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1.  Cervical Cancer Screening Among Chinese Immigrants in Seattle, Washington 
Journal of immigrant health  2001;3(1):15-21.
Introduction
Chinese American women have high rates of invasive cervical cancer, compared to the general population. However, little is known about the Pap testing behavior of ethnic Chinese immigrants.
Methods
We conducted a community-based survey of Chinese immigrants living in Seattle, Washington, during 1999. Two indicators of cervical cancer screening participation were examined: at least one previous Pap smear and Pap testing in the last 2 years.
Results
The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample for this analysis included 647 women. Nearly one quarter (24%) of the respondents had never had a Pap test, and only 60% had been screened recently. Factors independently associated with cervical cancer screening use included marital status, housing type, and age at immigration.
Conclusion
Our findings confirm low levels of cervical cancer screening among Chinese immigrants to North America. Culturally and linguistically appropriate Pap testing intervention programs for less acculturated Chinese women should be developed, implemented, and evaluated.
doi:10.1023/A:1026606401164
PMCID: PMC1618776  PMID: 16228798
Chinese immigrants; cervical cancer; Pap testing
2.  Pap smear rates among Haitian immigrant women in eastern Massachusetts. 
Public Health Reports  2005;120(2):133-139.
OBJECTIVE: Given limited prior evidence of high rates of cervical cancer in Haitian immigrant women in the U.S., this study was designed to examine self-reported Pap smear screening rates for Haitian immigrant women and compare them to rates for women of other ethnicities. METHODS: Multi-ethnic women at least 40 years of age living in neighborhoods with large Haitian immigrant populations in eastern Massachusetts were surveyed in 2000-2002. Multivariate logistic regression analyses were used to examine the effect of demographic and health care characteristics on Pap smear rates. RESULTS: Overall, 81% (95% confidence interval 79%, 84%) of women in the study sample reported having had a Pap smear within three years. In unadjusted analyses, Pap smear rates differed by ethnicity (p=0.003), with women identified as Haitian having a lower crude Pap smear rate (78%) than women identified as African American (87%), English-speaking Caribbean (88%), or Latina (92%). Women identified as Haitian had a higher rate than women identified as non-Hispanic white (74%). Adjustment for differences in demographic factors known to predict Pap smear acquisition (age, marital status, education level, and household income) only partially accounted for the observed difference in Pap smear rates. However, adjustment for these variables as well as those related to health care access (single site for primary care, health insurance status, and physician gender) eliminated the ethnic difference in Pap smear rates. CONCLUSIONS: The lower crude Pap smear rate for Haitian immigrants relative to other women of color was in part due to differences in (1) utilization of a single source for primary care, (2) health insurance, and (3) care provided by female physicians. Public health programs, such as the cancer prevention programs currently utilized in eastern Massachusetts, may influence these factors. Thus, the relatively high Pap rate among women in this study may reflect the success of these programs. Public health and elected officials will need to consider closely how implementing or withdrawing these programs may impact immigrant and minority communities.
PMCID: PMC1497699  PMID: 15842114
3.  PAP SMEAR RECEIPT AMONG VIETNAMESE IMMIGRANTS: THE IMPORTANCE OF HEALTH CARE FACTORS 
Ethnicity & health  2009;14(6):575-589.
Objective
Recent US data indicate that women of Vietnamese descent have higher cervical cancer incidence rates than women of any other race/ethnicity, and lower levels of Pap testing than white, black, and Latina women. Our objective was to provide information about Pap testing barriers and facilitators that could be used to develop cervical cancer control intervention programs for Vietnamese American women.
Design
We conducted a cross-sectional, community-based survey of Vietnamese immigrants. Our study was conducted in metropolitan Seattle, Washington. A total of 1,532 Vietnamese American women participated in the study. Demographic, health care, and knowledge/belief items associated with previous cervical cancer screening participation (ever screened and screened according to interval screening guidelines) were examined.
Results
Eighty-one percent of the respondents had been screened for cervical cancer in the previous three years. Recent Pap testing was strongly associated (p<0.001) with having a regular doctor, having a physical in the last year, previous physician recommendation for testing, and having asked a physician for testing. Women whose regular doctor was a Vietnamese man were no more likely to have received a recent Pap smear than those with no regular doctor.
Conclusion
Our findings indicate that cervical cancer screening disparities between Vietnamese and other racial/ethnic groups are decreasing. Efforts to further increase Pap smear receipt in Vietnamese American communities should enable women without a source of health care to find a regular provider. Additionally, intervention programs should improve patient-provider communication by encouraging health care providers (especially male Vietnamese physicians serving women living in ethnic enclaves) to recommend Pap testing, as well as by empowering Vietnamese women to specifically ask their physicians for Pap testing.
doi:10.1080/13557850903111589
PMCID: PMC2788032  PMID: 19626504
Cervical cancer; Immigrants; Pap testing; Vietnamese
4.  Knowledge, attitudes and practices on cervical cancer screening among the medical workers of Mulago Hospital, Uganda 
Background
Cervical cancer is the commonest cancer of women in Uganda. Over 80% of women diagnosed in Mulago national referral and teaching hospital, the biggest hospital in Uganda, have advanced disease. Pap smear screening, on opportunistic rather than systematic basis, is offered free in the gynaecological outpatients clinic and the postnatal/family planning clinics. Medical students in the third and final clerkships are expected to learn the techniques of screening. Objectives of this study were to describe knowledge on cervical cancer, attitudes and practices towards cervical cancer screening among the medical workers of Mulago hospital.
Methods
In a descriptive cross-sectional study, a weighted sample of 310 medical workers including nurses, doctors and final year medical students were interviewed using a self-administered questionnaire. We measured knowledge about cervical cancer: (risk factors, eligibility for screening and screening techniques), attitudes towards cervical cancer screening and practices regarding screening.
Results
Response rate was 92% (285). Of these, 93% considered cancer of the cervix a public health problem and knowledge about Pap smear was 83% among respondents. Less than 40% knew risk factors for cervical cancer, eligibility for and screening interval. Of the female respondents, 65% didn't feel susceptible to cervical cancer and 81% had never been screened. Of the male respondents, only 26% had partners who had ever been screened. Only 14% of the final year medical students felt skilled enough to use a vaginal speculum and 87% had never performed a pap smear.
Conclusion
Despite knowledge of the gravity of cervical cancer and prevention by screening using a Pap smear, attitudes and practices towards screening were negative. The medical workers who should be responsible for opportunistic screening of women they care for are not keen on getting screened themselves. There is need to explain/understand the cause of these attitudes and practices and identify possible interventions to change them. Medical students leave medical school without adequate skills to be able to effectively screen women for cervical cancer wherever they go to practice. Medical students and nurses training curricula needs review to incorporate practical skills on cervical cancer screening.
doi:10.1186/1472-6920-6-13
PMCID: PMC1413529  PMID: 16509979
5.  Rationale and design of the research project of the South Florida Center for the Reduction of Cancer Health Disparities (SUCCESS): study protocol for a randomized controlled trial 
Trials  2014;15:299.
Background
In the United States certain minority groups, such as racial/ethnic immigrant women, are less likely than non-Hispanic White women to be screened for cervical cancer. Barriers to such care include health insurance, cost, knowledge, attitudes, health literacy, and cultural norms and practices. Among the most promising approaches to increase screening in these groups are patient navigators that can link women to sources of appropriate care. Another recent promising approach is using human papilloma virus (HPV) self-sampling. In this manuscript, we describe our National Cancer Institute-sponsored study testing such approaches among immigrant minority women.
Design
The South Florida Center for the Reduction of Cancer Health Disparities (SUCCESS) is conducting a three-arm randomized trial among Hispanic, Haitian, and African American women in Miami-Dade County. Community health workers (CHW) based in each of three communities are recruiting 200 women at each site (600 total). Eligibility criteria include women aged 30–65 years who have not had a Pap smear test in the last 3 years. Prior to randomization, all women undergo a standardized structured interview. Women randomized to public health outreach, Group 1, receive culturally tailored educational materials. Women in Group 2 receive an individualized comprehensive cervical cancer CHW-led education session followed by patient navigation to obtain the Pap smear test at community-based facilities. Women in Group 3 have the option of navigation to a Pap smear test or performing HPV self-sampling. The primary outcome is self-report of completed screening through a Pap smear test or HPV self-sampling within 6 months after enrollment.
Discussion
SUCCESS is one of the first trials testing HPV self-sampling as a screening strategy among underserved minority women. If successful, HPV self-sampling may be an important option in community outreach programs aimed at reducing disparities in cervical cancer.
Trial registration
Clinical Trials.gov # NCT02121548, registered April 21, 2014.
doi:10.1186/1745-6215-15-299
PMCID: PMC4127186  PMID: 25056208
Cervical cancer; Community-based participatory research; Haitian; Health disparities; Hispanic; Human papilloma virus; Immigrant; Minority; Screening
6.  A Randomized Controlled Trial of Interventions to Promote Cervical Cancer Screening Among Chinese Women in North America 
Background
North American Chinese women have lower levels of Papanicolaou (Pap) testing than other population subgroups. We conducted a randomized controlled trial to evaluate the effectiveness of two alternative cervical cancer screening interventions for Chinese women living in North America.
Methods
Four hundred and eighty-two Pap testing underutilizers were identified from community-based surveys of Chinese women conducted in Seattle, Washington, and Vancouver, British Columbia. These women were randomly assigned to one of two experimental arms or control status. Several Chinese-language materials were used in both experimental arms: an education-entertainment video, a motivational pamphlet, an educational brochure, and a fact sheet. Women in the first experimental group (outreach worker intervention) received the materials, as well as tailored counseling and logistic assistance, during home visits by trilingual, bicultural outreach workers. Those in the second experimental group (direct mail intervention) received the materials by mail. The control group received usual care. Follow-up surveys were completed 6 months after randomization to ascertain participants’ Pap testing behavior. All statistical tests were two-sided.
Results
A total of 402 women responded to the follow-up survey (83% response rate). Of these women, 50 (39%) of the 129 women in the outreach group, 35 (25%) of the 139 women in the direct mail group, and 20 (15%) of the 134 women in the control group reported Pap testing in the interval between randomization and follow-up data collection (P<.001 for outreach worker versus control, P = .03 for direct mail versus control, and P = .02 for outreach worker versus direct mail). Intervention effects were greater in Vancouver than in Seattle.
Conclusion
Culturally and linguistically appropriate interventions may improve Pap testing levels among Chinese women in North America.
PMCID: PMC1592333  PMID: 11983755
7.  Cervical cancer screening among Chinese Americans 
Cancer detection and prevention  2002;26(2):139-145.
Study purpose
Chinese women in North America have high rates of invasive cervical cancer and low levels of Papanicolaou (Pap) testing use. This study examined Pap testing barriers and facilitators among Chinese American women.
Basic procedures
A community-based, in-person survey of Chinese women was conducted in Seattle, Washington during 1999. Four hundred and thirty-two women in the 20–79 years age-group were included in this analysis. The main outcome measures were a history of at least one previous Pap smear and Pap testing within the last 2 years.
Main findings
Nineteen percent of the respondents had never received cervical cancer screening and 36% had not been screened in the previous 2 years. Eight characteristics were independently associated with a history of at least one Pap smear: being married, thinking Pap testing is necessary for sexually inactive women, lack of concerns about embarrassment or cancer being discovered, having received a physician or family recommendation, having obtained family planning services in North America, and having a regular provider. The following characteristics were independently associated with recent screening: thinking Pap testing is necessary for sexually inactive women, lack of concern about embarrassment, having received a physician recommendation, having obtained obstetric services in North America, and having a regular provider.
Principal conclusions
Pap testing levels among the study respondents were well below the National Cancer Institute’s Year 2000 goals. The findings suggest that cervical cancer control interventions for Chinese are more likely to be effective if they are multifaceted. © 2002 International Society for Preventive Oncology. Published by Elsevier Science Ltd. All rights reserved.
PMCID: PMC1592328  PMID: 12102148
Chinese Americans; Cervical cancer; Papanicolaou testing
8.  Knowledge, attitudes and practice toward cervical cancer screening among Sikkimese nursing staff in India 
Objectives:
To assess baseline knowledge of cancer cervix, screening and practice of Pap smear screening among Sikkimese staff nurses in India.
Materials and Methods:
Between April 2012 and February 2013, a predesigned, pretested, self -administered multiple responses questionnaire survey was conducted among staff nurses’ working in various hospitals of Sikkim. Questionnaire contained information about their demographics, knowledge of cervical cancer, its risk factors, screening methods, attitudes toward cervical cancer screening and practice of Pap smear amongst themselves.
Results:
Overall, 90.4% nurses responded that they were aware of cancer cervix. Three quarter of the staff nurses were not aware of commonest site being cancer cervix in women. Of the 320 participants, who had heard of cancer cervix, 253 (79.1%) were aware of cancer cervix screening. Pap smear screening should start at 21 years or 3 years after sexual debut was known to only one-third of the nursing staff. Age was found to be a significant predictor of awareness of Pap smear screening among nursing staff. Awareness was significantly more prevalent among older staff (P < 0.007). Married nursing staffs were significantly more likely to be aware of screening methods, and nursing staff of Christian and Buddhist religion were 1.25 times and 2.03 times more likely to aware of screening methods than Hindu religion respectively. Only 16.6% nurses, who were aware of a Pap smear (11.9% of the total sample), had ever undergone a Pap smear test. Most common reason offered for not undergoing Pap smear test were, they felt they were not at risk (41%), uncomfortable pelvic examination (25%) and fear of a bad result (16.6%).
Conclusion:
Knowledge of cancer cervix, screening and practice of Pap smear was low among Sikkimese nursing staff in India. There is an urgent need for re-orientation course for working nurses and integration of cervical cancer prevention issues in the nurses’ existing curriculum in India and other developing countries.
doi:10.4103/0971-5851.158840
PMCID: PMC4477372  PMID: 26157287
Cervical cancer; knowledge; nursing staff; Pap smear; screening
9.  HPV and cervical cancer related knowledge, awareness and testing behaviors in a community sample of female sex workers in China 
BMC Public Health  2013;13:696.
Background
Limited data suggested that the prevalence of Human Papillomavirus (HPV) among female sex workers (FSW) is much higher than in the general female population. The current study aimed to examine the HPV and cervical cancer related awareness, knowledge, and behaviors among FSW in China.
Methods
A total of 360 FSW recruited from entertainment establishments in Beijing completed a self-administered survey including demographics, HPV related knowledge, and health-seeking and cervical cancer preventive behaviors.
Results
Approximately 70.8% of the participants ever heard of cervical cancer, and as few as 22.1% and 13.3% ever heard of HPV and HPV vaccine, respectively. The mean score on a 7-item knowledge scale was 2.2 (SD = 2.4). Less than 10% of FSW perceived any risk of cervical cancer, and only 15.3% ever had a Pap smear. About 40.8% of FSW would accept HPV vaccine if it is free, and 21.8% would accept it even with a charge. Multivariate regression suggested that women with better knowledge of cervical cancer were more likely to have a Pap smear (aOR = 1.35); women who had tested for HIV were 11 times more likely to have a Pap smear, and women who had worked longer in commercial sex (aOR = 1.01) and had regular health check-ups (aOR = 1.95) were more likely to accept HPV vaccine.
Conclusions
Our study underscores the needs for effective cervical cancer prevention programs for FSW in China and other resource-limited countries. We specifically call for cervical cancer and HPV knowledge and awareness programs and regular screening as well as HPV risk-reduction programs for these vulnerable women.
doi:10.1186/1471-2458-13-696
PMCID: PMC3733604  PMID: 23898889
Cervical cancer; HPV; Female sex workers; Prevention
10.  Predictors of Cervical Cancer Screening Adherence in the United States: A Systematic Review 
Cervical cancer incidence rates have decreased dramatically since the implementation of the Papanicolaou (Pap) smear. Nevertheless, the American Cancer Society (ACS) estimates for 2013 predicted more than 12,000 new cases of cervical cancer in the United States. Given that some subpopulations in the United States are at a higher risk for cervical cancer than others, efforts to increase screening adherence are warranted. Many studies have explored the demographics of underscreened women, but no systematic reviews of screening demographics in adult US women were identified in the past 10 years, after release of the 2002 ACS cervical cancer screening guidelines. Knowledge of adherence to these guidelines becomes important as new guidelines were developed and released in 2012. The purpose of this systematic review of relevant studies was to identify factors that predict the use of cervical cancer screening in US women. Variables found to be significantly associated with adherence to screening included education, financial status, acculturation, psychosocial issues, and marital status. Using this information, nurse practitioners and other providers can target specific at-risk populations to increase screening by educating women about the need for cervical cancer screening and ensuring access to methods for prevention and early detection of the disease.
PMCID: PMC4093462  PMID: 25032031
11.  Community Health Worker Intervention to Decrease Cervical Cancer Disparities in Hispanic Women 
Journal of General Internal Medicine  2010;25(11):1186-1192.
INTRODUCTION
U.S. Hispanic women suffer a disproportionate burden of cervical cancer, with incidence and mortality rates almost twice that of whites. Community health workers, or promotoras, are considered a potential strategy for eliminating such racial and ethnic health disparities. The current study is a randomized trial of a promotora-led educational intervention focused on cervical cancer in a local Hispanic community.
METHODS
Four promotoras led a series of two workshops with community members covering content related to cervical cancer. Sociodemographic characteristics, cervical cancer risk, previous screening history, cervical cancer knowledge, and self-efficacy were measured by a pre-intervention questionnaire. The post-intervention questionnaire measured the following outcomes: cervical cancer knowledge (on a 0–6 scale), self-efficacy (on a 0–5 scale), and receipt of Pap smear screening during the previous 6 months (dichotomous). Univariate analyses were performed using chi square, t-test, and the Mann–Whitney test. Multivariate logistic regression was used to model the association between explanatory variables and receipt of Pap smear screening.
RESULTS
There were no statistically significant differences between the two experimental groups at baseline. Follow-up data revealed significant improvements in all outcome measures: Pap smear screening (65% vs. 36%, p-value 0.02), cervical cancer knowledge (5.4 vs. 3.5, p-value < 0.001), and self-efficacy (4.7 vs. 4.0, p-value 0.002). In multivariate analysis, cervical cancer knowledge (OR 1.68, 95% CI 1.10-2.81) and intervention group assignment (OR 6.74, 95% CI 1.77-25.66) were associated with receiving a Pap smear during the follow-up period.
DISCUSSION
Our randomized trial of a promotora-led educational intervention demonstrated improved Pap screening rates, in addition to increased knowledge about cervical cancer and self-efficacy. The observed association between cervical cancer knowledge and Pap smear receipt underscores the importance of educating vulnerable populations about the diseases that disproportionately affect them. Future research should evaluate such programs on a larger scale, and identify novel targets for intervention.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1434-6) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-010-1434-6
PMCID: PMC2947642  PMID: 20607434
cervical cancer; health disparities; community health worker; promotora
12.  Language Use and the Receipt of Cancer Screening Recommendations by Immigrant Chinese American Women 
Journal of Women's Health  2009;18(2):201-207.
Abstract
Background
Cancer screening rates are low among Chinese American women, a mostly immigrant minority population. This is possibly because they do not receive cancer screening recommendations from their physicians. The objective of this study was to determine if the rate at which physicians recommend cancer screening to older Chinese American women differs according to the language used during visits.
Methods
Data for the cross-sectional study were collected from a telephone survey of older Chinese American women residing in the Washington, DC, area. A total of 507 asymptomatic Chinese American women aged ≥50 who had a regular physician participated in this study. The main outcome was women's self-reported perception of having received a recommendation from their physician for mammography, Pap tests, or colorectal cancer screening in the past 2 years. The main independent variable was the language used during visits (English vs. Chinese). Patient age, educational level, employment status, cultural views, physician specialty, physician gender, and length of relationship with the physician were included in the multiple logistic regression analyses.
Results
Chinese women who communicated with their physicians in English were 1.71 (95% CI 1.00-2.96) and 1.73 (95% CI 1.00-3.00) times more likely to report having received mammography and colorectal cancer screening recommendations, respectively (p < 0.05). Physicians in family medicine or general practice were 2.11 (95% CI 1.31-3.40) and 1.70 (95% CI 1.06-2.48) times more likely to recommend cancer screening than those in other specialties.
Conclusions
Chinese American women who conversed with their physicians in Chinese were less likely to perceive receiving cancer screening recommendations. Future research is needed to identify physician-specific knowledge, attitude, and cultural barriers to recommending cancer screening.
doi:10.1089/jwh.2007.0709
PMCID: PMC2945721  PMID: 19183091
13.  Knowledge and Beliefs Related to Cervical Cancer and Screening Among Korean American Women 
The purpose of this article is to examine knowledge and health beliefs associated with cervical cancer screening among Korean American women. A telephone survey was conducted with 189 Korean American women in the Chicago area. Age, marital status, income, knowledge of early detection method for cervical cancer, and perceived beliefs about benefits of and barriers to receiving Pap tests were all related to outcomes of ever having a Pap test and having had one in the preceding 3 years. Variables uniquely related to ever having a Pap test were education, employment status, fluency in English, and proportion of life spent in the United States. Variables uniquely related to having had the test during the preceding 3 years were having a usual source of care and regular checkups. Different intervention components are suggested for the groups of Korean American women who have never had a Pap smear and for those who have not had one in the preceding 3 years, in addition to common intervention strategies that aim to increase knowledge and perceived benefit and to decrease perceived barriers to receiving Pap tests.
doi:10.1177/0193945908319250
PMCID: PMC3090726  PMID: 18539883
cervical cancer; screening behaviors; health behavior; symptom focus; Korean Americans; Pap smear; knowledge; beliefs
14.  Invasive Cervical Cancer and Screening: What are the Rates of Unscreened and Underscreened Women in the Modern Era? 
Objective
It has been reported that approximately 50% of invasive cervical malignancies are diagnosed in patients that have never been screened and 10% of the remaining cervical cancer patients have not had a Pap smear in the five years prior to diagnosis. We sought to determine if this holds true amongst a university based gynecologic oncology patient population.
Methods
Following IRB approval, a retrospective chart review of women in a university based gynecologic oncology group with cervical cancer from 2002-2007 was conducted. Patient demographics, referral Pap smear, method of diagnosis, histology, clinical stage, treatment, and time since last Pap smear were collected. Descriptive statistics were used during data analysis.
Results
419 women with cervical cancer were identified. 67% of patients were Caucasian, 18% Hispanic and 6% African-American. The most common referral Pap smear to our institution was HSIL (21%). Diagnosis was primarily made by cervical punch biopsy (47%). The most common histologic type was squamous cell carcinoma (70%). Clinical stage I disease was diagnosed in 80% of patients., Stage II cervical cancer 9%, and Stage III and IV were uncommon. The most common therapy was radical hysterectomy with lymph node dissection performed in 250 patients (60%). The length of time from last reported Pap smear to diagnosis of invasive cervical cancer ranged from 1-65 years with a median of 3 years. Stage IA1 patients ranged from 1- 12 years from last reported Pap with a median of 1 year (SD = 3.38); while Stage III/IV patients ranged from 1-20 years since last screening, with a median of 4 years (SD = 6.39). Regarding length of time since last reported Pap smear, 235 patients (56%) were unable to report the length of time since their last Pap smear. Of those who reported their last Pap smear, 4 patients (1%) reported never having a Pap smear, 39 patients (9%) reported last Pap smear greater than 10 years ago, and 10 patients (2%) reported a Pap smear greater than 20 years ago. 85 patients (20%) reported a Pap smear within 2 years. Of these 85 patients, 71 patients (84%) were diagnosed at Stage I, while more advanced stages were uncommon.
Conclusions
Traditionally, patients diagnosed with an invasive cervical malignancy are either unscreened or underscreened with cervical cytology. Our patient population was noncompliant with screening measures. A fraction of our patients were compliant with screening within the last 2 years, yet still developed a cervical malignancy – albeit early stage disease. As such, our data suggests that compliance continues to be an issue. However, even with adherence to screening guidelines, cervical cancer continues to develop.
doi:10.1097/LGT.0b013e3181f515a2
PMCID: PMC4465558  PMID: 21263352
cervical cancer; screening; compliance
15.  Confusion regarding cervical cancer screening and chlamydia screening among sexually active young women 
Objective
The American Congress of Obstetricians and Gynecologists (ACOG) recently recommended that cervical cancer screening begin at 21 years of age and occur biennially for low-risk women younger than 30 years. Earlier studies suggested that women may have limited understanding of the differences between cervical cancer screening and chlamydia screening. This study assessed the knowledge of chlamydia and cervical cancer screening tests and schedules in younger women.
Methods
A survey regarding knowledge of chlamydia and cervical cancer screening was administered to 60 younger women aged 18–25 years in an obstetrics and gynaecology clinic at an urban community health centre.
Results
The majority of respondents recalled having had a Pap smear (93.3%) or chlamydia test (75.0%). Although many respondents understood that a Pap smear checks for cervical cancer (88.3%) and human papillomavirus (68.3%), 71.7% mistakenly believed that a Pap smear screens for chlamydia. No respondent correctly identified the revised cervical cancer screening schedule, and 83.3% selected annual screening. Few respondents (23.3%) identified the annual chlamydia screening schedule and 26.7% were unsure.
Conclusion
Many younger women in an urban community health centre believed that cervical cancer screening also screens for chlamydia and were confused about chlamydia screening schedules. As there is limited knowledge of the revised ACOG cervical cancer screening guidelines, there is a risk that currently low chlamydia screening rates may decrease further after these new guidelines are better known. Obstetrician gynaecologists and primary care providers should educate younger women about the differences between chlamydia and cervical cancer screening and encourage sexually active younger women to have annual chlamydia screening.
doi:10.1136/sextrans-2011-050289
PMCID: PMC3724364  PMID: 22123163
16.  Health Beliefs Associated with Cervical Cancer Screening Among Vietnamese Americans 
Journal of Women's Health  2013;22(3):276-288.
Abstract
Background
Vietnamese American women represent one of the ethnic subgroups at great risk for cervical cancer in the United States. The underutilization of cervical cancer screening and the vulnerability of Vietnamese American women to cervical cancer may be compounded by their health beliefs.
Objective
The objective of this study was to explore the associations between factors of the Health Belief Model (HBM) and cervical cancer screening among Vietnamese American women.
Methods
Vietnamese American women (n=1,450) were enrolled into the randomized controlled trial (RCT) study who were recruited from 30 Vietnamese community-based organizations located in Pennsylvania and New Jersey. Participants completed baseline assessments of demographic and acculturation variables, health care access factors, and constructs of the HBM, as well as health behaviors in either English or Vietnamese.
Results
The rate of those who had ever undergone cervical cancer screening was 53% (769/1450) among the participants. After adjusting for sociodemographic variables, the significant associated factors from HBM included: believing themselves at risk and more likely than average women to get cervical cancer; believing that cervical cancer changes life; believing a Pap test is important for staying healthy, not understanding what is done during a Pap test, being scared to know having cervical cancer; taking a Pap test is embarrassing; not being available by doctors at convenient times; having too much time for a test; believing no need for a Pap test when feeling well; and being confident in getting a test.
Conclusion
Understanding how health beliefs may be associated with cervical cancer screening among underserved Vietnamese American women is essential for identifying the subgroup of women who are most at risk for cervical cancer and would benefit from intervention programs to increase screening rates.
doi:10.1089/jwh.2012.3587
PMCID: PMC3601630  PMID: 23428284
17.  Predictors of Papanicolaou Smear Use Among American Samoan Women 
To explore the rate and predictors of Papanicolaou (Pap) smear use among American Samoans, we conducted a survey of 986 randomly selected adult, self-identified Samoan women in American Samoa (n = 323), Hawaii (n = 325), and Los Angeles (n = 338). Only 46% of the women reported having a Pap smears within the past 3 years. These women were more likely than others to reside in Hawaii (odds ratio [OR], 1.7), be less than 40 years of age (OR, 2.2), be married (OR, 1.9), have more than 12 years of formal education (OR, 2.1), have an income of more than $20,000 per year (OR, 1.6), have health insurance (OR, 1.6), and have higher acculturation levels (OR, 1.9). Knowledge and attitudes about cervical cancer did not predict Pap smear screening. It is likely that the low rate of Pap smear screening contributes to the high site-specific incidence of cervical cancer among American Samoan women.
doi:10.1046/j.1525-1497.2001.00119.x
PMCID: PMC1495219  PMID: 11359551
18.  Knowledge, attitude and practice about cancer of the uterine cervix among women living in Kinshasa, the Democratic Republic of Congo 
BMC Women's Health  2014;14:30.
Background
Cervical cancer is the most frequent cancer of women in the Democratic Republic of Congo (DRC). Nevertheless, the level of women’s awareness about cervical cancer is unknown. Knowledge, attitude and practice (KAP) are important elements for designing and monitoring screening programs. The study purpose was to estimate KAP on cervical cancer and to identify associated factors.
Methods
A cross-sectional study was conducted in Kinshasa, DRC, including 524 women aged 16–78 years (median age 28; interquartile range 22–35). The women were interviewed at home by trained field workers using a standardized questionnaire. The women’s score on knowledge, attitude and practice were dichotomized as sufficient or insufficient. We used binary and multiple logistic regression to assess associations between obtaining sufficient scores and a series of socio-demographic factors: age, residence, marital status, education, occupation, religion, and parity.
Results
The women’s score on knowledge was not significantly correlated with their score on practice (Spearman’s rho = 0.08; P > 0.05). Obtaining a sufficient score on knowledge was positively associated with higher education (adjusted odds ratio (OR) 7.65; 95% confidence interval (95% CI) 3.31-17.66) and formal employment (adjusted OR 3.35; 95% CI 1.85-6.09); it was negatively associated with being single (adjusted OR 0.44; 95% CI 0.24-0.81) and living in the eastern, western and northern zone of Kinshasa compared to the city centre. The attitude score was associated with place of residence (adjusted OR for east Kinshasa: 0.49; 95% CI 0.27-0.86 and for south Kinshasa: 0.48; 95% CI 0.27-0.85) and with religion (adjusted OR 0.55; 95% CI 0.35-0.86 for women with a religion other than Catholicism or Protestantism compared to Catholics). Regarding practice, there were negative associations between a sufficient score on practice and being single (adjusted OR 0.24; 95% CI 0.13-0.41) and living in the eastern zone of the city (adjusted OR 0.39; 95% CI 0.22-0.70). Although 84% of women had heard about cervical cancer, only 9% had ever had a Papanicolaou (Pap) smear test.
Conclusions
This study shows a low level of knowledge, attitude and practice on cervical cancer among women in Kinshasa. Increasing women’s awareness would be a first step in the long chain of conditions to attain a lower incidence and mortality.
doi:10.1186/1472-6874-14-30
PMCID: PMC3937079  PMID: 24548698
19.  Awareness of cervical cancer screening among nursing staff in a tertiary institution of rural India 
Journal of Gynecologic Oncology  2012;23(3):141-146.
Objective
To determine the baseline information about the knowledge of cervical cancer and explore attitude and practice of Pap smear screening among staff nurses.
Methods
A pretested structured self administered questionnaire based survey was done on 205 staff nurses working in Rural Institute of Medical Sciences & Research, Saifai, Etawah, containing mostly recognition and some recall type questions about demographics, knowledge about cervical cancer, its risk factors, screening techniques, attitudes towards cervical cancer screening and its practices.
Results
In this study, 74% knew that Pap smear is used for detection of cervical cancer, but only 59% knew that it can detect both cancerous as well as precancerous lesions of the cervix. Only 18% of the respondents knew about human papillomavirus vaccine. A 47% of respondents had never taken a Pap smear; 63% never referred patients for the screening. Most nurses (79%) thought that a speculum examination and Pap smear are procedures to be performed by the doctors. Among all the respondents, only 11% had ever undergone a Pap smear on themselves.
Conclusion
Despite knowledge of the gravity of cervical cancer and prevention by screening, attitudes and practices towards screening were negative.
doi:10.3802/jgo.2012.23.3.141
PMCID: PMC3395008  PMID: 22808355
Cervical cancer; Pap smear; Screening attitude
20.  PAP TESTING AMONG VIETNAMESE WOMEN: HEALTH CARE SYSTEM AND PHYSICIAN FACTORS 
Journal of community health  2004;29(6):437-450.
Cervical cancer occurs more frequently among Vietnamese Americans than women of any other race/ethnicity. In addition, previous studies in California have documented low Papanicolaou (Pap) testing rates in Vietnamese communities. This study focused on health care system factors and physician characteristics associated with recent cervical cancer screening among Vietnamese women. A population-based survey was conducted in Seattle during 2002. In-person interviews were conducted by bilingual, bicultural female survey workers. The survey response rate was 82% and 518 women were included in the analysis. Seventy-four percent of the respondents reported having been screened for cervical cancer on at least one occasion, and 64% reported a Pap smear within the previous 2 years. Women with a regular doctor were more likely to have been recently screened than those without a regular doctor (OR = 2.33, 95% CI = 1.45–3.74). Among those with a regular doctor, having a male physician, receiving care at a private doctor’s office (rather than a community, hospital, or multi-specialty clinic), and concern about the cost of health care were independently associated with lower screening rates. Physician ethnicity was not associated with recent Pap smear receipt. The findings support targeted interventions for Vietnamese women without a regular physician and private doctors’ offices that serve Vietnamese Americans. The availability of low cost screening services should be publicized in Vietnamese communities.
PMCID: PMC1811063  PMID: 15587344
cervical cancer; immigrants; Pap testing; Vietnamese
21.  Pap smear screening in the primary health care setting: A study from Turkey 
Background:
Cervical cancer is one of the ten most frequent cancers in Turkey. It is well known that cervical cancer morbidity and mortality could be significantly reduced with an active cervical smear screening (Pap smear) program.
Aims:
The aims of this study were: 1) to evaluate the knowledge and attitudes of women about cervical smear testing; 2) to establish a cervical smear screening program and to evaluate the cervical cytological abnormalities that were found; 3) to determine the applicability, limitations and effectiveness of this screening in a primary health care unit.
Patients and Methods:
A total of 332 married women were included in our study. We collected data concerning socio-demographic and fertility characteristics, and knowledge about Pap smear testing was determined through printed questionnaires. A gynecological examination and Pap smear screening was performed on every woman in our study group.
Results:
Over ninety percent of our study group had never heard of and had not undergone Pap smear screening before. Of the 332 smears evaluated, 328 (98.8%) were accepted as normal, whereas epithelial cell anomalies were seen in 4 (1.2%), infection in 59 (17.7%), and reactive cell differences in 223 (67.2%) of the smears.
Conclusions:
The frequency of epithelial cell anomalies in our study group was less than the frequencies reported from Western countries. Knowledge regarding cervical cancer and Pap smear screening was very low. Pap smears can be easily taken and evaluated through a chain built between the primary health care unit and laboratory, and this kind of screening intervention is easily accepted by the population served.
doi:10.4297/najms.2010.2468
PMCID: PMC3339109  PMID: 22558549
Cervical smear; cervical intraepithelial lesion; cervical cancer screening
22.  Factors Associated with the Use of Uterine Cervical Cancer Screening Services in Korean Elderly Women 
Korean Journal of Family Medicine  2012;33(3):174-181.
Background
The Papanicolaou (Pap) smear test is an effective screening test for the early detection of uterine cervical cancer. The Pap test still plays an important role in Korean elderly women, as uterine cervical cancer remains a frequent form of cancer and an important cause of death. However, the participation rate and other factors related to the Pap test in Korean elderly women have been studied insufficiently.
Methods
This study included 654 individuals aged 65 and over who completed a cervical cancer screening questionnaire from the Third Korean National Health and Nutrition Examination Survey 2005. Using multiple logistic regression, odds ratios and confidence intervals for the association between attendance of the Pap test and sociodemographic or health-related factors were calculated.
Results
One hundred and eleven individuals (17.0%) of the study population showed compliance with Pap testing within the previous 2 years. We recognized that the most elderly women (75 years and over) or those with lower levels of education were less likely to have had the test.
Conclusion
Primary health care providers need to make efforts to improve attendance rates of Pap smear screening in Korean elderly women, individually taking into account previous Pap results, life expectancy, risk factors for cervical cancer, and preferences. More attention will especially be needed among the eldest elderly or less educated elderly women.
doi:10.4082/kjfm.2012.33.3.174
PMCID: PMC3391643  PMID: 22787540
Uterine Cervical Neoplasms; Vaginal Smears; Health Services for the Aged
23.  Prevalence and Correlates of Breast and Cervical Cancer Screening Among a Midwest Community Sample of Low-Acculturated Latinas 
Background
Low adherence to cervical and breast cancer (CBC) screening recommendations contributes to high CBC mortality among Latinas.
Purpose
To estimate the prevalence of, and factors associated with, last 12-month Pap smear and mammogram receipt among a Midwest community sample of low-acculturated Latinas.
Methods
We conducted a cross-sectional study with 278 Latina immigrants in Dane County, Wisconsin. Participants completed a self-administered questionnaire. We estimated multivariate logistic regression models to identify factors associated with CBC screening receipt.
Results
Rates of last 12-month Pap smear and mammogram receipt were 56.8% and 39.4%, respectively. Age, knowledge of screening recommendations, and having a regular health care provider were independently associated with both Pap smear and mammogram receipt. Having ever used Planned Parenthood and fatalism beliefs were uniquely correlated with Pap smear and mammogram receipt, respectively.
Conclusions
Modifiable individual, structural, and cultural factors contribute to suboptimal rates of CBC screening among low-acculturated Latina immigrants.
doi:10.1353/hpu.2013.0165
PMCID: PMC3959859  PMID: 24185166
Latinas; breast cancer; cervical cancer; screening; Social Ecological Model
24.  Awareness and knowledge regarding of cervical cancer, Pap smear screening and human papillomavirus infection in Gabonese women 
BMC Women's Health  2015;15:37.
Background
Cervical cancer is the commonest cancer and the leading cause of cancer mortality in women in Gabon. The age-standardized incidence of cervical cancer is 19.9 per 100 000 women and the mortality rate is 8.4 per 100 000. Various international studies have identified the lack of awareness and knowledge about cervical cancer as barriers to use preventive methods. This article assesses the awareness and knowledge about cervical cancer, Pap smear testing and its use and HPV among women living in Libreville, Gabon.
Methods
This study was conducted in October 2014 in Libreville. A total of 452 women aged 16 years and above were recruited from different town locations. Logistic regression analysis was used to identify the effect of demographic characteristics on the level of knowledge about cervical cancer, Pap smear testing and HPV. Odds ratio and 95% confidence intervals were used to identify the strength of association. Associations were considered statistically significant at p < 0.05.
Results
Of all the women interviewed, 91.6% (414/452) had heard about cervical cancer and only 27.9% (126/452) had heard of Pap smear test. Of these 126 women, only 65.1% (82/126) had done cervical cancer screening and 68.3% (56/82) on the suggestion of a doctor. The most common reason for not undergoing Pap smear testing was neglect (50%, 22/44) followed by lack of financial resources (13.6%, 6/44), fear of discovering a serious disease (13.6%, 6/44) and deeming it unimportant (13.6%, 6/44). Only 8% (40/452) of the participants had heard about HPV and their knowledge of HPV was fair. There is a very poor level of knowledge about cervical cancer among Gabonese women.
Conclusion
This study demonstrates a very low level of knowledge about cervical cancer, Pap smear testing and HPV in a sample of Gabonese women. There is a critical need for Gabonese women to be informed about cervical cancer and the Pap smear test to improve the use of this preventive method. The implication of health staff and Gabonese media should be included as a centerpiece in the effort to inform the population in order to reduce the burden of cervical cancer in Gabon and save women lives.
doi:10.1186/s12905-015-0193-2
PMCID: PMC4415219  PMID: 25924940
Cervical cancer; Pap smear test; HPV; Knowledge; Gabonese women
25.  Knowledge and Acceptability of Pap Smears, Self-Sampling and HPV Vaccination among Adult Women in Kenya 
PLoS ONE  2012;7(7):e40766.
Objectives
Our study aimed to assess adult women’s knowledge of human papillomavirus (HPV) and cervical cancer, and characterize their attitudes towards potential screening and prevention strategies.
Methods
Women were participants of an HIV-discordant couples cohort in Nairobi, Kenya. An interviewer-administered questionnaire was used to obtain information on sociodemographic status, and sexual and medical history at baseline and on knowledge and attitudes towards Pap smears, self-sampling, and HPV vaccination at study exit.
Results
Only 14% of the 409 women (67% HIV-positive; median age 29 years) had ever had a Pap smear prior to study enrollment and very few women had ever heard of HPV (18%). Although most women knew that Pap smears detect cervical cancer (69%), very few knew that routine Pap screening is the main way to prevent ICC (18%). Most women reported a high level of cultural acceptability for Pap smear screening and a low level of physical discomfort during Pap smear collection. In addition, over 80% of women reported that they would feel comfortable using a self-sampling device (82%) and would prefer at-home sample collection (84%). Nearly all women (94%) reported willingness to be vaccinated to prevent cervical cancer if offered at no or low cost.
Conclusions
These findings highlight the need to educate women on routine use of Pap smears in the prevention of cervical cancer and demonstrate that vaccination and self-sampling would be acceptable modalities for cervical cancer prevention and screening.
doi:10.1371/journal.pone.0040766
PMCID: PMC3393696  PMID: 22808257

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