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1.  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(1):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
2.  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
3.  Cervical Screening at Age 50–64 Years and the Risk of Cervical Cancer at Age 65 Years and Older: Population-Based Case Control Study 
PLoS Medicine  2014;11(1):e1001585.
Peter Sasieni and colleagues use a population-based case control study to assess the risk of cervical cancer in screened women aged over 65 years to help inform policy on the upper age of cervical cancer screening.
Please see later in the article for the Editors' Summary
Background
There is little consensus, and minimal evidence, regarding the age at which to stop cervical screening. We studied the association between screening at age 50–64 y and cervical cancer at age 65–83 y.
Methods and Findings
Cases were women (n = 1,341) diagnosed with cervical cancer at age 65–83 y between 1 April 2007 and 31 March 2012 in England and Wales; age-matched controls (n = 2,646) were randomly selected from population registers. Screening details from 1988 onwards were extracted from national databases. We calculated the odds ratios (OR) for different screening histories and subsequent cervical cancer. Women with adequate negative screening at age 65 y (288 cases, 1,395 controls) were at lowest risk of cervical cancer (20-y risk: 8 cancers per 10,000 women) compared with those (532 cases, 429 controls) not screened at age 50–64 y (20-y risk: 49 cancers per 10,000 women, with OR = 0.16, 95% CI 0.13–0.19). ORs depended on the age mix of women because of the weakening association with time since last screen: OR = 0.11, 95% CI 0.08–0.14 at 2.5 to 7.5 y since last screen; OR = 0.27, 95% CI 0.20–0.36 at 12.5 to 17.5 y since last screen. Screening at least every 5.5 y between the ages 50 and 64 y was associated with a 75% lower risk of cervical cancer between the ages 65 and 79 y (OR = 0.25, 95% CI 0.21–0.30), and the attributable risk was such that in the absence of screening, cervical cancer rates in women aged 65+ would have been 2.4 (95% CI 2.1–2.7) times higher. In women aged 80–83 y the association was weaker (OR = 0.49, 95% CI 0.28–0.83) than in those aged 65–69 y (OR = 0.12, 95% CI 0.09–0.17). This study was limited by an absence of data on confounding factors; additionally, findings based on cytology may not generalise to human papillomavirus testing.
Conclusions
Women with adequate negative screening at age 50–64 y had one-sixth of the risk of cervical cancer at age 65–83 y compared with women who were not screened. Stopping screening between ages 60 and 69 y in women with adequate negative screening seems sensible, but further screening may be justifiable as life expectancy increases.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Nearly one in ten cancers diagnosed in women occur in the cervix, the structure that connects the womb to the vagina. Every year, more than a quarter of a million women (mostly in developing countries) die because of cervical cancer, which occurs only after the cervix has been infected with human papillomavirus (HPV) through sexual intercourse. In the earliest stages of cervical cancer, abnormal cells begin to grow in the cervix. Cells with low-grade abnormalities (changes that often revert to normal), cells with high-grade abnormalities (which are more likely to become cancerous), and cancer cells can all be detected by collecting a few cells from the cervix and examining them under a microscope. This test forms the basis of cervical screening, which has greatly reduced cervical cancer deaths in countries with a national screening program by ensuring that cervical abnormalities are detected at an early, treatable stage. In the UK, for example, since the start of a cervical screening program in 1988 in which women aged 25–64 years are called for testing every 3–5 years, the incidence of cervical cancer (the number of new cases per year) has almost halved at a time when sexually transmitted diseases have more than doubled.
Why Was This Study Done?
Currently, there is little consensus about the age at which cervical screening should stop, and minimal evidence about the impact of cervical screening on the incidence of cervical cancer in older women. In this population-based case control study (a study that compares the characteristics of all the cases of a disease in a population with the characteristics of matched individuals without the disease), the researchers examine the association between screening in women aged 50–64 years and cervical cancer in women aged 65–83 years. They ask whether well-screened women with a history of negative results and no evidence of high-grade abnormalities are at sufficiently low risk of cervical cancer that screening can be stopped at age 65 years, and whether women who are regularly screened (at least once every 5.5 years) between the ages of 50 and 64 years are subsequently at reduced risk of cervical cancer.
What Did the Researchers Do and Find?
The researchers randomly selected two age-matched controls for every woman aged 65–83 years who was diagnosed with cervical cancer between 2007 and 2012 in England and Wales. The researchers included 1,341 women with cervical cancer and 2,646 controls. They extracted each woman's cervical screening details from national databases and calculated the association between screening history and subsequent cervical cancer. Women with adequate negative screening at age 65 years (at least three tests at age 50–64 years with the last one over age 60, the last three of which were negative, and no evidence of high-grade abnormalities) were at the lowest risk of cervical cancer (20-year risk of eight cancers per 10,000 women) compared with unscreened women (20-year risk of 49 cancers per 10,000 women). That is, women who were not screened at age 50–64 years were six times more likely to develop cervical cancer between the ages of 65 and 83 years than women who were screened. The risk of developing cervical cancer among adequately negatively screened women increased with age and with time since the last screen. Finally, the researchers estimate that in the absence of any cervical screening, the rate of cervical cancer among women aged 65–79 years would be 23 cases per 100,000 woman-years, 2.4 times higher than the current rate.
What Do These Findings Mean?
These findings show that women who exited the screening program in England and Wales with a history of adequate negative screening between the ages of 50 and 64 years were at a very low risk of being diagnosed with cervical cancer at the age of 65 years or older. The “protection” provided by screening was greatest for women aged 65–69 years and decreased steadily with increasing age and with time since the last negative screen. Because the researchers did not have any information on other characteristics that might have affected cervical cancer risk (for example, number of sexual partners), the women who were screened may have shared other characteristics that reduced their risk of developing cervical cancer. Moreover, these findings, which are based on microscopic examination of cells, may not generalise to the HPV-based screening programs that many countries are considering. Despite these limitations, the researchers conclude that, for now, it seems sensible to continue screening at least until age 60 years and not beyond age 69 years in women with adequate negative screening, but that given increasing life expectancy, screening in older women might be justified in the future.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001585.
This study is further discussed in a PLOS Medicine Perspective by Anne Rositch and colleagues
The US National Cancer Institute provides information about cervical cancer for patients and for health professionals, including information on cervical screening (in English and Spanish)
The US Centers for Disease Control and Prevention also has information about cervical cancer and about cervical screening
The UK National Health Service Cervical Screening Programme website has detailed information and statistics on cervical screening in England
The UK National Health Service Choices website has pages on cervical cancer (including a personal story about cervical cancer) and on cervical screening (including personal comments about screening)
Cancer Research UK provides detailed information about all aspects of cervical cancer
More information about cervical cancer and screening is available from the Macmillan cancer charity
MedlinePlus provides links to additional resources about cervical cancer and screening (in English and Spanish)
Personal stories about cervical cancer and about cervical screening are available through the charity Healthtalkonline
doi:10.1371/journal.pmed.1001585
PMCID: PMC3891624  PMID: 24453946
4.  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
5.  Cervical Cancer Screening in the Urgent Care Setting 
OBJECTIVE
To determine the feasibility of cervical cancer screening in an urgent care clinic.
DESIGN
Prospective randomized trial.
SETTING
Public teaching hospital.
PATIENTS
Women presenting to the urgent care clinic whose evaluation necessitated a pelvic examination were eligible for participation. Women who had a hysterectomy, had a documented Pap test at our institution in the past year, did not speak English or Spanish, or had significant vaginal bleeding were excluded. Women presenting to the gynecology clinic for a scheduled Pap test were used as a comparison group for rates of follow-up, Pap smear adequacy, and Pap smear abnormalities.
INTERVENTIONS
Women randomized to the intervention group had a Pap test performed as part of their pelvic examination, while women in the usual care group were encouraged to schedule an appointment in the gynecology clinic at a later date. The women in the two groups completed identical questionnaires regarding cervical cancer risk factors and demographic information.
MEASUREMENTS AND MAIN RESULTS
Ninety-four (84.7%) of 111 women in the intervention group received a Pap test, as compared with 25 (29%) of 86 in the usual care group (P < .01). However, only 5 (24%) of 21 women with abnormal Pap smears in the intervention group received follow-up compared with 6 (60%) of 10 women seen during the same time period in the gynecology clinic for self-referred, routine annual examinations (P = .11). Pap smears obtained in the urgent care clinic were similar to those in the gynecology clinic with regard to abnormality rate (22.3% vs 20%; P = .75, respectively) and specimen adequacy (67% vs 72%; P = .54, respectively).
CONCLUSIONS
Urgent care clinic visits can be used as opportunities to perform Pap test screening in women who are unlikely to adhere to cervical cancer screening recommendations. However, to accrue the full potential benefit from this intervention, an improved process to ensure patient follow-up must be developed.
doi:10.1046/j.1525-1497.2000.08001.x
PMCID: PMC1495471  PMID: 10886473
cervical cancer screening; urgent care clinic; Pap smears
6.  Self-reported history of Pap-smear in HIV-positive women in Northern Italy: a cross-sectional study 
BMC Cancer  2010;10:310.
Background
The incidence of invasive cervical cancer in HIV-positive women is higher than in the general population. There is evidence that HIV-positive women do not participate sufficiently in cervical cancer screening in Italy, where cervical cancer is more than 10-fold higher in women with AIDS than in the general population. The aim of the present study was to evaluate the history of Pap-smear in HIV-positive women in Italy in recent years. We also examined the sociodemographic, clinical, and organizational factors associated with adherence to cervical cancer screening.
Methods
A cross-sectional study was conducted between July 2006 and June 2007 in Emilia-Romagna region (Northern Italy). All HIV-positive women who received a follow-up visit in one of the 10 regional infectivology units were invited to participate. History of Pap-smear, including abnormal smears and subsequent treatment, was investigated through a self-administered anonymous questionnaire. The association between lack of Pap-smear in the year preceding the interview and selected characteristics was assessed by means of odds ratios (OR) and 95% confidence intervals adjusted for study centre and age.
Results
A total of 1,002 HIV-positive women were interviewed. Nine percent reported no history of Pap-smear, and 39% had no Pap-smear in the year prior to the date of questionnaire (last year). The lack of Pap-smear in the last year was significantly associated with age <35 years (OR = 1.4, compared to age ≥45 years), lower education level (OR = 1.3), first HIV-positive test in the last 2 years (OR = 1.4), and CD4 count <200 cells/μl (OR = 1.6). Conversely, when women were advised by a gynecologist rather than other health workers to undergo screening, it significantly increased adherence. Non-significantly higher proportions of lack of Pap-smear in the last year were found in women born in Central-Eastern Europe (OR = 1.8) and Africa (OR = 1.3). No difference in history of Pap-smear emerged by mode of HIV-acquisition or AIDS status.
Three hundred five (34%) women reported a previous abnormal Pap-smear, and of the 178 (58%) referred for treatment, 97% complied.
Conclusions
In recent years the self-reported history of Pap-smear in HIV-positive women, in some public clinics in Italy, is higher than previously reported, but further efforts are required to make sure cervical cancer screening is accessible to all HIV-positive women.
doi:10.1186/1471-2407-10-310
PMCID: PMC2904281  PMID: 20565935
7.  Mobile Phone Text Messaging Intervention for Cervical Cancer Screening: Changes in Knowledge and Behavior Pre-Post Intervention 
Background
Cervical cancer poses a significant threat to Korean American women, who are reported to have one of the highest cervical cancer mortality rates in the United States. Studies consistently report that Korean American women have the lowest Pap test screening rates across US ethnic groups.
Objective
In response to the need to enhance cervical cancer screening in this vulnerable population, we developed and tested a 7-day mobile phone text message-based cervical cancer Screening (mScreening) intervention designed to promote the receipt of Pap tests by young Korean American women.
Methods
We developed and assessed the acceptability and feasibility of a 1-week mScreening intervention to increase knowledge of cervical cancer screening, intent to receive screening, and the receipt of a Pap test. Fogg’s Behavior Model was the conceptual framework that guided the development of the mScreening intervention. A series of focus groups were conducted to inform the development of the intervention. The messages were individually tailored for each participant and delivered to them for a 7-day period at each participant’s preferred time. A quasi-experimental research design of 30 Korean American women aged 21 to 29 years was utilized with baseline, post (1 week after the completion of mScreening), and follow-up (3 months after the completion of mScreening) testing.
Results
Findings revealed a significant increase in participants’ knowledge of cervical cancer (P<.001) and guidelines for cervical cancer screening (P=.006). A total of 23% (7/30) (95% CI 9.9-42.3) of the mScreening participants received a Pap test; 83% (25/30) of the participants expressed satisfaction with the intervention and 97% (29/30) reported that they would recommend the program to their friends, indicating excellent acceptability and feasibility of the intervention.
Conclusions
This study provides evidence of the effectiveness and feasibility of the mScreening intervention. Mobile technology is a promising tool to increase both knowledge and receipt of cervical cancer screening. Given the widespread usage of mobile phones among young adults, a mobile phone-based health intervention could be a low-cost and effective method of reaching populations with low cervical cancer screening rates, using individually tailored messages that cover broad content areas and overcome restrictions to place and time of delivery.
doi:10.2196/jmir.3576
PMCID: PMC4180333  PMID: 25164545
cervical cancer; Pap test; mobile health; text-messaging intervention; health behavior change; Korean American women; health disparity
8.  Evidence-Based Intervention to Reduce Access Barriers to Cervical Cancer Screening Among Underserved Chinese American Women 
Journal of Women's Health  2010;19(3):463-469.
Abstract
Objective
The primary objective of the present study was to evaluate the effects of a community-based pilot intervention that combined cervical cancer education with patient navigation on cervical cancer screening behaviors among Chinese American women residing in New York City.
Methods
Chinese women (n = 134) who had not had a Pap test within the previous 12 months were recruited from four Asian community-based organizations (CBOs). Women from two of the CBOs received the intervention (n = 80) consisting of education, interaction with a Chinese physician, and navigation assistance, including help in identifying and accessing free or low-cost screening services. The control group (n = 54) received education delivered by Chinese community health educators and written materials on general health and cancer screening, including cervical cancer, the Pap test, and information about sites that provided free screening. Study assessments were obtained in-person at baseline and postintervention. Screening behavior was self-reported at 12-month postintervention and verified by medical staff.
Results
In the 12-month interval following the program, screening rates were significantly higher in the intervention group (70%) compared to the control group (11.1%). Hierarchical logistic regression analyses indicated that screening behavior was associated with older age (OR = 1.08, 95% CI = 1.01–1.15, p < .05). In addition, women with poorer English language fluency (OR = 0.30, 95% CI = 0.10–0.89, p < .05) and who did not have health insurance were less likely to obtain screening (OR = 0.15, 95% CI = 0.02–0.96, p < .05). Among health beliefs, greater perceived severity of disease was positively associated with screening behavior (OR = 4.26, 95% CI = 1.01-18.04, p < .05).
Conclusions
Community-based programs that provide combined education and patient navigation may be effective in overcoming the extensive linguistic and access barriers to screening faced by Chinese American women.
doi:10.1089/jwh.2009.1422
PMCID: PMC2867551  PMID: 20156089
9.  Evaluation of a Worksite Cervical Screening Initiative to Increase Pap Smear Uptake in Malaysia: A Cluster Randomized Controlled Trial 
BioMed Research International  2013;2013:572126.
Background. Despite the significant burden of cervical cancer, Malaysia like many middle-income countries relies on opportunistic cervical screening as opposed to a more organized population-based program. The aim of this study was to ascertain the effectiveness of a worksite screening initiative upon Papanicolaou smear test (Pap test) uptake among educated working women in Malaysia. Methods. 403 female teachers who never or infrequently attended for a Pap test from 40 public secondary schools in Kuala Lumpur were recruited into a cluster randomized trial conducted between January and November 2010. The intervention group participated in a worksite cervical screening initiative whilst the control group received usual care from the existing cervical screening program. Multivariate logistic regression was performed to determine the impact of the intervention program on Pap smear uptake after 24 weeks of followup. Results. The proportion of women attending for a Pap test was significantly higher in the intervention than in the control group (18.1% versus 10.1%, P value < 0.05) with the worksite screening initiative doubling the Pap smear uptake, adjusted odds ratio 2.44 (95% CI: 1.29–4.62). Conclusion. Worksite health promotion interventions can effectively increase cervical smear uptake rates among eligible workers in middle-income countries. Policy makers and health care providers in these countries should include such interventions in strategies for reducing cervical cancer burden. This trial is registered with IRCT201103186088N1.
doi:10.1155/2013/572126
PMCID: PMC3773923  PMID: 24073411
10.  Educating Hispanic Women About Breast Cancer Prevention: Evaluation of a Home-Based Promotora-Led Intervention 
Journal of Women's Health  2010;19(11):2049-2056.
Abstract
Objectives
Trained community health promoters (i.e., promotoras) conducted home-based group educational interventions (home health parties) to educate Hispanic women from the Lower Yakima Valley of Washington state about breast cancer and mammography screening.
Methods
Women aged 40–79 participating in the parties completed baseline and follow-up surveys 6 months postintervention (n = 70). Changes in general cancer knowledge, breast cancer screening practices, and intentions to be screened among participants from baseline to follow-up were measured using McNemar's test for marginal homogeneity to evaluate the effectiveness of the parties.
Results
The average age of the sample was 50.0 years (standard deviation [SD] 10.0), 84% reported less than an eighth grade education, and 54% were covered by the state's Basic Health Care Plan. Significant changes between baseline and follow-up were observed with respect to (1) believing that risk of cancer could not be reduced (41% vs. 15%, respectively, p = 0.001), (2) ever having a mammogram (83% vs. 91%, p = 0.014), (3) discussing a mammogram with a doctor (37% vs. 67%, p < 0.001), and (4) intending to have a mammogram within the next few months among women who did not report having a mammogram between baseline and follow-up (61% vs. 81%, p = 0.046).
Conclusions
Participation in home-based group educational interventions delivered by promotoras may be associated with improved breast cancer screening practices among Hispanic women.
doi:10.1089/jwh.2009.1733
PMCID: PMC2995340  PMID: 20849288
11.  Evaluation of an outreach intervention to promote cervical cancer screening among Cambodian American women 
Cancer detection and prevention  2002;26(4):320-327.
Introduction
Southeast Asian women have low levels of Papanicolaou (Pap) testing participation. We conducted a group-randomized controlled trial to evaluate a cervical cancer screening intervention program targeting Seattle’s Cambodian refugee community.
Methods
Women who completed a baseline, community-based survey were eligible for the trial. Neighborhoods were the unit of randomization. Three hundred and seventy survey participants living in 17 neighborhoods were randomized to intervention or control status. Intervention group women received home visits by outreach workers and were invited to group meetings in neighborhood settings. The primary outcome measure was self-reported Pap testing in the year prior to completing a follow-up survey.
Results
The proportion of women in the intervention group reporting recent cervical cancer screening increased from 44% at baseline to 61% at follow-up (+17%). The corresponding proportions among the control group were 51 and 62% (+11%). These temporal increases were statistically significant in both the intervention (P < 0.001) and control (P = 0.027) groups.
Discussion
This study was unable to document an increase in Pap testing use specifically in the neighborhood-based outreach intervention group; rather, we found an increase in both intervention and control groups. A general awareness of the project among women and their health care providers as well as other ongoing cervical cancer screening promotional efforts may all have contributed to increases in Pap testing rates.
PMCID: PMC1592335  PMID: 12430637
Cambodian Americans; Pap testing; Outreach
12.  Encouraging Vietnamese-American Women to Obtain Pap Tests Through Lay Health Worker Outreach and Media Education 
BACKGROUND
Five times more Vietnamese-American women develop cervical cancer than white women. Few studies have examined whether community-based participatory research can effectively address Asian immigrants' health problems. This article reports the preliminary evaluation of 1 such project.
METHODS
A coalition of 11 organizations in Santa Clara County, California worked with university researchers to design and simultaneously implement a media education (ME) campaign and a lay health worker outreach (LHWO) program to increase Vietnamese-American women's cervical cancer awareness, knowledge, and screening. Two agencies each recruited 10 lay health workers (LHWs), who, in turn, each recruited 20 women who were then randomized into 2 groups: 10 to LHWO+ME (n = 200) and 10 to ME alone (n = 200). LHWs organized meetings with women to increase their knowledge and to motivate them to obtain Pap tests. Participants completed pre- and post-intervention questionnaires.
RESULTS
At post-intervention, significantly more LHWO+ME women understood that human papillomavirus and smoking cause cervical cancer. The number of women who had obtained a Pap test increased significantly among women in both LHWO+ME and ME groups, but substantially more in the LHWO+ME group. Significantly more LHWO+ME women said they intended to have a Pap test.
CONCLUSIONS
Media education campaigns can increase Vietnamese women's awareness of the importance of Pap tests, but lay health workers are more effective at encouraging women to actually obtain the tests. Lay health workers are effective because they use their cultural knowledge and social networks to create change. Researchers, community members, and community-based organizations can share expert knowledge and skills, and build one another's capacities.
doi:10.1046/j.1525-1497.2003.21043.x
PMCID: PMC1494888  PMID: 12848834
cervical cancer; screening; vietnamese; lay health worker; media
13.  Interventions that increase use of Pap tests among ethnic minority women: A meta-analysis 
Psycho-oncology  2010;20(4):341-351.
Objective
Although a variety of intervention methods have been used to promote Pap test screening among ethnic minority women in the US, the effectiveness of such interventions is unclear. We performed a meta-analysis to examine the overall effectiveness of these interventions in increasing Pap test use by ethnic minority women in the US.
Methods
A search of databases (MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Science Citation Index-Expanded) and review articles for articles published between 1984 and April 2009 identified 18 randomized and nonrandomized controlled trials. The primary study outcome was the difference in the proportion of Pap tests between the treatment and comparison groups.
Results
The pooled mean weighted effect size (d) for the 18 studies was 0.158 (95% confidence interval [CI]=0.100, 0.215), indicating that the interventions were effective in improving Pap test use among ethnic minority women. Among the intervention types, access enhancement yielded the largest effect size (0.253 [95% CI=0.110, 0.397]), followed by community education (0.167 [95% CI=0.057, 0.278]) and individual counseling or letters (0.132 [95% CI=0.069, 0.195]). Combined intervention effects were significant for studies targeting Asian (0.177 [95% CI=0.098, 0.256]) and African American women (0.146 [95% CI=0.028, 0.265]), but not Hispanic women (0.116 [95% CI=−0.008, 0.240]).
Conclusions
Pap test use among ethnic minority women is most likely to increase when access-enhancing strategies are combined. Further research is needed to determine whether more tightly controlled trials of such interventions might reveal an improved rate of cervical cancer screening in Hispanic women as well.
doi:10.1002/pon.1754
PMCID: PMC3741532  PMID: 20878847
Pap test; ethnic minority; women; meta-analysis
14.  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
15.  Feasibility of self-sampling and human papillomavirus testing for cervical cancer screening in First Nation women from Northwest Ontario, Canada: a pilot study 
BMJ Open  2011;1(1):e000030.
Background
The incidence of cervical cancer is up to sixfold higher among First Nation women in Canada than in the general population. This is probably due to lower participation rates in cervical cancer prevention programmes.
Objective
To raise screening participation in this underserved population by launching an alternative approach to (Pap)anicolaou testing in a clinic—namely, vaginal self-sampling followed by human papillomavirus (HPV) diagnostics.
Methods
Good relationships were established with a First Nation community of the Northern Superior region in Northwest Ontario, and then 49 community women, aged 25–59, were recruited, who provided a vaginal self-sample and answered a questionnaire. Frequency distributions and cross-tabulations were used to summarise the data. Associations between categorical variables were assessed using the χ2 test of association, or the Goodman–Kruskal γ if both variables had ordered categories. Self-collected samples were tested for integrity and HPV using optimised molecular biological methods.
Results
The majority of participants (87.2%) were amenable to future HPV screening by self-sampling. This finding was independent of age, educational level and a previous history of abnormal Pap tests. Interestingly, the preferred way to learn about sexual health remained through interaction with healthcare professionals. As defined by the presence of a housekeeping gene, self-sample integrity was high (96%). Using polymerase chain reaction-based Luminex typing, the overall HPV positivity was 28.6% (ie, with either a low- or high-risk type) and 16.3% were infected with a high-risk type such as HPV16.
Conclusion
In this pilot study of First Nation women, self-sampling and HPV testing was well received and self-sample quality was excellent. A larger survey to be conducted in other Northern Superior communities in Northwest Ontario will determine whether this approach could become a viable screening strategy for First Nation women.
Article summary
Article focus
Independent international studies have shown that self-sampling for cervical screening is safe and equally reliable as sampling by a health professional.
Self-sampling has been reported to increase screening compliance for women who have never or not regularly been screened.
To date, self-sampling has not been studied in First Nation (aboriginal) women in Canada, an underserved population in whom cervical cancer is up to six times higher than in the general population.
Key messages
First Nation women participating in this pilot study were amenable to self-collection and 87.2% reported that this alternative screening approach would probably increase their screening participation.
The preferred way to learn about sexual health is through healthcare professionals.
Self-sample integrity was high (96%) as defined by the presence of a housekeeping gene. Using polymerase chain reaction-based Luminex typing, 28.6% of the participating women were HPV-positive (ie, with either a low- or high-risk type) and 16.3% were infected with a high-risk type such as HPV16.
Strengths and limitations of this study
Good relations with the largest First Nation community in Northwest Ontario have been established and our pilot study forms a basis for promoting cervical cancer screening in other First Nation communities in that region.
A larger study is needed to validate our findings and to achieve good statistical power.
doi:10.1136/bmjopen-2010-000030
PMCID: PMC3191400  PMID: 22021733
Cervical cancer screening; Pap test; HPV test; self-sampling; First Nation women; virology; oncology; gynaecological oncology
16.  Cervical Cancer Screening Practice and Knowledge Among Hispanic Migrant and Seasonal Farmworkers of Michigan 
Background
High incidence of cervical cancer among Hispanics and low utilization of cervical screening among farmworkers led us to examine Pap test use and knowledge among Hispanic farmworkers in Michigan.
Methods
Patients and potential patients of Northwest Michigan Health Services, Inc were surveyed in 2 communities (A and B) about their screening knowledge, attitudes, and practice.
Results
In all, 324 farmworkers participated, including 184 seasonal and 125 migrant farmworkers. Among the entire study population, 87.7% women reported receiving a Pap test recently, with no difference between migrant and seasonal farmworkers (88.0% and 87.4%, respectively, P = .088). More women from community B reported a recent Pap (93%) compared with those from community A (83%, P = .01). Only 35% of the participants had knowledge of any cervical cancer risk factors.
Discussion
Migrant farmworkers may not experience more difficulty in accessing Pap tests than seasonal farmworkers in Michigan. Knowledge about cervical cancer risk factors is low and needs to be addressed in future educational interventions.
doi:10.1177/2150131913476303
PMCID: PMC4276026  PMID: 23799709
cervical cancer; farmworkers; Hispanic; rural population
17.  Delay in Diagnostic Testing After Abnormal Mammography in Low-Income Women 
Oncology nursing forum  2009;36(6):709-715.
Purpose/Objectives
To identify factors associated with diagnostic delay after an incomplete or abnormal mammogram among women participating in a state mammography screening program.
Research Approach
Retrospective case-control design using bivariate and multivariate logistic regression analyses to explore the associations between age, race, ethnicity, marital status, breast cancer history, and self-reported breast symptoms and delay.
Setting
A statewide program of free screening mammography for women who are under- or uninsured.
Participants
11,460 women enrolled in a free, statewide screening program from 2002–2006.
Methodologic Approach
Using the Tennessee Breast and Cervical Cancer Screening Program database, further analyses were conducted.
Main Research Variables
The outcome measure was delay in completion of all diagnostic tests and was defined as women who did not complete testing within 60 days. Findings: Thirty-seven percent of women required follow-up, and of a subset used in the analysis, 30% experienced delay of more than 60 days. Controlling for marital status, age, and breast cancer history, women who experienced delay were more likely to be African American versus Caucasian (odds ratio [OR] = 1.45, 95% confidence interval [CI] = 1.13, 1.85) or Hispanic (OR = 0.72, 95% CI = 0.55, 0.93) and to have self-reported breast symptoms (OR = 1.50, 95% CI = 1.27, 1.77).
Conclusions
In a sample of women with low income needing mammography follow-up, delay was associated with three intrapersonal variables, potentially reducing the effectiveness of mammography screening for women who were African American, or Hispanic, or had self-reported breast symptoms.
Interpretation
Nurses providing cancer screening examinations are uniquely positioned to assess the knowledge, beliefs, and resources of women using the program and to navigate women through barriers to completion. Knowledge of factors associated with delay is valuable for planning interventions and allocating program resources.
doi:10.1188/09.ONF.709-715
PMCID: PMC3479661  PMID: 19887359
18.  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
19.  Anal Dysplasia Screening 
Executive Summary
Objective
This review considered the role of the anal Pap test as a screening test for anal dysplasia in patients at high risk of anal SCC. The screening process is now thought to be improved with the addition of testing for the human papillomavirus (HPV) in high-risk populations. High-resolution anoscopy (a method to view the rectal area, using an anoscope, a lighted instrument inserted into the rectum) rather than routine anoscopy-guided biopsy, is also now considered to be the diagnostic standard.
Clinical Need: Target Population and Condition
Anal cancer, like cervical cancer, is a member of a broader group of anogenital cancers known to be associated with sexually transmitted viral HPV infection. Human papillomavirus is extremely prevalent, particularly in young, sexually active populations. Sexual practices involving receptive anal intercourse lead to significantly elevated risk for anal dysplasia and cancer, particularly in those with immune dysfunctions.
Anal cancer is rare. It occurs at a rate of about 1 to 2 per 100,000 in the general population. It is the least common of the lower gastrointestinal cancers, representing about 4% of them, in contrast to colorectal cancers, which remain the third most commonly diagnosed malignancy. Certain segments of the population, however, such as HIV-positive men and women, other chronic immune-suppressed patients (e.g., after a transplant), injection drug users, and women with genital dysplasia /cancer, have a high susceptibility to anal cancer.
Those with the highest identified risk for anal cancer are HIV-positive homosexual and bisexual men, at a rate of 70 per 100,000 men. The risk for anal cancer is reported to be increasing dramatically in HIV-positive males and females, particularly since the introduction of highly active antiretroviral therapy in the mid-1990s. The introduction of effective viral therapy has been said to have transformed the AIDS epidemic in developed countries into a chronic disease state of long-term immunosuppression. In Ontario, there are about 25,000 people living with HIV infection; more than 6,000 of these are women. About 28% of the newly diagnosed HIV infections are in women, a doubling since 1999. It has also been estimated that 1 of 3 people living with HIV do no know it.
Health Technology Description
Anal Pap test screening involves the blind insertion of a swab into the anal canal and fixing cells either on a slide or in fluid for cytological examination. Anal cytology classified by the standardized Bethesda System is the same classification used for cervical cytology. It has 4 categories: normal, atypical squamous cells of uncertain significance, or squamous intraepithelial lesions which are further classified into low- or high-grade lesions. Abnormal cytological findings are subjected to further evaluations by high-resolution anoscopy, a technique similar to cervical colposcopy, and biopsy. Several HPV deoxyribonucleic acid detection technologies such as the Hybrid 11 Capture and the polymerase chain reaction are available to detect and differentiate HPV viral strains.
Unlike cervical cancer, there are no universally accepted guidelines or standards of care for anal dysplasia. Moreover, there are no formal screening programs provincially, nationally, or internationally. The New York State Department of Health AIDS Institute has recently recommended (March 2007) annual anal pap testing in high-risk groups. In Ontario, reimbursement exists only for Pap tests for cervical cancer screening. That is, there is no reimbursement for anal Pap testing in men or women, and HPV screening tests for cervical or anal cancer are also not reimbursed.
Methods
The scientific evidence base was evaluated through a systematic literature review. Assessments of current practices were obtained through consultations with various agencies and individuals including the Ministry of Health and Long-Term Care AIDS Bureau; Public Health Infectious Diseases Branch, Ministry of Health and Long-Term Care; Cancer Care Ontario; HIV/AIDS researchers; pathology experts; and HIV/AIDS clinical program directors. An Ontario-based budget impact was also done.
Findings
No direct evidence was found for the existence of controlled studies evaluating the effectiveness of anal Pap test screening programs for impact on anal cancer morbidity or mortality. In addition, no studies were found on the use of HPV DNA testing in the screening or diagnostic setting for anal dysplasia. The reported prevalence of HPV infection in high-risk groups, particularly HIV-positive males, however, was sufficiently high to preclude any utility of HPV testing as an adjunct to anal Pap testing.
Nine reports involving studies in the United States, United Kingdom, and Canada were identified that evaluated the performance characteristics of anal Pap test screening for anal dysplasia. All involved hospital-based specialty HIV/AIDS care clinics with mainly HIV-positive males. All studies involved experienced pathologists, so the results generally represent best-case scenarios. Estimates of anal Pap test sensitivity and specificity were highly variable, and depended on the varying prevalence of cytology abnormality and differential thresholds for abnormality for both cytology and histopathology.
In the largest study of HIV-positive males, sensitivity varied from 46% (95% confidence interval [CI], 36%–56%) to 69% (95% CI, 60%–78%). Specificity ranged from 59% (95% CI, 53%–65%) to 81% (95% CI, 76%–85%). In the only study of HIV-negative males, sensitivity ranged from 26% (95% CI, 5%-47%) to 47% (95% CI, 26%–68%). Specificity ranged from 81% (95% CI, 76%–85%) to 92% (95% CI, 89%–95%).
In comparison, cervical Pap testing has also been evaluated mainly in settings where there is a high prevalence of the disease, and estimates of sensitivitykij and specificity were also low and highly variable. In a systematic review involving cervical Pap testing, sensitivity ranged from 30% to 87% (mean, 47%) and specificity from 86% to 100% (mean, 95%).
Conclusions
No direct evidence exists to support the effectiveness of an anal Pap test screening program to reduce anal cancer mortality or morbidity. There are, however, strong parallels with cervical pap testing for cervical cancer. Sexually transmitted HPV viral infection is currently the acknowledged common causative agent for both anal and cervical cancer. Anal cancer rates in high-risk populations are approaching those of cervical cancer before the implementation of Pap testing.
The anal Pap test, although it has been mainly evaluated only in HIV-positive males, has similar operating characteristics of sensitivity and specificity as the cervical Pap test. In general, the treatment options for precancer dysplasia in the cervix and the anus are similar, but treatment involving a definitive surgical resection in the anus is more limited because of the higher risk of complications. A range of ablative therapies has been applied for anal dysplasia, but evidence on treatment effectiveness, tolerability and durability, particularly in the HIV-positive patient, is limited.
PMCID: PMC3377578  PMID: 23074504
20.  Rationale and design of the iPap trial: a randomized controlled trial of home-based HPV self-sampling for improving participation in cervical screening by never- and under-screened women in Australia 
BMC Cancer  2014;14:207.
Background
Organized screening based on Pap tests has substantially reduced deaths from cervical cancer in many countries, including Australia. However, the impact of the program depends upon the degree to which women participate. A new method of screening, testing for human papillomavirus (HPV) DNA to detect the virus that causes cervical cancer, has recently become available. Because women can collect their own samples for this test at home, it has the potential to overcome some of the barriers to Pap tests. The iPap trial will evaluate whether mailing an HPV self-sampling kit increases participation by never- and under-screened women within a cervical screening program.
Methods/Design
The iPap trial is a parallel randomized controlled, open label, trial. Participants will be Victorian women age 30–69 years, for whom there is either no record on the Victorian Cervical Cytology Registry (VCCR) of a Pap test (never-screened) or the last recorded Pap test was between five to fifteen years ago (under-screened). Enrolment information from the Victorian Electoral Commission will be linked to the VCCR to determine the never-screened women. Variables that will be used for record linkage include full name, address and date of birth. Never- and under-screened women will be randomly allocated to either receive an invitation letter with an HPV self-sampling kit or a reminder letter to attend for a Pap test, which is standard practice for women overdue for a test in Victoria. All resources have been focus group tested. The primary outcome will be the proportion of women who participate, by returning an HPV self-sampling kit for women in the self-sampling arm, and notification of a Pap test result to the Registry for women in the Pap test arm at 3 and 6 months after mailout. The most important secondary outcome is the proportion of test-positive women who undergo further investigations at 6 and 12 months after mailout of results.
Discussion
The iPap trial will provide strong evidence about whether HPV self-sampling could be used in Australia to improve participation in cervical screening for never-and under-screened women.
Trial registration
ANZCTR Identifier: ACTRN12613001104741; UTN: U1111-1148-3885
doi:10.1186/1471-2407-14-207
PMCID: PMC3994873  PMID: 24646201
HPV DNA testing; Home-based; Self-sample; Cervical screening; Participation
21.  Individual, Provider, and System Risk Factors for Breast and Cervical Cancer Screening Among Underserved Black, Latina, and Arab Women 
Journal of Women's Health  2014;23(1):57-64.
Abstract
Background: Socioeconomic and racial/ethnic disparities in breast and cervical cancer screening persist. An exploratory study was conducted to better understand co-occurring risk factors in underserved groups that could inform interventions to improve screening adherence. The objective of this study was to examine associations between breast and cervical cancer screening adherence and co-occurring risk factors in three racial/ethnic groups of underserved women.
Methods: Black, Latina, and Arab women (N=514), ages 21 to 70 years, were enrolled into the Kin KeeperSM randomized controlled trial in communities around Detroit, Michigan. We used participant baseline assessments (e.g., demographic characteristics, health literacy) to explore screening risks using an additive approach and multivariate logistic analyses.
Results: For black women, having more health literacy risks were associated with reduced odds of a clinical breast exam (CBE), mammogram, and Papanicolaou (Pap) test; more competing priorities were associated with reduced odds of a Pap test; lack of doctor mammogram recommendation was significantly associated with decreased odds of CBE. For Latina women, lack of doctor recommendations were significantly associated with decreased odds of CBE, mammogram, and Pap test. For Arab women, lack of doctor recommendations were significantly associated with decreased odds of CBE, mammogram, and Pap test; more competing priorities were significantly associated with reduced odds of CBE and Pap test. All results were significant at p<0.05.
Conclusions: Characteristics associated with breast and cervical screening adherence differs among Black, Latina, and Arab underserved women. Interventions to improve screening should be tailored for racial/ethnic groups with particular attention to competing survival priorities, health literacy risks factors, and provider recommendations.
doi:10.1089/jwh.2013.4397
PMCID: PMC4056454  PMID: 24283674
22.  Risk of Cervical Pre-Cancer and Cancer Among HIV-Infected Women With Normal Cervical Cytology and No Evidence of Oncogenic HPV Infection 
Context
U.S. cervical cancer screening guidelines for HIV-uninfected women 30 years of age and older have recently been revised, increasing the suggested interval between Pap tests from three years to five years among those with normal cervical cytology (the Pap test) who test negative for oncogenic human papillomavirus (HPV). Whether a three-year or five-year screening interval might be used in HIV-infected women who are cytologically normal and oncogenic HPV-negative is unknown.
Objective
To determine the risk of cervical pre-cancer or cancer defined cytologically (high-grade squamous intraepithelial lesions or greater [HSIL+]) or histologically (cervical intraepithelial neoplasia 2 or greater [CIN-2+]), as two separate endpoints, in HIV-infected women and HIV-uninfected women who at baseline had a normal Pap test and were negative for oncogenic HPV.
Design, Setting and Participants
Participants included 420 HIV-infected women and 279 HIV-uninfected women with normal cervical cytology at their enrollment in a multi-institutional cohort, between October 1, 2001 and September 30, 2002, with follow-up through April 30, 2011. Clinical sites were in the Bronx, Brooklyn, Chicago, Los Angeles, San Francisco, and Washington, DC. Semi-annual visits included Pap testing and, if indicated, cervical biopsy. Cervicovaginal lavage specimens from enrollment were tested for HPV DNA using PCR. The primary analysis was truncated at five years of follow-up.
Main Outcome Measure
The five-year cumulative incidence of cervical pre-cancer and cancer.
Results
No oncogenic HPV was detected in 369 (88%; 95% CI, 84%-91%) of the HIV-infected women and 255 (91%; 95% CI, 88%-94%) of the HIV-uninfected women with normal cervical cytology at enrollment. Among these oncogenic HPV-negative women two cases of HSIL+ were observed; an HIV-uninfected woman and an HIV-infected woman with a CD4 cell count of 500/μL or greater. Histologic data were obtained from four of the six sites. There were six cases of CIN-2+ in N=145 HIV-uninfected women (cumulative incidence = 5% [95% CI, 1%-8%]) and nine cases in N=219 HIV-infected women (cumulative incidence = 5% [95% CI, 2%-8%]). This included one case of CIN-2+ in N=44 oncogenic HPV-negative HIV-infected women with CD4 cell counts less than 350/μL (cumulative incidence = 2% [95% CI, 0%-7%]), one case in N=47 women with CD4 cell counts of 350 to 499/μL (cumulative incidence = 2% [95% CI, 0%-7%]), and seven cases in N=128 women with CD4 cell counts of 500/μL or greater (cumulative incidence = 6% [95% CI, 2%-10%]). One HIV-infected and one HIV-uninfected woman had CIN-3, but none had cancer.
Conclusion
The five-year cumulative incidence of HSIL+ and CIN-2+ was similar in HIV-infected women and HIV-uninfected women who were cytologically normal and oncogenic HPV-negative at enrollment.
doi:10.1001/jama.2012.5664
PMCID: PMC3556987  PMID: 22820789
23.  Pap Test and HIV testing behaviors of South Carolina women 18–64 years old 
Background
Pap tests are used to detect abnormal cell growth in the cervix. Early detection of precancerous cells increases the likelihood of treatment success. In fact, the Pap test is one of only a few cancer screening procedures that can prevent cancer by virtue of identifying and intervening upon abnormal precancerous cells in the early stages. There has been a growing prevalence of cervical cancer among HIV-positive women. Early diagnosis is essential to improving survival outcomes of women living with HIV/AIDS. The purpose of this study was to describe Pap test behaviors among women in South Carolina and examine its relationship with HIV testing.
Methods
Behavioral Risk Factor Surveillance System (BRFSS) data from 2008 were analyzed. Chi-square tests and logistic regression analyses were performed to describe Pap test behaviors among our sample (n=3,404) of non-Hispanic White and non-Hispanic Black women (18–64 years old).
Results
The majority of participants (97%) reported ever having a Pap test. Participants who reported never having a Pap test were 50% less likely to have ever been tested for HIV.
Conclusions
The participants in our study met the Healthy People 2010 target of ever having a Pap test. However, less than half of participants (42%) had ever been tested for HIV. A larger proportion of women who have had a Pap test had also been tested for HIV.
Practice Implications
Our findings suggest that offering women an HIV test during routine Pap tests may present an opportunity to increase the number of women in South Carolina who know their HIV serostatus.
PMCID: PMC2874936  PMID: 20108718
24.  CERVICAL CANCER CONTROL RESEARCH IN VIETNAMESE AMERICAN COMMUNITIES 
Census data show that the US Vietnamese population now exceeds 1,250,000. Cervical cancer among Vietnamese American women has been identified as an important health disparity. Available data indicate the cervical cancer disparity may be due to low Pap testing rates rather than variations in HPV infection rates and/or types. The cervical cancer incidence rates among Vietnamese and non-Latina white women in California during 2000–2002 were 14.0 and 7.3 per 100,000, respectively. Only 70% of Vietnamese women who participated in the 2003 California Health Interview Survey reported a recent Pap smear, compared to 84% of non-Latina white women. Higher levels of cervical cancer screening participation among Vietnamese women are strongly associated with current/previous marriage, having a usual source of care/doctor, and previous physician recommendation. Vietnamese language media campaigns and lay health worker intervention programs have been effective in increasing Pap smear use in Vietnamese American communities. Cervical cancer control programs for Vietnamese women should address knowledge deficits; enable women who are without a usual source of care to find a primary care doctor; and improve patient-provider communication by encouraging health care providers to recommend Pap testing, as well as by empowering women to ask for testing.
doi:10.1158/1055-9965.EPI-08-0386
PMCID: PMC2665877  PMID: 18990732
Cervical cancer; Pap testing; Vietnamese Americans
25.  Risk Factors for Cervical Cancer in Criminal Justice Settings 
Journal of Women's Health  2011;20(12):1839-1845.
Abstract
Background
Women in criminal justice settings have an increased prevalence of cervical cancer compared with the general population. However, little is known about abnormal cervical cancer screening results among women in jail and community-based criminal justice settings. Thus, the aims of this study were to compare the prevalence of self-reported abnormal Papanicolou (Pap) test results in women in jail and under community criminal justice supervision and to examine factors associated with abnormal Pap tests in these criminal justice settings.
Methods
We analyzed data from two cross-sectional surveys of women in jails and community corrections in two Southern cities (n=380) about their history of abnormal Pap tests and risk factors for cervical cancer. Univariate analyses (analysis of variance [ANOVA] and chi-square) and a binary logistic regression analysis were conducted to test associations between a history of abnormal Pap testing and factors known to be associated with cervical cancer.
Results
Nearly half of the women surveyed (n=163, 43%) reported ever having an abnormal Pap test. There was a high prevalence of risk factors for cervical cancer among women with and without an abnormal Pap test. After controlling for age and race, there were significant associations between an abnormal Pap test and inconsistent use of barrier protection (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.18-3.43), having a history of gynecologic infections (OR 1.68, 95% CI 1.05-2.67), and having a history of sexually transmitted diseases (OR 1.92, 95% CI 1.17-3.15).
Conclusions
Women in jail and under community justice supervision reported a high prevalence of risk factors for cervical cancer. Because of their high prevalence of abnormal Pap testing, women in criminal justice settings may be appropriate targets for improved cervical cancer screening, prevention with human papillomavirus (HPV) vaccination, risk reduction education, and treatment.
doi:10.1089/jwh.2011.2864
PMCID: PMC3236985  PMID: 22004180

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