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1.  Knowledge of HPV Among United States Hispanic Women: Opportunities and Challenges for Cancer Prevention 
Journal of health communication  2010;15(0 3):10.1080/10810730.2010.522695.
In the United States, Hispanic women contribute disproportionately to cervical cancer incidence and mortality. This disparity, which primarily reflects lack of access to, and underutilization of, routine Pap smear screening may improve with increased availability of vaccines to prevent Human Papillomavirus (HPV) infection, the principal cause of cervical cancer. However, limited research has explored known determinants of HPV vaccine acceptability among Hispanic women. The current study examines two such determinants, HPV awareness and knowledge, using data from the 2007 Health Interview National Trends Survey (HINTS) and a cross-section of callers to the National Cancer Institute’s (NCI) Cancer Information Service (CIS). Study data indicate that HPV awareness was high in both samples (69.5% and 63.8% had heard of the virus) but that knowledge of the virus and its association with cervical cancer varied between the two groups of women. The CIS sample, which was more impoverished and less acculturated than their HINTS counterparts, were less able to correctly identify that HPV causes cervical cancer (67.1% vs. 78.7%) and that it is a prevalent sexually transmitted infection (STI; 66.8% vs. 70.4%). Such findings imply that future research may benefit from disaggregating data collected with Hispanics to reflect important heterogeneity in this population subgroup’s ancestries, levels of income, educational attainment, and acculturation. Failing to do so may preclude opportunity to understand, as well as to attenuate, cancer disparity.
doi:10.1080/10810730.2010.522695
PMCID: PMC3858859  PMID: 21154081
2.  Knowledge and Intention to Participate in Cervical Cancer Screening after the Human Papillomavirus Vaccine 
Vaccine  2011;29(25):4238-4243.
Background
If women who receive the human papillomavirus (HPV) vaccine are unduly reassured about the cancer prevention benefits of vaccination, they may choose not to participate in screening, thereby increasing their risk for cervical cancer. This study assesses adult women’s knowledge of the need to continue cervical cancer screening after HPV vaccination, describes Pap test intentions of vaccinated young adult women, and evaluates whether knowledge and intentions differ across groups at greatest risk for cervical cancer.
Methods
Data were from the 2008 Health Information National Trends Survey (HINTS) and the 2008 National Health Interview Survey (NHIS), which initiated data collection approximately 18 months after the first FDA approval of an HPV vaccine. We calculated associations between independent variables and the outcomes using chi-square tests.
Results
Of 1,586 female HINTS respondents ages 18 through 74, 95.6% knew that HPV-vaccinated women should continue to receive Pap tests. This knowledge did not vary significantly by race/ethnicity, education, income, or healthcare access. Among 1,101 female NHIS respondents ages 18 to 26 who had ever received a Pap test, the proportion (12.7%; n = 139) who reported receipt of the HPV vaccine were more likely than those not vaccinated to plan to receive a Pap test within three years (98.1% vs. 92.5%, p<0.001).
Conclusions
US adult women possess high knowledge and intention to participate in Pap testing after HPV vaccination. The vast majority of young adult women who received the HPV vaccine within its first two years on the market intend to participate in cervical cancer screening in the near future. Future studies are needed to examine whether those vaccinated in adolescence will become aware of, and adhere to, screening guidelines as they become eligible.
doi:10.1016/j.vaccine.2011.03.076
PMCID: PMC3105777  PMID: 21473953
human papillomavirus (HPV); cervical cancer; cancer screening; disparities
3.  The Frequency of Pap Smear Screening in the United States 
BACKGROUND
U.S. professional medical societies and the national health systems of all other industrialized nations recommend that most women need not undergo Papanicolaou (Pap) smear screening annually. There are no data, however, regarding the frequency at which women actually undergo screening.
OBJECTIVE
To describe the frequency of cervical cancer screening in the United States.
DESIGN
National Health Interview Survey, a cross-sectional population-based telephone survey conducted by the National Center for Health Statistics.
PARTICIPANTS
Representative sample of U.S. women age 21 and older who denied a history of cancer (N = 16,467).
MEASUREMENTS
Pap smear screening frequency, categorized as no regular screening or screening at 1 of 3 discrete screening intervals (every year, every 2 years, or every 3 years) based on each woman's reported number of Pap smears in the previous 6 years.
RESULTS
The vast majority (93%) of American women report having had at least one Pap smear in their lifetime. Among women with no history of abnormal smears, 55% undergo Pap smear screening annually, 17% report a 2-year screening interval, 16% report being screened every 3 years, and 11% are not being screened regularly. Even the very elderly report frequent screening—38% of women age 75 to 84 and 20% of women age 85 and older reported annual Pap smears. Overall, 20% of women reported having had at least one abnormal Pap smear. Among these women, rates of frequent Pap smear screening are considerably higher—80% undergo annual screening, with only a modest decline in screening frequency with increasing age.
CONCLUSIONS
The majority of American women report being screened for cervical cancer more frequently than recommended. Lengthening the screening interval would not only reduce the volume of specimens that cytotechnologists are required to read, but would also reduce the follow-up testing after abnormal smears.
doi:10.1111/j.1525-1497.2004.21107.x
PMCID: PMC1492158  PMID: 15009779
cervical cancer screening; Pap smear; test frequency; overutilization
4.  Does Patient Health and Hysterectomy Status Influence Cervical Cancer Screening in Older Women? 
Journal of General Internal Medicine  2008;23(11):1822-1828.
Background
Decisions to screen older patients for cancer are complicated by the fact that aging populations are heterogeneous with respect to life expectancy.
Objective
To examine national trends in the association between cervical cancer screening and age, health and hysterectomy status.
Design and participants
Cross-sectional data from the 1993, 1998, 2000, and 2005 National Health Interview Surveys (NHIS) were used to examine trends in screening for women age 35–64 and 65+ years of age. We investigated whether health is associated with Pap testing among older women using the 2005 NHIS ( = 3,073). We excluded women with a history of cervical cancer or who had their last Pap because of a problem.
Measurements
The dependent variable was having a Pap test within the past 3 years. Independent variables included three measures of respondent health (the Charlson comorbidity index (CCI), general health status and having a chronic disability), hysterectomy status and sociodemographic factors.
Main results
NHIS data showed a consistent pattern of lower Pap use among older women (65+) compared to younger women regardless of hysterectomy status. Screening also was lower among older women who reported being in fair/poor health, having a chronic disability, or a higher CCI score (4+). Multivariate models showed that over 50% of older women reporting poor health status or a chronic disability and 47% with a hysterectomy still had a recent Pap.
Conclusions
Though age, health and hysterectomy status appear to influence Pap test use, current national data suggest that there still may be overutilization and inappropriate screening of older women.
doi:10.1007/s11606-008-0775-x
PMCID: PMC2585656  PMID: 18784967
cervical screening; hysterectomy; older age; health status; comorbidity
5.  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
6.  Performance of Papanicolaou Testing and Detection of Cervical Carcinoma In Situ in Participants of Organized Cervical Cancer Screening in South Korea 
PLoS ONE  2012;7(4):e35469.
Background
The present study measured the performance of the Papanicolaou (Pap) test and detection of cervical carcinoma in situ (CIS) and cancer in participants of organized cervical cancer screening in South Korea, and examined differences in the proportion of CIS according to socio-demographic factors.
Methods
Data were obtained from the National Cancer Screening Program and National Health Insurance Cancer Screening Program databases. We analyzed data from 4,072,997 screenings of women aged 30 years or older who underwent cervical cancer screening by Pap test between January 1, 2005 and December 31, 2006. We calculated the performances of the Pap test and compared that according to socio-demographic factors.
Results
The positivity rate for all screenings was 6.6%. The cancer detection rate (CDR) and interval cancer rate (ICR) were 0.32 per 1,000 screenings, and 0.13 per 1,000 negative screenings, respectively. About 63.4% of screen-detected CIS+ cases (CIS or invasive cervical cancer) were CIS. The CDR and ICR, and percentage of CIS among all CIS+ were significantly different by age group and health insurance status. The odds ratios of CDR and ICR were higher for Medical Aid Program (MAP) recipients compared with National Health Insurance (NHI) beneficiaries. The likelihood of a detected CIS+ case to be CIS was significantly lower among MAP recipients than among NHI beneficiaries.
Conclusions
The difference in performance of cervical cancer screening among different socio-demographic groups may indicate an important influence of socio-demographic factors on preventive behavior. The findings of the study support the critical need for increasing efforts to raise awareness and provide more screening in at-risk populations, specifically low-income groups.
doi:10.1371/journal.pone.0035469
PMCID: PMC3328331  PMID: 22530028
7.  Epidemiology and costs of cervical cancer screening and cervical dysplasia in Italy 
BMC Public Health  2009;9:71.
Background
We estimated the number of women undergoing cervical cancer screening annually in Italy, the rates of cervical abnormalities detected, and the costs of screening and management of abnormalities.
Methods
The annual number of screened women was estimated from National Health Interview data. Data from the Italian Group for Cervical Cancer Screening were used to estimate the number of positive, negative and unsatisfactory Pap smears. The incidence of CIN (cervical intra-epithelial neoplasia) was estimated from the Emilia Romagna Cancer Registry. Patterns of follow-up and treatment costs were estimated using a typical disease management approach based on national guidelines and data from the Italian Group for Cervical Cancer Screening. Treatment unit costs were obtained from Italian National Health Service and Hospital Information System of the Lazio Region.
Results
An estimated 6.4 million women aged 25–69 years undergo screening annually in Italy (1.2 million and 5.2 million through organized and opportunistic screening programs, respectively). Approximately 2.4% of tests have positive findings. There are approximately 21,000 cases of CIN1 and 7,000–17,000 cases of CIN2/3. Estimated costs to the healthcare service amount to €158.5 million for screening and €22.9 million for the management of cervical abnormalities.
Conclusion
Although some cervical abnormalities might have been underestimated, the total annual cost of cervical cancer prevention in Italy is approximately €181.5 million, of which 87% is attributable to screening.
doi:10.1186/1471-2458-9-71
PMCID: PMC2651166  PMID: 19243586
8.  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
9.  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
10.  The Vicious Cycle of Inadequate Early Detection: A Complementary Study on Barriers to Cervical Cancer Screening Among Middle-Aged and Older Women 
Preventing Chronic Disease  2007;4(4):A95.
Introduction
Although rates of invasive cervical cancer have declined precipitously over the past 50 years, nearly 10,000 new cases and 3700 deaths result from this cancer annually. Given the efficacy of early detection, invasive cervical cancer should no longer constitute a health threat; however, national studies reveal that many women, especially older women, do not receive Papanicolaou (Pap) tests.
Methods
In this complementary study, we examined data from the National Health Interview Survey focusing on the correlates of screening for women aged 55 years or older, an age group in which invasive cervical cancer rates escalate and rates of obtaining Pap tests decline. To more richly understand grounded perspectives, we queried 25 women who were rarely or never screened about factors and circumstances underlying their decision not to obtain a Pap test.
Results
Quantitative data indicate an association between Pap test use and demographic factors (being married, being younger, and having suburban or urban residence) and access to preventive care (obtaining mammograms, having a regular source of health care, and having contact with an obstetrician/gynecologist). Participants who provided qualitative data echoed this theme of inadequate use of preventive services, particularly among women with weak social ties, who were older, and who lived in rural areas. Shortages of health care professionals and a lack of continuity of care and privacy contribute to suboptimal prevention.
Conclusion
A vicious cycle emerges: many women decline to pursue preventive care because of competing health and financial demands and insufficient resources to seek care. When such women do go to the doctor's office, they feel chastised by providers, which alienates them and thwarts future preventive care.
PMCID: PMC2099293  PMID: 17875270
11.  Identifying barriers to Papanicolaou smear screening in Korean women: Korean National Health and Nutrition Examination Survey 2005 
Objective
This study was conducted to provide a nationwide analysis on barriers to cervical cancer screening in Korea.
Methods
Data used for this study was obtained in a survey called Korean National Health and Nutrition Examination Survey (KNHANES) 2005, which collected data from 2,590 Korean women aged older than 21 years who had not had a hysterectomy and were eligible for Papanicolaou (Pap) smears. Multivariate analysis was adopted to control each demographic factor and unhealthy behavior variable. Demographic factors included age, education, income, job and region; health-related behavior factors were defined as current smoking, obesity, hormone replacement therapy and disability.
Results
The study found that cervical cancer screening rate was significantly positively associated with income (odds ratio [OR], 1.002; 95% confidence interval [CI], 1.001 to 1.002), with education (OR, 1.324; 95% CI, 1.030 to 1.703), with job (OR, 1.420; 95% CI, 1.030 to 1.957), and with hormone replacement therapy (OR, 3.732; 95% CI, 2.354 to 5.916). Meanwhile, the age (OR, 0.977; 95% CI, 0.968 to 0.985), disability (OR, 0.358; 95% CI, 0.143 to 0.894) and smoking (OR, 0.447; 95% CI, 0.280 to 0.715) were significantly negatively associated with one's chances to take cervical cytology.
Conclusion
In order to increase the rates of Korean women taking Pap test, cervical cancer screening programs will have to pay special attention to the elderly, low-income group, smokers, and the disabled.
doi:10.3802/jgo.2010.21.2.81
PMCID: PMC2895721  PMID: 20613896
Papanicolaou; Barrier; Korean women
12.  Age-Related Differences in Health Beliefs Regarding Cervical Cancer Screening Among Korean American Women 
Journal of Transcultural Nursing  2012;23(3):237-245.
Cervical cancer screening rates among older Korean American (KA) women are much lower than the rates for younger KA women, even though the overall cancer screening rates in the population continue to have one of the lowest Papanicolaou (Pap) test adherence rates compared with non-Hispanic White women. Variables based on the Health Belief Model related to cervical cancer screening were compared by age group among KA women. A telephone survey was conducted with 189 KA women living in the midwestern United States. Perceived barriers to having a Pap test predicted the outcome variable of having had Pap tests in the preceding 3 years in older KA women who were 65 or older, but not in younger women who were between 40 and 64 years old. Having physical examinations without symptoms in the preceding 2 years predicted the outcome variable in both age groups. Intervention strategies for all KA women should focus on encouraging them to receive routine physical examinations. In addition, attempts should be made to reduce perception of barriers in older KA women to improve their cervical cancer screening behaviors.
doi:10.1177/1043659612441015
PMCID: PMC3387286  PMID: 22477716
cervical cancer; cancer beliefs; Pap tests; Korean American older women
13.  Current status of the National Cancer Screening Program for cervical cancer in Korea, 2009 
Objective
The National Cancer Screening Program (NCSP) began in 1999. In this report, we evaluate the results of the NCSP for cervical cancer in 2009 and provide participation rates in an organized cervical cancer screening program in Korea.
Methods
Using data obtained from the National Cancer Screening Information System, cervical cancer screening participation rates were calculated. Recall rates, defined as the proportion of abnormal cases among women screened, were also estimated with 95% confidence intervals.
Results
The target population of cervical cancer screening in 2009 included 4,577,200 Korean women aged 30 and over, 1,349,668 of whom underwent the Papanicolaou smear test (29.5% participation rate). Compared with the participation rate of women covered by the National Health Insurance Program (31.3%), the participation rate of women covered by the Medical Aid Program was lower (18.4%). Participation rates also varied in different age groups (the highest of 39.3% in women aged 50 to 59 and the lowest of 14.4% in those aged 70 and older), and different areas (the highest of 34.1% in Busan and the lowest of 21.5% in Chungnam). The overall recall rate for cervical cancer screening was 0.41% (95% confidence interval, 0.40 to 0.42).
Conclusion
According to our study, efforts to facilitate participation and reduce disparities in cervical cancer screening among Korean women are needed.
doi:10.3802/jgo.2012.23.1.16
PMCID: PMC3280061  PMID: 22355462
Age distribution; Health insurance; Korea; Mass screening; Uterine cervical neoplasms
14.  Factors associated with obtaining health screening among women of reproductive age. 
Public Health Reports  1993;108(1):76-86.
Death and disability associated with breast and cervical cancer and hypertension can be reduced by early detection and treatment. The authors examined the rates for having obtained a Papanicolaou (Pap) test or pelvic examination, a breast physical examination, and a blood pressure test within the last 12 months among women of reproductive age in the United States in 1988, as reported by the 8,450 women interviewed for the 1988 National Survey of Family Growth. Overall, the annual rates of screening for women ages 15-44 years for those tests were 67 percent for a Pap test or pelvic examination, 67 percent for a breast examination, and 82 percent for a blood pressure test. Standard recommendations for the frequency of screening and survey data were examined to see whether actual screening practice was consistent with those recommendations. More than 90 percent of women who had a family planning service visit within 12 months received each of the tests, regardless of who provided the service or who paid for the visit. Women who were not sexually active, women with little education or low income, American Indian women, Hispanic women, and women of Asian or Pacific Islander descent had lower rates of screening than others, regardless of their risk status. These findings strongly suggest that the likelihood of having obtained screening among women 15-44 years old is determined primarily by how often a woman uses health care, rather than by her risk of disease.
PMCID: PMC1403334  PMID: 8434102
15.  Sociodemographic gradients in breast and cervical cancer screening in Korea: the Korean National Cancer Screening Survey (KNCSS) 2005-2009 
BMC Cancer  2011;11:257.
Background
Cancer screening rates in Korea for five cancer types have increased steadily since 2002. With regard to the life-time cancer screening rates in 2009 according to cancer sites, the second highest was breast cancer (78.1%) and the third highest was cervical cancer (76.1%). Despite overall increases in the screening rate, disparities in breast and cervical cancer screening, based on sociodemographic characteristics, still exist.
Methods
Data from 4,139 women aged 40 to74 years from the 2005 to 2009 Korea National Cancer Screening Survey were used to analyze the relationship between sociodemographic characteristics and receiving mammograms and Pap smears. The main outcome measures were ever having had a mammogram and ever having had a Pap smear. Using these items of information, we classified women into those who had had both types of screening, only one screening type, and neither screening type. We used logistic regression to investigate relationships between screening history and sociodemographic characteristics of the women.
Results
Being married, having a higher education, a rural residence, and private health insurance were significantly associated with higher rates of breast and cervical cancer screening after adjusting for age and sociodemographic factors. Household income was not significantly associated with mammograms or Pap smears after adjusting for age and sociodemographic factors.
Conclusions
Disparities in breast and cervical cancer screening associated with low sociodemographic status persist in Korea.
doi:10.1186/1471-2407-11-257
PMCID: PMC3144456  PMID: 21682886
16.  Cervical cancer screening among vulnerable women 
Canadian Family Physician  2012;58(9):e521-e526.
Abstract
Objective
To see if refugee women at a community health centre (CHC) in Toronto, Ont, are appropriately screened for cervical cancer and if there are any demographic characteristics that affect whether they are screened.
Design
Chart review.
Setting
A CHC in downtown Toronto.
Participants
A total of 357 eligible refugee women attending the CHC.
Main outcome measures
Papanicolaou test received or documented reason for no Pap test.
Results
Ninety-two percent of women in the study sample were either appropriately screened for cervical cancer or had been approached for screening. Eighty percent of women were appropriately screened. Demographic variables including pregnancy, being uninsured, not speaking English, recent migration to Canada, and being a visible minority did not affect receipt of a Pap test after migration in multivariate analyses. Not speaking English was associated with a delay to receiving a first Pap test after migration.
Conclusion
The clients at our centre are demographically similar to women who are typically overlooked for Pap tests in the greater Toronto area. Despite belonging to a high-risk population, refugee women in this multidisciplinary CHC were screened for cervical cancer at a higher rate than the local population.
PMCID: PMC3440294  PMID: 22972744
17.  Integrating behavior and intention regarding mammography by respondents in the 1990 National Health Interview Survey of Health Promotion and Disease Prevention. 
Public Health Reports  1993;108(5):605-624.
Achieving and maintaining high rates of screening mammography are major public health priorities. This report examines data from the 1990 National Health Interview Survey of Health Promotion and Disease Prevention on the utilization of mammography among women ages 40-75. Results show that progress is being made in some areas--57.7 percent of women "ever had" a mammogram; 50.3 percent, in previous 2 years. However, those not having repeated regular screening appear to be a sizable proportion. Only 28.6 percent of women ages 40-75 had been both screened on the recommended age-specific schedule and expressed an intention to continue screening; another 29.2 percent indicated no intention to have a mammogram in the near future. Income, clinical breast examination, and Pap (Papanicolaou's) test, having no regular source of care, region of the country and residential variables, smoking status, not exercising, not knowing how to do breast self-examination, and race were among the variables having the strongest associations with mammography status. Several groups in the population therefore remain at risk of not receiving regular screening. The combination of mammography status to date and future intention to have the examination provides an important perspective on efforts to reach public health screening objectives and appears to provide a strategy for targeting interventions.
PMCID: PMC1403437  PMID: 8210259
18.  Breast and Cervical Cancer Screening 
Background
Obesity and depression may each be associated with less cervical and breast cancer screening. Studies have examined obesity or depression alone, but not together, despite the established link between them.
Purpose
To disentangle the effects of depression and obesity on receipt of breast and cervical cancer screening.
Methods
A stratified sampling design was used to recruit women aged 40–65 years with information on BMI from an integrated health plan in Washington in 2003–2005. A telephone survey included the PHQ-9 for depression, weight, and height. Automated data assessed Paps for 3097 women over a 3-year period and screening mammograms over a 2-year period for 2163 women aged ≥51 years. Logistic regression models (conducted in 2008) examined the association between obesity and depression and receipt of screening tests.
Results
In univariate logistic regression models, women were less likely to receive a Pap if they were obese (OR = 0.53, 95% CI 0.41–0.69) or depressed (OR = 0.60, 95% CI= 0.42–0.87). Women were less likely to receive a screening mammogram if they were depressed (OR = 0.45, 95% CI= 0.30–0.67). In multivariable models, only obesity remained significantly associated with lower likelihood of Pap screening (OR =0.67, 95% CI= 0.0.49–0.93) and only depression remained significantly associated with less screening mammography (OR =0.49, 95% CI 0.31–0.76). Obesity and depression did not interact significantly in either model.
Conclusions
Obesity and depression appear to have specific effects on receipt of different cancer screening tests.
doi:10.1016/j.amepre.2009.10.039
PMCID: PMC2835516  PMID: 20171532
19.  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
20.  Socioeconomic disparities in the uptake of breast and cervical cancer screening in Italy: a cross sectional study 
BMC Public Health  2012;12:99.
Background
Breast and cervical cancer screening are widely recognized as effective preventive procedures in reducing cancer mortality. The aim of this study was to evaluate the impact of socioeconomic disparities in the uptake of female screening in Italy, with a specific focus on different types of screening programs.
Methods
A cross-sectional study was conducted using data from the 2004-2005 national health interview survey. A sample of 15, 486 women aged 50-69 years for mammography and one of 35, 349 women aged 25-64 years for Pap smear were analysed. Logistic regression models were used to estimate the association between socioeconomic factors and female screening utilization.
Results
Education and occupation were positively associated with attendance to both screening. Women with higher levels of education were more likely to have a mammogram than those with a lower level (OR = 1.28; 95% CI = 1.10-1.49). Women of intermediate and high occupational classes were more likely to use breast cancer screening (OR = 1.77; 95% CI = 1.55-2.03, OR = 1.63; 95% CI = 1.40-1.91) compared to unemployed women. Women in the highest occupational class had a higher likelihood of cervical cancer screening compared to those in the lowest class (OR = 1.81; 95% CI = 1.63-2.01). Among women who attended screening, those with lower levels of education and lower occupational classes were more likely than more advantaged women to attend organized screening programs rather than being screened on the basis of their own initiative.
Conclusions
Inequalities in the uptake of female screening widely exist in Italy. Organized screening programs may have an important role in increasing screening attendance and tackling inequalities.
doi:10.1186/1471-2458-12-99
PMCID: PMC3314546  PMID: 22305108
21.  12-county program: screening of 34,318 women for cervical cancer in California, 1975-78. 
Public Health Reports  1981;96(6):547-554.
The California Department of Health Services conducted a cervical cancer screening program in 12 counties where local health agencies provided the screening services. A major purpose of the study was to screen women at high risk of cervical cancer and to assure that women with abnormal results on cervical cytology testing obtained appropriate diagnostic workup and treatment. A total of 34,318 women were screened, and 7,811 returned for up to 3 annual rescreening examinations. Final cytologic results were 33,658 normal, 100 unsatisfactory, and 560 abnormal smears. Of the abnormal smears, 484 were indicative of cervical dysplasia, 41 of in situ cervical cancer and 22 of invasive cervical cancer. In 13 women, endometrial cancer was suspected. Complete followup information on diagnostic evaluation and treatment was obtained for 80 percent of the women with abnormal Pap test results. Histological confirmation of neoplasia was reported for 173 women. The diagnoses were cervical dysplasia in 108, cervical cancer in 58 (49 in situ, 9 invasive) and endometrial cancer in 7. The program reached greater proportions of older women, the less affluent, women of Spanish origin and oriental women and a smaller proportion of blacks than were present in the general female population of California.
PMCID: PMC1424263  PMID: 7302109
22.  Predictors of Cervical Cancer Screening for Rarely or Never Screened Rural Appalachian Women 
Background and Purpose
Women who have not had a Papanicolaou test in five years or more have increased risk of developing invasive cervical cancer. This study compares Appalachian women whose last screening was more than one year ago but less than five years ago with those not screened for the previous five years or more.
Methods
Using PRECEDE/PROCEED as a guide, factors related to obtaining Pap tests were examined using cross-sectional data from 345 Appalachian Kentucky women. Bivariate and multivariate analyses were conducted to identify predictors of screening.
Results
Thirty-four percent of participants were rarely- or never-screened. In multiple logistic regression analyses, several factors increased those odds, including belief that cervical cancer has symptoms, and not having a regular source of medical care.
Conclusion
The findings from this study may lead to the development of effective intervention and policies that increase cervical cancer screening in this population.
doi:10.1353/hpu.2011.0021
PMCID: PMC3041591  PMID: 21317514
Cervical cancer screening; Appalachian women; access; predictors
23.  Caregiving associated with selected cancer risk behaviors and screening utilization among women: cross-sectional results of the 2009 BRFSS 
BMC Public Health  2012;12:685.
Background
Informal caregiving is increasingly common as the U.S. population ages, and there is concern that caregivers are less likely than non-caregivers to practice health-promoting behaviors, including cancer screening. We examined caregiving effects on cancer risk behaviors and breast and cervical cancer screening in the 2009 Behavioral Risk Factor Surveillance System.
Methods
Women age ≥41 with data on breast and cervical cancer screening were included (weighted frequency 3,478,000 women). Cancer screening was classified according to American Cancer Society guidelines. We evaluated the association of caregiving with cancer risk behaviors (obesity, physical activity, alcohol intake, smoking status, and fruit/vegetable consumption) and cancer screening (mammography, clinical breast exam [CBE], and Pap test) using logistic regression overall and with stratification on age (<65, ≥65) or race (white, non-white).
Results
Caregivers had greater odds of being obese, physically active, and current smokers. Subgroup analyses revealed that caregiving was associated with obesity in younger women and whites, and with less obesity in older women. Also, caregiving was associated with smoking only among younger women and non-whites. Caregivers had greater odds of ever having had a mammogram or CBE, yet there was no association with mammogram, CBE, or Pap test within guidelines.
Conclusions
Caregiving was associated with some health behaviors that increase cancer risk, yet not with cancer screening within guidelines. Effects of caregiving by age and race require confirmation by additional studies.
doi:10.1186/1471-2458-12-685
PMCID: PMC3499215  PMID: 22908937
Caregiving; Mammography; Pap test; Health behaviors
24.  The Association Between Insurance Status and Cervical Cancer Screening in Community Health Centers: Exploring the Potential of Electronic Health Records for Population-Level Surveillance, 2008–2010 
Introduction
Cervical cancer incidence and mortality rates in the United States have decreased 67% over the past 3 decades, a reduction mainly attributed to widespread use of the Papanicolaou (Pap) test for cervical cancer screening. In the general population, receipt of cervical cancer screening is positively associated with having health insurance. Less is known about the role insurance plays among women seeking care in community health centers, where screening services are available regardless of insurance status. The objective of our study was to assess the association between cervical cancer screening and insurance status in Oregon and California community health centers by using data from electronic health records.
Methods
We used bilevel log-binomial regression models to estimate prevalence ratios and 95% confidence intervals for receipt of a Pap test by insurance status, adjusted for patient-level demographic factors and a clinic-level random effect.
Results
Insurance status was a significant predictor of cervical cancer screening, but the effect varied by race/ethnicity and age. In our study uninsured non-Hispanic white women were less likely to receive a Pap test than were uninsured women of other races. Young, uninsured Hispanic women were more likely to receive a Pap test than were young, fully insured Hispanic women, a finding not previously reported.
Conclusion
Electronic health records enable population-level surveillance in community health centers and can reveal factors influencing use of preventive services. Although community health centers provide cervical cancer screening regardless of insurance status, disparities persist in the association between insurance status and receipt of Pap tests. In our study, after adjusting for demographic factors, being continuously insured throughout the study period improved the likelihood of receiving a Pap test for many women.
doi:10.5888/pcd10.130034
PMCID: PMC3809921  PMID: 24157076
25.  Attendance at Cervical Cancer Screening and Use of Diagnostic and Therapeutic Procedures on the Uterine Cervix Assessed from Individual Health Insurance Data (Belgium, 2002-2006) 
PLoS ONE  2014;9(4):e92615.
Objective
To assess the coverage for cervical cancer screening as well as the use of cervical cytology, colposcopy and other diagnostic and therapeutic interventions on the uterine cervix in Belgium, using individual health insurance data.
Methods
The Intermutualistic Agency compiled a database containing 14 million records from reimbursement claims for Pap smears, colposcopies, cervical biopsies and surgery, performed between 2002 and 2006. Cervical cancer screening coverage was defined as the proportion of women aged 25–64 that had a Pap smear within the last 3 years.
Results
Cervical cancer screening coverage was 61% at national level, for the target population of women between 25 and 64 years old, in the period 2004–2006. Differences between the 3 regions were small, but varied more substantially between provinces. Coverage was 70% for 25–34 year old women, 67% for those aged 35–39 years, and decreased to 44% in the age group of 60–64 years. The median screening interval was 13 months. The screening coverage varied substantially by social category: 40% and 64%, in women categorised as beneficiary or not-beneficiary of increased reimbursement from social insurance, respectively. In the 3-year period 2004–2006, 3.2 million screen tests were done in the target group consisting of 2.8 million women. However, only 1.7 million women got one or more smears and 1.1 million women had no smears, corresponding to an average of 1.88 smears per woman in three years of time. Colposcopy was excessively used (number of Pap smears over colposcopies = 3.2). The proportion of women with a history of conisation or hysterectomy, before the age of 65, was 7% and 19%, respectively.
Conclusion
The screening coverage increased slightly from 59% in 2000 to 61% in 2006. The screening intensity remained at a high level, and the number of cytological examinations was theoretically sufficient to cover more than the whole target population.
doi:10.1371/journal.pone.0092615
PMCID: PMC3972167  PMID: 24690620

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