Masarat Saqib, Chris Ardern, & Hala Tamim

School of Kinesiology and Health Science, York University, Toronto, ON, Canada

Corresponding author:

Masarat Saqib

School of Kinesiology and Health Science

Bethune College, 4700 Keele Street

Toronto ON M3J 1P3, Canada

Tel: 416-736-2100 Ext. 20850

E-mail: masaratsaqib@Hotmail.com

Objectives: To determine the prevalence and predictors of Pap smear utilization among women in the Canadian provinces and to evaluate the association between health care satisfaction and Pap smear utilization in the context of a universal health care system.

Design: The sub-sample 3 module of the Canadian Community Health Survey cycle 3.1 (2005) was used.

Setting: All Canadian provinces.

Participants: Women aged 18-69 years without a hysterectomy.

Measurements: Pap smear utilization was defined as having had a Pap smear in the 3 years prior to the survey. A Stepwise logistic regression model was performed using all of the relevant sociodemographic, health, lifestyle, and health care satisfaction variables.

Results: The prevalence of Pap smear utilization was 78.1%. Estimates of Pap smear utilization varied significantly (P < 0.001, 2-sided) across provinces, from 71.9 % in Quebec to 82.9% in the Atlantic provinces. Multivariate analysis revealed that women who had a Pap smear were more likely to be married or living common law, be widowed or divorced or separated, be between the ages of 25-54, have higher level of education, be employed and white. Women who had a regular doctor, a chronic condition, or who perceived themselves to be in excellent health, were also at increased odds of having a Pap smear. On the other hand, health care satisfaction was not significantly associated with Pap smear utilization.

Conclusions: An intervention directed at underprivileged women particularly single, older women who are visible minorities and who are not regular health care users should be implemented.

Keywords: delivery of health care, mass screening, patient satisfaction, prevalence, preventive health services, vaginal smears

Cervical cancer is one of the most preventable cancers (1) and remains the 11^th most common cancer-related diagnosis in Canadian women (2). It has been estimated in 2009 that 1300 Canadian women were diagnosed with invasive cervical cancer and approximately 380 deaths transpired as a result (3).

One of the best ways to reduce mortality and morbidity in cervical cancer is through early detection using a cervical Papanicolaou (Pap) test. This gynaecological screening test is used to detect premalignant and malignant lesions in the cervix. Current Canadian guidelines for women suggest annual screening with the onset of sexual activity or age 18, and reducing frequency to every three years until age 69 after two normal Pap smears, if they have had no significant abnormalities in the past (4, 5). These recommendations are based upon 8 cervical cancer screening programs consisting of more than 1.8 million women (6).

Although cervical cancer is almost entirely preventable, there remains a proportion of eligible women who do not have Pap smear tests done at all or do so irregularly. In 2005, self-reported records confirm that 72.8% of Canadian women ages 18-69 have had a Pap smear test within the past 3 years (7). Rates for Pap smear tests within the past 3 years have varied between provinces. This spans from low rates of 68.5% in Quebec and 72.6% in British Columbia to higher rates in Saskatchewan (77.1%), Prince Edward Island (79.9%) and Nova Scotia (81%) for women 18-69 years old (7).

 Previous studies have identified a number of factors which may contribute to significant variations in Pap smear utilization among Canadian women. Factors which are positively associated include living in urban regions (8), being a non-recent immigrant (9, 10), having a      high socioeconomic status (11, 12), and being fluent in English (13). On the contrary, women who are single (1), who are foreign-born (14), who did not have a recent blood pressure check or a regular physician (15), and who did not live in an area serviced by a teaching hospital (16) were highly associated with lower Pap smear rates. Furthermore, based on studies done in the United States, it has been shown that satisfaction with health care services affect cervical cancer screening utilization (17). Higher Pap smear rates have been demonstrated among women who had private health insurance (18), continuity of care from medical services (19), a regular doctor (20), and a medical check-up within the past year (17).

While satisfaction of health care services is a determinant of preventative service use, no national study in Canada has assessed their role in cervical cancer screening. The abundance of studies come from the United States and its pertinence to the Canadian universal health care system remains to be determined. Furthermore, there have been few large-scale Canadian studies that have examined Pap smear utilization across the different provinces. The latest study examining predictors of Pap smear utilization was the 1996/97 National Population Health Survey (15). The objectives of this current study were therefore to give updated prevalence and describe the predictors of Pap smear utilization for Canadian women 18-69 years old within the different provinces as well as to examine the satisfaction of health care services and its association with Pap smear utilization.

This study proceeded as a secondary data analysis using self-reported data from the sub-sample 3 module of the Canadian Community Health Survey (CCHS) cycle 3.1. This cross-sectional survey, conducted by Statistics Canada, examined the health determinants, health status, and health care utilization among the Canadian population between the period of January, 2005 and December, 2005. The subsample 3 module collected information from 35,968 individuals 15 years or older residing in private occupied dwellings in the 122 health regions covering all provinces and territories.

To identify households, a multistage cluster sampling strategy was employed by the CCHS, which was representative of approximately 98% of the Canadian population. One person was randomly selected from each household to participate in the survey. Approximately half of the interviews were conducted through telephone and the other half were personal interviews. Detailed information on design and survey methodology appears elsewhere (21).

The target population of this study encompassed all women between the ages of 18-69 y (n = 15, 313) who resided in a Canadian province. Excluded from the sample were women who had a hysterectomy or lived in a Canadian territory, and hence the final study sample was comprised of 13,122 women.

Participation in cervical cancer screening was assessed through the use of several survey questions. Women aged 18 and over were asked if they had ever had a Pap smear, the recency of their latest Pap smear and the reasons for not having had a Pap smear in the past 3 years. Based on the current Canadian recommendations, the main outcome of the study was defined as having had a Pap smear in the 3 years prior to the interview for those 18-69 years old. In the analyses, potential diagnostic Pap smears were retained.

For the present study, specific focus was drawn to women’s satisfaction with health care services and its relation to their Pap smear experiences. To address this, 2 questions were employed from the survey. These were: self-rated satisfaction with the way health care services were provided; and having ever felt that you needed health care but didn’t receive it in the past 12 months. Responses to the former question consisted of 4 categories ranging from “very satisfied” to “somewhat dissatisfied or very dissatisfied”. Responses to the latter question were classified as “yes” or “no”.

Previously identified variables from the literature known to be associated with mammography utilization were included in the analysis to provide an adjusted estimate of the association. Potential predictors included sociodemographic factors (age, province, household income adjusted for household size, education, working status, language most often spoken at home, country of birth, marital status, immigration status, place of residence, and cultural/racial origin), health factors (presence of a regular doctor, self-rated general health, self-rated mental health, self-rated satisfaction with life in general, ever diagnosed with cancer, and presence of long-term chronic conditions) (22), lifestyle factors (current smoking status, and frequency of physical activity) (22) and health care satisfaction factors as described above.

Data analysis

The prevalence of Pap smear utilization was assessed through population weights using descriptive statistics. A bivariate analysis was performed to examine the differences in the proportions of time-appropriate Pap smear screeners among the various sociodemographic, health, lifestyle, and health care satisfaction factors. All categorical variables were analyzed using chi square test. A stepwise logistic regression model was performed with the dependent variable being Pap smear utilization in the past 3 years and the independent variables being all of the sociodemographic, health, lifestyle and health care satisfaction variables. Adjusted odds ratios (OR) and 95 % confidence intervals (CI) were reported in the final model. All derived estimates were weighted by the sample weights to account for non-responses and unequal probabilities of sample selection. To account for the complex survey design (23), 95% confidence intervals were estimated with the bootstrapping technique using Statistical Analysis Software (SAS, version 9.2). All other analyses were performed using the Statistical Package for Social Sciences (SPSS, version 16.0).

The mean age was 43 years old, 80.1% were born in Canada and 60.1% had obtained post-secondary education. Figure 1 presents the percentage distribution by province of ever having a Pap smear and having had a Pap smear in the 3 years prior to the interview. Overall, an estimated 88.7% of women 18-69 years old reported ever having had a Pap smear. Having a Pap smear in the past 3 years was reported by 78.1% of women 18-69 years old, with nearly a third having had their last Pap smear 6 months to less than one year prior to the interview. Estimates of Pap smear utilization within the past 3 years varied significantly (P < 0.001, 2-sided) across provinces, from 71.9 % in Quebec to 82.9% in the Atlantic provinces. Among women who did not have a Pap smear in the past 3 years (n = 2,695), 40.4 % reported that they did not think it was necessary. The next most common reasons were not getting around to it (24.8%), followed by other reasons (17.6%) including waiting time too long, transportation problem, did not know where to go, cost, unable to leave the house because of a health problem, or personal or family responsibility. Only 4.1% reported fear as a barrier to screening.

Table 1 depicts the unadjusted and adjusted associations between Pap smear utilization in the past 3 years and potential predictors. Among sociodemographic factors, all but household income were found significant in the final model. Women who were 25-34 years old or married or living in a common law relationship were, respectively, 2.54 (95% CI: 1.90-3.40) and 2.46 (95% CI: 1.95-3.10) times as likely to have a Pap smear in the past 3 years as compared to their counterparts. The likelihood of screening also increased for women who had post-secondary education as compared with women with less than secondary school education (OR: 2.29, 95% CI: 1.80, 2.91). Health indicators selected in the final model included all but self-rated satisfaction with life in general. Women who had a regular doctor were 2.59 times (95% CI: 2.05, 3.28) as likely to have a Pap smear than those who did not have one. Furthermore, while those who perceived their general health to be excellent were 1.64 times (95% CI: 1.15, 2.32) as likely to have a Pap smear, and women who had one or more chronic conditions increased the likelihood of having a Pap smear by 1.38 times (95% CI: 1.10, 1.72) as compared to their counterparts. With respect to lifestyle indicators, only physical activity frequency remained in the final model albeit neither level was found significant at an alpha of 0.05. Lastly, although satisfaction with health care services was selected in the final model, there was no clear (or significant) trend towards Pap smear utilization in the past 3 years.

The purpose of the present study was to determine among Canadian women aged 18-69 years, the prevalence and predictors of Pap smear utilization in the past 3 years. The study also aimed to evaluate the association between health care satisfaction and Pap smear utilization in the context of a universal health care system. The results indicate that overall, 78.1% of the women had a Pap smear within the recommended 3 years. Multivariate analysis revealed that women who had a Pap smear in the past 3 years were more likely to be white; married/living common law or widowed/divorced/separated; between the ages of 25-54; have a higher level of education; and be employed. Women who had a regular doctor, a chronic condition, or who perceived themselves to be in better health, also had higher likelihood of having a Pap smear. Neither health care satisfaction variables was found significant at an alpha of 0.05.

Results of the present study revealed little change in the prevalence of ‘ever’ having a Pap smear between 2005 (88.7%) and the 1996/97 National Population Health Survey (NPHS; 87%). However, the proportion of women who reported having a Pap smear in the past 3 years (78.1%) was considerably higher than both the 1996/97 NPHS (72% of women 18+ years) and 2005 Statistics Canada (72.8% of women ages 18-69 years) rates.

The 3-year screening rate in Pap smears varied significantly across provinces. Such use was highest in the Atlantic provinces (82.9%) and lowest in Quebec (71.9%). This pattern is dissimilar from the 1996/97 NPHS which found that Alberta (82.3%) had the highest rate and Prince Edward Island (75.7%) the lowest. Conversely, in 2005, Statistics Canada (7) also reported Quebec (68.5%) as having the lowest Pap smear uptake in the past 3 years and Nova Scotia (81.0%) as the highest. Interestingly, it has been shown that Quebec residents are less likely to have a Pap smear test than residents of other provinces (1, 24). Although two of the most well-established Canadian cervical cancer screening programs are British Columbia and Nova Scotia, which were initiated in 1949 and 1991 respectively (8, 14), the data indicates that the recommended guidelines are not being fully met in these provinces. Nonetheless, the prevalence rates for most of the regions appear to have increased since the 1996/97 NPHS. The trend can be attributed in part to developments in organized cervical cancer screening programs, heightened media attention, and enhanced health promotion strategies (1).

Although rates of Pap smears have increased, the results of the study revealed that sociodemographic disparities persist for women who are single, 55-69 years or between 18-24, and have lower educational attainment. These findings are consistently noted in other studies (13, 15, 25, 26). Snider & Beauvais (27) reported an inverted u-shape trend with a peak in the 45-54 age group, while Latif (28) noted that married women were more likely to undergo a Pap smear test than their single counterparts. A high estimate in this age group may be a result of peri-menopausal women visiting their physician more often or the monitoring of women who are utilizing hormone replacement therapy (27). Having been married may increase cervical cancer screening because it potentially increases a women’s use of health care services as a result of more pregnancies and gynaecological concerns (29). Lack of timely participation among older women in the present study may be attributed to attention to other chronic disease prevention, lack of appropriate counselling around menopause, and other cancer screening measures, which may take priority (30). Owing to these competing health needs, physicians may be less likely to recommend older women to have a Pap smear.

Numerous studies have uncovered an inverse association between education and Pap smear utilization (31, 32). A recent American review (18) found that most studies found that women with a high school education or less were less likely to obtain a Pap smear when compared to women with greater than a high school education. Among other factors, women who are highly educated may understand the importance of preventative healthcare and the benefits of screening. Consistent with other studies, our results found current employment (32, 33) and white ethnicity (1, 8, 9) were strongly associated with Pap smear utilization. According to Health Canada (34), one of the determinants of health and illness is culture. Therefore, dominant cultural values can play a role in the stigmatization, marginalization, and devaluation of culture, and in the impediment of accessing culturally appropriate services (8).

Based on the study’s findings, the perception of being in excellent health and having one or more chronic conditions were paradoxically both positively associated with Pap smear utilization. While a positive association with self-rated health status have been previously noted in the literature (26, 35), the results remain inconclusive for chronic conditions and Pap smear utilization (36). No association was found among depressed women (30), while those with cerebral palsy (37), schizophrenia (24), and more physical limitations (35) had decreased odds and those being HIV infected (38) had increased odds of Pap smear utilization. These contradicting results may be due to variations in study design (i.e. case-control, cohort, or cross-sectional study), sampling (i.e. randomization, stratification, and the application of sampling weights), definition (i.e. time frame of diagnosis, severity of condition, and type of symptoms included), and measurement (i.e. clinically diagnosed, or self-reported) of each chronic condition. In the present study, increased Pap smear rates in women who have chronic conditions can perhaps be attributed to more frequent healthcare visits and health conscience attitudes. Latif (28) noted that persons who were sick and perceived to have poor health status will possibly take more preventative care (in comparison to healthy individuals) in order to avoid the additional costs related to cancer treatment. After adjusting for potential covariates, a significant association was found between Pap smear utilization and the presence of a regular doctor. This finding is well-documented in the literature (10, 30, 39). Woltman & Newbold (25) noted that Canadian immigrants who had a regular doctor were 1.63 times as likely to have a Pap smear than those without a regular doctor. As a result, women who have a regular doctor are more likely to get information and advice regarding preventative health practices (28).

Rather perplexing was the lack of association between Pap smear utilization in the past 3 years and satisfaction with health care services. There was no significant difference in the likehood of Pap smear utilization with satisfied, dissatisfied or indifferent women. Furthermore, there was no association between Pap smear utilization in the past 3 years and unmet healthcare needs. These findings are generally inconsistent with studies conducted in the United States (18, 19). However, there is a paucity of research that has uncovered mixed results which partially confirm our data (17, 29, 40). In a largely rural region of West Texas, Borders et al. (41), found that women who rated their overall quality of their health care as excellent were 2.37 times as likely to receive an annual Pap smear than those who rated their quality as good, fair, or poor. Women who rated their overall accessibility of their health care as excellent were 0.60 times as likely to receive an annual Pap smear, while those who rated their physician’s appointment waiting time as excellent were not significantly associated (OR= 0.78 95% CI 0.44, 1.39) with having a Pap smear. Somkin et al. (17) found mixed results in that private insurance and knowing where to get a Pap test were significantly associated with regular Pap smear testing, while no association was found with satisfaction with interpersonal processes of general medical care, waiting time for doctor and other satisfaction predictors.

Results of the present study indicate that improvements in healthcare services overall and one’s lifestyle may have little effect on increasing women’s Pap smear utilization. It could be that perception of satisfaction becomes relevant depending on the type of health care system provided (i.e. privately or publicly funded system). Thus, it appears that only if women are paying for their health care that their level of satisfaction actually matters. However, it is speculated that because health care services represent such a broad genre and each service is unique in its function, procedure and role, it is difficult to deem it as a proxy for Pap smear utilization. Health care services are complex in nature and the present study included only two indicators of health care satisfaction hence; there may be a need to look at Pap smear testing satisfaction to more fully understand the role of “satisfaction with care”. Furthermore, several undetermined factors such as ethnicity may still require further investigation.

The strengths of this study include the use of a population-based survey sample that is nationally representative, as well as the ability to adjust for many individual level factors known to influence preventative screening. Furthermore, given the high response rate (79%) to the CCHS (42), potential response bias remained minimal in this study. The following limitations should be taken into account while interpreting the results of the current study. Firstly, the CCHS collected self-reported information, so its results are subject to potential recall bias. However, although medical charts were not used to verify usage, there is some evidence demonstrating high validity with self-reported Pap smear utilization, particularly over a 3-year recall period (43). Secondly, despite the detailed information available, it was difficult to measure all potential factors that may influence cervical cancer screening. Information on the role of women’s attitudes, beliefs, and knowledge concerning cancer and preventative health practices was absent from the analyses. In addition, measures of sexual activity such as number of sexual partners, history of sexually transmitted infections, and age at first intercourse were not addressed. Furthermore, due to the cross-sectional design, associations in the data can be identified but causality cannot be inferred. Longitudinal studies are needed (15) to assess the temporal relation between factors essential in increasing screening as well as to determine the type of Pap smear users (i.e. regular, opportunistic, or first-time users).

The results of the present study suggest that factors other than general healthcare satisfaction and lifestyle are highly influential in Pap smear utilization. An intervention directed at underprivileged women, and particularly single, older women who are visible minorities and who are not regular health care users should be implemented. Health promotion strategies should consider U.S. models of community-based outreach (44) that may be adapted to the Canadian healthcare setting to educate and motivate women who are outside of the health care system. Such developments in turn will facilitate more timely diagnosis and treatment in these vulnerable populations.

CONFLICTS OF INTEREST

The authors thank all the staff at the Toronto Region Statistics Canada Research Data Centre for providing statistical support. The study also acknowledges that while the research and analysis are based on data from Statistics Canada, the opinions expressed do not represent the views of Statistics Canada.

1.  McDonald JT, Kennedy S. Cervical cancer screening by immigrant and minority women in Canada.J Immigr Minor Health. 2007; 9(4): 323-334.
2. National Cancer Institute of Canada. Canadian Cancer Statistics 2006. Toronto: National Cancer Institute of Canada; 2006.
3. Canadian Cancer Society. Canadian Cancer Statistics 2009. Toronto: Canadian Cancer Society; 2009.
4. Health Canada. Programmatic guidelines for screening for cancer of the cervix in Canada. Quality Management Working Group Cervical Prevention Network, Ottawa: Health Canada; 2002.
5. Kazanjian A, Morettin D, Cho R. Health care utilization by Canadian women [electronic article]. BMC Women's Health (2004); 4 Suppl 1: S33.
6. IARC working group on evaluation of cervical cancer screening programmes. Screening for squamous cervical cancer: Duration of low risk after negative results of cervical cytology and its implication for screening policies. Br Med J (Clin Res Ed). 1986; 293(6548): 659-664.
7. Statistics Canada. Table 105-4042 - Pap smear, females aged 18 to 69 years, Canada, provinces and territories, occasional, CANSIM (database).Ottawa, Canada: Statistics Canada; 2007. (http://cansim2.statcan.gc.ca/cgi-win/cnsmcgi.exe?Lang=E&CNSM-Fi=CII/CII_1-eng.htm). (Accessed: December 18, 2010).
8. Johnston GM, Boyd CJ, MacIsaac MA. Community-based cultural predictors of pap smear screening in Nova Scotia. Can J Public Health. 2004; 95(2): 95-98.
9. Lofters A, Glazier RH, Agha M, et al. Inadequacy of cervical cancer screening among urban recent immigrants: A population-based study of physician and laboratory claims in Toronto, Canada. Prev Med. 2007; 44(6): 536-542.
10. Tu SP, Jackson SL, Yasui Y, et al. Cancer preventive screening: A cross-border comparison of United States and Canadian Chinese women. Prev Med. 2005; 41(1): 36-46.
11. Snider J, Beauvais J, Levy I, et al. Trends in mammography and pap smear utilization in Canada. Chronic Dis Can. 1996; 17(3-4): 108-117.
12. Gupta A, Kumar A, Stewart DE. Cervical cancer screening among South Asian women in Canada: The role of education and acculturation. Health Care Women Int. 2002; 23(2): 123-134.
13. Hislop TG, Deschamps M, Teh C, et al. Facilitators and barriers to cervical cancer screening among Chinese Canadian women. Can J Public Health. 2003; 94(1): 68-73.
14. Lee J, Parsons GF, Gentleman JF. Falling short of pap test guidelines. Health Rep. 1998; 10(1), 9-19(ENG); 9-21(FRE).
15. Maxwell CJ, Bancej CM, Snider J, et al. Factors important in promoting cervical cancer screening among Canadian women: Findings from the 1996-97 National Population Health Survey (NPHS). Can J Public Health. 2001; 92(2): 127-133.
16. Fehringer G, Howlett R, Cotterchio M, et al. Comparison of papanicolaou (pap) test rates across Ontario and factors associated with cervical screening. Can J Public Health. 2005; 96(2): 140-144.
17. Somkin CP, McPhee SJ, Nguyen T, et al. The effect of access and satisfaction on regular mammogram and papanicolaou test screening in a multiethnic population. Medical Care. 2004; 42(9): 914-926.
18. Ackerson K, Gretebeck K. Factors influencing cancer screening practices of underserved women. J Am Acad Nurse Pract. 2007; 19(11): 591-601.
19. Bazargan M, Bazargan SH, Farooq M, et al. Correlates of cervical cancer screening among underserved Hispanic and African-American women.Prev Med. 2004; 39(3): 465-473.
20. Randolph WM, Freeman DH, Freeman JL. Pap smear use in a population of older Mexican-American women. Women & Health. 2002; 36(1): 21-31.
21. Beland Y. Canadian community health survey--methodological overview. Health Rep. 2002; 13(3): 9-14.
22. Statistics Canada. Canadian Community Health Survey (CCHS) Cycle 3.1 (2005). Integrated Derived Variable (DV) and Grouped Variable Specification. Ottawa, Canada: Statistics Canada; 2006.
23. Rust KF, Rao JN. Variance estimation for complex surveys using replication techniques. Stat Methods Med Res.1996; 5(3): 283-310.
24. Martens PJ, Chochinov HM, Prior HJ, et al. Are cervical cancer screening rates different for women with schizophrenia? A Manitoba population-based study. Schizophr Res. Advanced access: July 25, 2009. (DOI: 10.1016/j.schres.2009.04.015).
25. Woltman KJ, Newbold KB. Immigrant women and cervical cancer screening uptake: A multilevel analysis.Can J Public Health. 2007; 98(6): 470-475.
26. Blackwell DL, Martinez ME, Gentleman JF. Women's compliance with public health guidelines for mammograms and pap tests in Canada and the United States: An analysis of data from the joint Canada/United States survey of health. Women's Health Issues. 2008; 18(2): 85-99.
27. Snider JA, Beauvais JE. Pap smear utilization in Canada: Estimates after adjusting the eligible population for hysterectomy status. Chronic Dis Can. 1998; 19(1): 19-24.
28. Latif E. Recent immigrants and the use of cervical cancer screening test in Canada. J Immigr Minor Health. Advance Access: August 1, 2009.(DOI: 10.1007/s10903-009-9237-8).
29. Otero-Sabogal R, Stewart S, Sabogal F, et al. Access and attitudinal factors related to breast and cervical cancer rescreening: Why are Latinas still underscreened? Health Educ Behav. 2003; 30(3), 337.
30. Kaida A, Colman I, Janssen PA. Recent pap tests among Canadian women: Is depression a barrier to cervical cancer screening? J Womens Health (Larchmt). 2008; 17(7): 1175-1181.
31. Qi V, Phillips SP, Hopman WM. Determinants of a healthy lifestyle and use of preventive screening in Canada. [electronic article]. BMC Public Health. 2006; 6: 275.
32. Katz SJ, Hofer TP. Socioeconomic disparities in preventive care persist despite universal coverage: Breast and cervical cancer screening in Ontario and the United States. JAMA. 1994; 272(7): 530-534.
33. Lockwood-Rayermann S. Characteristics of participation in cervical cancer screening. Cancer Nurs. 2004; 27(5): 353-363.
34. 34. Health Canada. (2001). Towards a Common Understanding: Clarifying the Core Concepts of Population Health, A Discussion Paper, Appendix E: Culture as a Determinant of Health. Cat. No. H39-391/1996E ISBN 0-662-25122-9. (http://www.phac-aspc.gc.ca/ph-sp/docs/common-commune/index-eng.php). (Accessed June 4, 2009).
35. 35. Wu S. Sickness and preventive medical behavior.J Health Econ. 2003; 22(4): 675-689.
36. 36. Kiefe CI, Funkhouser E, Fouad MN, et al. Chronic disease as a barrier to breast and cervical cancer screening. J Gen Intern Med. 1998; 13(6): 357-365.
37. 37. Cooper NS, Yoshida KK. Cancer screening behaviors among Canadian women living with physical disabilities. Arch Phys Med Rehabil. 2007; 88(5): 597-603.
38. 38. McKnight B, McKnight I, Kerr T, et al. Prevalence and correlates of cervical cancer screening among injection drug users. J Obstet Gynaecol Can. 2006; 28(8): 695-699.
39. 39. Lee-Lin F, Pett M, Menon U, et al. Cervical cancer beliefs and pap test screening practices among Chinese American immigrants. Oncol Nurs Forum. 2007; 34(6): 1203-1209.
40. Coughlin SS, Leadbetter S, Richards T, et al. Contextual analysis of breast and cervical cancer screening and factors associated with health care access among United States women, 2002. Soc Sci Med. 2008; 66(2): 260-275.
41. Borders TF, Warner RD, Sutkin G. Satisfaction with health care and cancer screening practices among women in a largely rural region of west Texas. Prev Med. 2003; 36(6): 652-658.
42. Statistics Canada. Canadian Community Health Survey (CCHS) Cycle 3.1 (2005). Public use Microdata File (PUMF) User Guide. Ottawa, Canada: Statistics Canada; 2006.
43. Caplan LS, McQueen DV, Qualters JR, et al. Validity of women's self-reports of cancer screening test utilization in a managed care population. Cancer Epidemiol Biomarkers Prev. 2003; 12(11 Pt 1): 1182-1187.
44. Hiatt RA, Pasick RJ, Stewart S, et al. Community-based cancer screening for underserved women: Design and baseline findings from the breast and cervical cancer intervention study. Prev Med. 2001; 33(3): 190-203.