in test-requests persisted (P < .01) despite controlling for the effects of all 11 study variables. Table 2 summarizes results from multiple logistic regressions that together point to ethnic differences in predictors of requesting a pregnancy test. While an ethnic difference in the pattern of predictors is apparent, few of the posited variables exert statistically significant net effects on test-request status in either ethnic group. Among blacks, pregnancy is the only significant predictor of requesting a test, with pregnancy symptoms and age the only significant predictors among whites.
DISCUSSION The first objective was to confirm that black women in the study sample were significantly less likely to request a pregnancy test. The authors found that this JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
effect appears greater than their previous study had suggested and, furthermore, that it persists regardless of pregnancy status and after controlling for the effects of other study variables (P < .01). Ethnic differences in the likelihood of requesting a pregnancy test have not been considered elsewhere, but lower use by blacks of other diagnostic procedures has been found in both ambulatory and hospital settings.5'10 Although other explanations are possible, lower black utilization may have resulted in part from fewer patient requests for these services. This possibility is also consistent with findings of delayed recognition of pregnancy 11 and later initiation of prenatal care by some black women,12'13 effects that are independent of income, insurance coverage, and education in some studies."I The second objective was to describe ethnic differences in sample characteristics and in factors that predicted requests for pregnancy tests. It was found that while black and white subjects differed with respect to marital status, insurance coverage, and parity, these differences did not predict test requests. There were, however, ethnic differences in the patterns of significant predictors, with being pregnant the only predictor among black patients, and the presence of pregnancy symptoms and older age the only predictors among whites. These results are especially meaningful as they represent net effects of multivariable analyses that controlled for the effects of all other potential testrequest determinants considered in this study. The third objective was to generate explanations for ethnic variation in the requesting of pregnancy tests based on results of the study. Although the authors were unable to draw definitive conclusions, several hypotheses merit consideration, the first being that black 405
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women requested fewer tests because of culturallymediated ethnic differences in reactions to symptoms. In this context, "culture" is a learned system of beliefs and values transmitted from one generation to the next,14 and governing behavior in a number of domains, including decisions to seek health care. Among blacks, these cultural influences may include greater tolerance of symptoms, necessitated by historically severe economic and prejudicial barriers to care, or negative feelings about the health-care system resulting from impeded access.6'14 Others have suggested that blacks are less likely than whites to define transitory symptoms as illness,'5 or are more likely to use internal and family coping mechanisms for symptoms before seeking health care. 14 Postulating that ethnic differences in responses to symptoms influenced the likelihood of requesting a pregnancy test is therefore consistent with prior literature and suggested by the authors' finding that while symptoms were elicited equally from both blacks and whites, they predicted a test request only among whites. A second possible explanation involves economic considerations. In this sample, a greater proportion of black women were uninsured and a similar pattern was observed for marital status, considered a proxy measure for economic stability and resources in young women. 16 These factors did not predict test requests, but nonetheless represent a constrained ability to purchase such services. Such constraints continue to limit health-care utilization by blacks in other contexts17 and could influence decisions to request pregnancy tests as well, although the results did not demonstrate this. More direct measurement of household income and factors presenting barriers to health-care access are therefore recommended for future studies in this area. A third explanation is that biologic variation might have produced differences in clinical factors influencing pregnancy test requests, and a fourth explanation is that more negative affective responses to pregnancy among blacks led to delay in seeking medical attention.3'11'13'18 Ethnic similarities in symptoms scores, the duration of amenorrhea, menstrual regularity, contraceptive use, and desire for pregnancy all argue against these two hypotheses. The finding that older age predicted test requests among white women might suggest maturational or educational differences in the ability to recognize symptoms as being related to gestation4-a fifth possible explanation. This interpretation, however, is not supported in this particular study given the absence of mean age differences, the greater proportion of black women with a prior pregnancy, and the finding that actually being 406
pregnant predicted test requests among blacks. A sixth possible explanation is that the results were inconclusive because of several possible study limitations. First, symptoms scores for blacks may have been artifactually high. Research on health status indicates that young black adults report fewer symptoms than whites of similar age,19 and failure to observe such a difference may have occurred because the authors' data were obtained from providers who recorded symptoms elicited by direct inquiry rather than symptoms volunteered. This procedure may have inflated the number of symptoms noted for black women and introduced other inaccuracies in the recording of information. For example, provider assessments of desired pregnancy on the basis of apparent reactions to test results may have been incorrect. Inaccurate recording of whether or not a patient requested a test is possible, but unlikely given the specific nature of such requests. Second, other factors that are believed to predict care-seeking and use of services were not measured in this study. In particular, education and health knowledge were not assessed, nor were popular psychosocial measures such as emotional distress, social support, perceived health, and locus of control.4'13"8'20 Third, relationships with providers were not assessed, and limited rapport or lack of provider continuity may have hindered discussion of sensitive issues2l such as possible pregnancy. Fourth, concurrent illnesses, the degree of adherence to contraceptive technique, and other clinical variables that might define the perceived likelihood of pregnancy were not considered. Finally, nonrandom sampling and listwise deletions may have introduced systematic errors; it is presumed the 11 patients excluded because of lack of information regarding test-request status did not differ substantially from those considered in the study.
SUMMARY This study identified a strong black-white difference in the likelihood of requesting a pregnancy test. This difference persists in both pregnant and nonpregnant women, and after controlling for the effects of all other study variables. Factors predicting test requests differ by ethnicity and suggest variation in reaction to symptoms as one possible explanation for our findings; reasons for this variation will need future explanation. Black-white sample differences suggest that economic explanations be considered as well. Several other explanations were not consistent with our results, but' cannot be ruled out at this time. It must be noted, however, that these interpretations are neither definitive JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
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nor exhaustive, and they may oversimplify the complex phenomenon of care-seeking behavior. Inferences made for groups may have little to do with the behaviors of individuals or subgroups in this study, and may not apply to other settings.5 Despite these qualifications, the authors' findings imply that clinicians may be able to improve care for some black women of reproductive age by facilitating the expression of symptoms and opinions regarding the likelihood of pregnancy. The authors' findings can also guide subsequent inquiries that would replicate the association between ethnicity and pregnancy test requests in other samples, and lead to more refined explanatory hypotheses through 1) direct measurement of determinants of care-seeking behaviors, 2) disentanglement of the cultural, socioeconomic, and biologic effects of ethnicity,21 and 3) accounting for the socioeconomic, cultural, and personal diversity within ethnic groups.22 Such research should also investigate the impact of pregnancy test requests on the quality and cost of patient care. Potential benefits of this research agenda therefore include an improved understanding of care-seeking, thus leading to better doctor-patient communication and better clinical care both for black women and women in general. Acknowledgments The authors thank Robert Hewes, BS, for his assistance with computer programming and Peggy Schmader, BA, for her help in preparing this manuscript. Literature Cited 1. Laubach GE, Wilchins SA. III patients with unknown or hidden pregnancy. Postgrad Med. 1975;58:1 15-118. 2. Bluestein DA. The unanticipated pregnancy: a preliminary study. Fam Pract Res J. 1990;9:105-113. 3. Joyce TJ, Grossman M. Pregnancy wantedness and the early initiation of prenatal care. Demography 1990;27:1-7. 4. Burr WA, Schulz KF. Delayed abortion in an area of easy accessibility. JAMA. 1980;244:44-48. 5. Wenneker MB, Epstein AM. Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts. JAMA. 1989;261:253-257. 6. McDavid LM. An overlooked resource: the black patient,
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in Mayfield J, Grady ML (eds). Primary Care Research: An Agenda for the 90s. Washington, DC: US Government Printing Office; 1990. US Department of Health and Human Services publication PHS 90-3460. 7. Bluestein DA. Should you trust office pregnancy tests? Postgrad Med. 1990;87:57-58,61,64,67-68. 8. Robinson ET, Barber JH. Early diagnosis of pregnancy in general practice. Journal of the Royal College of General Practitioners. 1977;27:335-338. 9. SAS Institute. VMS SAS Production Release 5.18 [software]. Cary, NC: SAS Institute; 1988. 10. Baquet C, Ringen K. Health policy: gaps in access, delivery, and utilization of the PAP smear in the United States. Milbank 0. 1987;65(suppl 2):322-347. 11. Petitti D, Coleman C, Binsacca D, Allen B. Early prenatal care in urban black and white women. Birth. 1990;17:1-5. 12. Ku L. Factors influencing early prenatal enrollment in the WIC program. Public Health Rep. 1989;104:301-306. 13. Brown SS. Drawing women into prenatal care. Fam Plann Perspect. 1989;21 :73-80. 14. Bailey EJ. Sociocultural factors and health care-seeking behavior among black Americans. J Natl Med Assoc. 1 987;79:389-392. 15. Berkanovic E, Telesky C. Mexican-American, blackAmerican, and white American differences in reporting illnesses, disability, and physician visits for illnesses. Soc Sci Med. 1985;20:567-577. 16. Centers for Disease Control. Infant mortality by marital status of mother [editorial note]. MMWR. 1990;30:522-523. 17. Davis K, Lillie-Blanton M, Lyons B, Mullan F, Powe N, Rowland D. Health care for black Americans: the public sector role. Milbarhk 0. 1987;65 (suppl 1):213-247. 18. Bluestein DA, Levin JS. Symptom reporting in wanted and unwanted pregnancy. Fam Med. 1991;23:271-274. 19. Anderson RM, Mullner RM, Cornelius U. Black-white differences in health status: methods or substance? Milbank Q. 1987;65(suppl 1):72-99. 20. McKay DA, Gill DG, Colwill JM. Sociocultural influences on medicine and health. In Rakel RE, ed. Textbook of Family Practice. 3rd ed. Philadelphia, Pa: WB Saunders;1984:217223. 21. Schlesinger M. Paying the price: medical care, minorities, and the newly competitive health care system. Milbank Q. 1987;65(suppl 2):270-296. 22. Cabral H, Fried LE, Levenson S, Amaro H, Zuckerman B. Foreign-born and US-born black women: differences in health behaviors and birth outcomes. Am J Public Health. 1 990;80:70-71.
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This study identifies a black-white difference in pregnancy test requests and in factors predicting such requests among 324 women tested at an academic family practice in 1986. Data were obtained from encounter sheets filled out by clinicians at the time tests were ordered. Analysis of variance revealed that blacks requested fewer pregnancy tests than whites, and that this finding remained significant (P < .01) after controlling for the effects of gestational status and other clinical and sociodemographic factors. Blacks were less likely to be married or possess health insurance, but more likely to have been pregnant before. Logistic regressions indicated that factors predicting test requests differed by ethnicity, with symptoms and age predicting test requests among whites, and pregnancy the only significant predictor among blacks. Explanations consistent with these findings include possible ethnic differences in reactions to symptoms and economic factors. Further refinement of these hypotheses and consideration of other alternatives will advance understanding of ethnicity as a factor in testrequesting behavior, and enable clinicians to communicate with and care for b'ack women more effectively. (J Nati Med Assoc. 1 992;84:403-407.) Key words * pregnancy tests * ethnic variation From the Department of Family and Community Medicine, Eastern Virginia Medical School, Norfolk, Virginia. Requests for reprints should be addressed to Dr Daniel Bluestein, Dept of Family and Community Medicine, Eastern Virginia Medical School, PO Box 1980, Norfolk, VA 23501. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
Pregnancy tests are often ordered at patients' requests and failure to make such requests may contribute to misdiagnosis.' In these circumstances, teratogenic and iatrogenic misadventures may occur more frequently, and counselling regarding pregnancy disposition may be delayed.2 Patients may have less time to make difficult choices about abortion and, for those who carry the pregnancy, late initiation of prenatal care may increase the likelihood of an adverse pregnancy outcome.3 Understanding why patients do or do not request pregnancy tests may therefore improve doctor-patient communication and result in better quality of care. Pregnancy test requests are determined in part by clinical variables such as symptoms, contraceptive practices, parity, menstrual regularity, and desire for pregnancy.4 Requests may also be shaped by sociodemographic factors that predict health-care utilization in general. Ethnicity is one such factor,5 and the study of ethnic differences in health and health-care utilization is a crucial issue in primary care research.6 For both planners and providers of care, it is essential to verify whether black patients use services differently than whites, and, if so, which services and why. The current study considers whether black women request pregnancy tests less frequently than whites. The authors have found that black women more often received provider-initiated rather than patient-initiated pregnancy tests (P < .05) in a study based on a small sample and low-order analyses.2 The authors now examine ethnic differences in the requesting of pregnancy tests in a large sample using multivariable methods. Specific objectives are 1) to confirm that black women are less likely to request pregnancy tests, 2) to identify ethnic differences both in sample characteristics and in factors predicting test requests, and 3) to generate explanatory hypotheses based on these differences. 403
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Variable Requested testt Pregnant Symptoms score Duration of amenorrhea Desires pregnancy Menstrual regularity Contraceptive use Prior pregnancy* Age Marital statust Employed lnsuredt
TABLE 1. ETHNIC DIFFERENCES IN STUDY VARIABLES Blacks Whites x (SD) n x (SD) 0.40 (0.49) 154 0.54 (0.50) 0.36 (0.48) 154 0.33 (0.47) 1.44 1.28 134 (0.98) (0.99) 144 54.3 52.4 (55.6) (34.9) 0.19 (0.40) 139 0.28 (0.45) 0.73 (0.44) 153 0.65 (0.48) 147 0.50 0.49 (0.50) (0.50) 0.72 (0.45) 151 0.59 (0.49) 26.2 (6.47) 153 25.6 (5.49) 0.29 (0.46) 150 0.52 (0.50) 0.60 (0.49) 150 0.83 (0.38) 0.72 0.58 (0.49) 153 (0.45)
n 155 155 145 149 138 154 153 152 155 154 149 154
*P < .05. tP < .01. tP < .001.
METHODS The Study Subjects were drawn from the population of 324 women undergoing a pregnancy test at an academic primary care practice during 1986. Eleven women were excluded because data on whether or not they requested a pregnancy test were unavailable, leaving a sample of 313 individuals (107 pregnant; 206 nonpregnant). There were 146 women (82 pregnant; 64 nonpregnant) who requested a pregnancy test and 167 (25 pregnant; 142 nonpregnant) who did not. Additional information on this study's sample can be found elsewhere.2
uninsured, 1 = insured). Symptoms considered are those typically associated with normal pregnancy (amenorrhea, breast tenderness, morning sickness),8 and are combined as a summary score (coded: 0 to 3) for the 279 subjects among whom data on the presence or absence of all three symptoms were available. Other clinical variables include duration of amenorrhea (in days), contraceptive use (coded: 0 = no, 1 = yes), gravidity (coded: 0 = no prior pregnancy, 1 = one or more prior pregnancies), menstrual regularity (coded: 0 = irregular, 1 = regular), and desire for pregnancy (coded: 0 = unwanted, 1 = wanted).
Variables
Data Analysis
The pregnancy test used throughout, the Tandem ICON (Hybritech Inc, San Diego, California), detects hCG (human chorionic gonadotropin) concentrations between 20 and 50 IU/L, and because of this high analytic sensitivity, pregnancy status was defined according to test results.7 Data were supplied by a questionnaire filled out by providers ordering these tests who specified whether or not the patient requested the test and whether or not pregnancy was desired. Data were also obtained on ethnicity (coded: 0 = white, 1 = black) and other clinical and sociodemographic variables known to affect the perceived likelihood of pregnancy,4 and thus the likelihood of requesting a pregnancy test. Sociodemographic variables include age (in years), marital status (coded: 0 = unmarried, 1 = married), employment status (coded: 0 = unemployed, 1 = employed), and insurance coverage (coded: 0 =
In order to identify and describe possible ethnic differences in requests for pregnancy tests, sample characteristics, and relevant clinical variables, two analyses were conducted. First, analyses of variance (ANOVAs) were run to test for ethnic differences (black versus white) in these variables. Analyses were run using GLM in mainframe version 5.18 of the SAS software package for statistical analysis.9 Analyses of variance were also conducted separately by pregnancy status in order to determine if potential differences in such requests differed by whether or not one was actually pregnant. An analysis of covariance (ANCOVA) was run to assess the significance of black-white differences in test requests controlling for the effects of all 11 study variables. Second, pregnancy test request status (0 = test not requested, 1 = test requested) was logistically regressed onto the clinical and sociodemographic varia-
404
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TABLE 2. PREDICTORS OF REQUESTING A PREGNANCY TEST, BY ETHNICITY Whites(N = 125) Blacks (N = 110) b (1) (1) se b Variable 1.84 0.60 -0.05 (-0.01) Pregnant (0.50)* (0.81)t 1.47 0.34 0.58 (0.32) Symptoms score (-0.05) -0.00 0.01 0.01 (0.10) Duration of amenorrhea (0.37) 1.51 0.72 0.27 (0.06) Desires pregnancy 0.50 0.62 0.85 (0.21) (0.13) Menstrual regularity 0.12 0.55 0.15 (0.03) (0.04) Contraceptive use (0.07) 0.27 0.70 1.14 (0.29) Prior pregnancy 0.16 0.05 (-0.19) -0.05 (0.50)* Age (0.00) 0.01 0.68 (-0.20) -0.83 Marital status (-0.21) -1.02 0.70 0.60 (0.16) Employed (-0.04) -0.20 0.64 0.68 (0.18) Insured
se 0.70 0.37 0.01 0.82 0.57 0.59 0.52 0.05 0.58 0.82 0.65
*P < .01.
tP < .001. bles identified earlier. Logistic regressions were conducted separately by ethnicity in order to identify potential black-white differences in the patterns of predictors of requesting a pregnancy test. These analyses were run using LOGIST in the SUGI supplement to SAS mainframe version 5.
RESULTS Table 1 presents ANOVA results for ethnic differences in pregnancy-test requests and other study variables. These findings reveal statistically significant ethnic differences in requesting a test and in prior pregnancy, marital status, and insurance status. Specifically, black women were less likely than white women to request a pregnancy test, be married, or be insured, but more likely to have had a prior pregnancy. These differences persisted upon stratification for pregnancy status, and results of an ANCOVA (not reported in Table 1) revealed that the black-white difference in test-requests persisted (P < .01) despite controlling for the effects of all 11 study variables. Table 2 summarizes results from multiple logistic regressions that together point to ethnic differences in predictors of requesting a pregnancy test. While an ethnic difference in the pattern of predictors is apparent, few of the posited variables exert statistically significant net effects on test-request status in either ethnic group. Among blacks, pregnancy is the only significant predictor of requesting a test, with pregnancy symptoms and age the only significant predictors among whites.
DISCUSSION The first objective was to confirm that black women in the study sample were significantly less likely to request a pregnancy test. The authors found that this JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
effect appears greater than their previous study had suggested and, furthermore, that it persists regardless of pregnancy status and after controlling for the effects of other study variables (P < .01). Ethnic differences in the likelihood of requesting a pregnancy test have not been considered elsewhere, but lower use by blacks of other diagnostic procedures has been found in both ambulatory and hospital settings.5'10 Although other explanations are possible, lower black utilization may have resulted in part from fewer patient requests for these services. This possibility is also consistent with findings of delayed recognition of pregnancy 11 and later initiation of prenatal care by some black women,12'13 effects that are independent of income, insurance coverage, and education in some studies."I The second objective was to describe ethnic differences in sample characteristics and in factors that predicted requests for pregnancy tests. It was found that while black and white subjects differed with respect to marital status, insurance coverage, and parity, these differences did not predict test requests. There were, however, ethnic differences in the patterns of significant predictors, with being pregnant the only predictor among black patients, and the presence of pregnancy symptoms and older age the only predictors among whites. These results are especially meaningful as they represent net effects of multivariable analyses that controlled for the effects of all other potential testrequest determinants considered in this study. The third objective was to generate explanations for ethnic variation in the requesting of pregnancy tests based on results of the study. Although the authors were unable to draw definitive conclusions, several hypotheses merit consideration, the first being that black 405
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women requested fewer tests because of culturallymediated ethnic differences in reactions to symptoms. In this context, "culture" is a learned system of beliefs and values transmitted from one generation to the next,14 and governing behavior in a number of domains, including decisions to seek health care. Among blacks, these cultural influences may include greater tolerance of symptoms, necessitated by historically severe economic and prejudicial barriers to care, or negative feelings about the health-care system resulting from impeded access.6'14 Others have suggested that blacks are less likely than whites to define transitory symptoms as illness,'5 or are more likely to use internal and family coping mechanisms for symptoms before seeking health care. 14 Postulating that ethnic differences in responses to symptoms influenced the likelihood of requesting a pregnancy test is therefore consistent with prior literature and suggested by the authors' finding that while symptoms were elicited equally from both blacks and whites, they predicted a test request only among whites. A second possible explanation involves economic considerations. In this sample, a greater proportion of black women were uninsured and a similar pattern was observed for marital status, considered a proxy measure for economic stability and resources in young women. 16 These factors did not predict test requests, but nonetheless represent a constrained ability to purchase such services. Such constraints continue to limit health-care utilization by blacks in other contexts17 and could influence decisions to request pregnancy tests as well, although the results did not demonstrate this. More direct measurement of household income and factors presenting barriers to health-care access are therefore recommended for future studies in this area. A third explanation is that biologic variation might have produced differences in clinical factors influencing pregnancy test requests, and a fourth explanation is that more negative affective responses to pregnancy among blacks led to delay in seeking medical attention.3'11'13'18 Ethnic similarities in symptoms scores, the duration of amenorrhea, menstrual regularity, contraceptive use, and desire for pregnancy all argue against these two hypotheses. The finding that older age predicted test requests among white women might suggest maturational or educational differences in the ability to recognize symptoms as being related to gestation4-a fifth possible explanation. This interpretation, however, is not supported in this particular study given the absence of mean age differences, the greater proportion of black women with a prior pregnancy, and the finding that actually being 406
pregnant predicted test requests among blacks. A sixth possible explanation is that the results were inconclusive because of several possible study limitations. First, symptoms scores for blacks may have been artifactually high. Research on health status indicates that young black adults report fewer symptoms than whites of similar age,19 and failure to observe such a difference may have occurred because the authors' data were obtained from providers who recorded symptoms elicited by direct inquiry rather than symptoms volunteered. This procedure may have inflated the number of symptoms noted for black women and introduced other inaccuracies in the recording of information. For example, provider assessments of desired pregnancy on the basis of apparent reactions to test results may have been incorrect. Inaccurate recording of whether or not a patient requested a test is possible, but unlikely given the specific nature of such requests. Second, other factors that are believed to predict care-seeking and use of services were not measured in this study. In particular, education and health knowledge were not assessed, nor were popular psychosocial measures such as emotional distress, social support, perceived health, and locus of control.4'13"8'20 Third, relationships with providers were not assessed, and limited rapport or lack of provider continuity may have hindered discussion of sensitive issues2l such as possible pregnancy. Fourth, concurrent illnesses, the degree of adherence to contraceptive technique, and other clinical variables that might define the perceived likelihood of pregnancy were not considered. Finally, nonrandom sampling and listwise deletions may have introduced systematic errors; it is presumed the 11 patients excluded because of lack of information regarding test-request status did not differ substantially from those considered in the study.
SUMMARY This study identified a strong black-white difference in the likelihood of requesting a pregnancy test. This difference persists in both pregnant and nonpregnant women, and after controlling for the effects of all other study variables. Factors predicting test requests differ by ethnicity and suggest variation in reaction to symptoms as one possible explanation for our findings; reasons for this variation will need future explanation. Black-white sample differences suggest that economic explanations be considered as well. Several other explanations were not consistent with our results, but' cannot be ruled out at this time. It must be noted, however, that these interpretations are neither definitive JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 5
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nor exhaustive, and they may oversimplify the complex phenomenon of care-seeking behavior. Inferences made for groups may have little to do with the behaviors of individuals or subgroups in this study, and may not apply to other settings.5 Despite these qualifications, the authors' findings imply that clinicians may be able to improve care for some black women of reproductive age by facilitating the expression of symptoms and opinions regarding the likelihood of pregnancy. The authors' findings can also guide subsequent inquiries that would replicate the association between ethnicity and pregnancy test requests in other samples, and lead to more refined explanatory hypotheses through 1) direct measurement of determinants of care-seeking behaviors, 2) disentanglement of the cultural, socioeconomic, and biologic effects of ethnicity,21 and 3) accounting for the socioeconomic, cultural, and personal diversity within ethnic groups.22 Such research should also investigate the impact of pregnancy test requests on the quality and cost of patient care. Potential benefits of this research agenda therefore include an improved understanding of care-seeking, thus leading to better doctor-patient communication and better clinical care both for black women and women in general. Acknowledgments The authors thank Robert Hewes, BS, for his assistance with computer programming and Peggy Schmader, BA, for her help in preparing this manuscript. Literature Cited 1. Laubach GE, Wilchins SA. III patients with unknown or hidden pregnancy. Postgrad Med. 1975;58:1 15-118. 2. Bluestein DA. The unanticipated pregnancy: a preliminary study. Fam Pract Res J. 1990;9:105-113. 3. Joyce TJ, Grossman M. Pregnancy wantedness and the early initiation of prenatal care. Demography 1990;27:1-7. 4. Burr WA, Schulz KF. Delayed abortion in an area of easy accessibility. JAMA. 1980;244:44-48. 5. Wenneker MB, Epstein AM. Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts. JAMA. 1989;261:253-257. 6. McDavid LM. An overlooked resource: the black patient,
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in Mayfield J, Grady ML (eds). Primary Care Research: An Agenda for the 90s. Washington, DC: US Government Printing Office; 1990. US Department of Health and Human Services publication PHS 90-3460. 7. Bluestein DA. Should you trust office pregnancy tests? Postgrad Med. 1990;87:57-58,61,64,67-68. 8. Robinson ET, Barber JH. Early diagnosis of pregnancy in general practice. Journal of the Royal College of General Practitioners. 1977;27:335-338. 9. SAS Institute. VMS SAS Production Release 5.18 [software]. Cary, NC: SAS Institute; 1988. 10. Baquet C, Ringen K. Health policy: gaps in access, delivery, and utilization of the PAP smear in the United States. Milbank 0. 1987;65(suppl 2):322-347. 11. Petitti D, Coleman C, Binsacca D, Allen B. Early prenatal care in urban black and white women. Birth. 1990;17:1-5. 12. Ku L. Factors influencing early prenatal enrollment in the WIC program. Public Health Rep. 1989;104:301-306. 13. Brown SS. Drawing women into prenatal care. Fam Plann Perspect. 1989;21 :73-80. 14. Bailey EJ. Sociocultural factors and health care-seeking behavior among black Americans. J Natl Med Assoc. 1 987;79:389-392. 15. Berkanovic E, Telesky C. Mexican-American, blackAmerican, and white American differences in reporting illnesses, disability, and physician visits for illnesses. Soc Sci Med. 1985;20:567-577. 16. Centers for Disease Control. Infant mortality by marital status of mother [editorial note]. MMWR. 1990;30:522-523. 17. Davis K, Lillie-Blanton M, Lyons B, Mullan F, Powe N, Rowland D. Health care for black Americans: the public sector role. Milbarhk 0. 1987;65 (suppl 1):213-247. 18. Bluestein DA, Levin JS. Symptom reporting in wanted and unwanted pregnancy. Fam Med. 1991;23:271-274. 19. Anderson RM, Mullner RM, Cornelius U. Black-white differences in health status: methods or substance? Milbank Q. 1987;65(suppl 1):72-99. 20. McKay DA, Gill DG, Colwill JM. Sociocultural influences on medicine and health. In Rakel RE, ed. Textbook of Family Practice. 3rd ed. Philadelphia, Pa: WB Saunders;1984:217223. 21. Schlesinger M. Paying the price: medical care, minorities, and the newly competitive health care system. Milbank Q. 1987;65(suppl 2):270-296. 22. Cabral H, Fried LE, Levenson S, Amaro H, Zuckerman B. Foreign-born and US-born black women: differences in health behaviors and birth outcomes. Am J Public Health. 1 990;80:70-71.
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