Confusion About Pap Smears: Lack of Knowledge Among High-Risk Women

Abstract

Background:

The impact of the Papanicolaou (Pap) smear on the prevention of cervical cancer is one of the greatest public health success stories. However, it is not clear if women understand the purpose of the Pap smear despite recent advancements and national attention over cervical cancer prevention. The purpose of this study was to examine Pap smear knowledge among three high-risk populations at different points in time.

Methods:

Women from three separate human papillomavirus (HPV) psychosocial studies completed surveys assessing Pap smear knowledge: (1) HPV-positive women (prevaccine population in 2005–2006, n=154, mean age 23.5), (2) college women (postvaccine population in 2008, n=276, mean age 18.9), and (3) minority college women (postvaccine population in 2011, n=711, mean age 23.3). Frequencies and logistic regression were employed to examine associations between demographic factors and accurate knowledge of Pap smear testing within each study.

Results:

Approximately one quarter of participants across all three samples did not know that the Pap smear is a test for cervical cancer. Participants also incorrectly believed that the Pap smear tests for HPV (82%–91%), vaginal infections (76%–92%), yeast infections (65%–86%), gonorrhea (55%–81%), herpes (53%–80%), HIV/AIDS (22%–59%), and pregnancy (17%–38%). Among all three studies, older age was the only factor significant with higher Pap knowledge. Higher HPV knowledge scores were significantly associated with higher Pap knowledge in studies 2 and 3 only.

Conclusions:

Knowledge about the purpose of the Pap smear remains low. Findings underscore the significant need for clear and consistent messages among high-risk women regarding the prevention of cervical cancer and other reproductive health conditions.

Introduction

The impact of the Papanicolaou (Pap) smear on prevention and early detection of cervical cancer is one of the greatest public health success stories in the United States. Since the 1950s, cervical cancer mortality rates have declined by>70%,¹ and today,>80% of women in the United States report having had a Pap smear within the last 3 years.² The role of human papillomavirus (HPV) as the etiologic cause of cervical cancer and other cancers has been well established.¹ Scientific advancements that provide primary and secondary prevention, such as the HPV vaccine and the HPV test, have further contributed to the decrease in cervical cancer morbidity and mortality rates. The HPV vaccine was approved for females aged 9–26 for the prevention of cervical cancer and genital warts in 2006, approved for males aged 9–26 for the prevention of genital warts in 2009, and approved for the prevention of anal cancer in both men and women in 2011.^3,4

Although a significant proportion of women in the United States receive cervical cancer screening, recent studies suggest that women hold inaccurate beliefs about the Pap smear, believing that it screens for a number of gynecologic cancers, pregnancy, and sexually transmitted infections (STIs).^5

–12 The HPV vaccine was released in 2006 and has received widespread attention from the media, professional associations, and government health agencies. It is of concern, therefore, that although rates of cervical cancer screening are encouraging, knowledge of the screening's purpose is limited. Therefore, it is not clear if women understand the purpose of the Pap smear even with recent advancements and national attention over cervical cancer prevention.

An accurate understanding of the Pap smear is important to reduce the burden of disease from cervical cancer and other diseases for which the Pap smear does not test. This is particularly important in high-risk populations, where cervical cancer disparities exist. For example, racial and ethnic minority women account for a disproportionate number of cervical cancer deaths.¹³ Specifically, more black and Hispanic women are diagnosed with cervical cancer and are diagnosed at later stages of the disease than women of other races or ethnicities.^13
–15 Likewise, black women are twice as likely as white women to die from cervical cancer (5.0 vs. 2.4 deaths per 100,000 women, respectively). The cervical cancer mortality rate is also 50% higher among Hispanic women compared to non-Hispanic white women.¹⁶

In the case of college-age women, it is important that they understand the purpose of the Pap smear, as they have one of the highest age-specific rates of STIs, including HPV.¹⁷ The purpose of this current investigation is to examine women's Pap smear knowledge among three high-risk populations at three different periods in time: (1) HPV-positive women (prevaccine population in 2005–2006), (2) college women (postvaccine population in 2008), and (3) minority college women (postvaccine population in 2011).

Materials and Methods

Procedures and study participants varied among the three studies: HPV-positive women (study 1), general college women (study 2), and racial and ethnic minority women (study 3); therefore, procedures for each study are briefly described.

Study 1

The HPV-positive women's sample (n=154) was derived from a previous study conducted in 2005 and funded by the Centers for Disease Control and Prevention (CDC) prior to the release of the HPV vaccine.^18,19 The purpose of this study was to assess the knowledge and information-seeking practices among women who had recently received an HPV-positive test result after an abnormal Pap smear. In brief, HPV-positive women residing in a southeastern region of the United States completed a 15-minute paper-and-pencil survey that assessed items related to knowledge, attitudes, and behaviors regarding HPV, cervical cancer, and intentions toward receiving the HPV vaccine prior to the Food and Drug Administration (FDA) approval of the HPV vaccine.

Study 2

The general college women's sample (n=276) was derived from a previous study conducted in 2008 that sampled undergraduate students enrolled in social science courses at a large, public, urban university in a southeastern region of the United States.²⁰ In brief, undergraduate students completed a 10-minute paper-and-pencil survey that assessed items related to knowledge, attitudes, behaviors, and vaccine acceptance postlicensure of the HPV vaccine. Although both females and males completed the survey, males' data are excluded from this analysis because of the purpose of this report. Details of the HPV-positive women^18,19 and general college²⁰ studies have been reported previously.

Study 3

Women from the racial and ethnic minority sample (n=711) were derived from a recent study conducted in 2011. Study participants were self-identified as Hispanic or Latino/Latina, black or African American, Asian, Middle Eastern, Native American, Alaska Native, Native Hawaiian or Other Pacific Islander, Indian, white, or other between the ages of 18 and 58. A sample of racial and ethnic minority students was sent an email invitation from the university registrar's office with a link asking them to participate in a 15-minute web-based survey (Checkbox^® 4.6). Items from the web-based survey were adapted from previous research,^18,20

–23 as well as constructs from the Health Belief Model²⁴ and Social Cognitive Theory.²⁵ The survey contained multiple sections, including sociodemographics, sexual behaviors, HPV knowledge and awareness, psychosocial factors, mistrust of healthcare providers, HPV vaccine beliefs, acculturation, and HPV vaccination status. Although both females and males completed the survey, males' data are excluded from this analysis because of the purpose of this report.

The University of South Florida's Institutional Review Board approved all three studies.

Outcome variable

Knowledge of the purpose of the Pap smear was assessed in all three studies with a single item: What is the Pap smear a test for? Participants were provided with a list of eight sexually related outcomes that they may believe a Pap smear tests for, including pregnancy, HIV/AIDS, herpes, gonorrhea, HPV, cervical cancer, yeast infections, and vaginal infections. The Pap smear knowledge item and the corresponding sexually related outcomes were derived from a pilot sample during the qualitative phase of the original study (study 1).^18,19 The response options for each item included agree, disagree, and not sure for study 1 and true, false, not sure for studies 2 and 3.

Independent variables

Age, marital status, insurance status, and education (highest level obtained) were assessed by a single item in each study. An HPV knowledge score was created by summing the number of correct responses on 11 knowledge items that were the same across all three studies (theoretical range=0–11, with a higher score indicating greater HPV knowledge). In studies 1 and 2, race was measured with a single check all that apply item, and Hispanic ethnicity was measured with a single yes or no item. In study 3, race and ethnicity were measured with a single item. This item asked participants to select how they formally identified themselves and included racial categories and Hispanic ethnicity as response options. Participants in studies 2 and 3 responded to two items that assessed whether they had ever been told they had HPV by a healthcare provider and whether they had ever had an abnormal Pap smear.

Analysis

Frequencies were employed to examine demographic characteristics of participants in the three samples. In addition, the percents of correct, incorrect, and not sure responses regarding the purpose of the Pap smear by item were assessed across the three samples. Participants who accurately responded that the Pap smear tests for cervical cancer and does not test for pregnancy, HIV/AIDS, gonorrhea, herpes, yeast infections, and vaginal infections were compared to those who did not respond accurately to these items. Participants were categorized regardless of how they responded to whether the Pap smear tests for HPV, as there could be confusion because of Pap specimens being tested for HPV when abnormal cells are found (also referred to as reflex testing). Logistic regression was employed to examine associations between demographic factors and accurate knowledge of Pap smear testing within each study. In studies 1, 2, and 3, 144, 259, and 711 women, respectively, completed all 8 items assessing the purpose of the Pap smear and were included in the logistic regression analysis. Factors significant at p<0.05 in univariate analysis were included in multivariate analyses.

Results

Table 1 shows the demographic characteristics for each total study sample. Study 1 participants (n=154) had higher knowledge overall than the other two groups. Study 2 participants (n=276) were on average younger than study 1 participants and study 3 participants (n=711) and were most likely to be unmarried and single (92%).

Table 1.

Demographic Characteristics of Participants, by Study

	Study 1 n=154	Study 2 n=276	Study 3 n=711
	% (n)	% (n)	% (n)
Age, mean (SD)	23.5 (4.6)	18.9 (2.2)	23.3 (6.5)
Range	18–45	17–42	17–58
HPV knowledge, mean (SD)	10.0 (1.2)	7.5 (2.4)	7.7 (2.9)
Range	6–11	0–11	0–11
Race	^a	^a	^b
White	69 (106)	75 (188)	5 (32)
Black or African American	12 (19)	7 (18)	27 (189)
Asian	4 (6)	5 (12)	12 (85)
American Indian, Alaskan Native	NA	0	0
Native Hawaiian or other Pacific Islander	NA	<1% (1)	1 (6)
Middle Eastern	NA	NA	1 (6)
Indian	NA	NA	3 (23)
Other	14 (22)	7 (18)	6 (41)
Multiracial	NA	6 (15)	NA
Ethnicity
Non-Hispanic	84 (129)	82 (226)	NA
Hispanic	16 (24)	18 (48)	46 (329)
Marital status
Unmarried, single	71 (110)	92 (253)	73 (519)
Unmarried, living with a partner	18 (28)	7 (18)	13 (91)
Married	5 (8)	1 (3)	12 (84)
Separated/divorced	5 (7)	1 (2)	2 (15)
Widowed	0	0	<1 (2)
Insurance
Yes	60 (91)	79 (213)	76 (540)
No	40 (61)	21 (55)	24 (171)
Education
12th grade or less, no diploma	3 (4)	NA	NA
High school diploma or GED	10 (15)	22 (60)	6 (40)
Some college credit but no degree	51 (79)	NA
First or second year college student	NA	67 (184)	26 (183)
Third to fifth year college student	NA	9 (26)	37 (261)
2-year college degree (A.A., A.S.)	NA	1 (4)	11 (81)
College undergraduate degree (B.A., B.S.)	29 (44)	1 (2)	13 (92)
College masters or doctoral degree (M.S.W., PhD. M.D.)	8 (12)	0 (0)	8 (54)

Race measured by a single item, and ethnicity measured by a separate yes or no item.

Race and ethnicity measured by a single item.

HPV, human papillomavirus; NA, not available; SD, standard deviation.

Participants in study 1 all had abnormal Pap smears and an HPV-positive test result. Among participants in study 2 and study 3, 4% (10) and 11% (77) reported they had been told they had HPV by a healthcare provider, and 10% (28) and 17% (123) reported they previously had an abnormal Pap smear, respectively. Overall, 11% (28) of participants in study 2 and 20% (140) of participants in study 3 reported a history of abnormal Pap smear or having HPV (data not shown).

Although the majority of the participants in all three studies (75%–84%) correctly answered that the Pap smear is a test for cervical cancer, a considerable proportion from each population incorrectly believed the Pap smear tests for HPV (82%–91%), vaginal infections (76%–92%), yeast infections (65%–86%), gonorrhea (55%–81%), and herpes (53%–80%). Although still incorrect, fewer participants believed that the Pap smear tests for HIV/AIDS (22%–59%) and pregnancy (17%–38%). Data are presented in Figure 1.

FIG. 1.

Percent of correct, incorrect, and not sure responses regarding the purpose of the Pap smear, by item, by study. Study 1, human papillomavirus (HPV)-positive women, 2005; study 2, general college women, 2008; study 3, racial and ethnic minority college women, 2011.

Logistic regression was performed within each study to assess factors that may be associated with participants' overall accurate knowledge of the purpose of the Pap smear test (Table 2). As mentioned, participants were categorized regardless of how they responded to whether the Pap smear tests for HPV, as there could be confusion because Pap specimens were tested for HPV when abnormal cells were found (also referred to as reflex testing). Moreover, few participants were correct that the Pap smear did not test for HPV: 8 participants (6%) in study 1, 4 participants (2%) in study 2, and 52 participants (7%) in study 3. Age was the only factor that was associated with accurate knowledge in all three studies, although it did not retain significance in the multivariate model for study 2. Older age was associated with higher overall accurate answers. Higher HPV knowledge scores were found to be significantly associated with higher accurate Pap smear test knowledge in multivariable analyses for studies 2 and 3 only. Marital status was significant in the univariate analysis for studies 1 and 3, but this effect was not maintained in multivariable analyses.

Table 2.

Factors Associated with Accurate Knowledge of Pap Smear Purpose, by Study

	Study 1		Study 2		Study 3
	Univariate	Multivariate	Univariate	Multivariate	Univariate	Multivariate
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Age	1.16 (1.06-1.27)	1.14 (1.02-1.28)	1.18 (1.03-1.35)	1.13 (0.98-1.29)	1.08 (1.05-1.11)	1.07 (1.04-1.11)
HPV knowledge	1.57 (0.95-2.61)		2.10 (1.28-3.45)	2.01 (1.21-3.33)	1.22 (1.12-1.32)	1.19 (1.09-1.30)
Race^a
White	1.00 (Reference)		1.00 (Reference)		-	-
Nonwhite	0.21 (0.05-0.95)	0.24 (0.05-1.14)	1.05 (0.27-4.08)		-	-
Ethnicity^a
Non-Hispanic	1.00 (Reference)		1.00 (Reference)		-	-
Hispanic	1.19 (0.36-3.92)		1.73 (0.44-6.78)		-	-
Race^b
White	-	-	-	-	1.00 (Reference)
Hispanic	-	-	-	-	1.17 (0.46-2.96)
Black or African American	-	-	-	-	0.85 (0.32-2.24)
Asian	-	-	-	-	0.86 (0.30-2.46)
Other	-	-	-	-	0.89 (0.31-2.31)
Marital status
Unmarried, single	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)	1.00 (Reference)
Unmarried living with a partner	0.52 (0.11-2.45)	0.46 (0.10-2.24)	3.56 (0.70-18.19)		1.13 (0.63-2.00)	0.84 (0.46-1.53)
Currently or ever married	5.14 (1.52-17.42)	3.76 (0.89-15.86)	7.13 (0.71-71.20)		1.97 (1.21-3.21)	0.72 (0.38-1.37)
Insurance
Yes	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)
No	0.52 (0.19-1.42)		Not estimatable		1.09 (0.71-1.69)
Education
High school diploma or less	1.02 (0.20-5.25)		0.32 (0.04-2.53)		1.09 (0.44-2.70)	1.62 (0.64-4.15)
First to fifth year college student	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)	1.00 (Reference)
Associate or undergraduate degree	2.54 (0.91-7.05)		Not estimatable		2.10 (1.36-3.25)	1.50 (0.94-2.38)
Graduate degree	3.05 (0.67-13.88)		Not estimatable		4.24 (2.31-7.76)	1.94 (0.96-3.90)
Self-reported history of abnormal Pap or HPV diagnosis^c
No	-	-	1.00 (Reference)		1.00 (Reference)
Yes	-	-	2.23 (0.45-11.11)		1.49 (0.96-2.32)

Race measured by a single item, and ethnicity measured by a separate yes or no item (study 1 and study 2).

Race and ethnicity measured by a single item (study 3).

All women in study 1 had an abnormal Pap smear and were diagnosed with HPV.

CI, confidence interval; OR, odds ratio.

Discussion

This study examined women's knowledge of the purpose of the Pap smear among three different samples at three different points in time. All three studies were conducted in the same geographic area, included college age women, and included similar measures of Pap smear knowledge. Although most participants in these three studies correctly reported that the Pap smear is a test for cervical cancer (75%–84%), approximately one quarter of participants lacked knowledge on this secondary prevention measure that has the ability to detect precancerous cells and prevent unnecessary morbidity and mortality due to cervical cancer. In addition, a substantial proportion of participants incorrectly reported that a Pap smear tests for a range of STIs and vaginal infections. These findings are consistent with other studies that found low knowledge and confusion over the Pap smear.^5

–12 Approximately one quarter to one third of participants in studies 2 and 3, all college women, incorrectly believed that a Pap smear was a test for pregnancy, a finding that alludes to a lack of understanding of the basic components of annual preventive gynecologic vists. Providing accurate sexual health education in elementary and high school health classes might have prevented this misunderstanding.

Our finding of a statistically significant association between age and Pap smear knowledge has been found in other studies.^8,10 This finding might simply reflect that the more often a person engages in a health-seeking behavior, the greater the awareness of the meaning of that preventive behavior. On the other hand, it is also possible that findings again suggest that women are not receiving health education about the purpose of the Pap smear at an early enough age,¹⁰ as college-age women are at greatest risk for an HPV infection.¹⁷ Given the political and ideologic barriers inhibiting young individuals in receiving medically accurate and age-appropriate sexual health information, it is not surprising that there is incorrect knowledge and language associated with reproductive health screenings.

The complex intersection of sexual behaviors and knowledge about HPV, Pap smear screenings, HPV vaccination, and cervical cancer with other reproductive screenings (e.g., pregnancy screening, pelvic examinations) and conditions (e.g., STIs, vaginal infections) necessitates clear and consistent messaging.⁹ Confusion can lead to delays and missed screening and treatment opportunities not only for cervical cancer but also for a range of other reproductive health issues. Moreover, confusion over the Pap smear may interfere with women's understanding of the need for and timing of other preventive behaviors. For instance, although women may not need a Pap smear performed annually, they should still receive an annual physical examination. Women should not forgo this important encounter with a healthcare provider, which includes other essential and comprehensive health education, counseling, screening, and diagnoses (e.g., STI testing, contraception counseling, pelvic examination, clinical breast examination, blood pressure checks, body mass index [BMI] review). Furthermore, the need for a Pap smear remains even if women receive the HPV vaccine.⁸

Lack of understanding of the Pap smear in relation to other gynecologic conditions can interfere with women's ability to communicate effectively with their healthcare provider about their testing history, past results, and current need for a range of gynecologic screenings.⁸ Lack of clear communication can also result from providers not fully explaining or ensuring that women understand the tests they are receiving. For instance, confusion still remained over the purpose of the Pap smear even among study 1 participants, who all received an abnormal Pap smear test result. This finding is similar to findings of other studies that assessed Pap smear knowledge among women who both have and have not received a Pap smear and among those who have received an abnormal result.⁹ However, Hawkins et al.⁵ found that a higher proportion of women who had a history of cervical cancer or an abnormal Pap smear knew that it is a screening test for cervical cancer. Conversely, those women with a prior HPV infection or a gynecologic cancer other than cervical cancer did not have higher knowledge about the association between HPV and cervical cancer.⁵ Thus, women may not be receiving information from providers in a manner that is understandable, or this communication may be absent altogether. The psychosocial impact of receiving Pap smear test results could be creating a barrier to understanding the purpose and meaning of this test; for instance, participants in the study 1 sample were not able to accurately report their Pap smear test results even though the results were provided in both verbal and written formats.¹⁹

Professional organizations should be conscientious about developing clear and consistent health education messages, as different organizations have historically provided different screening guidelines, including screening methods and intervals, screening among women who have received a total hysterectomy or those who have received the HPV vaccine, and the need for pelvic examinations.²⁶ In addition, as screening guidelines change, as is the case at the time of this writing, such changes should be explained using simple language and justifications for women of varying backgrounds to understand. Recently (March 2012), the U.S. Preventive Services Task Force (USPSTF) updated their 2003 cervical screening recommendations to include Pap smear screenings at 3-year intervals for women aged 21–65, regardless of their sexual history.²⁷ The USPSTF recommends against cervical cancer screening for women<age 25,>age 65, and among women who have had a hysterectomy with removal of the cervix and who have had no history of high-grade precancer or cervical cancer.²⁷ Women between the ages of 30 and 65 can also opt for Pap smear screenings in combination with an HPV test every 5 years if they would like to lengthen the screening interval.²⁷ These recommendations were made after assessing the evidence and balancing the benefits and harms associated with cervical cancer screening.²⁷

It is possible that we take for granted a public health program that has been so successful since the 1950s that we do not communicate the same clear and consistent message with future generations and that we do not position this screening measure within other medical advances and its relationship (or lack thereof) with other reproductive health conditions. With the abolishment of an annual Pap smear,²⁷ it is too soon to assess whether these new guidelines will impact women's beliefs and behaviors with regard to their reproductive health and, specifically, the impact of these guideline changes on other reproductive and sexual health screenings.

Findings must be interpreted in light of several limitations. Although data in the current analyses were derived from studies before and after HPV vaccine approval, we did not assess women's awareness and exposure to HPV messages.⁶ However, participants in study 1 all had abnormal Pap smear test results and received a considerable amount of HPV information in the clinic setting, and participants in studies 2 and 3 were derived from college populations post-HPV approval, where it is assumed they were exposed to HPV information messages in the years before attending college in addition to various health education messages distributed across the campus. Slightly different response options were used across studies, where agree/disagree was used in study 1 and true/false was used in studies 2 and 3. Often in behavioral research, agree/disagree is an attitude-type item where there is not necessarily a right or wrong answer, whereas true/false typically implies there is a right or wrong answer. These different response metrics used serve as a limitation. Furthermore, these samples were young women residing in a southeastern region of the United States, and, thus, findings cannot be generalized to women of other ages or those who reside in other geographical areas.

This study examined only one domain of Pap smear knowledge, and women require information beyond the purpose of a Pap smear. Breitkopf et al.⁹ found that women reported the need for more information on the following themes (reported by highest frequency): prognosis of Pap smear test results, meaning and consequences of an abnormal Pap smear test result, mechanics and procedures of the Pap smear, purpose and importance of the Pap smear, general inquiries on women's health conditions, scheduling and timing of the Pap test, and doctor-patient communication. Thus, future research should explore the impact of Pap smear knowledge on subsequent sexual and preventive behaviors, including continuing and adhering to follow-up screenings, accurately disclosing Pap smear screening histories to providers, and communicating and discussing results with sexual partners.⁹ As future research establishes a larger body of findings regarding Pap smear knowledge, additional studies could use meta-anlaytic techiniques to compare multiple studies across populations.

Future research might also explore the domains of health literacy as they relate to Pap smear screening. Health literacy can be defined as “the ability to access, understand, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings across the life-course.”²⁸ Interventions targeting the following four domains of health literacy may assist women in being informed consumers over their own reproductive health: access (accessing health information and Pap smear screening services), comprehension (understanding what a Pap smear is, why it is needed, how to obtain screening, when screening should be done), evaluation (analyzing personal health history and experiences along with recommended guidelines), and communication (positively interacting with providers and sexual partners to facilitate health-promoting behaviors).²⁹

Conclusions

Findings from this study indicate the critical need for clear and consistent health education messages about the purpose, meaning, timing, and consequences of Pap smear testing. These messages should address the need for Pap smear screening, even among women who have received the HPV vaccine, and should also dispel myths related to the Pap smear and other gynecologic conditions (e.g., STI testing, pregnancy testing, vaginal infections). Health education messages may need to be tailored for different populations, including those who are low-income, racial/ethnic minorities infected with other STIs (e.g., HIV/AIDS), and those with lower levels of health literacy.^8,9,30

Lack of knowledge about the purpose of the Pap smear has persisted over the last several decades and remains low even in light of current medical and technologic advances. Even after the approval and widespread marketing of the HPV vaccine, our findings are consistent with those of Head et al.,⁸ where Pap smear knowledge remains dismal. Some studies have found modest increases in HPV and cervical cancer knowledge; however, significant knowledge gaps remain.³⁰ Findings from this study underscore the lack of knowledge and the significant need for clear and consistent educational messages beginning at an early age and repeated among high-risk women. Such information is critical to increasing women's understanding of the purpose of the Pap smear and their ability to be informed and empowered on a range of reproductive prevention behaviors.

Footnotes

Disclosure Statement

The authors have no conflicts of interest to report.

References

American Cancer Society. Cervical cancer. www.cancer.org/acs/groups/cid/documents/webcontent/003094-pdf.pdf. 2012 January 24.

The Henry J. Kaiser Foundation. United States: Percent of women age 18 and older who report having had a Pap smear within the last three years. 2010. www.statehealthfacts.org/profileind.jsp?rgn=1&cat=10&ind=482. 2012 January 24.

Centers for Disease Control and Prevention. Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR, 2007; 56:1–23.

Centers for Disease Control and Prevention. Recommendations on the use of quadrivalent human papillomavirus vaccine in males. MMWR, 2011; 60:1709–1711.

Hawkins

, Cooper

, Saraiya

, Gelb

, Polonec

. Why the Pap test? Awareness and use of the Pap test among women in the United States. J Womens Health, 2011; 20:511–515.

Massad

, Evans

, Wilson

et al. Knowledge of cervical cancer prevention and human papillomavirus among women with HIV. Gynecol Oncol, 2010; 117:70–76.

Massad

, Meyer

, Hobbs

. Knowledge of cervical cancer screening among women attending urban colposcopy clinics. Cancer Detect Prev, 1997; 21:103–109.

Head

, Crosby

, Moore

. Pap smear knowledge among young women following the introduction of the HPV vaccine. J Pediatr Adolesc Gynecol, 2009; 22:251–256.

Breitkopf

, Pearson

, Breitkopf

. Poor knowledge regarding the Pap test among low-income women undergoing routine screening. Perspect Sex Reprod Health, 2005; 37:78–84.

10.

Blake

, Weber

, Fletcher

. Adolescent and young adult women's misunderstanding of the term Pap smear. Arch Pediatr Adolesc Med, 2004; 158:966–970.

11.

Sharp

, Dignan

, Dammers

, Michielutte

, Jackson

. Knowledge and attitudes about cervical cancer and the Pap smear among 10th-grade girls. South Med J, 1990; 83:1016–1018.

12.

Cooper

, Polonec

, Gelb

. Women's knowledge and awareness of gynecologic cancer: A multisite qualitative study in the United States. J Womens Health, 2011; 20:517–534.

13.

Watson

, Saraiya

, Benard

et al. Burden of cervical cancer in the United States, 1998–2003. Cancer, 2008; 113:2855–2864.

14.

Patel

, Rollison

, Barnholtz-Sloan

, Mackinnon

, Green

, Giuliano

. Racial and ethnic disparities in the incidence of invasive cervical cancer in Florida. Cancer, 2009; 115:3991–4000.

15.

Barnholtz-Sloan

, Patel

, Rollison

, Kortepeter

, MacKinnon

, Giuliano

. Incidence trends of invasive cervical cancer in the United States by combined race and ethnicity. Cancer Causes Control, 2009; 20:1129–1138.

16.

Ries

LAG

, Eisner

, Kosary

et al. SEER cancer statistics review, 1975–2002. Bethesda, MD: National Cancer Institute, 2005.

17.

Centers for Disease Control and Prevention. Sexually transmitted disease surveillance, 2010. Atlanta, GA: Department of Health and Human Services, 2011.

18.

Daley

, Perrin

, Vamos

et al. HPV knowledge among HPV+women. Am J Health Behav, 2008; 32:477–487.

19.

Daley

, Perrin

, McDermott

et al. The psychosocial burden of HPV: A mixed-method study of knowledge, attitudes and behaviors among HPV+women. J Health Psychol, 2010; 15:279–290.

20.

Daley

, Vamos

, Buhi

et al. Influences on human papillomavirus vaccination status among female college students. J Womens Health, 2010; 19:1885–1891.

21.

Daley

, Buhi

, Baldwin

et al. Men's responses to HPV test results: Development of a theory-based survey. Am J Health Behav, 2009; 33:728–744.

22.

Gerend

, Magloire

. Awareness, knowledge, and beliefs about human papillomavirus in a racially diverse sample of young adults. J Adolesc Health, 2008; 42:237–242.

23.

Wheldon

, Daley

, Buhi

, Nyitray

, Giuliano

. Health beliefs and attitudes associated with HPV vaccine intention among young gay and bisexual men in the southeastern United States. Vaccine, 2011; 29:8060–8065.

24.

Janz

, Champion

, Strecher

. The Health Belief Model. Glanz

, Rimer

, Lewis

. Health behavior and health education: Theory, research and practice. San Francisco, CA: Jossey-Bass, 2002; 45–66.

25.

Coreil

. Behavioral and social sciences theory. Coriel

. Social and behavioral foundation of public health. Thousand Oaks, CA: Sage Publications, 2010; 67–90.

26.

Centers for Disease Control and Prevention. Cervical cancer screening guidelines, 2010. www.cdc.gov/cancer/cervical/pdf/guidelines.pdf. 2012 Februrary 23 .

27.

Moyer

. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med, 2012[Epub ahead of print]

28.

Rootman

, Gordon-El-Bihbet

. A vision for a health literate Canada: Report on the Expert Panel of Health Literacy. Ottawa, ON: Canadian Public Health Association, 2008.

29.

Vamos

. Applying a health literacy lens to preventative children's oral health programming. Umwelt Gesundheit Online, 2011; 4:30–34.

30.

Massad

, Evans

, Weber

et al. Changes in knowledge of cervical cancer prevention and human papillomavirus among women with human immunodeficiency virus. Obset Gynecol, 2010; 116:941–947.