Soc. Sci, & Med., Voi. 13A, pp. 807 to 811 Pergamon Press Ltd 1979. Printed in Great Britain
RESEARCH NOTE SOCIAL C O N T A C T FACTORS IN THE D I F F U S I O N OF CERVICAL C Y T O L O G Y A M O N G M E X I C A N - A M E R I C A N S IN LOS A N G E L E S COUNTY, CALIFORNIA JOHN W. McCURTIS Department of Sociology, California State University, Dominguez Hills, California, U.S.A. Abstract--Cancer of the cervix is responsible for many thousands of deaths in the United States each year. These deaths occur in spite of the fact that if the disease is found early, treatment is almost always successful. It is important, therefore, to understand more about factors associated with acceptance and non-acceptance of cervical cytology among women, particularly those at high risk for this desease. In our study, we wished to examine the extent to which chicana patients utilize the Papanicolaou smear and the characteristics o f those who did and did not.
The findings suggest that if measures could increase periodic contact With physicians, whatever the service, these physicians could, in turn, influence them to obtain regular cytologic examinations. In essence, all physicians who attend females should be encouraged to emphasize and insist on periodic examinations of the cervix uteri. This approach to cancer prevention and control seems most needed in light of the data presented in this study. It therefore seems that if motivating programs were directed toward channels suggested by these findings, a significant number of currently irregular or non-acceptors of cytological screening would obtain peri,odic screenings for cancer.
INTRODUCTION
Data on the incidence of cancer in the United States population reveal a number of factors relevant to its control and prevention. One factor is that malignancies of the reproductive organs tend to be higher among the lower income non-white U.S. female population [1]. A second factor is that of the twenty-four most frequent types of cancers studied, one of the most prevalent types found in the low income nonwhite female is cervical cancer [2]. In short, although medical technicians have sufficient knowledge as to what should be done to effect control and prevention of cancer, the social problem of getting the high risk lower income, non-white populations properly screened and the disease prevented is not yet solved. This problem has prompted investigation of factors responsible for the delay in the initiation of cytological screening for cancer. While there are some exceptions, most of the previous research has produced little in the way of understanding and/or modifying the behavior of the non-user of cytological screening. In attempting to explain and predict acceptance of an innovation, such as cytological screening, social scientists have focused on the forces that influence the contact which the potential acceptor has with the innovation. For example, Beal [3] and Rogers [4] assert that mass media is a most useful and effective source of contact information, particularly with early acceptors of an innovation. Katz and Lazarsfeld assert a "two-step flow of communication" where people who are more exposed to communicative messages, via the mass media, pass on what they see
and hear to people less exposed [5]. To date, the most useful approaches to the acceptance of an innovation have avoided a simplistic variable approach. For example, the works of Naquib [6], Coleman [7] and Barnett [8] concentrate on the multiplicity of contact factors operating to influence behavioral change. Research studies on public behavior regarding cervical cytology indicates that such sociocultural factors as age [16, 19, 21], race [16, 21], socioeconomic status [18, 20, 21], education [16, 21], marital status [19, 17] and method of payment [19] profoundly influences the use and non-use of preventive cytological screening. This paper examines the social contact factors responsible for the use and non-use of cervical cytological screening. Its focus will be on Mexican-Americans, a population asserted t o have a high risk for cervical cancer and on whom little published data are available.
M E T H O D S A N D PROCEDURES
This study has as its focus the social contact factors associated with the use and non-use of cervical cytological screening among low-income groups, particularly Mexican-Americans, for whom almost no published data are available. The subsequent analysis focuses on the following comparison: those betweert u s e r s - - f e m a l e s who had two or more cytological screening in a minimum of three years prior to being interviewed; and nonu s e r s - - f e m a l e s who had none or only one screening
807
808
Research Note
examinations. The subjects systematically covered in in a minimum of three y.ears prior to being interthe interview schedule were: viewed. This study c~in attempt no more than a preliminary 1. Detailed information on the socio-economic analysis of the problem and therefore the sample size status and background of the respondents and their was limited to 120 meeting the criterion of users and families. 112 meeting the criterion of non-users of cytological 2. Material on attitudes toward and use of medical screening. We were interested in use of cytological facilities and medical professionals. screening because of the conviction that, at the 3. Various sources of information concerning the present state of knowledge, this is the only means symptoms and treatment of cancer. of identifying cervical cancer in its earliest stage. 4. Detailed information concerning past medical In this study patients were selected from the Family history, behavio?, and attitudes toward preventative Planning, Diabetic, and Gynecological Clinics of the medical care. Los Angeles County-Uniyersity of Southern CaliforThe nature of the material in the interview schedule nia Medical Center. The sample consists of patients dictated special caution in the selection and training available to us in the clinics during the study period, of the interviewers. Most importantly, all interviewers March 1973--December 1975. were female and Spanish-speaking so as to enhance It must be emphasized that our sample is not a the rapport between the interviewer and respondent, representative sample of Mexican-Americans as it dethus reducing the possibility of bias and error. Addirives from a particular hospital, University of Southtionally, interviewers were selected who were mature, ern California, Los Angeles County Hospital, and from a particular medical service area. In addition, had poise and who were especially comfortable in the sample of patients derive from three hospital dealing with the subject matter covered in the services, which limits our generalizations to that par- s c h e d u l e . Efforts were also made to recruit interticular hospital. Some patients were ill with Obgyn viewers who had prior medical and/or interviewing disorders or symptoms of diabetes; others, from experience. Included in the design of the study was an attempt family planning clinics, are asymptomatic. It must be to assess the reliability of the various questions asked further emphasized that we are not studying behavior by the study. To facilitate such a reliability check, in response to present illness brought into the hospiduplicate questions were included in the interview tal. We specifically excluded any behavior which could have been engendered by the present illness. schedule. This made possible comparison of answers Thus we required information, for example, use of to assess consistency. In addition, a 10~o random cervical cytology or symptoms up to one year before sample of respondents were also re-interviewed by interviewers using long distance calls from the Departthe onset of symptoms for the present illness. For example, we asked information on cervical cytologic ment of Sociology in Buffalo, New York. Also inexaminations in the time period up to and one year cluded in the design was a 100~o double-coding of materials to be punched so as to assess quality of before becoming patients in the hospital. coding and to make corrections where necessary. The ideal would be a random sample of MexicanAll of the data were obtained in a semi-nondirected Americans in the United States or of an entire community such as Los Angeles. However, a sample of manner based on a structured interview schedule. The specific questions were all asked in Spanish and, this type is difficult to obtain due to the fact that where possible, were phrased in order to avoid the there are no lists of low-income Mexican-Americans from which to sample. In addition, the study focuses implication of a desired answer. The raw data were on sensitive sexual behavior and as a result, impelled coded but not analyzed until after all interviews were the utilization of a community setting where confiden- completed. The characteristics of the group as a whole were studied and then broken down into user tiality was the mode. We therefore, used a hospital and non-user groups and compared. setting as the locus of this study. The Obstetrics and Gynecology clinic was the most logical choice for this study because Obgyn specialists have a vital interest FINDINGS in the use and lack of use of cervical cytology. We are aware of the biases of this inquiry evolving This study examined the social contact characterfrom the use of a very special sample. We are also istics which are related to use and non-use of cytoloaware that the very peculiarity of this sample makes gical screening among Mexican-Americans, Of the it very useful to some scientists, particularly Obstet232 patients included in the study 49~, or 112, fell rics and Gyneological specialists. We would hope that into the category of non-users of periodic screening. future investigations can be based on more represenIt was hypothesized that the mass media would tative groups of Mexican-Americans and on much have a significant influence on the awareness and aclarger numbers. The Mexican-American population, ceptance of cytological screening. The data in Table 1 a high risk group for cervical cancer, is of special fail to support this assertion, as both radio and interest, however, and completely unstudied with television appear to be poor sources of health inforregards to their cervical cancer screening behavior. mation for each study group. Only 28~o of both For this reason, we feel that an exploratory study groups obtained health information from radio of this kind is warranted. media, while 44 and 4 0 ~ of the users and non-users Due to the uniqueness of the study as a first obtained health information from television medi/t. approach to the question, the emphasis was on cover- Typical responses to the mass media questions were, "when I do listen to the radio or watch television, ing as broad a range of topics as possible, so as to discover significant areas for later, more intensive it's usually to hear or watch the news, a favorite soap
Research Note Table 1 Major sources of health information Radio
TV
Mag. or 6tl~er " printed Relatives
Nonusers Number Total Percent
30 49 (111) (110) 27.0 44.5
29 (111) 26.1
31 (112) 27.6
Users Number Total Percent
35 49 (120) (120) 29.1 40.8
38 (120) 31.6
13 (120) 10.8
Totals
(231) (230)
(231)
(232)
P < 0.05, based on summary 7.2. opera or my favorite music station". Many subjects stated that they "usually did not have time to watch television or listen to the radio" as they "had to get up early to get to work" and "came home so late" that by the time they were finished with supper, it was time to go to bed. In general, most of the subjects are not readers. In response to a question regarding newspaper and magazine purchases and subscriptions, the number responding were too few to present in table form. As with the other media, time was a major limiting factor. In addition, several respondents stated that they "could not read at all". While the majority of both study groups fail to read anything, especially about cancer, differences do exist between the two; for example 31% of the user group had read about cancer from at least one source, as compared to 26% of the non-users (Table 1). This finding seems to build on Dodson's thesis that "fatiguing work and little time and energy do impose Serious barriers to contact, via the media" [9]; this seems especially true of the nonuser group. In most cases, the patients stated that even their "weekends did not allow much time for reading or watching television" due to shopping and other necessary errands. The most convenient time for the non-users, especially for reading, was "while waiting in a physician's office". If Dodson's assertion regarding the amount and type of social interaction between "in groups" among working class families is correct, it would seem that relatives would serve as important providers of information regarding health information. The data in Table 1 supports this assertion, especially among the non-users, who frequently cite relatives as sources of health information; 27% of the non-users compared
809
to 11% of the users cited relatives as a health information source. In cases where a relative was named, it was usually a distant relative, e.g. aunt, cousin, etc. This finding may suggest that although the non-user does obtain a great deal of their health information from relative sources, relatives do not serve as "triggers" to preventive medical care as do other sources with which the non-user comes in contact. It must be pointed out, however that the sample consisted of individuals whose immediate relatives were still residing in Mexico. Therefore, familial sources of health information were not available to some patients. With regard to the source of information concerning cytological screening other than physicians, Table 2 shows interesting differences. The major source of information concerning cytological screening, prior to hearing about it from the physician, included friends and the mass media which together comprised a small percentage of informational sources. Note the larger proportion of non-users reporting no source of information concerning cytological screening before the physician. Wilkening asserts that persons seek out, as sources of information, those individuals who reflect the traditional values of the community [10]. By tradition, physicians are highly ranked in almost all societies. The role of the physician in cancer control and prevention is clearly depicted in Table 3. The majority of both study groups, 83% of the non-users and users, named the physician as the major influential to obtaining cytological screening. These data reemphasize the significance of physician participation in triggering the individual to seek preventive cytological screening. In addition to being traditionally accepted sources of medical information, physicians are also in a more viable position to give advice and to reinforce, disseminate and interpret information vital to the acceptance of an innovation such as cytological screening. Therefore, as medical researchers develop new techniques and accumulate new information for the prevention and control of such chronic illnesses as cancer, it is of vital importance for the physician to utilize his charisma, prestige, and technical knowledge in t h e public health effort to both translate and communicate these findings into action programs for the patient. SUMMARY AND CONCLUSIONS
Among the relatively objective contact characteristics studies, the contributions of relatives, corn-
Table 2. Source of information concerning cytologic screening before physician None Relative
Friend
Other Media medical
Other
Totals
Nonusers
Number Percent Users Number Percent
79 72.5
3 2.8
12 11
9 8.2
3 2.7
3 2.7
109 100
72 60
5 4.2
22 18.3
11 9.2
1 8
9 7.5
. 120 100
P > 0.05, based on summary Z2.
Research Note
810 Table 3. Major influential to obtain cytological None Physician ~Friend
Other
Totals
Nonusers Number Percent
7 6.9
85 83.3
5 4.9
5 4.9
102 100
Users Number Percent
7 5.9
98 83.1
9 7.6
4 3.4
118 100
P > 0.05. based on summary
~2.
munity members and the media to medical knowledge and behavior was essentially the same for both regular and irregular users. These factors are difficult to interpret, especially since the patients' interpretation of the contribution and influence of media, relatives, etc. would seem to vary depending upon their subjective adjustment and sensitivity to family members and other influentials to medical care. It was hypothesized that the major influences or "triggers" would be different for the two study groups. This hypothesis proved only partially correct. It is interesting to note that, although similar studies on the high risk Mexican-American are few, studies of other groups appear generally to corroborate with the findings of this study. Martin's [11] research on motivation for cytological screening similarly found the lack of physician contact and influence as barriers to preventive screening behavior. In general, it is theorized that the mass media are effective mechanisms in bringing to groups the information necessary to insure the response desired by the public health worker. However, the data presented in this study indicate that the assets and liabilities of this traditional theoretical approach need to be reconsidered when influence of the media on medical behavior of certain populations, especially Mexican-Americans. As did Lazarsfeld and Kendall, we found that individuals from certain social-status groups do not utilize the media, electronic or printed matter, as vehicles to health information. Therefore, those individuals who are regarded most hopefully as the target of media communications are least likely to receive information transmitted via the media. As a result, educational programs utilizing the media as their primary mechanism of information very likely do not reach these individuals. A great deal of behavior change theory has been devoted to the potential power of personal influence mechanisms and agents in communication and persuasion, especially among lower socioeconomic groups. In studying factors responsible for the acceptance or non-acceptance of cytological screening, earlier studies emphasized the importance of the physician as an influential in medical behavior. For example, research findings by Park and Gallo [12], Harms [13], and Levin [14] all point out the importance of the physician in the diffusion of innovation process. The findings of the present study compare closely with those in these earlier studies and reemphasize the crucial role of the physician in influencing patients to obtain cytological screening. Therefore, the physician, whether general practitioner or special-
ist, intern or surgeon, must operate his own cancer detection clinic by taking a careful and complete medical history and doing a pelvic examination of each patient regardless of the medical setting or service performed. However, the task of influencing the individual to undertake preventive action cannot be left solely to the physician. Innovative approaches must be developed to extend the physician's competence in the management of chronic disease, especially cancer. For example, well-trained allied medical workers should be utilized in educational and diagnostic aspects of the preventive programs, thus improving community participation and conserving valuable physician time. In the case of Mexican-Americans, an important share of the medical practitioner's activities is directed toward patients whose cultural patterns differ, to a considerable degree, from that of the mainstream United States population. The basic consideration in the introduction of preventive medicine to individuals from other cultural groups is that medical techniques and knowledge cannot be transmitted as isolated processes. With regard to illness behavior and treatment, Mexican-Americans have many traits common to the mainstream American society. However, the uniqueness of Mexican-American medical behavior derives from several varying cultural sources. Mexican-Americans, for example, draw their illness behavior and treatment from (1) folk medical practices of medieval Spain, (2) the cultures of the American Indian, and (3) scientific medical sources in Mexico and America. In a given situation, elements from any one or combination of the sources may be utilized in responding to medical problems or processes. This point seems especially relevant in view of the difference in the syndrome of preventive actions and treatment of symptoms in the users and non-users involved in this study. by S.U.N.Y. Buffalo Research Program in Social Epidemiology and Control of Cancer, Dr Saxon Graham, Director; National Cancer Institute Grant No. 11535. Acknowledgements--Supported
REFERENCES
1. Dorn H. F. and Cutler S. J. Morbidity from cancer in the United States; Part I, variation by age, sex, race, marital status and geographical region. Public Health Monograph, No. 29. United States Government Printing Office, Washington, D.C., 1955. 2. Department of Health, Education and Welfare, National Cancer Institute, Biometry Branch, Preliminary Report, Third National Cancer Survey, 1969, Incidence, Bethesda. Publication No. NIH 72-128, 1971. 3. Beal G. M. et al. Validity of the concept of stages in the adoption process. Rur. Sociol. 22, 166-68, 1957. 4. Rogers E. M. Diffusion of Innovations. Free Press, New York, 1962. 5. Katz E. and Lazarsfeld P. F. Personal Influence. Free Press, New York, 1955. 6. Naquib S. et al. Responses to a program of screening for cervical cancer. Publ. Hlth Rep. 83, 1968. 7. Coleman James S. et al. (Eds.). Medical Innovation: A Diffi~sion Study. Bobbs-Merrill Company, New York, t966.
Research Note 8. Barnett H. G. Innovation: The Basis of Cultural Change. McGraw-Hill, New York, 1953. 9. Dodson Floyd. Patterns of voluntary association among urban working class families. Am. Sociol. Rev. 16, 1961. 10. Wilkening E. A. Informal leaders and innovators in farm practices. Rur. Sociol. 17, 1972. 11. Martin P. L. Motivation for cytological screening. Calif. Med. 101, 1964. 12. Park George T. and Gallo James S. The culpability for delay in the treatment of cancer. Am. J. Cancer, 33, 1939. 13. Harms Charles et al. Delay in the treatment of cancer. Cancer 121, 1943. 14. Levin Alfred. Certain factors influencing cancer curability. Sth. med. J., La Grange 411, 1974. 15. Saunders Lyle. Cultural Differences and Medical Care: The Case of Spanish-speaking People of the Southwest. Russell Sage Foundation, New York, 1954. 16. Breslow L. and Hochstim J. R. Sociocultural aspects
17. 18. 19. 20. 21. 22.
811
of cervical cytology in Alameda County, California. Publ. Hlth Rep. 79, 107-112, 1964. Currier R. Is early and periodic screening, diagnosis and treatment (EPSDT) worthwhile? Publ. HIth Rep. 92, 527-536, 1977. Brand F. N., Smith R. T. and Brand P. Effect of economic barriers to medical care on patients noncompliance. Publ. HIth Rep. 92, 72-78, 1977. Brown A. J. Awareness and use of cervical cancer tests in a southern Appalachian community. Publ. HIth Rep. 91, 237-242, 1976. Kegeles S. S. Attitudes and behavior of the public regarding cervical cytology: current findings and new directions for research. ,L chron. Dis. 20, 911-922, 1967. Kegeles S. S., Kirscht J. P., Haefner P, and Rosenstock I.M. Survey of beliefs about cancer detection and taking Papanicalaou test. Publ. Hlth Rep. 80, 815-827, 1965. Sanson C. D., Wakefield J. and Penncak K. M. Choice or chance: how women come to have a cytotest done by their family doctor. Int. J. Hlth 2, 54q59, 1971.
RESEARCH NOTE SOCIAL C O N T A C T FACTORS IN THE D I F F U S I O N OF CERVICAL C Y T O L O G Y A M O N G M E X I C A N - A M E R I C A N S IN LOS A N G E L E S COUNTY, CALIFORNIA JOHN W. McCURTIS Department of Sociology, California State University, Dominguez Hills, California, U.S.A. Abstract--Cancer of the cervix is responsible for many thousands of deaths in the United States each year. These deaths occur in spite of the fact that if the disease is found early, treatment is almost always successful. It is important, therefore, to understand more about factors associated with acceptance and non-acceptance of cervical cytology among women, particularly those at high risk for this desease. In our study, we wished to examine the extent to which chicana patients utilize the Papanicolaou smear and the characteristics o f those who did and did not.
The findings suggest that if measures could increase periodic contact With physicians, whatever the service, these physicians could, in turn, influence them to obtain regular cytologic examinations. In essence, all physicians who attend females should be encouraged to emphasize and insist on periodic examinations of the cervix uteri. This approach to cancer prevention and control seems most needed in light of the data presented in this study. It therefore seems that if motivating programs were directed toward channels suggested by these findings, a significant number of currently irregular or non-acceptors of cytological screening would obtain peri,odic screenings for cancer.
INTRODUCTION
Data on the incidence of cancer in the United States population reveal a number of factors relevant to its control and prevention. One factor is that malignancies of the reproductive organs tend to be higher among the lower income non-white U.S. female population [1]. A second factor is that of the twenty-four most frequent types of cancers studied, one of the most prevalent types found in the low income nonwhite female is cervical cancer [2]. In short, although medical technicians have sufficient knowledge as to what should be done to effect control and prevention of cancer, the social problem of getting the high risk lower income, non-white populations properly screened and the disease prevented is not yet solved. This problem has prompted investigation of factors responsible for the delay in the initiation of cytological screening for cancer. While there are some exceptions, most of the previous research has produced little in the way of understanding and/or modifying the behavior of the non-user of cytological screening. In attempting to explain and predict acceptance of an innovation, such as cytological screening, social scientists have focused on the forces that influence the contact which the potential acceptor has with the innovation. For example, Beal [3] and Rogers [4] assert that mass media is a most useful and effective source of contact information, particularly with early acceptors of an innovation. Katz and Lazarsfeld assert a "two-step flow of communication" where people who are more exposed to communicative messages, via the mass media, pass on what they see
and hear to people less exposed [5]. To date, the most useful approaches to the acceptance of an innovation have avoided a simplistic variable approach. For example, the works of Naquib [6], Coleman [7] and Barnett [8] concentrate on the multiplicity of contact factors operating to influence behavioral change. Research studies on public behavior regarding cervical cytology indicates that such sociocultural factors as age [16, 19, 21], race [16, 21], socioeconomic status [18, 20, 21], education [16, 21], marital status [19, 17] and method of payment [19] profoundly influences the use and non-use of preventive cytological screening. This paper examines the social contact factors responsible for the use and non-use of cervical cytological screening. Its focus will be on Mexican-Americans, a population asserted t o have a high risk for cervical cancer and on whom little published data are available.
M E T H O D S A N D PROCEDURES
This study has as its focus the social contact factors associated with the use and non-use of cervical cytological screening among low-income groups, particularly Mexican-Americans, for whom almost no published data are available. The subsequent analysis focuses on the following comparison: those betweert u s e r s - - f e m a l e s who had two or more cytological screening in a minimum of three years prior to being interviewed; and nonu s e r s - - f e m a l e s who had none or only one screening
807
808
Research Note
examinations. The subjects systematically covered in in a minimum of three y.ears prior to being interthe interview schedule were: viewed. This study c~in attempt no more than a preliminary 1. Detailed information on the socio-economic analysis of the problem and therefore the sample size status and background of the respondents and their was limited to 120 meeting the criterion of users and families. 112 meeting the criterion of non-users of cytological 2. Material on attitudes toward and use of medical screening. We were interested in use of cytological facilities and medical professionals. screening because of the conviction that, at the 3. Various sources of information concerning the present state of knowledge, this is the only means symptoms and treatment of cancer. of identifying cervical cancer in its earliest stage. 4. Detailed information concerning past medical In this study patients were selected from the Family history, behavio?, and attitudes toward preventative Planning, Diabetic, and Gynecological Clinics of the medical care. Los Angeles County-Uniyersity of Southern CaliforThe nature of the material in the interview schedule nia Medical Center. The sample consists of patients dictated special caution in the selection and training available to us in the clinics during the study period, of the interviewers. Most importantly, all interviewers March 1973--December 1975. were female and Spanish-speaking so as to enhance It must be emphasized that our sample is not a the rapport between the interviewer and respondent, representative sample of Mexican-Americans as it dethus reducing the possibility of bias and error. Addirives from a particular hospital, University of Southtionally, interviewers were selected who were mature, ern California, Los Angeles County Hospital, and from a particular medical service area. In addition, had poise and who were especially comfortable in the sample of patients derive from three hospital dealing with the subject matter covered in the services, which limits our generalizations to that par- s c h e d u l e . Efforts were also made to recruit interticular hospital. Some patients were ill with Obgyn viewers who had prior medical and/or interviewing disorders or symptoms of diabetes; others, from experience. Included in the design of the study was an attempt family planning clinics, are asymptomatic. It must be to assess the reliability of the various questions asked further emphasized that we are not studying behavior by the study. To facilitate such a reliability check, in response to present illness brought into the hospiduplicate questions were included in the interview tal. We specifically excluded any behavior which could have been engendered by the present illness. schedule. This made possible comparison of answers Thus we required information, for example, use of to assess consistency. In addition, a 10~o random cervical cytology or symptoms up to one year before sample of respondents were also re-interviewed by interviewers using long distance calls from the Departthe onset of symptoms for the present illness. For example, we asked information on cervical cytologic ment of Sociology in Buffalo, New York. Also inexaminations in the time period up to and one year cluded in the design was a 100~o double-coding of materials to be punched so as to assess quality of before becoming patients in the hospital. coding and to make corrections where necessary. The ideal would be a random sample of MexicanAll of the data were obtained in a semi-nondirected Americans in the United States or of an entire community such as Los Angeles. However, a sample of manner based on a structured interview schedule. The specific questions were all asked in Spanish and, this type is difficult to obtain due to the fact that where possible, were phrased in order to avoid the there are no lists of low-income Mexican-Americans from which to sample. In addition, the study focuses implication of a desired answer. The raw data were on sensitive sexual behavior and as a result, impelled coded but not analyzed until after all interviews were the utilization of a community setting where confiden- completed. The characteristics of the group as a whole were studied and then broken down into user tiality was the mode. We therefore, used a hospital and non-user groups and compared. setting as the locus of this study. The Obstetrics and Gynecology clinic was the most logical choice for this study because Obgyn specialists have a vital interest FINDINGS in the use and lack of use of cervical cytology. We are aware of the biases of this inquiry evolving This study examined the social contact characterfrom the use of a very special sample. We are also istics which are related to use and non-use of cytoloaware that the very peculiarity of this sample makes gical screening among Mexican-Americans, Of the it very useful to some scientists, particularly Obstet232 patients included in the study 49~, or 112, fell rics and Gyneological specialists. We would hope that into the category of non-users of periodic screening. future investigations can be based on more represenIt was hypothesized that the mass media would tative groups of Mexican-Americans and on much have a significant influence on the awareness and aclarger numbers. The Mexican-American population, ceptance of cytological screening. The data in Table 1 a high risk group for cervical cancer, is of special fail to support this assertion, as both radio and interest, however, and completely unstudied with television appear to be poor sources of health inforregards to their cervical cancer screening behavior. mation for each study group. Only 28~o of both For this reason, we feel that an exploratory study groups obtained health information from radio of this kind is warranted. media, while 44 and 4 0 ~ of the users and non-users Due to the uniqueness of the study as a first obtained health information from television medi/t. approach to the question, the emphasis was on cover- Typical responses to the mass media questions were, "when I do listen to the radio or watch television, ing as broad a range of topics as possible, so as to discover significant areas for later, more intensive it's usually to hear or watch the news, a favorite soap
Research Note Table 1 Major sources of health information Radio
TV
Mag. or 6tl~er " printed Relatives
Nonusers Number Total Percent
30 49 (111) (110) 27.0 44.5
29 (111) 26.1
31 (112) 27.6
Users Number Total Percent
35 49 (120) (120) 29.1 40.8
38 (120) 31.6
13 (120) 10.8
Totals
(231) (230)
(231)
(232)
P < 0.05, based on summary 7.2. opera or my favorite music station". Many subjects stated that they "usually did not have time to watch television or listen to the radio" as they "had to get up early to get to work" and "came home so late" that by the time they were finished with supper, it was time to go to bed. In general, most of the subjects are not readers. In response to a question regarding newspaper and magazine purchases and subscriptions, the number responding were too few to present in table form. As with the other media, time was a major limiting factor. In addition, several respondents stated that they "could not read at all". While the majority of both study groups fail to read anything, especially about cancer, differences do exist between the two; for example 31% of the user group had read about cancer from at least one source, as compared to 26% of the non-users (Table 1). This finding seems to build on Dodson's thesis that "fatiguing work and little time and energy do impose Serious barriers to contact, via the media" [9]; this seems especially true of the nonuser group. In most cases, the patients stated that even their "weekends did not allow much time for reading or watching television" due to shopping and other necessary errands. The most convenient time for the non-users, especially for reading, was "while waiting in a physician's office". If Dodson's assertion regarding the amount and type of social interaction between "in groups" among working class families is correct, it would seem that relatives would serve as important providers of information regarding health information. The data in Table 1 supports this assertion, especially among the non-users, who frequently cite relatives as sources of health information; 27% of the non-users compared
809
to 11% of the users cited relatives as a health information source. In cases where a relative was named, it was usually a distant relative, e.g. aunt, cousin, etc. This finding may suggest that although the non-user does obtain a great deal of their health information from relative sources, relatives do not serve as "triggers" to preventive medical care as do other sources with which the non-user comes in contact. It must be pointed out, however that the sample consisted of individuals whose immediate relatives were still residing in Mexico. Therefore, familial sources of health information were not available to some patients. With regard to the source of information concerning cytological screening other than physicians, Table 2 shows interesting differences. The major source of information concerning cytological screening, prior to hearing about it from the physician, included friends and the mass media which together comprised a small percentage of informational sources. Note the larger proportion of non-users reporting no source of information concerning cytological screening before the physician. Wilkening asserts that persons seek out, as sources of information, those individuals who reflect the traditional values of the community [10]. By tradition, physicians are highly ranked in almost all societies. The role of the physician in cancer control and prevention is clearly depicted in Table 3. The majority of both study groups, 83% of the non-users and users, named the physician as the major influential to obtaining cytological screening. These data reemphasize the significance of physician participation in triggering the individual to seek preventive cytological screening. In addition to being traditionally accepted sources of medical information, physicians are also in a more viable position to give advice and to reinforce, disseminate and interpret information vital to the acceptance of an innovation such as cytological screening. Therefore, as medical researchers develop new techniques and accumulate new information for the prevention and control of such chronic illnesses as cancer, it is of vital importance for the physician to utilize his charisma, prestige, and technical knowledge in t h e public health effort to both translate and communicate these findings into action programs for the patient. SUMMARY AND CONCLUSIONS
Among the relatively objective contact characteristics studies, the contributions of relatives, corn-
Table 2. Source of information concerning cytologic screening before physician None Relative
Friend
Other Media medical
Other
Totals
Nonusers
Number Percent Users Number Percent
79 72.5
3 2.8
12 11
9 8.2
3 2.7
3 2.7
109 100
72 60
5 4.2
22 18.3
11 9.2
1 8
9 7.5
. 120 100
P > 0.05, based on summary Z2.
Research Note
810 Table 3. Major influential to obtain cytological None Physician ~Friend
Other
Totals
Nonusers Number Percent
7 6.9
85 83.3
5 4.9
5 4.9
102 100
Users Number Percent
7 5.9
98 83.1
9 7.6
4 3.4
118 100
P > 0.05. based on summary
~2.
munity members and the media to medical knowledge and behavior was essentially the same for both regular and irregular users. These factors are difficult to interpret, especially since the patients' interpretation of the contribution and influence of media, relatives, etc. would seem to vary depending upon their subjective adjustment and sensitivity to family members and other influentials to medical care. It was hypothesized that the major influences or "triggers" would be different for the two study groups. This hypothesis proved only partially correct. It is interesting to note that, although similar studies on the high risk Mexican-American are few, studies of other groups appear generally to corroborate with the findings of this study. Martin's [11] research on motivation for cytological screening similarly found the lack of physician contact and influence as barriers to preventive screening behavior. In general, it is theorized that the mass media are effective mechanisms in bringing to groups the information necessary to insure the response desired by the public health worker. However, the data presented in this study indicate that the assets and liabilities of this traditional theoretical approach need to be reconsidered when influence of the media on medical behavior of certain populations, especially Mexican-Americans. As did Lazarsfeld and Kendall, we found that individuals from certain social-status groups do not utilize the media, electronic or printed matter, as vehicles to health information. Therefore, those individuals who are regarded most hopefully as the target of media communications are least likely to receive information transmitted via the media. As a result, educational programs utilizing the media as their primary mechanism of information very likely do not reach these individuals. A great deal of behavior change theory has been devoted to the potential power of personal influence mechanisms and agents in communication and persuasion, especially among lower socioeconomic groups. In studying factors responsible for the acceptance or non-acceptance of cytological screening, earlier studies emphasized the importance of the physician as an influential in medical behavior. For example, research findings by Park and Gallo [12], Harms [13], and Levin [14] all point out the importance of the physician in the diffusion of innovation process. The findings of the present study compare closely with those in these earlier studies and reemphasize the crucial role of the physician in influencing patients to obtain cytological screening. Therefore, the physician, whether general practitioner or special-
ist, intern or surgeon, must operate his own cancer detection clinic by taking a careful and complete medical history and doing a pelvic examination of each patient regardless of the medical setting or service performed. However, the task of influencing the individual to undertake preventive action cannot be left solely to the physician. Innovative approaches must be developed to extend the physician's competence in the management of chronic disease, especially cancer. For example, well-trained allied medical workers should be utilized in educational and diagnostic aspects of the preventive programs, thus improving community participation and conserving valuable physician time. In the case of Mexican-Americans, an important share of the medical practitioner's activities is directed toward patients whose cultural patterns differ, to a considerable degree, from that of the mainstream United States population. The basic consideration in the introduction of preventive medicine to individuals from other cultural groups is that medical techniques and knowledge cannot be transmitted as isolated processes. With regard to illness behavior and treatment, Mexican-Americans have many traits common to the mainstream American society. However, the uniqueness of Mexican-American medical behavior derives from several varying cultural sources. Mexican-Americans, for example, draw their illness behavior and treatment from (1) folk medical practices of medieval Spain, (2) the cultures of the American Indian, and (3) scientific medical sources in Mexico and America. In a given situation, elements from any one or combination of the sources may be utilized in responding to medical problems or processes. This point seems especially relevant in view of the difference in the syndrome of preventive actions and treatment of symptoms in the users and non-users involved in this study. by S.U.N.Y. Buffalo Research Program in Social Epidemiology and Control of Cancer, Dr Saxon Graham, Director; National Cancer Institute Grant No. 11535. Acknowledgements--Supported
REFERENCES
1. Dorn H. F. and Cutler S. J. Morbidity from cancer in the United States; Part I, variation by age, sex, race, marital status and geographical region. Public Health Monograph, No. 29. United States Government Printing Office, Washington, D.C., 1955. 2. Department of Health, Education and Welfare, National Cancer Institute, Biometry Branch, Preliminary Report, Third National Cancer Survey, 1969, Incidence, Bethesda. Publication No. NIH 72-128, 1971. 3. Beal G. M. et al. Validity of the concept of stages in the adoption process. Rur. Sociol. 22, 166-68, 1957. 4. Rogers E. M. Diffusion of Innovations. Free Press, New York, 1962. 5. Katz E. and Lazarsfeld P. F. Personal Influence. Free Press, New York, 1955. 6. Naquib S. et al. Responses to a program of screening for cervical cancer. Publ. Hlth Rep. 83, 1968. 7. Coleman James S. et al. (Eds.). Medical Innovation: A Diffi~sion Study. Bobbs-Merrill Company, New York, t966.
Research Note 8. Barnett H. G. Innovation: The Basis of Cultural Change. McGraw-Hill, New York, 1953. 9. Dodson Floyd. Patterns of voluntary association among urban working class families. Am. Sociol. Rev. 16, 1961. 10. Wilkening E. A. Informal leaders and innovators in farm practices. Rur. Sociol. 17, 1972. 11. Martin P. L. Motivation for cytological screening. Calif. Med. 101, 1964. 12. Park George T. and Gallo James S. The culpability for delay in the treatment of cancer. Am. J. Cancer, 33, 1939. 13. Harms Charles et al. Delay in the treatment of cancer. Cancer 121, 1943. 14. Levin Alfred. Certain factors influencing cancer curability. Sth. med. J., La Grange 411, 1974. 15. Saunders Lyle. Cultural Differences and Medical Care: The Case of Spanish-speaking People of the Southwest. Russell Sage Foundation, New York, 1954. 16. Breslow L. and Hochstim J. R. Sociocultural aspects
17. 18. 19. 20. 21. 22.
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of cervical cytology in Alameda County, California. Publ. Hlth Rep. 79, 107-112, 1964. Currier R. Is early and periodic screening, diagnosis and treatment (EPSDT) worthwhile? Publ. HIth Rep. 92, 527-536, 1977. Brand F. N., Smith R. T. and Brand P. Effect of economic barriers to medical care on patients noncompliance. Publ. HIth Rep. 92, 72-78, 1977. Brown A. J. Awareness and use of cervical cancer tests in a southern Appalachian community. Publ. HIth Rep. 91, 237-242, 1976. Kegeles S. S. Attitudes and behavior of the public regarding cervical cytology: current findings and new directions for research. ,L chron. Dis. 20, 911-922, 1967. Kegeles S. S., Kirscht J. P., Haefner P, and Rosenstock I.M. Survey of beliefs about cancer detection and taking Papanicalaou test. Publ. Hlth Rep. 80, 815-827, 1965. Sanson C. D., Wakefield J. and Penncak K. M. Choice or chance: how women come to have a cytotest done by their family doctor. Int. J. Hlth 2, 54q59, 1971.
