Beliefs about Papanicolaou smears and compliance with Papanicolaou smear follow-up in adolescents

Barriers and facilitators for cervical cancer screening among adolescents and young people: a systematic review

BACKGROUND

Though cervical cancer is one of the leading causes of cancer-related death globally, its incidence is nearly entirely preventable. Young people have been an international priority for screening as this population has historically been under-screened. However, in both high-income and low-income countries, young people have not been screened appropriately according to country-specific guidelines. The aim of this systematic review was to systematically characterize the existing literature on barriers and facilitators for cervical cancer screening (CCS) among adolescents and young people globally.

METHODS

We conducted a systematic review following PRISMA guidelines of three key databases: Medline-OVID, EMBASE, and CINAHL. Supplementary searches were done through ClinicialTrials.Gov and Scopus. Databases were examined from 1946 until the date of our literature searches on March 12th 2020. We only examined original, peer-reviewed literature. Articles were excluded if they did not specifically discuss CCS, were not specific to individuals under the age of 35, or did not report outcomes or evaluation. All screening, extraction, and synthesis was completed in duplicate with two independent reviewers. Outcomes were summarized descriptively. Risk of bias for individual studies was graded using an adapted rating scale based on the Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices.

RESULTS

Of the 2177 original database citations, we included 36 studies that met inclusion criteria. The 36 studies included a total of 14,362 participants, and around half (17/36, 47.2%) of studies specifically targeted students. The majority of studies (31/36, 86.1%) discussed barriers and facilitators to Pap testing specifically, while one study analyzed self-sampling (1/36, 2.8%), one study targeted HPV DNA testing (1/36, 2.8%), and the remainder (4/36, 11.1%) were not specified. Our systematic review found that there are three large categories of barriers for young people: lack of knowledge/awareness, negative perceptions of the test, and systemic barriers to testing. Facilitators included stronger relationships with healthcare providers, social norms, support from family, and self-efficacy.

CONCLUSION

There are unique barriers and facilitators that affect CCS rates in adolescents and young people. Health systems and healthcare providers worldwide should address the challenges for this unique population.

Prevalence of Potentially Unnecessary Bimanual Pelvic Examinations and Papanicolaou Tests Among Adolescent Girls and Young Women Aged 15-20 Years in the United States

IMPORTANCE

Pelvic examination is no longer recommended for asymptomatic, nonpregnant women and may cause harms such as false-positive test results, overdiagnosis, anxiety, and unnecessary costs. The bimanual pelvic examination (BPE) is an invasive and controversial examination component. Cervical cancer screening is not recommended for women younger than 21 years.

OBJECTIVES

To estimate prevalence of potentially unnecessary BPE and Papanicolaou (Pap) tests performed among adolescent girls and women younger than 21 years (hereinafter referred to as young women) in the United States and to identify factors associated with receiving these examinations.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis of the National Survey of Family Growth from September 2011 through September 2017 focused on a population-based sample of young women aged 15 to 20 years (n = 3410). The analysis used survey weights to estimate prevalence and the number of people represented in the US population. Data were analyzed from December 21, 2018, through September 3, 2019.

MAIN OUTCOMES AND MEASURES

Receipt of a BPE or a Pap test in the last 12 months and the proportion of potentially unnecessary examinations and tests.

RESULTS

Responses from 3410 young women aged 15 to 20 years were included in the analysis with 6-year sampling weights applied. Among US young women aged 15 to 20 years represented during the 2011-2017 study period, 4.8% (95% CI, 3.9%-5.9%) were pregnant, 22.3% (95% CI, 20.1%-24.6%) had undergone STI testing, and 4.5% (95% CI, 3.6%-5.5%) received treatment or medication for an STI in the past 12 months (Table 1). Only 2.0% (95% CI, 1.4%-2.9%) reported using an IUD, and 33.5% (95% CI, 30.8%-36.4%) used at least 1 other type of hormonal contraception in the past 12 months. Among US young women aged 15 to 20 years who were surveyed in the years 2011 through 2017, approximately 2.6 million (22.9%; 95% CI, 20.7%-25.3%) reported having received a BPE in the last 12 months. Approximately half of these examinations (54.4%; 95% CI, 48.8%-59.9%) were potentially unnecessary, representing an estimated 1.4 million individuals. Receipt of a BPE was associated with having a Pap test (adjusted prevalence ratio [aPR], 7.12; 95% CI, 5.56-9.12), testing for sexually transmitted infections (aPR, 1.60; 95% CI, 1.34-1.90), and using hormonal contraception other than an intrauterine device (aPR, 1.31; 95% CI, 1.11-1.54). In addition, an estimated 2.2 million young women (19.2%; 95% CI, 17.2%-21.4%) reported having received a Pap test in the past 12 months, and 71.9% (95% CI, 66.0%-77.1%) of these tests were potentially unnecessary.

CONCLUSIONS AND RELEVANCE

This analysis found that more than half of BPEs and almost three-quarters of Pap tests performed among young women aged 15 to 20 years during the years 2011 through 2017 were potentially unnecessary, exposing women to preventable harms. The results suggest that compliance with the current professional guidelines regarding the appropriate use of these examinations and tests may be lacking.

Are You Covered? Associations Between Patient Protection and Affordable Care Act Knowledge and Preventive Reproductive Service Use

PURPOSE

Sexual and reproductive health conditions (eg, infections, cancers) represent public health concerns for American women. The present study examined how knowledge of the Patient Protection and Affordable Care Act (PPACA) relates to receipt of preventive reproductive health services among women.

DESIGN

Cross-sectional online survey.

SETTING

Online questionnaires were completed via Amazon Mechanical Turk, a crowdsourcing website where individuals complete web-based tasks for compensation.

PARTICIPANTS

Cisgendered women aged 18 to 44 years (N = 1083) from across the United States.

MEASURES

Participants completed online questionnaires assessing demographics, insurance status, preventive service use, and knowledge of PPACA provisions.

ANALYSIS

Chi-squares showed that receipt of well-woman, pelvic, and breast examinations, as well as pap smears, was related to insurance coverage, with those not having coverage at all during the previous year having significantly lower rates of use. Hierarchical logistic regressions determined the independent relationship between PPACA knowledge and use of health services after controlling for demographic factors and insurance status.

RESULTS

Knowledge of PPACA provisions was associated with receiving well-woman, pelvic, and breast examinations, human papillomavirus vaccination, and sexually transmitted infections testing, after controlling for these factors. Results indicate that expanding knowledge about health-care legislation may be beneficial in increasing preventive reproductive health service use among women.

CONCLUSION

Current findings provide support for increasing resources for outreach and education of the general population about the provisions and benefits of health-care legislation, as well as personal health coverage plans.

Speculum Lubrication and Patient Comfort: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The aim of the study was to examine the effect of water-based gel lubrication in decreasing discomfort during speculum examination.

MATERIALS AND METHODS

Searches of standard databases were performed. Randomized controlled trials comparing speculums lubricated with water-based gel to no lubrication or water alone in women undergoing gynecologic examinations were included. Selected studies were required to report on the outcome of discomfort experienced during the examination. Six studies met the criteria. Two reviewers independently performed the search and excluded articles that did not meet the inclusion criteria. The primary outcome was change in the visual analog scale (VAS) measure of discomfort. Pooled mean differences and 95% confidence interval (CI) were calculated and heterogeneity was assessed.

RESULTS

Five studies, totaling 2,383 subjects, each noted a significant decrease in the VAS score with use of lubrication. Pooling all studies, the VAS score with lubrication changed -0.87 (95% CI = -1.22 to -0.53, 6 studies, 2,453 subjects). Studies measured discomfort at different points in the examination and noted significant decreases with insertion (mean difference, -0.98; 95% CI = -1.13 to -0.83, 5 studies, 2,383 subjects), opening (mean difference, -1.52; 95% CI = -2.43 to -0.61, 3 studies, 1,864 subjects), and extraction (mean difference, -0.97; 95% CI = -1.29 to -0.65, 2 studies, 284 subjects). These significant decreases were consistent in subgroups of premenopausal, postmenopausal, gynecologic oncology, and radiation therapy patients.

CONCLUSIONS

Water-based gel lubrication decreased discomfort for women undergoing a plastic speculum examination in all populations studied.

Interventions to improve cervical cancer screening uptake amongst young women: a systematic review

OBJECTIVES

In view of declining screening uptake in young women, this review aims to summarise the available evidence relating to interventions designed to increase cervical screening uptake amongst women aged ≤ 35 years.

METHODS

Electronic databases were searched and further articles located by manual searches. Study designs employing a valid comparison group and including women aged ≤ 35 years published through 2012 were considered. Data was extracted on the uptake from either screening programme statistics or as reported by the study subjects. A narrative synthesis was undertaken for each category of interventions identified.

RESULTS

Ninety-two records were screened with 36 articles retrieved for further assessment. Four studies met the inclusion criteria, two of which evaluated more than one intervention. One of the studies evaluated the use of a modified invitation letter and reported no significant increase in uptake compared to a standard invitation. Three studies investigated the use of a reminder letter, with two reporting a positive effect on screening uptake in women aged 24-34. Three studies were included which supported the use of physician and telephone reminders. One study on HPV self-sampling reported a positive effect when compared with a reminder letter.

CONCLUSIONS

There is a lack of randomised controlled trials designed to specifically address falling cervical screening uptake in amongst young women. Cervical screening programmes need to look beyond the use of invitation/reminders letters in this group of women to develop interventions which attempt to overcome as many barriers to uptake as possible.

Impact of human papillomavirus-related genital diseases on quality of life and psychosocial wellbeing: results of an observational, health-related quality of life study in the UK

BACKGROUND

Data on the psychosocial burden of human papillomavirus (HPV)-related diseases other than cervical cancer are scarce. The objectives of this study were to measure and compare the psychosocial burden and the impact on health-related quality of life (HRQoL) of HPV-related lower genital tract diseases and genital warts (GW) using several generic and disease-specific instruments.

METHODS

Overall, 842 individuals with normal cervical cytology (n = 241), borderline nuclear abnormalities and/or mild dyskaryosis (n = 23), cervical intraepithelial neoplasia (CIN)1 (n = 84), CIN2/3 (n = 203), vulval intraepithelial neoplasia (VIN)2/3 (n = 43), GW (n = 186) and a history of GW (non-current) (n = 62) were included. The generic European Quality of Life Index Version 5D (EQ-5D) questionnaire was completed by patients with GW and VIN2/3. Sexual functioning was evaluated using the Change in Sexual Functioning Questionnaire (CSFQ). Psychosocial impact was measured in women using the HPV Impact Profile (HIP) questionnaire. HRQoL was assessed using a GW-specific questionnaire, the Cuestionario Especifico en Condilomas Acuminados (CECA) (completed by patients with GW and history of GW). For each instrument, scores were compared between groups using the Student's t-test. In addition, utility loss due to GW and VIN2/3 was evaluated by comparing mean EQ-5D scores weighted by age and sex with the UK general population normal values.

RESULTS

A significant psychosocial impact was found in women diagnosed with HPV-related genital diseases, particularly in those with GW. The health state of younger adults with GW was significantly impaired compared with UK normal values (mean EQ-5D index score 0.86 vs 0.94, p < 0.001 for 18-24-year-olds; 0.87 vs 0.93, p = 0.030 for 25-34-year-olds). VIN2/3 was found to have a significant negative impact on sexual functioning, and women with VIN2/3 had a highly impaired health state compared with women in the UK general population (weighted mean EQ-5D index score 0.72 vs 0.89, p < 0.001; weighted mean Visual Analogue Scale score 62 vs 85, p < 0.001).

CONCLUSIONS

HPV-related lower genital tract lesions and GW significantly impair psychosocial wellbeing and HRQoL. The psychosocial aspects of HPV-related diseases need to be considered when evaluating the potential benefit of HPV vaccination.

The role of gel application in decreasing pain during speculum examination and its effects on papanicolaou smear results

PURPOSE

This study aimed to investigate the effects of water-based gel application in reducing pain or discomfort associated with speculum examination, and compared the presence of unsatisfactory Papanicolaou smear results between gel-applied and control groups.

METHODS

In this prospective randomized controlled study, a total of 1,580 patients were analyzed. The subjects were randomized to a gel group and a control group. For the collection of the smear sample, water-based gel was used in the gel group and dry speculum was used in the control group. All patients were asked to score their pain on a numeric pain scale at two time points during the procedure (insertion and opening phase of speculum). Cytopathologists who analyzed the smear cytology were blinded to the study. Pain intensity during speculum examination, as well as unsatisfactory smear results, were analyzed between the groups.

RESULTS

The pain scores obtained at two different time points of speculum application were significantly lower in the gel group compared to the control group both in premenopausal and postmenopausal women (p < 0.001). The ratios of unsatisfactory cytopathologic examination results were 1.13 and 1.39% for the gel-applied and control groups, which were not significantly different.

CONCLUSION

Lubrication of the outer superior and inferior blade of the plastic vaginal speculum with a small amount of a water-soluble lubricant gel decreases the pain associated with insertion and opening of the vaginal speculum in both premenopausal and postmenopausal women without affecting the quality of the cytology results during the collection of Papanicolaou test specimens.

Screening adolescents and young women

Recent guidelines from multiple organizations stress screening initiation no earlier than the age of 21 years and increased screening intervals for women aged 21 to 29 years. Primary prevention with human papillomavirus vaccination has the potential to significantly affect the development of high-grade cervical lesions, including cancer, and will likely affect screening guidelines in the future.

Effect of lubricating gel on patient comfort during vaginal speculum examination: a randomized controlled trial

OBJECTIVE

To estimate the efficacy of lubricating gel compared with using water for pain during vaginal speculum insertion.

METHODS

This study was a randomized trial of nonpregnant women aged 18-50 years who required a vaginal speculum examination between February and July 2011. Patients blinded to study assignment underwent vaginal speculum examination using a standardized technique with a medium-sized plastic speculum prepared with either 0.3 mL lubricating gel or 3 mL of water used to cover both speculum blades. Patients recorded pain using a 10-cm visual analog scale immediately after speculum insertion. A pre hoc power analysis determined that 55 patients in each arm would be required to detect a difference of 0.9 cm on a 10-cm visual analog scale.

RESULTS

A total of 299 consecutive women requiring vaginal speculum examination were screened for enrollment and 120 women were randomized with 60 per group. There were no marked differences in the demographic characteristics of the gel (n=59) and water (n=60) participants available for final analysis. The gel group showed significantly lower pain scores for speculum insertion (mean±standard deviation: 1.41±1.55 compared with water 2.15±1.93, P<.01). Of patients undergoing examination with gel, 20 of 59 (33.9%) marked zero on the pain scale compared with six of 60 (10%) patients receiving water (P=.002). All 73 patients who underwent Pap screening had adequate cytology.

CONCLUSION

Applying a small amount of lubricating gel significantly decreases patient pain during vaginal speculum insertion.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01289665.

LEVEL OF EVIDENCE

: I.

Avoiding piecemeal research on participation in cervical cancer screening: the advantages of a social identity framework

BACKGROUND

Cervical cancer screening research has predominantly focused on one type of participation, namely compliance with medical recommendations, and has largely ignored other types of participation. While there is some research that has taken a different approach, findings in this research area are not well integrated under a theoretical framework.

OBJECTIVE

The aim of this study is to show how consideration of a broader definition of participation and better integration of the theoretical conceptualization of participation in cervical cancer screening are both possible and desirable to enable a better understanding of women's experiences of cervical cancer screening specifically and to improve women's health generally.

MAIN CONCLUSION

It is suggested that alternative types of participation in cervical cancer screening warrant further investigation and that a social identity theoretical approach offers one way of integrating such conceptualizations of participation. The paper also argues for more explicit consideration of the role of social processes and of the variables, such as power, social identity and relational justice, which are involved in participation in cervical cancer screening.

Effect of liquid-based gel application during speculum examination on satisfactory level of smear examination

PURPOSE

The aim was to evaluate the use of liquid-based gel during cytologic follow-up and the effect of liquid-based gel application during speculum examination on satisfactory level of smear.

METHODS

A total of 1,999 patients were taken into the study. Patients were divided into two groups as gel-applied group and control group. Age and menopausal status of patients, and the physicians taking the smear (resident or specialist) were recorded. In control group, dry speculum was used for the collection of smear sample. All specimens were evaluated for correlation of the cytopathology, the number of "unsatisfactory" samples, and any secondary diagnoses.

RESULTS

Assessment of smear satisfactoriness revealed that 2.2% (43) of them were unsatisfactory. Unsatisfactory smear ratio was significantly high in gel-applied group. Screening done by residents increased unsatisfactory result risk for about 5.5 times. Evaluation of effect of menopausal status on smear adequency revealed no difference between premenopausal and postmenopausal women.

CONCLUSION

Cervical smear seems to be more accurate without gel application. Experience of the physician is also important. Water-based gel can be used in some women who experience overt pain during speculum examination, but these patients must be warned about unsatisfactory results and the need of repeat test.

After-effects reported by women having follow-up cervical cytology tests in primary care: a cohort study within the TOMBOLA trial

BACKGROUND

Although it is recognised that some women experience pain or bleeding during a cervical cytology test, few studies have quantified physical after-effects of these tests.

AIM

To investigate the frequency, severity, and duration of after-effects in women undergoing follow-up cervical cytology tests, and to identify subgroups with higher frequencies in Grampian, Tayside, and Nottingham.

DESIGN

Cohort study nested with a multi-centre individually randomised controlled trial.

METHOD

The cohort included 1120 women, aged 20-59 years, with low-grade abnormal cervical cytology who completed a baseline sociodemographic questionnaire and had a follow-up cervical cytology test in primary care 6 months later. Six weeks after this test, women completed a postal questionnaire on pain, bleeding, and discharge experienced after the test, including duration and severity. The adjusted prevalence of each after-effect was computed using logistic regression.

RESULTS

A total of 884 women (79%) completed the after-effects questionnaire; 30% of women experienced one or more after-effect: 15% reported pain, 16% bleeding, and 7% discharge. The duration of discharge was ≤2 days for 66%, 3-6 days for 22%, and ≥7 days for 11% of women. Pain or bleeding lasted ≤2 days in more than 80% of women. Severe after-effects were reported by <1% of women. The prevalence of pain decreased with increasing age. Bleeding was more frequent among nulliparous women. Discharge was more common among oral contraceptive users.

CONCLUSION

Pain, bleeding, and discharge are not uncommon in women having follow-up cervical cytology tests. Informing women about possible after-effects could better prepare them and provide reassurance, thereby minimising potential non-adherence with follow-up or non-participation with screening in the future.

HPV vaccine decision making in pediatric primary care: a semi-structured interview study

BACKGROUND

Despite national recommendations, as of 2009 human papillomavirus (HPV) vaccination rates were low with < 30% of adolescent girls fully vaccinated. Research on barriers to vaccination has focused separately on parents, adolescents, or clinicians and not on the decision making process among all participants at the point of care. By incorporating three distinct perspectives, we sought to generate hypotheses to inform interventions to increase vaccine receipt.

METHODS

Between March and June, 2010, we conducted qualitative interviews with 20 adolescent-mother-clinician triads (60 individual interviews) directly after a preventive visit with the initial HPV vaccine due. Interviews followed a guide based on published HPV literature, involved 9 practices, and continued until saturation of the primary themes was achieved. Purposive sampling balanced adolescent ages and practice type (urban resident teaching versus non-teaching). Using a modified grounded theory approach, we analyzed data with NVivo8 software both within and across triads to generate primary themes.

RESULTS

The study population was comprised of 20 mothers (12 Black, 9 < high school diploma), 20 adolescents (ten 11-12 years old), and 20 clinicians (16 female). Nine adolescents received the HPV vaccine at the visit, eight of whom were African American. Among the 11 not vaccinated, all either concurrently received or were already up-to-date on Tdap and MCV4. We did not observe systematic patterns of vaccine acceptance or refusal based on adolescent age or years of clinician experience. We identified 3 themes: (1) Parents delayed, rather than refused vaccination, and when they expressed reluctance, clinicians were hesitant to engage them in discussion. (2) Clinicians used one of two strategies to present the HPV vaccine, either presenting it as a routine vaccine with no additional information or presenting it as optional and highlighting risks and benefits. (3) Teens considered themselves passive participants in decision making, even when parents and clinicians reported including them in the process.

CONCLUSIONS

Programs to improve HPV vaccine delivery in primary care should focus on promoting effective parent-clinician communication. Research is needed to evaluate strategies to help clinicians engage reluctant parents and passive teens in discussion and measure the impact of distinct clinician decision making approaches on HPV vaccine delivery.

Pelvic examinations and access to oral hormonal contraception

OBJECTIVE

Requiring a pelvic examination before prescribing oral contraception poses an unnecessary barrier to contraceptive access. Medical guidelines have outlined the safety of oral contraception provision without a pelvic examination, yet little is known about the practices of clinicians providing reproductive health care. Our purpose was to investigate clinicians' requirements for pelvic examination and what may account for practice differences.

METHODS

We administered a mailed survey to a national probability sample of obstetrician-gynecologists (ob-gyns), family medicine physicians, and advanced practice nurses specializing in obstetrics and gynecology and women's health or family medicine in 2008-2009 (N=1,196), with a response rate of 65.3%.

RESULTS

Nearly one third of ob-gyns and family medicine physicians reported always requiring a pelvic examination when prescribing oral contraception (ob-gyns 29%; family medicine 33%). A higher proportion of advanced practice nurses in primary care (45%) and a markedly lower percentage of advanced practice nurses in reproductive health (17%) reported always requiring the examination. In adjusted analyses, older clinicians were more likely to require the pelvic examination (odds ratio [OR] 1.03, P<.01) and clinicians serving a higher proportion of Medicaid patients more likely (OR 1.62, P<.05). Providers in private practice were more than twice as likely as those working in family-planning or community clinics to require pelvic examinations (OR 2.30, P<.01).

CONCLUSION

One third of clinicians we surveyed require pelvic examinations before provision of oral contraceptives, despite guidelines indicating they are unnecessary and research suggesting they can pose a barrier to contraceptive access.

The psychological impact of illness among women experiencing human papillomavirus-related illness or screening interventions

The present study describes the psychological impact of human papillomavirus (HPV)-related conditions or preventive interventions on Taiwanese women. Women with an HPV-related diagnosis or intervention within the past 3 months were invited to participate in a cross-sectional survey before the receipt of HPV-related diagnostic results. Participants completed a 29-item HPV impact profile (HIP), which was a questionnaire designed to represent the full spectrum of potential HPV-related impacts. The HIP assesses worries and concerns; emotional impact; sexual impact; self-image; partner issues and transmission; interactions with doctors; and control/life impact. The final sample size was 249 women from three hospitals. The mean HIP score (0-100) was normal Pap: 28.2; abnormal Pap: 44.3; CIN: 47.5; genital warts: 62.5; abnormal Pap with high-risk HPV positive: 48.8. This study indicates that significant psychological impact is found in women diagnosed with abnormal Pap, CIN, high-risk HPV test positive and genital wart compared to women with a normal Pap. Women with genital warts had the highest psychological impact scores. This is the first quantitative data that can lay the ground work for future studies that enable the comparison of the effectiveness of different interventions in alleviating the psychological burden of HPV-associated infection and preventive interventions in Taiwan.

Association of knowledge, anxiety, and fear with adherence to follow up for colposcopy

OBJECTIVES

To evaluate the association of pre-visit anxiety with pre- and post-visit knowledge, satisfaction, and adherence to colposcopy follow-up visits.

METHODS

A group of 122 women presenting for colposcopy between July 1999 and May 2000 were studied. Immediately prior to their appointment, 98% of eligible patients participated in a self-administered questionnaire. Patients were sent a follow-up questionnaire within two weeks of the appointment. Statistical analyses included Chi-Square and Fisher's exact tests for categorical variables.

RESULTS

The mean follow up was 112 days (SE 9.47). Although the mean fear score was 7.3 (SE 3, range 1-10) and mean anxiety score was 7.8 (SE 2.8, range 1-10), there was no significant association with pre-visit fear and adherence to follow up. Pre-evaluation knowledge was positively associated with fear, anxiety, post-visit knowledge, and adherence to follow up.

CONCLUSIONS

Pre-visit intervention may improve adherence and reduce anxiety associated with colposcopy.

Development and psychometric properties of the HPV Impact Profile (HIP) to assess the psychosocial burden of HPV

OBJECTIVE

A comprehensive questionnaire designed to assess the full spectrum of potential human papillomavirus (HPV)-related psychosocial effects in women does not exist. The HPV Impact Profile (HIP) was developed to determine the psychosocial impact of HPV infection and related interventions.

RESEARCH DESIGN AND METHODS

Draft instrument items and domains were developed using a literature review and cognitive debriefing interviews with women who had experienced HPV-related conditions. An importance rating questionnaire guided item ranking and reduction. A draft questionnaire was pilot-tested for comprehension and ease of completion. Psychometric evaluation of the final HIP was conducted in a survey of 583 women. Data quality, item acceptability, scale acceptability, reliability, and discriminate construct validity were assessed.

OUTCOME MEASURE

The final HIP contained 29 items rated on a 0-10 point discretized visual analog scales grouped into seven hypothesized domains.

RESULTS

Total HIP scores ranged from 0 (no impact) to 100 (worst impact). Data quality was high, with missing data for items ranging from 0 to 0.7% and over 99% of the scores were computable. Cronbach's alpha ranged from 0.64 to 0.90 and was > or =0.7 for 5/7 domains. Discriminant construct validity was demonstrated. Appropriate modifications could potentially be made to improve some aspects of the HIP, including modification to include other HPV diseases such as head and neck, anal, and vulvovaginal cancers and HPV disease in men.

CONCLUSIONS

The disease-specific HIP has favorable reliability and construct validity and a good ability to discriminate among disease severity.

Pap smear knowledge among young women following the introduction of the HPV vaccine

STUDY OBJECTIVE

Investigate sexually active young women's knowledge of the term Pap smear since development of the HPV vaccine.

DESIGN

Cross-sectional study conducted January-May 2007.

SETTING

University health services clinic at a university in southern United States.

PARTICIPANTS

Sexually active women, age 18-24, presenting for a Pap smear or STD testing (N=145).

MAIN OUTCOME MEASURES

Pap smear knowledge was assessed by participants' written definition of the term Pap smear and by multiple choice responses indicating Pap smear as a test for cervical cancer/ HPV and not a pelvic exam, STD test, or pregnancy test.

RESULTS

9.7% provided accurate definitions; 12.4% checked appropriate Pap smear synonyms. 68.5% incorrectly responded that Pap smear was the same as "pelvic exam"; 42.5% indicated "STD test"; 11.7% indicated "pregnancy test." Indicators of HPV risk (age of sexual debut, previous abnormal Pap smear, previous STD diagnosis) were not associated with knowledge. Never using condoms, increasing age, and lower depression scores predicted accurate Pap smear definition rating (R2=0.08). Never using condoms, Caucasian race, and decreased lifetime number of sex partners predicted accurate identification of Pap smear synonyms (R2=0.15).

RESULTS

Few participants understood the meaning of the term Pap smear; there does not appear to be improvement in women's knowledge after development of the HPV vaccine. Poor Pap smear knowledge may affect young women's understanding of their overall sexual health.

Do women comply with recommendations for Papanicolaou smears following colposcopy? A retrospective study

The objective of this study was to determine compliance with follow-up serial Papanicolaou smears after the completion of colposcopic examination and treatment as required in women with abnormal Papanicolaou smears. Following a retrospective chart review, data were selected from 103 charts of women who had undergone colposcopy. Patient compliance with the treatment plan was tracked for 18 months. Compliance was defined as having at least two cervical cancer screenings performed in the year and a half following colposcopy. Thirty-two percent of the study population complied with the plan of care. Eighty-six percent of those patients who had at least one Papanicolaou smear in the 18 months following colposcopy had no progression of dysplasia. Less than one-third of the patients in this study population followed the recommendations given to them after their colposcopic examination and treatment. Health care providers will be aware of the low percentage of patient follow-up as well as the importance of educating patients about prevention of cervical cancer and reducing risk of cervical dysplasia.

Reasons for non-attendance at cervical screening as reported by non-attendees in Sweden

PURPOSE

To describe reasons for non-attendance at cervical screening, as reported by non-attendees, in Sweden.

METHODS

Four hundred women were randomized from a population-based register, of which 133 non-attendees answered the Cervical Screening Questionnaire (CSQ) in telephone interviews. Pearson's Chi2 and Mann-Whitney U-test were used to analyze differences between groups. Logistic regression was used to study the relationship between explanatory variables and a binary response variable.

RESULTS

The most common reasons for non-attendance were: feeling healthy, lack of time, and feelings of discomfort with the gynecologic examination. Non-attendees, who reported non-attendance due to experiences of discomfort associated with the gynecologic examination, estimated great discomfort at their latest examination. A history of sexual abuse was reported by 16.5%, but there were no differences regarding non-attendance due to experiences of discomfort associated with the gynecologic examination, between non-attendees who had no history of sexual abuse and those who had.

CONCLUSION

It seems as though non-attendees did not attend cervical screening as they felt healthy, and thereby did not give time to preventive efforts. Earlier negative experiences such as discomfort during earlier gynecologic examinations seem to guide their decision not to attend.

Awareness, knowledge, and beliefs about human papillomavirus in a racially diverse sample of young adults

PURPOSE

To assess current levels and correlates of awareness, knowledge, and beliefs about human papillomavirus (HPV) in a racially diverse sample of young adults. Correlates of interest in HPV education and the HPV vaccine were also examined.

METHODS

A total of 124 students 18-26 years of age from two southeastern universities (including a historically black university) completed a survey assessing demographic characteristics, sexual history, awareness and knowledge of HPV, HPV-related beliefs (perceived risk of HPV infection, perceived shame associated with HPV infection), interest in learning more about HPV, and interest in the HPV vaccine (women only).

RESULTS

More than 75% of the sample had heard of HPV. Although some misunderstandings were observed, HPV knowledge was relatively high. Women reported greater awareness and knowledge of HPV than did men. Higher perceptions of risk were observed among sexually active participants and those with multiple sexual partners. Younger participants, men, and those with less HPV knowledge indicated they would feel more ashamed if diagnosed with HPV. Black/African-American and sexually active participants reported greater interest in HPV education. Greater interest in the HPV vaccine was observed among women who were sexually active, had multiple sexual partners, and felt vulnerable to HPV infection.

CONCLUSIONS

This study is one of the first to assess awareness, knowledge, and beliefs about HPV since the HPV vaccine was approved. Findings suggest that awareness of HPV may be increasing, yet many misconceptions remain. Continued efforts are needed to promote further understanding of HPV infection, the HPV vaccine, and the importance of routine cervical screening.

"I have never heard that one": young girls' knowledge and perception of cervical cancer

With the advent of a vaccine for the human papillomavirus (HPV), many are claiming that cervical cancer may become a health worry of the past. While the vaccine certainly represents an important step forward in the fight against HPV and cervical cancer, it does not diminish the importance of health education or screening interventions particularly amongst adolescents. This study explores the existing state of cancer and cervical cancer knowledge of Latina and African American adolescent girls from low-income, urban neighborhoods. We found that the study participants expressed a range of attitudes toward cancer. Knowledge of cancer also was varied and somewhat anecdotal, showing no unified body of knowledge, but instead representing an assemblage of information culled from formal and informal sources. Participants were most familiar with breast and lung cancer and mentioned these types of cancer most frequently in the focus groups. Most participants had never heard of cervical cancer, while a few were familiar with several aspects of the disease. Cancer knowledge seemed to be gleaned mostly from personal stories, perhaps suggesting the pervasiveness of cancer incidence in their community. The predominant attitudes expressed toward cancer included fear, uncertainty, and anxiety. Our findings suggest that considerable continued health promotion efforts are needed to improve knowledge about cancer in general, and particularly about cervical cancer, to reduce fear and to highlight the effectiveness of prevention and screening.

Why do women participate in the English cervical cancer screening programme?

The vast majority of women in England attend for cervical cancer screening. Conventional economic theorising fails to explain why and its predictions are inconsistent with the evidence. Using questionnaire data, we analyse directly motivations for screening attendance. We conclude that regular attendance at screening is driven primarily by a search for reassurance, a sense of duty and herd signalling. It is evident that recognisable sub-groups of attenders exist, in which the configurations of motivational factors differ. Being motivated to attend by physicians is less significant that is widely supposed and is more frequently associated with irregular attendance.

Understanding and overcoming barriers to human papillomavirus vaccine acceptance

New vaccines designed to prevent human papillomavirus (HPV) infection have the potential to reduce the incidence of serious illness and death worldwide among women, substantially reduce the emotional suffering associated with abnormal Papanicolaou (Pap) test results and the diagnosis of cervical cancer, and save significant health care dollars. However, these benefits may not be fully realized until the vaccine is accepted by patients, parents, and health care practitioners. Furthermore, there may be unique issues related to the acceptance of a vaccine designed to prevent a sexually transmitted infection that is poorly understood by many women. Among the acceptance issues are: individual comfort with a sexually transmitted infection (STI) vaccine; parental comfort with vaccination of their preadolescent/early adolescent daughters; physician comfort with recommending a human papillomavirus vaccine to women and parents of preadolescents; and physician communication skills related to talking with women and parents about the vaccine. Potentially difficult as it might be to implement a vaccination program, vaccination and prevention of HPV-associated disease are still infinitely preferable to observation and treatment. This article will review some of the potential barriers to HPV Vaccine acceptance, with a particular focus on factors relevant to female patients, parents, and health care providers.

Is Liquid-Based Pap Testing Affected by Water-Based Lubricant?

OBJECTIVE

To estimate the effect of water-based lubricant on the liquid-based Pap test.

METHODS

Two hundred women each had 2 simultaneous Pap test collections. One specimen was randomly contaminated with 0.5 mL of water-based lubricant after collection. The physician was blinded as to which collection was contaminated. Both specimens were sent for cytology. Cytopathologists were blinded to the study. The rate of abnormal cytology and discordance between the control and the contaminated specimens was estimated. The discordance of secondary diagnoses, such as yeast infections and bacterial vaginosis, was also estimated.

RESULTS

The incidence of abnormal cytology was similar in the contaminated specimens and the control specimens (6.5%, 95% confidence interval [CI] 3.5-10.9% versus 7.0%, 95% CI 3.9-11.5%). The rate of disagreement between the 2 specimens collected from each patient was 7.5% (95% CI 4.6-12.1%) and is similar to previously published estimates of discordance using conventional cytology. Secondary diagnoses, such as yeast infections or bacterial vaginosis, were similar in both groups, suggesting no interference from the lubricant.

CONCLUSION

Water-based lubricant does not affect liquid-based cervical cytology Pap testing. Water-based lubricant does not affect secondary diagnoses such as bacterial vaginosis or yeast infections.

LEVEL OF EVIDENCE

II-1.

Improving adolescent health: focus on HPV vaccine acceptance

The success of future human papillomavirus (HPV) vaccination programs will depend on individuals' willingness to accept vaccination, parents' willingness to have their preadolescent and early adolescent children vaccinated, and health care providers' willingness to recommend HPV vaccination. The purpose of this article is to provide a qualitative review of the relevant literature, including research on knowledge and attitudes about HPV infection and its clinical sequelae, the acceptability of HPV vaccination to individuals and parents, and health care providers' attitudes about recommending HPV vaccination. Additionally, strategies are suggested by which providers of adolescent health care can discuss and recommend HPV vaccines with parents and their children. The research published to date suggests that there is a good deal of misunderstanding about HPV infection, cervical cancer screening, and the sequelae of HPV infection. However, the majority of research studies to date indicate that young women, parents, and health care providers are interested in vaccines that prevent HPV and other sexually transmitted infections (STIs). Of particular note are the consistent findings that providers are less comfortable vaccinating younger versus older adolescents and that endorsement of vaccination by a professional organization is of great importance. Furthermore, research suggests that most parents are interested in having their preadolescent and adolescent children vaccinated against HPV. Parents value the information and recommendations provided by their children's health care providers. To the extent that providers are concerned about potential negative reactions of parents to a recommendation of HPV vaccination, these findings should provide reassurance. At the same time, health care providers will need to be prepared to provide patients and parents with information about HPV and HPV immunization and to respond productively to the rare parent who expresses opposition to HPV vaccine or any other vaccine.

Vaginal speculum lubrication and its effects on cervical cytology and microbiology

The prevailing approach to Papanicolaou (Pap) and endocervical Gen-Probe(R) screening is to use an unlubricated vaginal speculum because of concerns that gel lubricant interferes with Pap smear adequacy and cervical microbiology. This study tests the hypothesis that lubrication of metal specula with a bacteriostatic gel does not increase unsatisfactory cervical cytology or decrease detection rates of endocervical Chlamydia trachomatis or Neisseria gonorrhoeae. At a publicly funded family planning clinic site, each of eight consecutive months was randomly designated by computer as an exclusively gel-lubricated or water-moistened specula use month. The assigned vaginal speculum intervention was used on all patients receiving a Pap smear and/or combination DNA probe assay for endocervical C. trachomatis and N. gonorrhoeae. From July 2003 through February 2004, 3460 Pap smears and 5535 combination probe assays for C. trachomatis and N. gonorrhoeae were collected from 6538 patients. During the 4 months of gel lubricant use, the rate of unsatisfactory cytology was 1.1% compared to 1.5% during the 4 months of water lubrication [odds ratio (OR) 0.74; 95% confidence interval (CI) 0.41-1.35]. During the 4 months of gel lubricant use, the detection rate for endocervical C. trachomatis was 1.5% compared to 1.5% (OR 1.05; 95% CI 0.67-1.62) in water lubricant months. The study population N. gonorrhoeae infection rate was too low to statistically analyze. The use of a small amount of gel lubricant on metal vaginal specula did not increase unsatisfactory cytology or decrease endocervical C. trachomatis detection rates when compared to water lubricant.

Speculum ‘self-insertion’: a pilot study

AIM

This paper reports phase II of a pilot study that aimed to determine whether self-insertion of a speculum by women undergoing a pap smear would be more comfortable and lead to an improvement in satisfaction and a decrease in anxiety associated with this procedure.

BACKGROUND

Research demonstrates that pelvic examinations are considered by most women to be unpleasant and are routinely associated with embarrassment, apprehension, fear and often some level of discomfort and/or pain.

DESIGN

The study used quantitative and qualitative data collection techniques. Phase I (described elsewhere) tested the newly developed Speculum Self-Insertion Satisfaction Questionnaire for content validity, internal consistency and clarity. Phase II pilot study tested the technique of speculum self-insertion. Women's general level of anxiety was measured using the State Trait Anxiety Inventory, both before and after they performed the self-insertion procedure. Women's satisfaction and acceptance of the procedure was measured using the Speculum Self-Insertion Satisfaction Questionnaire and explored through the use of qualitative research techniques.

PARTICIPANTS

A total of 198 women attending family planning clinics in Perth, Western Australia, between September and December 2003 were invited to participate in the study. One hundred and thirty-three women agreed to self-insert their own speculum.

RESULTS

The study demonstrated that speculum self-insertion was acceptable to most women, especially younger women. Nearly 91% of women either agreed or strongly agreed that they were satisfied with the experience of self-insertion and would choose to self-insert the speculum again. This included the women who had not previously had a speculum examination. The quality of specimen collected was not detrimentally affected by speculum self-insertion.

CONCLUSIONS

The results of this pilot research, while needing to be replicated in a larger study, demonstrate that offering women the opportunity to self-insert a speculum during a routine pelvic examination is an acceptable, innovative, simple and cost-neutral change in clinical practice that increases women's comfort and satisfaction and potentially makes sexual health screening less threatening to women of all ages.

RELEVANCE TO CLINICAL PRACTICE

Speculum self-insertion may encourage women's attendance at clinics for regular screening. Early diagnosis and treatment will result in better health outcomes for women, families and the community at large.

Psychological and Sociocultural Perspectives on Follow-up of Abnormal Papanicolaou Results

OBJECTIVE

To understand women's motivation to attend follow-up of an abnormal Papanicolaou (Pap) test by applying a general theoretical framework for voluntary behavior.

METHODS

Semistructured, face-to-face interviews were conducted among 120 low-income, African-American, Caucasian, or Hispanic outpatients, aged 25-50 years, who presented for routine gynecologic care. Interview questions assessed social, cognitive, environmental, and emotional factors surrounding follow-up for an abnormal Pap test. Content analysis was performed.

RESULTS

The majority of women (74%) described their attitude toward returning for a follow-up visit as favorable. Overall, knowledge regarding the significance of an abnormal result was poor, and misconceptions were common. Perceived barriers, consequences, and social influences associated with attending follow-up were qualitatively different across the 3 racial/ethnic groups. For example, African-American and Hispanic women expressed embarrassment more frequently than Caucasian women and were less likely to anticipate obstacles to attending follow-up. Furthermore, African-American women were the least likely to be influenced by others' opinions and to perceive difficulty in adhering to follow-up recommendations. For nearly all women, adequate communication with their provider was a key component of anticipated adherence.

CONCLUSION

Clinicians may exert a positive influence on adherence among patients who experience an abnormal Pap test by engaging patients in a dialogue that accommodates the patient's sociocultural environment, explores concerns regarding the partner's reaction, emphasizes the importance of follow-up, provides a clear understanding of the process and timeline surrounding follow-up recommendations, and encourages the patient to anticipate obstacles to adherence and assists with solutions.

Internet use for cancer information among racial/ethnic populations and low literacy groups

Many Web sites on the Internet offer health information related to cancer and are increasingly being used by patients, caregivers, and those interested in cancer prevention and treatment. To comprehensively review the cancer literature regarding Internet health information use among those of racial/ethnic populations and low literacy groups, a comprehensive review of the MEDLINE/Pre-MEDLINE, LISA, PsycInfo, CINAHL, Embase, and Web of Science databases was conducted. Eight relevant articles were retrieved: seven are classified as content research and one as outcomes research. Little empirical research exists on this topic of cancer Internet health information use among those of racial/ethnic populations and low literacy groups. This area of research is open for many unique contributions to the scientific literature.

The health care costs of cervical human papillomavirus--related disease

OBJECTIVE

The purpose of this study was to examine the health care costs of cervical human papillomavirus-related disease in a US health care setting.

STUDY DESIGN

We conducted an observational cohort study using 1997 through 2002 administrative and laboratory records from 103,476 female enrollees of the Kaiser Permanente Northwest health plan (Portland, Ore). We examined the cost per case and annual cost per 1000 enrollees for cervical human papillomavirus-related events.

RESULTS

A cervical examination with a normal routine papanicolaou smear incurred costs of 57 dollars (95% CI, 57-57). Costs that were associated with abnormal routine screening diagnoses ranged from 299 dollars for atypical squamous cells (95% CI, 245-352) to 2349 dollars for high-grade squamous intraepithelial lesion (95% CI, 1,047-3,650). The costs of histologically confirmed cervical intraepithelial neoplasia ranged from 1026 dollars for cervical intraepithelial neoplasia 1 (95% CI, 862-1191) to 3235 dollars for cervical intraepithelial neoplasia 3 (95% CI, 2051-4419); a cost of 376 dollars (95% CI, 315-436) was associated with false-positive test results. At the level of the health plan, overall annual cervical cancer prevention and treatment costs were 26,415 dollars per 1000 female enrollees, with routine cervical cancer screening accounting for expenditures of 16,746 dollars per 1000 female enrollees, cervical intraepithelial neoplasia accounting for expenditures of 4535 dollars per 1000 female enrollees, cervical cancer accounting for expenditures of 2629 dollars per 1000 female enrollees, and false-positive test results accounting for expenditures of 2394 dollars per 1000 female enrollees.

CONCLUSION

These are the first direct estimates of both individual and population level costs of cervical human papillomavirus-related disease in a general US health care setting. Routine cervical cancer screening comprises nearly two thirds of total annual cervical human papillomavirus-related health care costs, with 10% of expenditures dedicated to the treatment of invasive cervical cancer, 17% to the management of cervical precancers, and 9% to dealing with false-positive Papanicolaou test results.

Comparison of Adolescent and Young Adult Self-Collected and Clinician-Collected Samples for Human Papillomavirus

OBJECTIVE

To examine the concordance between self-collected and clinician-collected samples for human papillomavirus (HPV) DNA.

METHODS

Sexually active adolescent and young adult women aged 14-21 years (N = 101) were enrolled in a prospective cohort study of HPV testing. Participants self-collected vaginal samples for HPV DNA, and clinicians collected cervicovaginal samples for HPV DNA and a cervical cytology specimen. We determined concordance between the results of self- and clinician-collected specimens using a kappa statistic and McNemar's test.

RESULTS

Of the 51% of participants who were HPV positive, 53% had 1 type, 25% had 2 types, and 22% had 3 types or more; 25 different HPV types were identified. Self-collected samples detected more participants with HPV than clinician-collected samples (45% versus 42%, P =.65). When results were categorized into presence or absence of high-risk HPV types, agreement between self- and clinician-collected specimens was high (kappa 0.72) and the difference between test results was not significant (McNemar's P =.41). However, when all HPV types detected were considered, agreement was perfect in only 51% of those with 1 or more types of high-risk HPV type. There was no association between agreement and age or HPV type.

CONCLUSION

Self testing for HPV DNA may be sufficiently sensitive for the detection of high-risk HPV DNA among adolescent and young adult women in clinical settings.

Women's experiences of abnormal cervical cytology: illness representations, care processes, and outcomes

BACKGROUND

We wanted to explore the conceptual representations of illness and experiences with care among women who have learned of an abnormal Papanicolaou (Pap) smear result.

METHODS

The study took place in 2 primary care, family practice clinics serving low-income, multiethnic patients in the Bronx, New York City. We conducted qualitative, semistructured telephone interviews with 17 patients who had recently learned of abnormal findings on a Pap smear. After a preliminary coding phase, the investigators identified 2 important outcomes: distress and dissatisfaction with care, and factors affecting these outcomes. A model was developed on a subset of the data, which was then tested on each transcript with an explicit search for disconfirming cases. A revised coding scheme conforming to the dimensions of the model was used to recode transcripts.

RESULTS

Women reported complex, syncretic models of illness that included both biomedical and folk elements. Many concerns, especially nonbiomedical concerns, were not addressed in interactions with physicians. An important source of both distress and dissatisfaction with care was the women's lack of understanding of the inherent ambiguity of Pap smear results. When perceived care needs, which included emotional support as well as information, were not met, distress and dissatisfaction were greatly increased.

CONCLUSION

In this study, patients' illness models and expectations of care were not routinely addressed in their conversations with physicians about abnormal Pap smear results. When physicians can take the time to review patients' illness models carefully, distress and dissatisfaction with care can be reduced considerably.

Women's knowledge and experience of atypical Pap results in a high risk community

We sought to describe the knowledge of, understanding of, and follow-up after atypical cervical cytology among low-income, urban women. Of 554 women who had an ASCUS or atypical Pap result in 1996,215 (39%) completed a telephone survey. Many (19%) had poor follow-up. Thirty percent of women denied ever being told of abnormal cytology; Spanish-speakers were more likely to be unaware (43.2% vs. 22.7%, p < .01) of abnormal cytology. Cancer fear was quite high, as were misconceptions regarding cause. Many women were unsatisfied with the information they received regarding their cytology.

Pap test results among low-income youth: prevalence of dysplasia and practice implications

OBJECTIVES

To describe Papanicolaou (Pap) test findings and identify prevalence and correlates of dysplastic cervical abnormalities in low-income adolescent females.

DESIGN AND SETTING

This cross-sectional study included a modified random sample of female students ages 16 to 25 years at 54 U.S. Job Corps centers.

PARTICIPANTS

5,734 female students enrolled in a federal job training program. Admission health records were reviewed and abstracted.

MAIN OUTCOME MEASURE

Pap test findings using the Bethesda classifications. Pap smear results indicating dysplasia (atypical squamous cells of undetermined significance [ASCUS] with dysplasia) or squamous intraepithelial lesions (low-grade squamous interepithelial lesions [LGSIL] or high-grade squamous intraepithelial lesions [HGSIL]). Participants with less severe findings were compared with those who needed follow-up.

RESULTS

For 71.4% of participants, no abnormalities were found. 15.6% had benign cellular changes, 9.2% had reactive changes, and 9.9% had epithelial cell abnormalities. Of those tested, 5.6% (+/- 0.8%) had dysplastic Pap smear findings, with 0.3% (n = 12) HGSIL. All groups were equally affected, with abnormalities not associated with race/ethnicity, age, geographic region, education level, size of city of residence, or receiving public assistance.

CONCLUSIONS

In this population, dysplastic Pap smear results were not uncommon. Findings indicate that Pap screening, alone or in combination with more sensitive tests, can identify cervical abnormalities, including HGSIL, that suggest a need for further evaluation or follow-up.

Prevalence and correlates of pelvic examinations in sexually active female adolescents

OBJECTIVES

The pelvic examination is an important component of reproductive health services for adolescent girls and is recommended for those who become sexually active. The aims of this study were to describe self-reported rates of pelvic examinations in sexually active adolescent girls and to determine factors associated with having obtained an examination.

METHODS

Cross-sectional data from a national self-administered survey of nurses' adolescent daughters were used. Subjects were those girls (N = 635) who reported ever having had sexual intercourse. Bivariate and multivariate analyses were used to identify demographic and psychological variables, preventive health behaviors, and risk behaviors associated with having ever obtained a pelvic examination.

RESULTS

Median subject age was 16.0 years (range 12-19 years), and 46% of subjects reported having had a pelvic examination. Variables associated with having obtained an examination were older age (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.09-1.53), cigarette smoking (OR 1.51, 95% CI 1.02-2.24), higher number of sexual partners (OR 1.29, 95% CI 1.14-1.47), and no condom use during last sexual intercourse (OR 1.80, 95% CI 1.19-2.70).

CONCLUSIONS

Fewer than half of these sexually active adolescents had ever obtained a pelvic examination. Younger subjects who did not smoke regularly, had fewer partners, and used condoms were less likely to have obtained an examination; these adolescents may not be seeking reproductive health care services or be recognized by parents or providers as being in need of services.

Measurement of young women's attitudes about communication with providers regarding Papanicolaou smears

PURPOSE

To describe the psychometric properties of a scale created to measure communication with the provider regarding Papanicolaou (Pap) smears.

METHODS

A scale based on expectancy-value theory was developed and administered to 490 young women aged 12 to 24 years in an urban adolescent clinic. Psychometric properties were assessed using factor analysis to evaluate latent variables, intraclass correlation coefficient to evaluate test-retest reliability, and Cronbach coefficient alpha to evaluate internal consistency reliability. Content validity was assessed by qualitative interviews, feedback on a pilot survey, and expert review. Construct validity was evaluated by examining whether relevant health care characteristics, knowledge, and attitudes were significantly associated with perceived communication.

RESULTS

Mean respondent age was 18.2 +/- 2.1 years; 50% were black and 22% Hispanic. The scale items loaded on one factor. The intraclass correlation coefficient was 0.83 and Cronbach alpha 0.95. Report of a consistent provider, report that a provider recommended a Pap smear, knowledge of Pap smears and Human Papillomavirus (HPV), intention to return for follow-up Pap smears, and positive attitudes about Pap follow-up were significantly associated with good communication.

CONCLUSIONS

The scale appears to be reliable and valid as a measure of young women's communication with providers regarding Pap smears. Future research should focus on whether this newly developed scale is useful in the design and evaluation of cervical cancer prevention programs for young women.

Intention to return for papanicolaou smears in adolescent girls and young women

OBJECTIVE

Sexually active adolescent girls have high rates of abnormal cervical cytology. However, little is known about factors that influence intention to return for Papanicolaou screening or follow-up. The aim of this study was to determine whether a theory-based model that assessed knowledge, attitudes, and behaviors predicted intention to return.

METHODS

The study design consisted of a self-administered, cross-sectional survey that assessed knowledge, beliefs, perceived control over follow-up, perceived risk, cues for Papanicolaou smears, impulsivity, risk behaviors, and past compliance with Papanicolaou smear follow-up. Participants were recruited from a hospital-based adolescent clinic that provides primary and subspecialty care, and the study sample consisted of all sexually active girls and young women who were aged 12 to 24 years and had had previous Papanicolaou smears. The main outcome measure was intention to return for Papanicolaou smear screening or follow-up.

RESULTS

The enrollment rate was 92% (N = 490), mean age was 18.2 years, 50% were black, and 22% were Hispanic. Eighty-two percent of participants intended to return. Variables that were independently associated with intention to return included positive beliefs about follow-up (odds ratio [OR]: 1.07; 95% confidence interval [CI]: 1.02-1.11), perception that important others believe that the participant should obtain a Papanicolaou smear (OR: 1.93; 95% CI: 1.38-2.74), perceived control over returning (OR: 1.24; 95% CI: 1.06-1.46), and having received cues to obtain a Papanicolaou smear (OR: 1.31; 95% CI: 1.08-1.60).

CONCLUSIONS

Analysis of this novel theoretical framework demonstrated that knowledge and previous behaviors were not associated with intention to return for Papanicolaou smear screening and follow-up in this population of young women. However, modifiable attitudinal components, including personal beliefs, perception of others' beliefs, and cues to obtaining Papanicolaou smears, were associated with intention to return.