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PubMedDate not supplied

The influence of fatalism on self-reported use of Papanicolaou smears.

OBJECTIVE: Our objective was to examine the demographic and other predictors of fatalistic beliefs among Latinas (Hispanic women) and Anglo (non-Hispanic Caucasian) women and to assess the impact of these beliefs on the use of cervical cancer screening services. METHODS: We used ethnographic interviews and a cross-sectional telephone survey in Orange County, California. Our sample included 94 Latinas and 27 Anglo women selected through organization-based network sampling for the ethnographic interviews and 803 Latinas and 422 Anglo women randomly selected for the telephone survey. RESULTS: Latina immigrants (Latinas born outside the United States) were more likely than U.S.-born Latinas or Anglo women to have fatalistic beliefs. Immigration, education levels, and insurance status predicted fatalistic beliefs. Fatalistic beliefs were independent predictors of Pap smear use by Latinas but not Anglo women. For example, after adjusting for potentially confounding variables, Latinas who believed that fate was a risk factor for cervical cancer (odds ratio [OR] = .58), that they would rather not know if they had the disease (OR = .58), and that there is nothing one can do to prevent it (OR = .45) were less likely than others to report that they have had a Pap smear within the prior three years. Health insurance status, marital status, and immigration also predicted use of Pap smears. Insured Latinas were more likely than uninsured Latinas (OR = 2.89) to report having a Pap smear within the prior three years. In addition, married Latinas (OR = 2.32) and Anglo women (OR = 3.09) were more likely than unmarried women to report having appropriate cervical cancer screening. Finally, Latina immigrants were less likely than other Latinas to report having a Pap smear (OR = .26). CONCLUSIONS: We conclude that fatalistic beliefs are among the factors that negatively influence Latinas' use of Pap smears and that it is important for health care professionals to address those beliefs. Continued efforts are also necessary to decrease the economic and structural barriers to cervical cancer screening.

Adult↗
PubMed2003

Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey.

BACKGROUND: Understanding differences in cancer screening among population groups in 2000 and successes or failures in reducing disparities over time among groups is important for planning a public health strategy to reduce or eliminate health disparities, a major goal of Healthy People 2010 national cancer screening objectives. In 2000, the new cancer control module added to the National Health Interview Survey (NHIS) collected more detailed information on cancer screening compared with previous surveys. METHODS: Data from the 2000 NHIS and earlier surveys were analyzed to discern patterns and trends in cancer screening practices, including Pap tests, mammography, prostate specific antigen (PSA) screening, and colorectal screening. The data are reported for population subgroups that were defined by a number of demographic and socioeconomic characteristics. RESULTS: Women who were least likely to have had a mammogram within the last 2 years were those with no usual source of health care (61%), women with no health insurance (67%), and women who immigrated to the United States within the last 10 years (61%). Results for Pap tests within the last 3 years were similar. Among both men and women, those least likely to have had a fecal occult blood test or endoscopy within the recommended screening interval had no usual source of care (14% for men and 18% for women), no health insurance (20% for men and 18% for women), or were recent immigrants (20% for men and 18% for women). An analysis of changes in test use since the 1987 survey indicates that the disparities are widening among groups with no usual source of care. CONCLUSIONS: No striking improvements have been observed for the groups with greatest need. Although screening use for most groups has increased since 1987, major disparities remain. Some groups, notably individuals with no usual source of care and the uninsured are falling further behind; and, according to the 2000 data, recent immigrants also experience a significant gap in screening utilization. More attention is needed to overcome screening barriers for these groups if the population benefits of cancer screening are to be achieved.

Adult↗
PubMed2002

Breast and cervical carcinoma screening practices among women in rural and nonrural areas of the United States, 1998-1999.

BACKGROUND: Prior studies have suggested that women living in rural areas may be less likely than women living in urban areas to have had a recent mammogram and Papanicolau (Pap) test and that rural women may face substantial barriers to receiving preventive health care services. METHODS: The authors examined both breast and cervical carcinoma screening practices of women living in rural and nonrural areas of the United States from 1998 through 1999 using data from the Behavioral Risk Factor Surveillance System. The authors limited their analyses of screening mammography and clinical breast examination to women aged 40 years or older (n = 108,326). In addition, they limited their analyses of Pap testing to women aged 18 years or older who did not have a history of hysterectomy (n = 131,813). They divided the geographic areas of residence into rural areas and small towns, suburban areas and smaller metropolitan areas, and larger metropolitan areas. RESULTS: Approximately 66.7% (95% confidence interval [CI] = 65.8% to 67.6%) of women aged 40 years or older who resided in rural areas had received a mammogram in the past 2 years, compared with 75.4% of women living in larger metropolitan areas (95% CI = 74.9% to 75.9%). About 73.0% (95% CI = 72.2% to 73.9%) of women aged 40 years or older who resided in rural areas had received a clinical breast examination in the past 2 years, compared with 78.2% of women living in larger metropolitan areas (95% CI = 77.8% to 78.7%). About 81.3% (95% CI = 80.6% to 82.0%) of 131,813 rural women aged 18 years or older who had not undergone a hysterectomy had received a Pap test in the past 3 years, compared with 84.5% of women living in larger metropolitan areas (95% CI = 84.1% to 84.9%). The differences in screening across rural and nonrural areas persisted in multivariate analysis (P < 0.001). CONCLUSIONS: These results underscore the need for continued efforts to provide breast and cervical carcinoma screening to women living in rural areas of the United States.

Adolescent↗
PubMedDate not supplied

Abnormal Pap screening among Mexican-American women: impediments to receiving and reporting follow-up care.

PURPOSE/OBJECTIVES: To understand impediments to receiving and reporting timely follow-up care for abnormal Pap tests among Hispanic women. DESIGN: Descriptive, qualitative. SETTING: A federally funded cancer screening clinic in urban South Texas. SAMPLE: 11 Mexican/Mexican-American women over 40 years old who appear in clinic records as "lapsed" in follow-up and 5 clinic staff members. METHODS: Semistructured, qualitative interviews regarding staff and patient concepts about cancer, cancer screening, and follow-up. Abstraction of patients' clinic charts. MAIN RESEARCH VARIABLES: Factors associated with women being classified as "lapsed" in follow-up care for abnormal Pap tests. FINDINGS: Only two patients had no follow-up, while nine eventually had follow-up, either elsewhere or after several missed appointments. Contrary to expectations, poor knowledge, lack of social support, and lack of availability of care were not factors impeding follow-up. Reluctance to be examined by a male practitioner, lack of flexibility in scheduling clinic appointments, and poor staff communication regarding appointments and the seriousness of the condition were all influences negatively affecting follow-up behavior. Nevertheless, these women went to significant lengths to comply with follow-up recommendations. CONCLUSIONS: The classification of patients' follow-up behavior as "lapsed" was not attributable to culturally based beliefs and attitudes, nor lack of knowledge and motivation, but was primarily the result of institutional features such as scheduling and record-keeping practices and policies. IMPLICATIONS FOR NURSING PRACTICE: More thorough evaluation of actual behaviors would ensure more accurate assessment of follow-up behavior in this group. More female practitioners, better communication of appointments and of the seriousness of the condition, and more flexible scheduling options would reduce the difficulty these Hispanic patients encountered in having timely follow-up care.

Adult↗
PubMed2000

Acceptability evaluation of a natural rubber latex, a polyurethane, and a new non-latex condom.

After more than a century of reliance on latex condoms, male condoms fabricated from new materials are finally becoming commercially available to consumers. This study was an open label acceptability study that compared three lubricated condom products during vaginal intercourse: a natural rubber latex condom, a polyurethane condom, and a new non-latex (styrene ethylene butylene styrene, SEBS) condom. Fifty-four couples who were using condoms for birth control were enrolled in this three-way crossover study. Each couple tested three condoms of each type in a randomized sequence. Couples reported condom performance after each use and rated condom acceptability after use of three condoms of each type. At the completion of the study, participants selected their preferred condom type for overall acceptability, sensitivity, ease of use, appearance, and comfort. All three condom types had low clinical breakage and slippage rates (</= 3.3%) although the polyurethane condom did not perform as well in other measures of performance including unrolling, discomfort, stretching, bunching, and sliding along the penis during intercourse. None of the condom types were statistically preferred overall [males: natural rubber latex 37%, polyurethane 24%, new non-latex (SEBS) 37%, no preference 2%; females: natural rubber latex 33%, polyurethane 27%, new non-latex 37%, no preference 2%]. A statistically higher proportion of couples preferred both the natural rubber latex condom and the new non-latex condom above the polyurethane condom for ease of unrolling, and the natural rubber latex condom above the other condom types for perceived safety. Approximately two-thirds of both male and female participants preferred one of the two condoms made of synthetic materials suggesting that consumers will appreciate the availability of these products.

Adolescent↗
PubMed1995

Attitudes of Colorado health professionals toward breast and cervical cancer screening in Hispanic women.

BACKGROUND: A variety of economic, cultural, and communication barriers appear to be involved in breast and cervical cancer screening among Hispanic women. These barriers include culture-based embarrassment both for mammography and for Pap smears and fear and hopelessness concerning a diagnosis of cancer. Cost and access barriers are shared by low-income women from various ethnic and racial groups, as is a purported lack of physician referral. Hispanic women may have the latter problem enhanced by a language barrier between physicians and patients when the physicians do not speak or understand Spanish. PURPOSE: The goal of this project, conducted by the Cancer Education Division of the University of Colorado Cancer Center, has been to determine the attitudes and practices among health care providers in areas of Colorado with relatively large Hispanic populations (concerning screening mammography, clinical breast examination, breast self-examination, and Pap testing) and to design interventions to address any deficiencies or problems recognized. These studies were coordinated with telephone surveys and focus groups involving Hispanic women, directed by E. Flores in the Department of Sociology of the University of Colorado at Boulder and by C. Chrvala at the Colorado Department of Health. METHODS: Data were collected from 520 primary care physicians, nurses, and allied health personnel in 11 Colorado counties through focus groups and mailed questionnaires. Responses were analyzed by considering a variety of demographic characteristics of the respondents and by stratifying the associated practices by percent of Hispanic patients. RESULTS: The physicians involved in the focus groups and responding to the questionnaires, as well as their associated nurses and other health care personnel, are generally familiar with the breast and cervical cancer-screening guidelines as developed and disseminated by several organizations, including the National Cancer Institute and the American Cancer Society. Major barriers to screening Hispanic women, as perceived by these health care providers, appear to be cost; lack of transportation, child care, and release from work; fear of diagnosis of cancer; patients considering the test unnecessary; discomfort; and embarrassment. The prompt use of colposcopy to evaluate patients whose Pap smears indicated dysplasia appeared less than optimal, especially among internists. CONCLUSIONS: Familiarity with guidelines for breast and cervical cancer screening is widespread among Colorado physicians and associated health care personnel, including those with high percentages of Hispanic patients in their practices. Increased continuing education efforts may be indicated concerning the application of colposcopy to the evaluation of women with abnormal Pap smears and concerning the application of computer technology to cancer-screening reminder systems. IMPLICATIONS: Educational approaches to primary care professionals may improve the effectiveness of breast and cervical cancer screening, although a variety of other approaches will also be necessary to decrease barriers to screening of Hispanic women.

Adult↗
PubMed2000

Human papillomavirus DNA testing for cervical cancer screening in low-resource settings.

BACKGROUND: In many low-resource settings, there are barriers to cytologic screening for cervical cancer. This study evaluates human papillomavirus (HPV) DNA testing as an alternative screening method. METHODS: Cervical samples from 2944 previously unscreened South African women aged 35-65 years were tested for high-risk types of HPV with the use of the Hybrid Capture I (HCI) assay. Women also had a Pap smear, direct visual inspection of the cervix, and Cervicography(TM). Women positive on any screening test were referred for colposcopy. Samples from women with biopsy-confirmed, low-grade squamous intraepithelial lesions (SILs) (n = 95), high-grade SILs (n = 74), or invasive cervical cancer (n = 12) and a random sample of women with no cervical disease (n = 243) were retested for HPV DNA with the use of the more sensitive Hybrid Capture II (HCII) assay. All P values are two-sided. RESULTS: High-risk HPV DNA was detected in 73.3% and 88.4% of 86 women with high-grade SIL or invasive cancer and in 12.2% of 2680 and 18.1% of 243 women without evidence of cervical disease, with the use of the HCI and HCII assays, respectively. HPV DNA testing with the HCII assay was more sensitive than cytology for detecting high-grade SIL and invasive cancer (McNemar's test, P =.04), and testing with the HCI assay was of equivalent sensitivity (P =.61). Cytology had a statistically significantly better specificity (96.8%) than either the HCI assay (87.8%) or the HCII assay (81.9%) (P<.01). Receiver operating characteristic curves identified test cutoff values that allow HPV DNA testing to identify 57% of women with high-grade SIL or cancer, while classifying less than 5% of women with no cervical disease as HPV DNA positive. CONCLUSIONS: HPV DNA testing has a sensitivity equivalent to, or better than, that of cytology. Since HPV DNA testing programs may be easier to implement than cytologic screening, HPV testing should be considered for primary cervical cancer screening in low-resource settings.

Adult↗
PubMed2004

Inadequate functional health literacy in Spanish as a barrier to cervical cancer screening among immigrant Latinas in New York City.

INTRODUCTION: The objective of this study was to examine the association between inadequate functional health literacy in Spanish among low-income Latinas aged 40 and older and cervical cancer screening knowledge and behavior. METHODS: Spanish-speaking Latinas aged 40-78 of various nationalities (n = 205) participated in a study that included a survey on cervical cancer knowledge and behavior administered in Spanish and the Spanish version of the Test of Functional Health Literacy in Adults. RESULTS: Compared to those with adequate and marginal health literacy, women with inadequate functional health literacy in Spanish were significantly less likely to have ever had a Papanicolaou (Pap) test (odds ratio, 0.12; 95% confidence interval [CI], 0.04-0.37) or in the last three years (odds ratio, 0.35; 95% CI, 0.18-0.68) and were significantly more likely to have had their last Pap test at a local public hospital (odds ratio, 2.43; 95% CI, 1.18-4.97). Even when controlling for other factors, women with inadequate health literacy were 16.7 times less likely (adjusted odds ratio, 0.06; 95% CI, 0.01-0.55) to have ever had a Pap test. CONCLUSION: Almost half of the population we studied will have difficulty interpreting written medical materials, even in Spanish. When developing efforts to reach women who have not been screened, programs and service providers need to be aware that the women most in need of information about screening may be more likely to be unable to read any written materials provided to them, regardless of the language or level of simplicity of the materials. Programs and strategies need to be implemented to increase screening prevalence and to minimize the identified gaps in regular screening for Latinas who have low health literacy.

Adult↗
PubMed1994

Self-reported use of cancer screening tests among Latinos and Anglos in a prepaid health plan.

OBJECTIVE: To evaluate self-reported use of cancer screening tests by Latino and Anglo prepaid health plan members, we conducted telephone interviews about the knowledge of, use of, and reason for Papanicolaou (Pap) smear, clinical breast examination, mammogram, rectal examination, fecal occult blood test, and sigmoidoscopy. METHODS: Cross-sectional telephone survey of randomly selected Kaiser Permanente Medical Care Program members in San Francisco and Alameda Counties, California. A total of 844 Latinos (432 men and 412 women) and 510 Anglos (208 men and 302 women), between 35 and 74 years of age, completed the interview. RESULTS: Overall, 97.4% of Latinas reported having had at least one Pap smear compared with 99.7% of Anglo women; 90% in each group reported a Pap smear within 3 years. A clinical breast examination within 2 years was reported by 87% of Latina and 90% of Anglo women. Seventy-six percent of Latina and 85% of Anglo women aged 35 years or more reported having had at least one mammogram; and 65% of Latina and 75% of Anglo women reported a mammogram within 2 years. Among members 40 to 74 years of age, a lower proportion of Latinos compared with Anglos reported having had at least one digital rectal examination (67% vs 80%) and one fecal occult blood test (46% vs 54%); among those 50 to 74 years of age, fewer Latinos reported at least one sigmoidoscopy (29% vs 41%). After adjusting for age, education, employment, perceived health status, marital status, and county of residence, Latinos were significantly less likely to report having had at least one digital rectal examination (odds ratio; 0.60, 95% confidence interval, 0.45, 0.79), fecal occult blood test (odds ratio, 0.77; 95% confidence interval, 0.59-1.01), and sigmoidoscopy (odds ratio, 0.70; 95% confidence interval, 0.52, 0.95). After adjusting for the same variables, Latinos were more likely than Anglos to claim forgetfulness/carelessness (75% vs 60%; odds ratio, 1.84; 95% confidence interval, 1.41-2.40) as a reason for not obtaining cancer screening tests. CONCLUSION: These data suggest that, within this prepaid health plan without direct financial barriers to cancer screening services, Latinos are less likely than Anglos to obtain selected recommended cancer screening tests.

Adult↗
PubMed2006

Reasons for participation and non-participation in a randomized controlled trial: postal questionnaire surveys of women eligible for TOMBOLA (Trial Of Management of Borderline and Other Low-Grade Abnormal smears).

BACKGROUND: Better understanding of motivators for, and barriers to, participation in randomized controlled trials (RCTs) in different study populations and settings has the potential to improve participation of historically under-represented groups (eg, women) in future trials. PURPOSE: To investigate reasons why women agreed, or declined, to participate in a RCT. METHODS: In two postal questionnaire-based studies, we investigated women's reasons for participation or non-participation in TOMBOLA, a RCT comparing management policies for low-grade cervical abnormalities. Four-hundred and ninety-two TOMBOLA participants (response rate 56%) completed questionnaires on reasons for participation. One-hundred and thiry-seven women (38%) who declined TOMBOLA participation completed questionnaires on reasons for this. RESULTS: Eighty percent of women reported that one of their reasons for attending their TOMBOLA recruitment appointment was worries about their smear result. Ninety-four percent participated in the RCT because it was a worthwhile contribution to the cervical screening programme and other women; for 70% this was the most important reason. These proportions did not vary by socio-demographic factors. Thirty-two percent thought participation would result in better care. The most common reason for non-participation was preference for follow-up from the woman's GP. Logistical issues (eg, inconvenient appointments, travel time, arranging time off work or child-care) were commonly cited. Fourteen percent were too frightened to participate; this was unrelated to the grade of the recruitment smear. LIMITATIONS: Response rates were not high, but there was little evidence of response bias. Structured questionnaires were used. CONCLUSIONS: Future research should address how best to deliver information to ensure different social groups appreciate potential benefits of RCT participation and provide reassurance regarding fears about participation. Simple strategies (eg, appealing to the altruism of potential participants or offering flexible recruitment clinic locations and times) might enhance RCT recruitment rates. This in turn would ensure best use of research resources thus bringing the greatest benefits to participants and the population.

Adult↗
PubMed1997

Enhancing adherence following abnormal Pap smears among low-income minority women: a preventive telephone counseling strategy.

BACKGROUND: Although the incidence of precancerous conditions of the cervix has recently been increasing, prompt initial and long-term follow-up care can effectively reduce unnecessary morbidity and mortality. For example, the 4-year survival rates among those individuals at greatest risk for cervical cancer (i.e., minority women of low socioeconomic status) approach 95% with early detection. Women who present with advanced disease have a much poorer outlook (0%-39% survival). Yet, high-risk individuals are least likely to adhere to recommended diagnostic regimens. PURPOSE: We tested the effectiveness of a brief telephone counseling intervention directed to low-income, inner-city women after they had received an abnormal Pap smear result. The women were counseled on the importance of having an initial and 6-month repeat follow-up diagnostic procedure (i.e., colposcopic examination of the cervix). METHODS: A randomized trial design was used to compare the effects on these women of telephone counseling with (n = 192) or without (n = 203) a booster counseling telephone call prior to the appointment for a repeat colposcopy 6 months later, with a telephone appointment confirmation/reminder call (n = 216) and with standard care (i.e., no telephone contact) (n = 217). The telephone counseling protocol probed for and addressed three psychologic barriers to adherence (i.e., attendance at appointment for colposcopy examination): 1) encoding/expectancy (e.g., did the patient understand her risk of developing cervical cancer?); 2) affective/emotional (e.g., was the woman worried about the condition and its consequences?); and 3) self-regulatory/practical (e.g., was the woman likely to forget medical appointments?). Logistic regression was used to analyze the effects of the intervention group and the type of psychologic barriers elicited on colposcopy adherence. RESULTS: The results of logistic regression analysis (using those who received an appointment confirmation/reminder telephone call as the comparison group) revealed that telephone counseling produced significantly higher adherence rates to the initial colposcopy visit compared with telephone confirmation (300 [76%] of 395 women versus 147 [68%] of 216; odds ratio [OR] = 1.50; 95% confidence interval [CI] = 1.04-2.17). Additionally, standard care resulted in significantly lower adherence rates than did telephone confirmation (109 [50%] of 217 women versus 147 [68%] of 216; OR = 0.47; 95% CI = 0.32-0.73). Regarding attendance at the 6-month repeat colposcopy appointments, the 80 patients who had received telephone counseling prior to the initial visit (and were recommended for follow-up colposcopy) were significantly more likely to adhere than were the 47 patients who had received telephone confirmation (49 [61%] of 80 women versus 17 [36.2%] of 47; OR = 2.70; 95% CI = 1.15-6.51). The 6-month adherence rates for patients in the telephone confirmation group and the standard care group (n = 30) were low and did not differ significantly (17 [36.2%] of 47 women versus nine [30.0%] of 30; OR = 1.08; 95% CI = 0.40-2.89). Forgetting medical appointments (OR = 0.31; 95% CI = 0.19-0.51) and having scheduling conflicts (OR = 0.45; 95% CI = 0.28-0.72) were also associated with lower rates of adherence. CONCLUSION: The use of telephone counseling appears to be an effective strategy for enhancing initial and long-term adherence to a follow-up cervical diagnostic procedure in a traditionally underserved population. Patients who respond to a positive Pap test result with a particular profile of psychologic barriers may require more intensive and targeted counseling interventions.

Colposcopy↗
PubMed1995

Comparing acculturation scales and their relationship to cancer screening among older Mexican-American women.

BACKGROUND: Hispanic women in the United States are less likely to participate in breast and cervical cancer screening than women of other racial and ethnic groups. To plan appropriate interventions requires an understanding of the barriers to participation, including those of acculturation and assimilation. Few studies have examined the effects of acculturation and assimilation on the cancer-screening behavior of Mexican-American women. PURPOSE: Because of the extensive use of the Cuellar acculturation scale and the more recent use of the Hazuda scale, we explore the utility of these two measures to predict Pap smear and mammography screening. Using a population-based sample of Mexican-American women aged 40 years and older, we compare the two scales with each other and describe their relationship to sociodemographic factors and to participation in cancer screening. METHODS: The data are from baseline surveys in El Paso and Houston, Tex., conducted before the implementation of community interventions to improve Pap smear and mammography screening in low-income Mexican-American women. Study subjects were 923 randomly selected Mexican-American women aged 40 years and older living in 16 El Paso census tracts and seven Houston census tracts. Personal interviews solicited information on age, martial and employment status, household annual income and size, education, health insurance coverage, Pap smear and mammogram history, and a series of acculturation dimensions. Acculturation was measured using the abbreviated version of the Cuellar scale developed for the Hispanic Health and Nutrition Examination Survey, 1982-1984, and the Hazuda scale developed for the San Antonio Heart Study. The eight-item Cuellar acculturation scale assessed the extent to which Spanish and English were spoken, preferred, read, and written; the ethnic identification of the respondent and her parents; and generational status in the United States. The Hazuda scale assessed the following dimensions of acculturation: adult proficiency in English, adult pattern of English versus Spanish language usage, value placed on preserving Mexican cultural origin, attitude toward traditional family structure and sex-role organization, and adult interaction with members of mainstream society. RESULTS: The Cuellar scale was highly correlated with Hazuda's two language dimension. The Hazuda scale dimensions, Mexican cultural values and traditional family attitudes, correlated the least with Cuellar's scale. All the acculturation dimensions, Cuellar's and Hazuda's, were strongly associated with education and health insurance coverage. With the use of multiple logistic regression to adjust for education, health insurance, and other variables, English proficiency was a predictor of both a recent Pap smear and a recent mammogram. No other language-based acculturation dimension was associated with a recent screening with adjustment for education, health insurance, and other variables. However, in controlling for these factors, we found that a woman's attitude toward traditional family structure was related inversely to mammogram screening. That is, women who held the strongest traditional Mexican family attitudes were more likely to participate in mammography screening. CONCLUSION: This study shows the importance of separating the effects of acculturation on cancer screening from those due to social and economic conditions. Results suggest that the Hazuda scale provides a more multidimensional approach than the Cuellar scale and is a superior measure of the acculturation process. Traditional Mexican family attitudes positively influence mammogram-screening behavior, and this finding has implications for cancer control interventions in this population.

Acculturation↗