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1.  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
2.  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
3.  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
4.  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
5.  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
6.  Cervical Cancer Screening Among College Students in Ghana: Knowledge and Health Beliefs 
Background
Cervical cancer is the most incident cancer and the leading cause of cancer mortality in women in Ghana. Currently little is known about Ghanaian women's knowledge and beliefs about cervical cancer screening, yet this information is essential to the success of cervical cancer screening programs. The purpose of this study, therefore, was to describe the knowledge and beliefs of women university college students in Ghana.
Methods
A cross sectional survey among college women in a university in Ghana elicited information about sociodemographics, knowledge and beliefs and acceptability of cervical cancer screening, screening history, and sexual history. Bivariate analyses were conducted to identify factors associated with screening.
Results
140 females were recruited; the age range was 20-35 years. The prior pap screening rate was 12.0%; Women were unaware of local screening initiatives and only 7.9% were aware of the link between HPV and cervical cancer. The most prevalent barriers were lack of awareness that the purpose of pap screening is to diagnose cancer, concerns about what others may think, and lack of information about how to obtain screening services. Although women perceived the benefits of screening, only about half perceived themselves to be at risk. Women received few screening cues. Three barriers were negatively associated with screening in bivariate analyses: lack of belief that cervical screening diagnoses cancer, belief that pap test is painful and belief that the test will take away virginity.
Conclusion
New screening programs in Ghana should address these barriers and increase screening cues to the public.
doi:10.1111/IGC.0b013e3181a1d6de
PMCID: PMC2826278  PMID: 19407569
cervical cancer screening; health beliefs; Ghanaian women
7.  Disparities in mammographic screening for Asian women in California: a cross-sectional analysis to identify meaningful groups for targeted intervention 
BMC Cancer  2007;7:201.
Background
Breast cancer is the most commonly diagnosed cancer among the rapidly growing population of Asian Americans; it is also the most common cause of cancer mortality among Filipinas. Asian women continue to have lower rates of mammographic screening than women of most other racial/ethnic groups. While prior studies have described the effects of sociodemographic and other characteristics of women on non-adherence to screening guidelines, they have not identified the distinct segments of the population who remain at highest risk of not being screened.
Methods
To better describe characteristics of Asian women associated with not having a mammogram in the last two years, we applied recursive partitioning to population-based data (N = 1521) from the 2001 California Health Interview Survey (CHIS), for seven racial/ethnic groups of interest: Chinese, Japanese, Filipino, Korean, South Asian, Vietnamese, and all Asians combined.
Results
We identified two major subgroups of Asian women who reported not having a mammogram in the past two years and therefore, did not follow mammography screening recommendations: 1) women who have never had a pap exam to screen for cervical cancer (68% had no mammogram), and 2) women who have had a pap exam, but have no women's health issues (osteoporosis, using menopausal hormone therapies, and/or hysterectomy) nor a usual source of care (62% had no mammogram). Only 19% of Asian women who have had pap screening and have women's health issues did not have a mammogram in the past two years. In virtually all ethnic subgroups, having had pap or colorectal screening were the strongest delineators of mammography usage. Other characteristics of women least likely to have had a mammogram included: Chinese non-U.S. citizens or citizens without usual source of health care, Filipinas with no health insurance, Koreans without women's health issues and public or no health insurance, South Asians less than age 50 who were unemployed or non-citizens, and Vietnamese women who were never married.
Conclusion
We identified distinct subgroups of Asian women at highest risk of not adhering to mammography screening guidelines; these data can inform outreach efforts aimed at reducing the disparity in mammography screening among Asian women.
doi:10.1186/1471-2407-7-201
PMCID: PMC2198916  PMID: 17961259
8.  Smoking prevalence and factors associated with smoking status among Vietnamese in California 
Nicotine & Tobacco Research  2010;12(6):613-621.
Introduction:
Vietnamese American men have smoking prevalence rates higher than the general population. We analyzed Vietnamese American smoking behavior by demographic and health-related factors, including some specific to Vietnamese, in the largest tobacco-specific survey yet targeting the Vietnamese population.
Methods:
Using a statewide surname probability sample and computer-assisted telephone interviewing, we surveyed 1,101 Vietnamese men and 1,078 Vietnamese women in California (63.5% participation among successfully contacted eligible individuals) in 2007–2008. We conducted multivariate regression models to analyze the association between Vietnamese male smoking status and demographic and health-related factors.
Results:
Among women, <1% were current smokers and <2% were former smokers. Among men, 25% were current and 24% were former smokers. Regression models for Vietnamese men delineated factors associated with both current and former smoking (vs. never smoking): being married, being employed, having lower educational attainment, and consuming alcohol. Other factors associated with current smoking (vs. never smoking) were having no health insurance, having seen a Vietnamese doctor or no doctor visit in the past year, having Vietnamese military or Vietnamese reeducation camp experience, having less knowledge about the harms of smoking, and reporting higher depression symptoms. Increasing age and not being Buddhist were associated with former (vs. never) smoking.
Discussion:
Smoking patterns of Vietnamese women and Vietnamese men are significantly different from the general California population. Tobacco control efforts targeting Vietnamese men should include community outreach since current smokers have low health care access, utilization, and knowledge.
doi:10.1093/ntr/ntq056
PMCID: PMC2878729  PMID: 20488931
9.  Cervical Cancer Screening: Attitudes and Behaviors of Young Asian American Women 
Compared to other racial/ethnic groups, Korean, Filipino, and Vietnamese American women experience high incidence rates of cervical cancer but low rates of cervical cancer screenings. This study examines the behaviors and attitudes towards screening in young Korean, Filipino, and Vietnamese American women (n=304) in the San Francisco Bay Area. Results indicated Vietnamese American (OR=2.51) and Filipino American (OR=2.31) women had greater odds of ever having a Pap test than Korean American women. Those older (OR=1.55), born in the USA (OR=2.64), and those comfortable with the test (OR=3.41) also had greater odds of ever having a Pap test. Correct knowledge of cervical cancer and the human papillomavirus did not significantly affect the odds of having a Pap test. Interventions to increase Pap testing in these populations should focus on increasing levels of comfort and should target those younger and foreign born.
doi:10.1007/s13187-011-0230-2
PMCID: PMC3880118  PMID: 21553330
Cervical cancer screening; Pap testing; Young Asian American women; Korean; Vietnamese; Filipino; San Francisco
10.  Cervical Cancer Prevention: New Tools and Old Barriers 
Cancer  2010;116(11):2531-2542.
Cervical cancer is the second most common female tumor worldwide and its incidence is disproportionately high (>80%) in the developing world. In the U.S., where Pap tests have reduced the annual incidence to approximately 11,000 cervical cancers, more than 60% of cases occur in medically-underserved populations as part of a complex of diseases linked to poverty, race/ethnicity, and/or health disparities. Because carcinogenic human papillomavirus (HPV) infections cause virtually all cervical cancer, two new approaches for cervical cancer prevention have emerged: 1) HPV vaccination to prevent infections in younger women (≤18 years old) and 2) carcinogenic HPV detection in older women (≥30 years old). Together, HPV vaccination and testing, if used in an age-appropriate manner, have the potential to transform cervical cancer prevention particularly among underserved populations. Yet significant barriers of access, acceptability, and adoption to any cervical cancer prevention strategy remain. Without understanding and addressing these obstacles, these promising new tools for cervical cancer prevention may be futile. We share our experiences in the delivery of cervical cancer prevention strategies to U.S. populations experiencing high cervical cancer burden: African-American women in South Carolina, Alabama, Mississippi; Haitian immigrant women in Miami; Hispanic women in the U.S.-Mexico Border; Sioux/Native American women in the Northern Plains; white women in the Appalachia; and Vietnamese-American women in Pennsylvania and New Jersey. Our goal is to inform future research and outreach efforts to reduce the burden of cervical cancer in underserved populations.
doi:10.1002/cncr.25065
PMCID: PMC2876205  PMID: 20310056
11.  Predictors of Cervical Pap Smear Screening Awareness, Intention, and Receipt Among Vietnamese-American Women 
Background
Compared with white women, Vietnamese women in the United States have a higher rate of cervical cancer and lower Papanicolau (Pap) test utilization. We evaluated factors associated with awareness of the Pap test, intention to obtain it, and its receipt in Vietnamese-American women.
Methods
In 2000, we conducted a telephone survey of Vietnamese-American women aged ≥18 years living in Santa Clara County, California, and Harris County, Texas. We collected data on sociodemographics, healthcare system access and attitudes, as well as Pap test awareness, attitudes, intentions, and practices.
Results
Of 1566 subjects, 74% had heard of the Pap test, and 76% had had at least one. Only 42% of those who never had a Pap test had considered obtaining one. There were no significant differences between the two sites. Women aged ≥65 had the lowest rates for all three outcomes. For all women, younger age, being married, having requested a Pap test, physician recommendation, and preferring a female standby if the doctor was male were associated with Pap test intention. Being married, higher level of education, having a female doctor, having a respectful doctor, having requested the test, and physician recommendation were associated with Pap test receipt.
Conclusion
Vietnamese-American women have low rates of Pap test awareness, intention, and receipt. The patient–doctor interaction is an important determinant. Efforts to increase Pap test utilization in this population need to be directed at encouraging physicians to offer the Pap test and empowering women to ask for the test.
PMCID: PMC1592337  PMID: 12350454
cervix neoplasms; ethnology; female; health behavior; health services accessibility; mass screening; patient acceptance of health care; primary prevention; Vietnam
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.  A Population-Based Evaluation of a Publicly Funded, School-Based HPV Vaccine Program in British Columbia, Canada: Parental Factors Associated with HPV Vaccine Receipt 
PLoS Medicine  2010;7(5):e1000270.
Analysis of a telephone survey by Gina Ogilvie and colleagues identifies the parental factors associated with HPV vaccine uptake in a school-based program in Canada.
Background
Information on factors that influence parental decisions for actual human papillomavirus (HPV) vaccine receipt in publicly funded, school-based HPV vaccine programs for girls is limited. We report on the level of uptake of the first dose of the HPV vaccine, and determine parental factors associated with receipt of the HPV vaccine, in a publicly funded school-based HPV vaccine program in British Columbia, Canada.
Methods and Findings
All parents of girls enrolled in grade 6 during the academic year of September 2008–June 2009 in the province of British Columbia were eligible to participate. Eligible households identified through the provincial public health information system were randomly selected and those who consented completed a validated survey exploring factors associated with HPV vaccine uptake. Bivariate and multivariate analyses were conducted to calculate adjusted odds ratios to identify the factors that were associated with parents' decision to vaccinate their daughter(s) against HPV. 2,025 parents agreed to complete the survey, and 65.1% (95% confidence interval [CI] 63.1–67.1) of parents in the survey reported that their daughters received the first dose of the HPV vaccine. In the same school-based vaccine program, 88.4% (95% CI 87.1–89.7) consented to the hepatitis B vaccine, and 86.5% (95% CI 85.1–87.9) consented to the meningococcal C vaccine. The main reasons for having a daughter receive the HPV vaccine were the effectiveness of the vaccine (47.9%), advice from a physician (8.7%), and concerns about daughter's health (8.4%). The main reasons for not having a daughter receive the HPV vaccine were concerns about HPV vaccine safety (29.2%), preference to wait until the daughter is older (15.6%), and not enough information to make an informed decision (12.6%). In multivariate analysis, overall attitudes to vaccines, the impact of the HPV vaccine on sexual practices, and childhood vaccine history were predictive of parents having a daughter receive the HPV vaccine in a publicly funded school-based HPV vaccine program. By contrast, having a family with two parents, having three or more children, and having more education was associated with a decreased likelihood of having a daughter receive the HPV vaccine.
Conclusions
This study is, to our knowledge, one of the first population-based assessments of factors associated with HPV vaccine uptake in a publicly funded school-based program worldwide. Policy makers need to consider that even with the removal of financial and health care barriers, parents, who are key decision makers in the uptake of this vaccine, are still hesitant to have their daughters receive the HPV vaccine, and strategies to ensure optimal HPV vaccine uptake need to be employed.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
About 10% of cancers in women occur in the cervix, the structure that connects the womb to the vagina. Every year, globally, more than a quarter of a million women die because of cervical cancer, which only occurs after the cervix has been infected with a human papillomavirus (HPV) through sexual intercourse. There are many types of HPV, a virus that infects the skin and the mucosa (the moist membranes that line various parts of the body, including the cervix). Although most people become infected with HPV at some time in their life, most never know they are infected. However, some HPV types cause harmless warts on the skin or around the genital area and several—in particular, HPV 16 and HPV 18, so-called high-risk HPVs—can cause cervical cancer. HPV infections are usually cleared by the immune system, but about 10% of women infected with a high-risk HPV develop a long-term infection that puts them at risk of developing cervical cancer.
Why Was This Study Done?
Screening programs have greatly reduced cervical cancer deaths in developed countries in recent decades by detecting the cancer early when it can be treated; but it would be better to prevent cervical cancer ever developing. Because HPV is necessary for the development of cervical cancer, vaccination of girls against HPV infection before the onset of sexual activity might be one way to do this. Scientists recently developed a vaccine that prevents infection with HPV 16 and HPV 18 (and with two HPVs that cause genital warts) and that should, therefore, reduce the incidence of cervical cancer. Publicly funded HPV vaccination programs are now planned or underway in several countries; but before girls can receive the HPV vaccine, parental consent is usually needed, so it is important to know what influences parental decisions about HPV vaccination. In this study, the researchers undertake a telephone survey to determine the uptake of the HPV vaccine by 11-year-old girls (grade 6) in British Columbia, Canada, and to determine the parental factors associated with vaccine uptake; British Columbia started a voluntary school-based HPV vaccine program in September 2008.
What Did the Researchers Do and Find?
In early 2009, the researchers contacted randomly selected parents of girls enrolled in grade 6 during the 2008–2009 academic year and asked them to complete a telephone survey that explored factors associated with HPV vaccine uptake. 65.1% of the 2,025 parents who completed the survey had consented to their daughter receiving the first dose of HPV vaccine. By contrast, more than 85% of the parents had consented to hepatitis B and meningitis C vaccination of their daughters. Nearly half of the parents surveyed said their main reason for consenting to HPV vaccination was the effectiveness of the vaccine. Conversely, nearly a third of the parents said concern about the vaccine's safety was their main reason for not consenting to vaccination and one in eight said they had been given insufficient information to make an informed decision. In a statistical analysis of the survey data, the researchers found that a positive parental attitude towards vaccination, a parental belief that HPV vaccination had limited impact on sexual practices, and completed childhood vaccination increased the likelihood of a daughter receiving the HPV vaccine. Having a family with two parents or three or more children and having well-educated parents decreased the likelihood of a daughter receiving the vaccine.
What Do These Findings Mean?
These findings provide one of the first population-based assessments of the factors that affect HPV vaccine uptake in a setting where there are no financial or health care barriers to vaccination. By identifying the factors associated with parental reluctance to agree to HPV vaccination for their daughters, these findings should help public-health officials design strategies to ensure optimal HPV vaccine uptake, although further studies are needed to discover why, for example, parents with more education are less likely to agree to vaccination than parents with less education. Importantly, the findings of this study, which are likely to be generalizable to other high-income countries, indicate that there is a continued need to ensure that the public receives credible, clear information about both the benefits and long-term safety of HPV vaccination.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000270.
The US National Cancer Institute provides information about cervical cancer for patients and for health professionals, including information on HPV vaccines (in English and Spanish)
The US Centers for Disease Control and Prevention also has information about cervical cancer and about HPV
The UK National Health Service Choices website has pages on cervical cancer and on HPV vaccination
More information about cervical cancer and HPV vaccination is available from the Macmillan cancer charity
ImmunizeBC provides general information about vaccination and information about HPV vaccination in British Columbia
MedlinePlus provides links to additional resources about cervical cancer (in English and Spanish)
doi:10.1371/journal.pmed.1000270
PMCID: PMC2864299  PMID: 20454567
14.  Factors Associated with Colorectal Cancer Screening Among Cambodians, Vietnamese, Koreans and Chinese Living in the United States 
The purpose of this community-based participatory study was to identify factors associated with colorectal cancer (CRC) screening compliance and non-compliance among Cambodians, Vietnamese, Koreans and Chinese men and women 50 years and older living in the United States. A cross-sectional design was used in the study. The completed sample included 815 Asian Americans which included Cambodians (N=215), Vietnamese (N=195), Koreans (N=94) and Chinese (N=311). A 95-item questionnaire was developed and pilot tested for content validity and reliability. An in-person data collection approach was utilized and participants were given choice in responding in English or their native language. Of the 815 participants, 79.1% (N=645) reported never-screened, 7.9% (N=64), non-compliance, and 13.0% (N=106) compliance. Education was significantly associated with never-screened for CRC for Vietnamese and Chinese; employment status for Cambodians and Koreans; lack of health insurance for Cambodians, Korean and Chinese; English fluency and years lived in the U.S. for Vietnamese, Koreans, and Chinese. Less acculturated Asian Americans were more likely to be never screened, but differentially across ethnic subgroups. Barriers to screening included lack of knowledge, language, transportation, and time. Increased culturally-targeted public awareness and education programs are needed to improve CRC screening and compliance among high risk Asian American ethnic subgroups.
PMCID: PMC3521597  PMID: 23243486
sigmoidoscopy or colonoscopy; fecal occult blood test; Vietnamese; Korean; Chinese; Cambodian; correlates of colorectal cancer screening
15.  Adherence to Cervical Cancer Screening Guidelines for U.S. Women Aged 25–64: Data from the 2005 Health Information National Trends Survey (HINTS) 
Journal of Women's Health  2009;18(11):1759-1768.
Abstract
Background
Although it is widely accepted that Papanicolaou (Pap) screening can reduce cervical cancer mortality, many women still do not maintain regular cervical cancer screenings.
Objective
To describe the prevalence of cervical cancer screening and the demographic, behavioral, psychological, and cancer-related knowledge factors associated with adherence to U.S. Preventive Services Task Force (USPSTF) cervical cancer screening guidelines among women in the United States.
Methods
Data for women aged 25–64 were obtained from the National Cancer Institute's (NCI) 2005 Health Information National Trends Survey (HINTS). Women were considered adherent to screening guidelines if they had two consecutive, on-schedule screenings and planned to have another within the next 3 years. The sample comprised 2070 women.
Results
Ninety-eight percent of women reported ever having a Pap smear, 90% reported having had a recent Pap smear (within 3 years), and 84% were adherent to USPSTF screening guidelines. Maintaining regular cervical cancer screening was significantly associated with having health insurance, normal body mass index (BMI), smoking status (nonsmoker), mood (absence of a mood disturbance), and being knowledgeable about cervical cancer screening and human papillomavirus (HPV) infection.
Conclusions
Based on the observation that women who were current smokers, obese, or experiencing a substantial degree of psychological distress were significantly less likely to adhere to recommended screening guidelines, we suggest that healthcare providers pay particular attention to the screening needs of these more vulnerable women.
doi:10.1089/jwh.2009.1430
PMCID: PMC2864462  PMID: 19951209
16.  HPV AWARENESS AMONG LATINA IMMIGRANTS AND ANGLO AMERICAN WOMEN IN THE SOUTHERN U.S.: CULTURAL MODELS OF CERVICAL CANCER RISK FACTORS AND BELIEFS 
NAPA bulletin  2010;34(1):84-104.
Latinas have higher cervical cancer age-adjusted incidence and mortality rates, and present with more advanced disease compared to non-Latino whites. This study used a cross-sectional mixed methods survey design, exploring knowledge, attitudes, and beliefs regarding the human papillomavirus (HPV), the HPV vaccine, and cervical cancer screening with four groups of women (Mexican, Honduran, Puerto-Rican, Anglo American; n=80) attending low-income health clinics along with one group of Latina health care workers (n=17). Data analyses included univariate frequency distributions and one-way ANOVA tests for quantitative data, thematic and content analysis of qualitative data, and cultural consensus analysis using the covariance method to compare groups. Results indicate overall cultural consensus for the five subgroups for both the agree/disagree questions and rankings on cervical cancer risk factors. However, differences were found between Latina women compared to Anglo American patients and health care clinic workers around birth control practices as possible causal factors for cervical cancer. Other findings suggested greater awareness of HPV and the HPV vaccine among Anglo American and Puerto Rican women compared to Mexican and Honduran women. Mexican and Honduran women were less likely to be aware of HPV and the HPV vaccine, and more likely to be uninsured and without a regular health care provider. Results point to the need to assess knowledge, attitudes, and beliefs in specific subgroups experiencing cervical cancer disparities to identify target areas for health education. Study findings will be used to inform the development and pilot testing of health education curriculum modules for cervical cancer prevention.
doi:10.1111/j.1556-4797.2010.01053.x
PMCID: PMC2992330  PMID: 21116468
17.  Decision-analytic modeling to evaluate the long-term effectiveness and cost-effectiveness of HPV-DNA testing in primary cervical cancer screening in Germany 
Background
Persistent infections with high-risk types of human papillomavirus (HPV) are associated with the development of cervical neoplasia. Compared to cytology HPV testing is more sensitive in detecting high-grade cervical cancer precursors, but with lower specificity. HPV based primary screening for cervical cancer is currently discussed in Germany. Decisions should be based on a systematic evaluation of the long-term effectiveness and cost-effectiveness of HPV based primary screening.
Research questions
What is the long-term clinical effectiveness (reduction in lifetime risk of cervical cancer and death due to cervical cancer, life years gained) of HPV testing and what is the cost-effectiveness in Euro per life year gained (LYG) of including HPV testing in primary cervical cancer screening in the German health care context? How can the screening program be improved with respect to test combination, age at start and end of screening and screening interval and which recommendations should be made for the German health care context?
Methods
A previously published and validated decision-analytic model for the German health care context was extended and adapted to the natural history of HPV infection and cervical cancer in order to evaluate different screening strategies that differ by screening interval, and tests, including cytology alone, HPV testing alone or in combination with cytology, and HPV testing with cytology triage for HPV-positive women. German clinical, epidemiological and economic data were used. In the absence of individual data, screening adherence was modelled independently from screening history. Test accuracy data were retrieved from international meta-analyses. Predicted outcomes included reduction in lifetime-risk for cervical cancer cases and deaths, life expectancy, lifetime costs, and discounted incremental cost-effectiveness ratios (ICER). The perspective of the third party payer and 3% annual discount rate were adopted. Extensive sensitivity analyses were performed in order to evaluate the robustness of results and identify areas of future research.
Results
In the base case analysis screening resulted in a 53% to 97% risk reduction for cervical cancer with a discounted ICER between 2,600 Euro/LYG (cytology alone every five years) and 155,500 Euro/LYG (Annual cytology age 20 to 29 years, and annual HPV age 30 years and older). Annual cytology, the current recommended screening strategy in Germany, was dominated. In sensitivity analyses variation in the relative increase in the sensitivity of HPV testing as compared to cytology, HPV test costs, screening adherence, HPV incidence, and annual discount rate influenced the ICER results. Variation in the screening start age also influenced the ICER. All cytology strategies were dominated by HPV screening strategies, when relative sensitivity increase by HPV testing compared to cytology was higher (scenario analysis with data for test accuracy from German studies). HPV testing every one, two or three years was more effective than annual cytology. With increased screening adherence a longer screening interval and with low screening adherence a shorter interval would be more cost-effective. With a reduction in HPV incidence of more than 70% triennial HPV screening in women aged 30 years and older (and biennial Pap screening in women aged 20 to 29 years) is cost-effective. The discounted ICER increases with increasing annual discount rate. Increasing screening start age to 25 years had no relevant loss in effectiveness but resulted in lower costs. An optimal strategy may be biennial HPV testing age 30 years and older with biennial cytology at age 25 to 29 years (ICER of 23,400 Euro/LYG).
Conclusions
Based on these results, HPV-based cervical cancer screening is more effective than cytology and could be cost-effective if performed at intervals of two years or greater. Increasing the age at screening start to 25 years causes no relevant loss in effectiveness but saves resources. In the German context an optimal screening strategy could be biennial HPV testing at age 30 years and older with biennial cytology at the age of 25 to 29 years. An extension to a three-yearly screening interval requires substantially improved screening adherence or a higher relative increase in the sensitivity of HPV testing as compared to cytology. The implementation of an organised screening program for quality-controlled introduction of HPV-screening and -vaccination with continued systematic outcome evaluation is recommended.
doi:10.3205/hta000083
PMCID: PMC3010885  PMID: 21289878
cervix; cervix of uterus; cervical carcinoma; carcinoma; cancer; cytology; human papillomavirus; HPV; DNA; HPV-DNA diagnosis; diagnosis; early finding; screening; primary screening; test; decision-analytical modelling; Markov model; effectiveness; systematic review; meta-analysis; Health Technology Assessment; long-term effectiveness; cost-effectiveness; health economic evaluation
18.  Factors Associated with Hepatitis B Testing Among Vietnamese Americans 
BACKGROUND
Chronic hepatitis B and hepatitis B-associated liver cancer is a major health disparity among Vietnamese Americans, who have a chronic hepatitis B prevalence rate of 7–14% and an incidence rate for liver cancer six times that of non-Latino whites.
OBJECTIVE
Describe factors associated with hepatitis B testing among Vietnamese Americans.
DESIGN
A population-based telephone survey conducted in 2007–2008.
PARTICIPANTS
Vietnamese Americans age 18–64 and living in the Northern California and Washington, DC areas (N = 1,704).
MAIN MEASURES
Variables included self-reports of sociodemographics, health care factors, and hepatitis B-related behaviors, knowledge, beliefs, and communication with others. The main outcome variable was self-reported receipt of hepatitis B testing.
KEY RESULTS
The cooperation rate was 63.1% and the response rate was 27.4%. Only 62% of respondents reported having received a hepatitis B test and 26%, hepatitis B vaccination. Only 54% knew that hepatitis B could be transmitted by sexual intercourse. In multivariable analyses, factors negatively associated with testing included: age 30–49 years, US residence for >10 years, less Vietnamese fluency, lower income, and believing that hepatitis B can be deadly. Factors positively associated with testing included: Northern California residence, having had hepatitis B vaccination, having discussed hepatitis B with family/friends, and employer requested testing. Physician recommendation of hepatitis B testing (OR 4.46, 95% CI 3.36, 5.93) and respondent's request for hepatitis B testing (OR 8.37, 95% CI 5.95, 11.78) were strongly associated with test receipt.
CONCLUSION
Self-reports of hepatitis B testing among Vietnamese Americans remain unacceptably low. Physician recommendation and patient request were the factors most strongly associated with test receipt. A comprehensive effort is needed to promote hepatitis B testing in this population, including culturally-targeted community outreach, increased access to testing, and physician education.
doi:10.1007/s11606-010-1285-1
PMCID: PMC2881980  PMID: 20306150
hepatitis B; Vietnamese Americans; testing
19.  Brief Report: Knowledge, attitudes, practices and perceived risk of cervical cancer among Kenyan women 
OBJECTIVES
Eastern Africa has the highest incidence and mortality rates from cervical cancer worldwide. It is important to describe the differences among women and their perceived risk of cervical cancer in order to determine target groups to increase cervical cancer screening.
METHOD
In this cross-sectional study we surveyed women seeking reproductive health services in Kisumu, Kenya to assess their perceived risk of cervical cancer and risk factors influencing cervical cancer screening uptake. Chi-square statistics and t-tests were used to determine significant factors, which were incorporated into a logistic model to determine factors independently associated with cervical cancer risk perception.
RESULTS
While 91% of the surveyed women had heard of cancer, only 29% of the 388 surveyed women had previously heard of cervical cancer. The majority had received their information from healthcare workers. Few women (6%) had ever been screened for cervical cancer and cited barriers such as fear, time, and lacking knowledge about cervical cancer. Nearly all previously screened women (22/24, 92%) believed that cervical cancer was curable if detected early, and that screening should be conducted annually (86%). Most women (254/388, 65%) felt they were at risk for cervical cancer. Women with perceived risk of cervical cancer were older (OR=1.06, 95% CI 1.02, 1.10), reported a history of marriage (OR=2.08, CI 1.00, 4.30), were less likely to feel adequately informed about cervical cancer by healthcare providers (OR= 0.76, CI 0.18, 0.83) and more likely to intend to have cervical cancer screening in the future (OR= 10.59, CI 3.96, 28.30). Only 5% of women reported that they would not be willing to undergo screening, regardless of cost.
Conclusions
Cervical cancer is a major health burden for women in sub-Saharan Africa, yet only one-third of women had ever heard of cervical cancer in Kisumu, Kenya. Understanding factors associated with women’s perceived risk of cervical cancer could guide future educational and clinical interventions to increase cervical cancer screening.
doi:10.1097/IGC.0b013e31828e425c
PMCID: PMC3662490  PMID: 23694983
Screening; Barriers; Cervical Cancer; Africa
20.  Packaging Health Services When Resources Are Limited: The Example of a Cervical Cancer Screening Visit 
PLoS Medicine  2006;3(11):e434.
Background
Increasing evidence supporting the value of screening women for cervical cancer once in their lifetime, coupled with mounting interest in scaling up successful screening demonstration projects, present challenges to public health decision makers seeking to take full advantage of the single-visit opportunity to provide additional services. We present an analytic framework for packaging multiple interventions during a single point of contact, explicitly taking into account a budget and scarce human resources, constraints acknowledged as significant obstacles for provision of health services in poor countries.
Methods and Findings
We developed a binary integer programming (IP) model capable of identifying an optimal package of health services to be provided during a single visit for a particular target population. Inputs to the IP model are derived using state-transition models, which compute lifetime costs and health benefits associated with each intervention. In a simplified example of a single lifetime cervical cancer screening visit, we identified packages of interventions among six diseases that maximized disability-adjusted life years (DALYs) averted subject to budget and human resource constraints in four resource-poor regions. Data were obtained from regional reports and surveys from the World Health Organization, international databases, the published literature, and expert opinion. With only a budget constraint, interventions for depression and iron deficiency anemia were packaged with cervical cancer screening, while the more costly breast cancer and cardiovascular disease interventions were not. Including personnel constraints resulted in shifting of interventions included in the package, not only across diseases but also between low- and high-intensity intervention options within diseases.
Conclusions
The results of our example suggest several key themes: Packaging other interventions during a one-time visit has the potential to increase health gains; the shortage of personnel represents a real-world constraint that can impact the optimal package of services; and the shortage of different types of personnel may influence the contents of the package of services. Our methods provide a general framework to enhance a decision maker's ability to simultaneously consider costs, benefits, and important nonmonetary constraints. We encourage analysts working on real-world problems to shift from considering costs and benefits of interventions for a single disease to exploring what synergies might be achievable by thinking across disease burdens.
Jane Kim and colleagues analyzed the possible ways that multiple health interventions might be packaged together during a single visit, taking into account scarce financial and human resources.
Editors' Summary
Background.
Public health decision makers in developed and developing countries are exploring the idea of providing packages of health checks at specific times during a person's lifetime to detect and/or prevent life-threatening diseases such as diabetes, heart problems, and some cancers. Bundling together tests for different diseases has advantages for both health-care systems and patients. It can save time and money for both parties and, by associating health checks with life events such as childbirth, it can take advantage of a valuable opportunity to check on the overall health of individuals who may otherwise rarely visit a doctor. But money and other resources (for example, nurses to measure blood pressure) are always limited, even in wealthy countries, so decision makers have to assess the likely costs and benefits of packages of interventions before putting them into action.
Why Was This Study Done?
Recent evidence suggests that women in developing countries would benefit from a once-in-a-lifetime screen for cervical cancer, a leading cause of cancer death for this population. If such a screening strategy for cervical cancer were introduced, it might provide a good opportunity to offer women other health checks, but it is unclear which interventions should be packaged together. In this study, the researchers have developed an analytic framework to identify an optimal package of health services to offer to women attending a clinic for their lifetime cervical cancer screen. Their model takes into account monetary limitations and possible shortages in trained personnel to do the health checks, and balances these constraints against the likely health benefits for the women.
What Did the Researchers Do and Find?
The researchers developed a “mathematical programming” model to identify an optimal package of health services to be provided during a single visit. They then used their model to estimate the average costs and health outcomes per woman of various combinations of health interventions for 35- to 40-year-old women living in four regions of the world with high adult death rates. The researchers chose breast cancer, cardiovascular disease, depression, anemia caused by iron deficiency, and sexually transmitted diseases as health conditions to be checked in addition to cervical cancer during the single visit. They considered two ways—one cheap in terms of money and people; the other more expensive but often more effective—of checking for or dealing with each potential health problem. When they set a realistic budgetary constraint (based on the annual health budget of the poorest countries and a single health check per woman in the two decades following her reproductive years), the optimal health package generated by the model for all four regions included cervical cancer screening done by testing for human papillomavirus (an effective but complex test), treatment for depression, and screening or treatment for anemia. When a 50% shortage in general (for example, nurses) and specialized (for example, doctors) personnel time was also included, the health benefits of the package were maximized by using a simpler test for cervical cancer and by treating anemia but not depression; this freed up resources in some regions to screen for breast cancer or cardiovascular disease.
What Do These Findings Mean?
The model described by the researchers provides a way to explore the potential advantages of delivering a package of health interventions to individuals in a single visit. Like all mathematical models, its conclusions rely heavily on the data used in its construction. Indeed, the researchers stress that, because they did not have full data on the effectiveness of each intervention and made many other assumptions, their results on their own cannot be used to make policy decisions. Nevertheless, their results clearly show that the packaging of multiple health services during a single visit has great potential to maximize health gains, provided the right interventions are chosen. Most importantly, their analysis shows that in the real world the shortage of personnel, which has been ignored in previous analyses even though it is a major problem in many developing countries, will affect which health conditions and specific interventions should be bundled together to provide the greatest impact on public health.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030434.g001.
The World Health Organization has information on choosing cost-effective health interventions and on human resources for health
The American Cancer Society offers patient information on cervical cancer
The Alliance for Cervical Cancer Prevention includes information about cervical cancer prevention programs in developing countries
doi:10.1371/journal.pmed.0030434
PMCID: PMC1635742  PMID: 17105337
21.  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
22.  Knowledge, attitudes and practices on cervical cancer screening among the medical workers of Mulago Hospital, Uganda 
Background
Cervical cancer is the commonest cancer of women in Uganda. Over 80% of women diagnosed in Mulago national referral and teaching hospital, the biggest hospital in Uganda, have advanced disease. Pap smear screening, on opportunistic rather than systematic basis, is offered free in the gynaecological outpatients clinic and the postnatal/family planning clinics. Medical students in the third and final clerkships are expected to learn the techniques of screening. Objectives of this study were to describe knowledge on cervical cancer, attitudes and practices towards cervical cancer screening among the medical workers of Mulago hospital.
Methods
In a descriptive cross-sectional study, a weighted sample of 310 medical workers including nurses, doctors and final year medical students were interviewed using a self-administered questionnaire. We measured knowledge about cervical cancer: (risk factors, eligibility for screening and screening techniques), attitudes towards cervical cancer screening and practices regarding screening.
Results
Response rate was 92% (285). Of these, 93% considered cancer of the cervix a public health problem and knowledge about Pap smear was 83% among respondents. Less than 40% knew risk factors for cervical cancer, eligibility for and screening interval. Of the female respondents, 65% didn't feel susceptible to cervical cancer and 81% had never been screened. Of the male respondents, only 26% had partners who had ever been screened. Only 14% of the final year medical students felt skilled enough to use a vaginal speculum and 87% had never performed a pap smear.
Conclusion
Despite knowledge of the gravity of cervical cancer and prevention by screening using a Pap smear, attitudes and practices towards screening were negative. The medical workers who should be responsible for opportunistic screening of women they care for are not keen on getting screened themselves. There is need to explain/understand the cause of these attitudes and practices and identify possible interventions to change them. Medical students leave medical school without adequate skills to be able to effectively screen women for cervical cancer wherever they go to practice. Medical students and nurses training curricula needs review to incorporate practical skills on cervical cancer screening.
doi:10.1186/1472-6920-6-13
PMCID: PMC1413529  PMID: 16509979
23.  Health seeking behavioral analysis associated with breast cancer screening among Asian American women 
Objective
The purpose of this community-based study was to apply a Sociocultural Health Behavior Model to determine the association of factors proposed in the model with breast cancer screening behaviors among Asian American women.
Methods
A cross-sectional design included a sample of 682 Chinese, Korean, and Vietnamese women aged 40 years and older. The frequency distribution analysis and Chi-square analysis were used for the initial screening of the following variables: sociodemographic, cultural, enabling, environmental, and social support. Univariate and multivariate analyses were conducted on factors for breast cancer screening using multinomial logistic regression analysis.
Results
Correlates to positive breast cancer screening included demographics (ethnicity), cultural factors (living in the United States for 15 years or more, speaking English well), enabling factors (having a regular physician to visit, health insurance covering the screening), and family/social support factors (those who had a family/friend receiving a mammogram).
Conclusions
The results of this study suggest that breast cancer screening programs will be more effective if they include the cultural and health beliefs, enabling, and social support factors associated with breast cancer screening. The use of community organizations may play a role in helping to increase breast cancer screening rates among Asian American women.
doi:10.2147/IJWH.S30738
PMCID: PMC3379860  PMID: 22723730
breast cancer screening; Vietnamese; Korean; Chinese; breast cancer; Asian American
24.  Pathways of cervical cancer screening among Chinese women 
Background
The purpose of this community-based study was to develop a structural equation model for factors contributing to cervical cancer screening among Chinese American women.
Methods
A cross-sectional design included a sample of 573 Chinese American women aged 18 years and older. The initial step involved use of confirmatory factor analysis, that included the following variables: access to and satisfaction with health care, and enabling and predisposing cultural and health beliefs. Structural equation model analyses were conducted on factors related to cervical cancer screening.
Results
Age, marital status, employment, household income, and having health insurance, but not educational level, were significantly related to cervical screening status. Predisposing and enabling factors were positively associated with cervical cancer screening. The cultural factor was significantly related to the enabling factor or the satisfaction with health care factor.
Conclusion
This model highlights the significance of sociocultural factors in relation to cervical cancer screening. These factors were significant, with cultural, predisposing, enabling, and health belief factors and access to and satisfaction with health care reinforcing the need to assist Chinese American women with poor English fluency in translation and awareness of the importance of cervical cancer screening. Community organizations may play a role in assisting Chinese American women, which could enhance cervical cancer screening rates.
doi:10.2147/IJWH.S45405
PMCID: PMC3702238  PMID: 23843708
Papanicolaou test; cervical cancer screening; Chinese women
25.  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

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