We have examined trends in the utilization of two preventive health procedures for women in Canada based on our analysis of the 1994 National Population Health Survey (NPHS) and comparisons with two previous large population health surveys. The NPHS provides evidence that Canadian women's use of mammography has continued to increase between 1990 and 1994, while use of Pap smears has remained steady. Increases in mammographic utilization are seen for all age groups and in all provinces of Canada. Women who are less than the recommended age of 50-69 years for screening mammography access these services in considerable numbers. Large proportions of women aged 18-24 and 65 or over have never had a Pap smear, and recency of Pap smear is associated with age. Income adequacy and educational attainment are still strong predictors of which women utilize Pap smears and mammograms. We conclude that the NPHS is sufficiently broad-based to be used in a surveillance program to track Pap smear and mammography utilization.

Key words: Canada; mammography utilization; mass screening; trends; vaginal smear utilization

Introduction

Mammographic screening for women who are 50-69 years of age has been shown in numerous clinical trials, demonstration projects and case-control studies to reduce mortality from breast cancer by as much as 30%; however, the benefit for women aged 40-49 remains controversial.¹ Use of the Papanicolaou (Pap) test has also been associated with a reduction of mortality from cervical cancer.² Nevertheless, a reduction of mortality through cancer screening can only be achieved if screening tests are accepted and used by significant proportions of the recommended target groups and are repeated at appropriate intervals in order to detect disease at an early stage when it is amenable to curative treatment.³

Large national surveys, such as the 1994 National Population Health Survey (NPHS)⁴ and the Health Promotion Survey (HPS) of 1985 ⁵ and of 1990 ⁶ provide information on a wide variety of Canadian health issues, including Pap smear and mammography utilization. This information can be used to describe the prevalence of these procedures, to track changes in their use and to measure adherence to Canadian policies as well as the use of these services by traditionally underserved groups.

The Canadian Task Force on the Periodic Health Examination ⁷ recommends screening for breast cancer by annual clinical examination of the breasts and biennial mammography for women aged 50-69 years. Screening by mammography for women aged 40-49 years is not recommended by the Task Force, although annual clinical examination is advised.

For the prevention of cervical cancer, the Task Force ⁷ recommends annual screening by Pap smears following the initiation of sexual activity or age of 18 years; after two normal smears, the recommended screening frequency is every three years until age 69 if all the elements of an organized system are in place, including appropriate quality control measures and information systems.⁸ Evidence from previous national ^5,6 and provincial surveys ^9,10 indicates that many women have never had a mammogram or Pap smear and that often those who have had a mammogram or Pap smear do not access these preventive health services on an appropriate schedule.¹¹ Canadian recommendations for screening mammography differ from recommendations in the United States in that, for most of the previous decade, most organizations in the US advocated screening mammography for women who were 40-49 years of age.¹² Results from analyses of the US National Health Interview Survey (NHIS)¹³ indicate that screening mammography increased in all age groups between 1987 and 1992 and that, in particular, large proportions of women aged 40-49 were accessing screening. These increases in screening mammography were also seen in an analysis of the US Behavioral Risk Factor Surveillance Survey (BRFSS).¹⁴ Rates of ever use of Pap smears have remained consistently high from 1987 to 1992. ^13,14

Previous Canadian studies have identified sociodemographic factors related to screening behaviour in Canadian women. In an analysis of Pap smear utilization from the Ontario Health Survey, Goel ¹⁰ found that recent immigrants, women who spoke neither English nor French and rural residents were less likely to have had a Pap smear. In Manitoba,¹⁵ single, older, rural, inner city and northern residents were most likely to not have had any or a recent Pap smear. Garceau's ¹⁶ analysis of the 1985 HPS identified that predictors of Pap utilization included age between 25 and 60 years, increased educational attainment and income adequacy.

Using the 1990 HPS data, O'Connor ¹¹ showed that increasing education, income and work status were predictors of both Pap and mammography utilization. The strongest predictors of recent mammography in Quebec ⁹ were benign breast disease or contralateral tumour; sociodemographic indicators were weaker predictors and included working outside the home, urban residence, increased education and income levels and accessing general practitioners. In the US,¹⁷ women who have had a mammogram are more likely to be younger and white and to have a higher income, more education, a usual source of health care and a regular physician.

The major determinants of Pap smear and mammography use identified in previous studies vary due to differing analytic strategies and the availability of information on sociodemographics, health care, behaviour and lifestyle as assessed by the particular survey instrument. For example, having recent sexual partners was found to be a significant predictor of Pap smear utilization in Ontario; however, sexual history information is inconsistently available on large surveys. In spite of contradictory information on the main determinants of Pap smear and mammographic use, it is generally acknowledged that there remain groups of women who do not undergo regular screening for breast and cervical cancers and that these women can be characterized as "generally disadvantaged."

The 1990 HPS ⁶ found considerable variation in the use of mammography for women over 50 years of age. The proportion of women over age 50 who had never had a mammogram ranged from 45% in Quebec to 74% in Newfoundland. The proportion of women over age 15 who reported never having had a Pap smear ranged from 12% in Ontario to 32% in Quebec. Provincial variations in female preventive cancer practices are likely due to a complex set of factors, including differences in approaches to cancer prevention, health promotion resources and the existence of organized screening programs for breast and cervical cancers.

The aim of this report is to estimate current trends in utilization of screening mammography and Pap smear practices in Canada as reported by women responding to the 1994 National Population Health Survey. In addition, reported changes in the areas of screening the appropriate age groups, reaching underserved groups and decreasing regional variations will be examined by comparing any type of mammography and Pap smear data from the NPHS with previously published data from both the 1985 and 1990 Health Promotion Surveys.

Methods

Current estimates of mammography, particularly screening mammography, and Pap smear utilization were derived from the NPHS. The NPHS surveyed a sample of 20,000 households with a provincial minimum of 1 200 households to ensure reliability of estimates by sex and age groups. Provinces could increase their provincial sample size by purchasing the option of having additional respondents ("buy-ins"). These additional households increased the final sample size to 26,430. An 88.7% response rate for the households was achieved. The core health component of the NPHS was asked of one randomly selected household member aged 12 years or older. The response rate among the individuals surveyed was 96.1% (n = 17,626). Currently, there is no information available for the non-responders to the survey.

The questionnaire included components on health status, use of health services, preventive health practices (Appendix), demographic factors and socio-economic status. The NPHS is a longitudinal survey that will collect information from the same panel of respondents every two years for up to two decades. Detailed information on sampling and survey methodology is documented elsewhere.⁴

As part of the preventive health practices component, questions about mammograms and Pap smear testing were asked of female respondents within specific age groups. Women aged 35 and over (n = 5 895) were asked if they had ever had a mammogram, the recency of their latest mammogram and the reason for their last mammogram. Response options for the reason for the last mammogram were "breast problem," "check-up, no particular problem" and "other." For this analysis, the response "breast problem" was used as a proxy indicating that the mammogram was a diagnostic mammogram, and the response "check-up, no particular problem" was used as a proxy for a screening mammogram and will be referred to as "screening mammogram" from this point onward.

Women aged 18 and older (n = 8 848) were asked if they had ever had a Pap smear and the recency of their latest Pap smear. The reason for this Pap smear, either check-up or diagnostic, was not ascertained. Those women refusing to provide information on mammography were not asked about Pap smear utilization.

Data analyses consisted of univariate and bivariate statistical procedures, using the Statistical Analysis Software (SAS).¹⁸ To derive meaningful population estimates from the survey, a weighting variable was provided in the NPHS microdata file. This variable was applied to all analyses, adjusting the estimates for non-responders as well as defining the number of persons in the population that the respondent represented. Coefficient-of-variation tables were also part of the NPHS documentation. These coefficients provide a guideline as to the degree of accuracy of the estimates as well as indicating when to use caution in the interpretation of the findings or when to censor them. Detailed analysis of the screening mammograms was not possible due to the resulting large coefficients of variation precluding release of the results.

To assess changes in mammography and Pap smear utilization over time, data from the NPHS were compared with previous published analyses of the 1985 ¹⁶ and 1990 ¹¹ HPS (Appendix). In 1985, Health and Welfare Canada conducted its first Health Promotion Survey, aimed at describing the health status and health behaviour of Canadians. The second such survey (in 1990) collected information on self-rated health, health improvement goals, lifestyle factors, health risks and safety precautions, risk of sexually transmitted disease, dental health and health concerns for government. Sampling and survey methodology for both Health Promotion Surveys is detailed elsewhere.^5,6

Results

The following section presents results from the analysis of the NPHS. Results are given separately for current trends in mammography use and in Pap smear practices. Each section on utilization is followed by a comparison with the previous Health Promotion Surveys.

NPHS Mammography Utilization, 1994

Of the eligible respondents asked about mammography practices, 56% stated that they had ever had a mammogram. This proportion of response is estimated to represent more than seven million Canadian women aged 35 years and over. In addition, 40% of women surveyed reported having had a mammogram within the two years preceding the survey and 18% reported having had a mammogram more than two years before the survey (Table 1). Three quarters (76%) of the women who previously received a mammogram indicated that their last mammogram was a screening mammogram, whereas 19% reported that the mammogram was for diagnostic purposes. "Other" reasons were cited by 3% of these women. Thirty-nine percent of respondents reported never having a mammogram; this represents approximately 2.8 million Canadian women.

Mammogram use varied widely by age. Sixty-nine percent of women aged 35-39 stated that they had never had a mammogram. Among women aged 40-49, 61% reported ever having a mammogram; two thirds of these mammograms were performed within the two years preceding the survey. Utilization increased to 75% in the 50-69 age group, with 57% of these mammograms occurring within the two years before the survey. In the oldest age group (70 and over), mammogram use decreased to 56% of women ever having had one and 34% of these women had the test in less than two years before the survey.

Assessing demographic characteristics of respondents revealed that the overall proportion of mammogram utilization varied somewhat among women with differing education levels (Table 2). The proportion of women aged 50 or older who had never had a mammogram was highest among women who had attained only an elementary school education level (39%). Also, women with higher education levels tended to have had their mammograms within the two years preceding the survey.

Regional variation was evident in mammography utilization (Table 1). The proportion of women who had never had a mammogram ranged from 34% in Quebec to 61% in Newfoundland. Interestingly, most provinces with well-established organized breast cancer screening programs (British Columbia, Alberta, Saskatchewan and Ontario), a greater proportion of mammograms were reported as being performed more recently, that is, within two years prior to the survey. Women in the Atlantic provinces reported the lowest use of mammography.

An analysis of screening mammograms by two broad age groups and province (Figure 1) shows that, in all provinces, women between the ages of 50 and 69 account for the largest share of women who have ever received screening mammograms. Over 60% of women in this age group in Prince Edward Island, Quebec, Ontario, Saskatchewan, Alberta and British Columbia reported having had a screening mammogram. In the remaining provinces, the proportions of women aged 50-69 who had ever received a screening mammogram ranged from 32% in Newfoundland to 55% in New Brunswick. Among women aged 35-49, the proportion who had ever received screening mammograms was generally under 40%, except for women in Quebec, where it was 42%.

Mammography Utilization: Comparison between the HPS and the NPHS

Between 1990 and 1994, there was a reduction in the proportion of Canadian women aged 50 or over who reported never having had a mammogram. In the 1990 HPS, 50% of women in this age group had never received a mammogram. By 1994 (NPHS), this figure had decreased to 31% (Table 3). The decrease occurred in all provinces, with the most notable reductions in Saskatchewan (67% in 1990, 28% in 1994) and British Columbia (53% in 1990, 26% in 1994). In 1994, Newfoundland was the only province in which more than half (59%) of its female residents aged 50 and over reported that they had never had a mammogram; still, this figure was down from 74% in 1990.

When stratified by age and recency of test, comparison of mammography use between the 1990 HPS and the 1994 NPHS shows that the proportion of women who received a mammogram within the two years preceding the survey increased across all age groups (over 39) [Figure 2]. There was little change in the proportion of women who reported having had a mammogram two or more years before each of the surveys.

NPHS Pap Smear Utilization, 1994

A positive response to the question of ever having had a Pap smear test was recorded for 82% (7 564) of the eligible respondents, a proportion representing almost 9 million Canadian women. Almost half (46%) of the respondents reported having had a Pap smear within the 12 months before the survey; 22%, 1-3 years before; and 15%, 3 or more years before the survey (Table 4). Fifteen percent of the women said that they had never had a Pap smear.

When stratified by age, the largest segments of women who had never had a Pap smear were those aged 18-24 (31%) and those aged 65 and over (28%) [Table 4]. The percentage of women who stated that their last Pap smear was within 12 months of the survey was highest in the 25-34 (59%) and 35-44 (52%) age groups. The proportion of women who reported having had a Pap smear one to three years prior to the survey was generally constant across all ages, whereas larger proportions of older women reported their last Pap smear as being three or more years before the survey.

When describing utilization according to education and income level (Table 5), we found that women with lower education levels and those with lower income adequacy had a much higher share of women who had never had a Pap smear. This trend can also be seen in recency of Pap smear practices as women with higher education and income levels were more likely to have had a Pap smear within the year preceding the NPHS.

Figure 3 illustrates that there is little provincial variation in Pap smear utilization and that over 40% of women aged 18 and over report having had their last Pap smear within the recommended 12 months. Similarly, there is little provincial variation among the proportions of women who received Pap smears one to three years prior to the survey.

Pap Smear Utilization: Comparisons between the HPS and the NPHS

Figure 4 compares age-stratified data on non-use of Pap smears from the 1985 and 1990 HPS and the 1994 NPHS. Among all ages (15+), there was a slight increase in the percentage of women who had never had a Pap smear, the highest levels being in the youngest (15-24) and oldest (65+) age groups. When stratified by province, Pap smear utilization over time did not show regional variation (Table 6).

The pattern in Pap smear practices by education and income has been maintained over the two surveys (Table 5). There has been no improvement over time in use of Pap smears among women with the lowest educational attainment.

Discussion

More than 60% of the women surveyed by the NPHS have ever had a mammogram, and three quarters of these women had their last mammogram for screening purposes. It is difficult to compare the trend in screening mammography over time because the 1990 HPS did not differentiate between screening and diagnostic mammograms. However, if one can assume that the proportion of diagnostic mammograms has remained constant over time, it can be hypothesized that the increase in overall mammograms is due to a net increase in screening mammograms. Dramatic increases in the use of mammography, and screening mammography in particular, have also been seen in the United States between 1987 and 1992.¹³

Currently, screening mammography is highest among women aged 50-69, the target group for whom screening mammography is recommended in Canada. However, large proportions of women aged 40-49, for whom screening is not recommended, have also had at least one screening mammogram. Significant controversy exists surrounding the effectiveness of screening mammography for women in the 40-49 age group.¹⁹ There appears to be considerable use of non-recommended services, suggesting a need for professional and public education.

Between 1990 and 1994, the proportion of women who ever had a mammogram increased in all provinces. Dedicated screening centres for breast cancer screening were recommended by an expert group in 1988 ²⁰ because such centres are most likely to ensure identification and recruitment of the target group, standardization, quality control, appropriate follow-up of women with abnormal findings and the lowest cost per unit.

Several organized breast cancer screening programs were in operation between 1988 and 1994, the period for which the NPHS and the 1990 HPS asked women about mammographic practices. Mammography rates are currently the highest for four of the five provinces which had dedicated programs during this period: British Columbia, Alberta, Saskatchewan and Ontario. While none of these programs screened enough women to account for the majority of total screens during the time period surveyed (J Beauvais, unpublished data), it is possible that the health education and promotion efforts of the screening programs in these provinces reached both women who were screened in the provincial programs and those screened outside of programs.

In contrast to the dramatic increases in mammography utilization, the proportion of Canadian women who have never had a Pap smear has remained fairly steady between the three surveys, at about 10-15% overall. However, Pap smears continue to be underused by young women and older women. More than half of the women aged 65 and over have either never had a Pap smear or have not had one in the last three years. Among women aged 18 and over, for whom Pap smears are recommended, more than 30% have not yet had one. These patterns of variation among age groups do not differ between provinces.

Two provinces, British Columbia (established in 1955, upgraded in 1995)²¹ and Nova Scotia (established in 1978, upgraded in 1992/93)²² have organized cervical cancer screening programs ²¹ with varying health promotion activities. According to the national surveys, they do not have improved recruitment compared to provinces without programs. However, many benefits of organized cervical cancer screening programs, such as quality control and improved follow-up, are not addressed by these surveys.

Although there has been improvement in rates of Pap smear and mammography utilization, the NPHS results reveal that disparities persist for women of low income and educational attainment. The NPHS is limited in its ability to relate Pap smear and mammography use to known determinants since the survey was not designed to provide information on the knowledge, attitudes and behaviours that influence screening practices. Nevertheless, the NPHS is effective for tracking improvements in the use of these preventive health procedures by women in generally disadvantaged groups. A more detailed analysis of indicators of Pap smear and mammography utilization has been presented by Maxwell et al.²³

Several other limitations must be considered in the analysis and interpretation of the NPHS. One limitation of using survey data for the surveillance of Pap smear and screening mammography utilization is that inaccuracies in self-reported data can affect population estimates of screening. In a study comparing self-reported cancer screening to that reported in medical charts, Gordon et al.²⁴ found that there was good agreement for screening, but that self-reports of recency of screening were significantly overestimated.

Additionally, the NPHS excluded several important groups of women: aboriginal women, women from the northern territories and regions, and women without telephone service. Although these groups represent a small proportion of women in Canada, they potentially represent a large proportion of the women who have never been screened for either breast cancer or cervical cancer. Therefore, exclusion of these groups may underestimate never-screened women.

Differences in the questions asked about mammograms, Pap smears and sociodemographics between the two Health Promotion Surveys and the NPHS restrict some of the comparisons. Analysis of trends in mammography use is difficult since the 1985 HPS did not ask about mammograms, the 1990 HPS collected mammographic information from all female respondents and the NPHS collected this information only from women aged 35 and over. In addition, the 1990 HPS did not collect information on the reason why a woman had a mammogram. There were also slight differences in the questions about Pap smears among all three surveys, particularly in the categories for recency. Finally, changes were made in the algorithm used to calculate income adequacy from the 1985 to the 1990 HPS.

Although the NPHS does provide population-based estimates of Pap smear testing and mammography utilization, it is limited in its ability to provide more detailed screening information. For example, questions on the NPHS about Pap smears do not differentiate between those performed for the purpose of screening and those performed for diagnostic purposes, thus limiting the NPHS population-based estimates of cervical cancer screening. In addition, women are asked about their last mammogram or last Pap smear. This makes it difficult to estimate the total number of screening mammograms received by these women since many women whose most recent mammogram was for diagnostic purposes could also have had a previous screening mammogram. As well, it is only possible to determine if a woman has not had a screening mammogram or Pap smear within an appropriate time frame; it is not possible to determine if the interval between screening procedures is appropriate. Nevertheless, because the NPHS is designed to resurvey the same panel every two years, it will be an ongoing source of useful trend data.

Conclusion

Mammography utilization continues to increase in Canada. Information from the NPHS indicates that a large proportion of women (above the age of 34) have had at least one screening mammogram and that many women aged 40-49, for whom screening is not recommended, have already had at least one screening mammogram. Pap smear utilization remains steady and high. However, young women and women aged 65 and over continue to underutilize Pap smears-many of these women have never had one.

The NPHS confirms that large disparities remain in the use of Pap smears and mammography by women of lower income and education levels. Further research is needed to identify underserved women, to track progress in these groups (particularly if they are not included in traditional surveys) and to determine whether these women underutilize Pap smears and mammography because of a lack of access or for other reasons. In addition, future research is needed to design interventions to increase recruitment among these underserved women.

We conclude that the National Population Health Survey can be successfully used to broadly track changes in the utilization of two common preventive health procedures for women, the Pap smear and screening mammography.

References

1. Shapiro S. Screening assessment of current studies. Cancer 1994;74:231-8.
2. Miller AB. An epidemiological perspective on cancer screening. Clin Biochem 1995;28:41-8.
3. Morrison AS. Screening in chronic disease. New York (NY): Oxford University Press, 1985.
4. Statistics Canada. National Population Health Survey (NPHS): public use microdata file documentation, 1994-1995. Ottawa: Health Statistics Division, Statistics Canada, 1995.
5. Health and Welfare Canada (Rootman I, Warren R, Stephens T, Peters L, eds). Canada's Health Promotion Survey 1985: technical report. Ottawa: Supply and Services Canada, 1988; Cat H39-119/1988E.
6. Health and Welfare Canada (Stephens T, Fowler Graham D, eds). Canada's Health Promotion Survey 1990: technical report. Ottawa: Supply and Services Canada, 1993; Cat H39-263/2-1990E.
7. Canadian Task Force on the Periodic Health Examination. The Canadian guide to clinical preventive health care. Ottawa: Supply and Services Canada, 1994; Health Canada Cat H21-117/1994E.
8. Miller AB, Anderson G, Brisson J, Laidlaw J, Le Pitre N, Malcolmson P, et al. Report of a national workshop on screening for cancer of the cervix. Can Med Assoc J 1991;145(10):1301-25.
9. Potvin L, Camirand J, Béland F. Patterns of health services utilization and mammography use among women aged 50-59 in the Québec Médicare system. Final report. Montreal: 1994 Apr; NHRDP 6605-3633-53.
10. Goel V. Factors associated with cervical cancer screening: results from the Ontario Health Survey. Can J Public Health 1994;85:125-7.
11. O'Connor A. Women's cancer prevention practices. In: Health and Welfare Canada (Stephens T, Fowler Graham D, eds). Canada's Health Promotion Survey 1990: technical report. Ottawa: Supply and Services Canada, 1993; Cat H39-263/2-1990E.
12. Romans MC. Utilization of mammography: social and behavioral trends. Cancer 1993;72:1475-7.
13. Breen N, Kessler L. Trends in cancer screening-United States, 1987 and 1992. Morbid Mortal Weekly Report 1995;45(3):57-61.
14. Ackerman SP, Brackbill RM, Bewerse BA, Sanderson LM. Cancer screening behaviors among US women: breast cancer, 1987-1989, and cervical cancer, 1988-1989. Morbid Mortal Weekly Report 1992;41(ss-2):17-34.
15. Cohen M, Hammarstrand KM. Papanicolaou test coverage without a cytology registry. Am J Epidemiol 1989;129:388-94.
16. Garceau S. Female preventive health practices. In: Health and Welfare Canada (Rootman I, Warren R, Stephens T, Peters L, eds). Canada's Health Promotion Survey 1985: technical report. Ottawa: Supply and Services Canada, 1988; Cat H39-119/1988E.
17. Breen N, Kessler L. Changes in the use of screening mammography: evidence from the 1987 and 1990 National Health Interview Surveys. Am J Public Health 1994;84:62-7.
18. SAS Institute Inc. SAS, Unix release 6.09 [statistical analysis software]. Cary (NC): SAS Institute Inc., 1992.
19. Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S. Report of the International Workshop on Screening for Breast Cancer. J Natl Cancer Inst 1993;85:1644-56.
20. The Workshop Group. Reducing deaths from breast cancer in Canada. Can Med Assoc J 1989;141:199-201.
21. Health Canada. Interchange '95: a Canadian forum to collaborate on cervical cancer screening program implementation strategies. Ottawa: Minister of National Health and Welfare, 1996; Cat H39-357/1995E.
22. Nova Scotia Gynaecological Cancer Screening Programme. Annual statistical report 1992. 1996 Jan.
23. Maxwell C, Kozak JF, Desjardins-Denault S. Factors important in promoting breast cancer screening behaviours among Canadian women: regional comparisons. A report for Disease Prevention Division. Ottawa: Health Canada, 1996.
24. Gordon NP, Hiatt RA, Lampert DI. Concordance of self-reported data for medical record audit for six cancer screening procedures. J Natl Cancer Inst 1993;85:566-70.

Author References

Judy Snider, Janet Beauvais, Isra Levy, Paul Villeneuve and Jennifer Pennock, Early Detection and Treatment Division, Cancer Bureau, Laboratory Centre for Disease Control
Mailing address: Janet Beauvais, Cancer Bureau, Laboratory Centre for Disease Control, Health Canada, Tunney's Pasture, Address Locator: 0601C1, Ottawa, Ontario K1A 0L2

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Trends in Mammography and Pap Smear Utilization in Canada

APPENDIX
1994 National Population Health Survey ¹ Preventive Health Practices

PHP-C2
If sex = female and age >= 35 then ask PHP-Q2.
If sex = female and age >= 18 and age < 35 then ask PHP-Q3.
If sex = male or female <= 17 then go to next section.

PHP-Q2 Have you ever had a mammogram, that is, a breast X-ray?

• Yes
• No (Go to PHP-Q3)
• DK (Go to PHP-Q3)
• R (Go to next section)

PHP-Q2a When was the last time? (Do not read list. Mark one only.)


• Less than 6 months ago
• 6 months to less than one year ago
• 1 year to less than 2 years ago
• 2 years or more ago

PHP-Q2b Why did you have your last mammogram? (Read list. Mark one only.)


• Breast Problem
• Check-up, no particular problem
• Other (specify _______________)

PHP-Q3 Have you ever had a Pap smear test?


• Yes
• No (Go to next section)
• DK (Go to next section)

PHP-Q3a When was the last time? (Do not read list. Mark one only.)


• Less than 6 months ago
• 6 months to less than one year ago
• 1 year to less than 3 years ago
• 3 years to less than 5 years ago
• 5 years or more ago

1990 Health Promotion Survey ² Section L: Women's Health

L1. INTERVIEWER CHECK ITEM:
Respondent is:

• Female Go to L2
• Male Go to M1

The next questions are about preventive health practices for women.

L3. Have you ever had a mammogram, that is, a breast X-ray?


• Yes
• No
• Don't Know
When was the last time?

• Less than 12 months ago
• 1 to 2 years ago
• More than 2 years ago
• Don't know

L4. Have you ever had a PAP smear?

• Yes
• No
• Don't Know
When was the last time?

• Less than 12 months ago
• 1 to 3 years ago
• More than 3 years ago
• Don't know

1985 Health Promotion Survey ³

60. INTERVIEWER CHECK ITEM:
Respondent is:

• Female Go to 61
• Male Go to 66

The next questions are about health practices.
65. When was the last time you had a PAP smear test for cancer?

• Within the past year
• Last 2-3 years
• More than 3 years ago
• Never
• Don't know

• Statistics Canada. National Population Health Survey (NPHS): public use microdata file documentation, 1994- 1995. Ottawa: Health Statistics Division, Statistics Canada, 1995.

• Health and Welfare Canada (Rootman I, Warren R, Stephens T, Peters L, eds). Canada's Health Promotion Survey 1985: technical report. Ottawa: Supply and Services Canada, 1988; Cat H39-119/1988E.

• Health and Welfare Canada (Stephens T, Fowler Graham D, eds). Canada's Health Promotion Survey 1990: technical report. Ottawa: Supply and Services Canada, 1993; Cat H39-263/ 2-1990E.