Personal and cultural beliefs may influence attitudes about the importance of cancer, the acceptability of the tests that they must undergo, and the mores of trying to alter the natural history of disease rather than allowing nature to take its course (Mandelblatt et al., 1999; Paskett et al., 1997; Bowen et al., 1997; Tortolero-Luna et al., 1995). Fears of cancer and fears of knowing whether it is present also influence the motivation to get tested. Finally, attitudes about cancer prevention exist in the context of the competing priorities patients face in their daily lives. Concerns related to one’s livelihood, income, family, or safety are often too substantial to make cancer screening a priority.

These attitudinal factors vary across ethnic and cultural traditions. Hispanic or Latino population groups are often treated as a monolithic entity on this (and many other) topics without consideration of heterogeneous cultural diversities. For example, Mexican Americans and Puerto Ricans may have more negative or fatalistic views about breast and cervical cancer than Cubans or Central Americans do (Ramirez et al., 2000a). Understanding of these cultural contexts and, more importantly, the involvement of individuals from within the particular culture who are sensitive to these concerns help craft interventions that are effective in shifting attitudes. For example, one randomized controlled trial found that the intervention that was effective in improving rates of screening for breast and cervical cancer among Latinas was organization of educational group sessions led by consejeras, lay Latino community volunteers (Navarro et al., 1998). Other research suggests that lay health advisers are effective among low-income women (Margolis et al., 1998; Skinner et al., 2000). Self-reported Pap smear utilization rates doubled in 6 months when lay health advisers assisted American Indian women (Dignan et al., 1996).

Ability

Even if people are knowledgeable about cancer and want to be screened, they may not be able to. A fundamental impediment is a lack of access to screening services. People who lack health insurance are less likely to receive cancer screening tests (Breen et al., 2001; Gordon et al., 1998; Hsia et al., 2000; Potosky et al., 1998), and this applies to a large proportion of U.S. citizens. In 1997, 22 percent of adults ages 18 to 44 and 12 percent of adults ages 45 to 64, respectively, were uninsured; among individuals under age 65 classified as poor or near poor, 34 and 36 percent, respectively, were uninsured. The proportion of older persons (age 65 and older) who are uninsured, however, is 1 percent because of Medicare coverage (National Center for Health Statistics, 2000). As noted earlier, people with health insurance typically find that most cancer screening tests are covered under their plans, although there are notable exceptions and an increasing requirement for copayments, a factor known to reduce the rate of adherence to screening tests



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