Cultural Differences in Preventative Health Care Choice: a Study of Participation in a Cervical Cancer Screening Program Among Mexican-Americans

Katherine Alexander, Pima Health Systems
James McCullough, University of Arizona
ABSTRACT - Cultural factors influencing participation in preventative health care programs are examined for Anglo and Mexican-American women. Significant differences are found in information seeking behavior, motivating factors, and examiner preference. Management suggestions are offered for health program directors.
[ to cite ]:
Katherine Alexander and James McCullough (1980) ,"Cultural Differences in Preventative Health Care Choice: a Study of Participation in a Cervical Cancer Screening Program Among Mexican-Americans", in NA - Advances in Consumer Research Volume 07, eds. Jerry C. Olson, Ann Abor, MI : Association for Consumer Research, Pages: 617-621.

Advances in Consumer Research Volume 7, 1980     Pages 617-621


Katherine Alexander, Pima Health Systems

James McCullough, University of Arizona

[This research was supported by a grant from the National Cancer Institute through the Arizona Department of Health Services (Contract #NOI-CN-65283)]


Cultural factors influencing participation in preventative health care programs are examined for Anglo and Mexican-American women. Significant differences are found in information seeking behavior, motivating factors, and examiner preference. Management suggestions are offered for health program directors.


Marketing activity in the health care field has increased significantly in the decade since Kotler and Levy (1969) suggested the applicability of marketing principles to the marketing of intangibles. Particular attention in the health care industry has been directed at low-income consumers who are also often members of ethnic minorities. This presents a particular problem for managers attempting to develop these programs since minority groups appear to behave almost as separate cultures in the consumption of many goods. Nicosia and Mayer (1976) have suggested that there is an increasing need for understanding the differences in consumer behavior manifested across different cultural groups. This study examines these differences as they exist for Mexican-American and Anglo consumers of preventative health care in a cervical cancer screening program conducted in Tucson, Arizona from October, 1976 - April, 1979.

Consumption of Preventative Health Care

A preventive health measure is an action "undertaken by a person who believes himself to be healthy for the purpose of preventing disease or detecting disease at an asymptomatic stage," (Kasl and Cobb, 1966). Participation in a cervical cancer screening program is a type of preventive health behavior as women without noticeable symptoms are given a Pap test to determine if they have cervical cancer. The test involves little discomfort and is done by physicians or other health care practitioners on an outpatient or clinic basis.

It is generally assumed that the marketing techniques necessary to motivate healthy persons toward consumption of preventative health care are somewhat different from those likely to encourage already ill persons to seek care and accept treatment. Rosenstock (1960) states that a person must believe himself to be susceptible to a particular health problem and that such a health problem would have serious consequences for him before he will be motivated to take preventive health measures. A potential consumer is further influenced by his beliefs about the benefits of the action, for example, the belief that the test effectively detects the problem, the personnel are competent to perform the test, or that early diagnosis improves prognosis, and his perception about the barriers preventing the action: cost, pain, inconvenience, or embarrassment. Rosenstock concludes that beliefs about benefits and barriers are most easily manipulated, and he suggests public health programs aim at minimizing the barriers to action, and increasing the opportunities to act which will increase perceived benefits.

More complex models explaining health behavior often incorporate Rosenstock's basic principles. Andersen (1968) discusses two types of influences on health behavior: enabling factors and predisposing factors. Enabling factors include such variables as cost and distribution of the service. The predisposing factors include psychological and sociological forces that cause an individual or group to take or not take the action in question.

Green (1974) adds another set of influences which he calls reinforcing factors. These include the experiences of the person when he seeks and receives a service. If the appointment clerk is rude, waiting time is long, and clinic personnel cold and unfriendly, the health behavior is not reinforced and not likely to be repeated in the future.

Zaltman and Vertinsky (1971) have elaborated a model of health behavior in less developed countries which is also appropriate in low-income communities. They discuss a chain of events that must occur before an individual takes a specific health action. Usually a message about a health problem acts as a stimulus to take action providing the message filters through the individual's process of selective perception and retention. If the information is retained and the individual believes he is susceptible to the serious health problem, and if he sees a clear course of action without insurmountable barriers, he is ready to respond and will act when given the opportunity.

Burger (1974) emphasizes the importance of this readiness concept. In his model of health behavior, he also discusses the affects of the mass media and service policies on the state of readiness. Oliver and Berger (1977) have suggested the behavioral intention model as the best predictor of consumption behavior in preventive health care.

This previous work seems to indicate that an individual is most likely to take a preventive health measure if he believes the measure will effectively detect a serious illness to which he is susceptible. If the measure is a service available only through the health care system, an individual will use the service only when he is aware of its availability and when his past negative experiences or present perceptions about barriers do not inhibit him from doing so.

Consumer Characteristics

Rosenstock (1974) reviewed literature and concluded that preventive health services were most typically used by the young, Anglos, females, the better educated, and the more affluent. Garcia and Juarez (1978) examined data concerning use of dental services in Pima County, Arizona, and discovered that Chicanos used preventive dental services significantly less often than Anglos. Fink (1972) studied factors relating to which type of women participated in an on-going breast cancer screening program and concluded that participants were most likely to be young, Jewish, educated, and more concerned about breast cancer than nonparticipants.

Lewis (1974) studied women who returned for more than om Pap test during a five-year screening program with those who did not. He found little differences in the two groups in their beliefs about cancer except that the returnees were more likely to be afraid about hearing their results, suggesting that perhaps they considered themselves more susceptible to cervical cancer. Hessilius (1975) did a similar study in Sweden. The factor which distinguished participants from nonparticipants was that women who failed to come for an examination viewed the examination as more unpleasant than did participants. Kegeles (1965) asked questions about use of cervical cancer screening in a general survey about health attitudes. They found women of higher socio-economic status and with a stronger belief in the benefits of early detection reported use of Pap tests.

These findings indicate that the segments of the population most likely to use preventive health care services are not those at particularly high risk to cervical cancer. The limited evidence about ethnic differences suggests that Mexican-American women will be more reluctant to take a preventive health measure, such as getting a Pap test, than will Anglo women.


This study of differences in health care consumption behavior between Mexican-American and Anglos was conducted in two phases--a survey of attitudes and knowledge, and an evaluation of behavior among program participants.

A survey of 185 women in randomly selected low-income census tracts in metropolitan Tucson, Arizona, was conducted to determine knowledge and attitudes concerning cervical cancer. These interviews were conducted in the respondents' homes during the day and early evening by bilingual interviewers. A majority of the interviewers were Mexican-American but no attempt was made to match interviewers and respondents on an ethnic basis. Based on the information found in the preliminary survey, a marketing program was developed to encourage participation in the screening program. The program focused on general informational messages directed at women and include the use of brochures and posters in Spanish and English and public service announcements on radio and television. Personal contact through service agencies and presentations to various organizations were also employed, and word of mouth promotion by program participants was encouraged. A total of 3,902 program participants were questioned to determine the effects of the marketing program. Some questions were asked throughout the program and some were added during the program. The number of individuals responding to some questions may differ, but there is no indication that the make up of the sample was different at different times. Differences between groups were tested for significance using a X2 analysis.


Attitude Survey

The attitude survey produced 183 usable responses. Sixty-six percent of the respondents were Mexican-Americans or Mexican-Nationals, and 26 percent were Anglos. Fifty-one percent of the women were Mexican-Americans. The remaining eight percent included members of other racial and ethnic groups.

Anglo women expressed greater knowledge about the purpose of the Pap test than the Mexican-American women. Sixty-three percent of the Anglo knew the Pap test detected cervical cancer, as compared to 59 percent of the Mexican-Americans. However, an additional 25 percent of the Mexican-Americans knew that the test detected cancer without specifying what type of cancer.

Mexican-American women perceived slightly greater susceptibility and severity of consequences than did the Anglo. Twenty-one percent of the Mexican-Americans believed they had some chance of developing cervical cancer as compared to 16 percent of the Anglos. Eighty percent of the Mexican-Americans said that death was the inevitable result of untreated cervical cancer as compared to 66 percent of the Anglo respondents.

In spite of the differences in awareness and perception about cervical cancer, the Pap test histories of the two groups were very similar. Ninety-three percent of each group said they had received at least one Pap test. Slightly more of the Anglos (69 percent) had received a Pap test within the last year, as compared to the Mexican-American women (65 percent). There may have been some amount of over-reporting in these figures, but response rates and responses to questions during clinic operation indicate that Pap tests may be received in the target groups at a higher rate than expected. Of the women who had received a recent Pap test, slightly more of the Anglo (78 percent) had received the test during a preventive type health visit as compared to the Mexican-American women (71 percent).

The reasons given by those women who had not had a recent Pap test varied between the two groups but the number of respondents is so small no valid conclusions can be drawn. Most of the Anglo women failing to get a recent Pap test said they didn't need an examination or they just never thought about it. Several of the Mexican-American women also gave these reasons; however, almost one-fourth mentioned they were embarrassed about getting an examination.

All subjects were asked how they usually found out about community programs in general. As seen from the data presented in Table 1, more Mexican-American women reported both television and radio as important sources of information. In fact, over twice as many Mexican-American women mentioned radio than did the Anglo women. Anglo women were somewhat more likely to list newspapers and friends as sources of information than were Mexican-American women.



These data were used to design a plan to encourage Mexican-American women to attend free Pap test clinics. The plan included the following features: 1) Messages aimed at increasing feelings of susceptibility of emphasizing the fact that the incidence of cervical cancer is twice as high among Mexican-American women as among Anglo women, 2) Publicity about the wide range of clinic locations and the availability of Spanish speaking staff to help reduce perceived barriers to attending a clinic, 3) Staffing clinics with female physicians or nurse practitioners whenever possible to reduce embarrassment experienced by some women, 4) Heavy emphasis on radio and television publicity including Spanish language programs.

Program Participation

Of 3,193 Anglo and 709 Mexican-American women that attended cervical cancer screening program clinics, Mexican-American screenees were younger and had lower incomes than the Anglos. The two groups reported different patterns in their usual source of medical care. Thirty-nine percent of the Mexican-American women reported their usual source of care was a clinic, as compared to only 21 percent of the Anglo women. Over half of the Anglo women (54 percent) reported their usual source of care was a physician, as compared to 42 percent of the Mexican-American women. Eighteen percent of the Anglos and 16 percent of the Mexican-Americans reported they had no regular source of medical care.

Twice as many Mexican-American screenees reported they had never had a Pap test as compared to the Anglo screenees. Ten percent of the Mexican-American women who attended the clinics said they had never before been examined, or didn't know if they has been examined, as compared to only tour percent of the Anglo women.

At least one-third of all screenees who had never before had a Pap test were under 25 years of age. However, a high proportion (44 percent) of the Anglo women who were receiving their first exam were 55 years or older. Considerably more of the Mexican-American women who had never before received a Pap test were in the middle years between 25 and 54.

Information Channels

As women called for an appointment, they were asked how they learned about the free Pap test clinics. As many as three answers were recorded. As shown in Table 2, a slightly greater percentage of the Anglos reported they had read about the program in the newspaper or had been referred by a local agency than did the Mexican-Americans.



The substantial number of women in both ethnic groups mentioning a social service agency as the source of information about the program is interesting since no one interviewed during the Pap test survey reported this information source as how they learned about community programs.

A somewhat greater proportion of the Mexican-American women reported that they had learned about the clinics from the radio or from a leaflet than did Anglo women. This difference can be explained by the fact that the Spanish language radio stations gave the program excellent publicity and that thousands of leaflets and coupons were distributed in areas of the city known to have many Mexican-American residents. Response to these leaflets and coupons was quite low among Mexican-Americans (as well as other ethnic groups). For example, 10,000 coupons were mailed to residences in these areas. Less than 0.10% of the recipients called for an appointment. This low rate of response may not be too surprising considering the fact that few interviewees during the Pap survey reported this method as a way of learning about community programs.

Data from the Pap test survey did suggest television would be reported significantly more often by Mexican-American women. The program data shown in Table 2 do not reflect a strong ethnic difference.

Motivation for Getting a Pap Test

The majority of women in each ethnic group reported they decided to get a Pap test simply because they were due for one. It is assumed these women are convinced that regular Pap tests are important and believe they should get a Pap test every year. However, nearly one-fourth (23 percent) of the Mexican-American women attended the clinic primarily from fear. They stated they were afraid something was wrong and wanted to get checked. Only 11 percent of the Anglo mentioned fear as a reason. These results are outlined in Table 3.



This particular ethnic difference was predicted by data from the Pap test survey. More Mexican-American women reported feelings of susceptibility to the disease and rated its consequences as very severe. These beliefs would result in more fear about the disease among Mexican-American women.

The most frequent reason in both ethnic groups given for attending the special Pap test clinics was that there was no charge for the service. More of the Anglo women gave this response than did the Mexican-American women. Nearly one-fourth (23 percent) of the Mexican-American women said they attended the clinic because of the availability of female examiners. This reason was important to only 10 percent of the Anglo women. This is one of the most significant ethnic differences. These results are shown in Table 4.



Examiner Preference

All women were also asked who they preferred to be examined by: a female physician, a male physician, a nurse or nurse practitioner. Thirty-two percent of these women said they preferred to receive a pelvic exam and Pap test by a female physician, while eleven percent said they preferred to be examined by a nurse. An additional eight percent said they preferred to receive an exam by a female and did not care if the examiner was a nurse or a physician. In total, fifty-one percent of the women mentioned a preference for a female examiner. Only five percent of these screenees said they preferred to receive an exam by a male physician. Forty-three percent of the women said neither the sex nor the status of the examiner mattered, presumably as long as the person was qualified to perform the exam.



As shown in Table 5, sixty-two percent of the Mexican-American women preferred a female examiner as compared to fifty-one percent of the Anglo women. Anglo women were more likely to have no preference regarding sex and status of examiner than were the Mexican-American women. This significant difference as well as the greater number of Mexican-American women who attended the clinics due to the availability of a female examiner and the greater number of Mexican-American women who stated during the Pap test survey they hesitated to get a Pap test due to embarrassment, suggest the importance of staffing clinics with female examiners in motivating this population to get a Pap test.


The incidence of cervical cancer is twice as high among Mexican-American women as among Anglo women. Cervical cancer screening programs are often aimed at the Mexican-American women because of their higher risk to the disease.

On the basis of previous research and theories about preventive health behavior and the data developed during this three-year screening program, the following suggestions are offered for motivating Mexican-American women to attend Pap test clinics when the promotional strategy must be implemented with limited time and money:

- Encourage Mexican-American women to tell their friends and relatives about the service. This can be done during the publicity about the clinic, when the appointment is made, as the screenee leaves the clinic, or when the screenee receives notification of Pap test results or is recalled for another exam.

- Notify the staff of all agencies who serve Mexican-American women urging them to inform their clients about the program.

- Avoid direct mail and poster campaigns. They are costly and ineffective.

- Staff the clinics with female physicians. If not available, female nurse practitioners would be far more acceptable to the Mexican-American women than male physicians.

- Publicize that female examiners are available.

- Arouse some fear about the possibility of cervical cancer. For example, by mentioning the higher than expected incidence and death rate among Mexican-American women and elaborating on the symptoms of cervical cancer.

- Staff the clinics and appointment desk with Spanish-speaking personnel.

Cultural differences in health care choice are very important in the design of programs aimed at low income consumers. Income level may be important in determining some aspects of health care consumption, but clearly attitudes toward female health practitioners go beyond income level. When income level is controlled, the same ethnic characteristics are found. An understanding of these cultural differences permits design of effective programs capable of reaching the target groups in the population. Failure to consider these differences increases perceived risk, reduces satisfaction, and results in poor program performance.


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