What is the research question and the hyphotesis in this study?

Does Knowledge Influence Pap Test Screening Among Young African-American Women?

Abstract Pap test screening among African-American women has substantially increased. However, African-American women continue to bear the burden of cervical cancer as compared to White women. The objective of this study was to assess the influence of Pap test knowledge on cervical screening history among young African-American women. Between January and April 2009, 320 women from historically black colleges and universities located in the southeastern United States who met study inclusion criteria completed an anonymous self-report questionnaire to assess their awareness, knowledge, and behaviors related to human papillomavirus and cervical cancer prevention and control. Seventy-six percent of women reported ever having a Pap test, 54 % reported having a Pap test less than 1 year ago, and 25 % reported ever having an abnormal Pap test result. The overall mean score on the six-point Pap test knowledge scale was 4.461.02. Women who reported having an abnormal Pap test (4.960.82) had significantly higher Pap test knowledge compared to those never having an abnormal result (4.491.04), p <0.01. No other differences were found. Efforts to improve Pap test knowledge among all women, including those with no prior abnormal Pap test history, are critical to cervical cancer prevention and control over the life course. Such efforts should include creating information that is relevant to the population and enables informed decision making about cervical health. Keywords African-American . Young adult . Females . Cervical cancer . Papanicolaou test Introduction Over the last few decades, cervical cancer incidence and mortality in the United States (US) has drastically decreased [1]. Today, approximately 12,000 women are diagnosed with cervical cancer and roughly 4,000 die of the disease each year [1]. Cervical cancer, which is caused by oncogenic types of human papillomavirus (HPV), is preventable through routine Pap testing and timely follow-up care. Despite the ability of the Pap test to reduce cervical cancer incidence and mortality, some populations continue to bear a larger burden of disease. African-American women compared to White women have a 34 % higher incidence of cervical cancer and are twice as likely to die of the disease in the US [2]. To this end, identifying opportunities to improve Pap test screening utilization are key to cervical cancer prevention and control. Research suggests that misconceptions about the Pap test are pervasive among women [3, 4]. However, to date, research assessing the influence of knowledge on Pap test screening history has been mixed. Breitkopf et al. found that women generally had low levels of Pap knowledge, but knowledge did not differ by Pap test screening history [5]. In contrast, Gu et al. found that women with higher Pap test knowledge were more likely to undergo Pap test screening [6]. Although cervical cancer prevention education is an important public health priority, there is a paucity of literature and mixed findings regarding the influence of knowledge on Pap test S. A. Bynum (*) : D. A. Guillaume Department of Preventive Medicine and Biometrics, F. Edward Hbert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA e-mail: S..m@usuhs.edu H. M. Brandt Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 800 Sumter Street, Columbia, SC 29208, USA F. E. Fletcher Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor Street, Chicago, IL 60612, USA J Canc Educ (2014) 29:478-481 DOI 10.1007/s13187-013-0543-4 # Springer Science+Business Media New York (outside the USA) 2014 screening. Expanding our understanding of the influence of knowledge on Pap test screening behaviors, especially among women who may be at greatest risk of cervical disease, can aid in promoting informed decision-making, routine screening, and ultimately reducing the excess burden of cervical disease among African-American women. Undoubtedly, cervical cancer is rare among young women; however, focusing on women early in life has important implications for future disease prevention. Thus, the purpose of this study was to assess the influence of Pap test knowledge on young African-American women's Pap test screening history. Methods This study used data from a larger study exploring HPV and cervical cancer knowledge, beliefs, and behaviors of male and female college students attending three historically Black colleges/universities (HBCUs) in the southeastern US [7, 12, 13]. Participants were recruited from January to April 2009. The current study focused on women for whom Pap test screening was recommended. At the time of the study, prevailing cervical cancer screening guidelines were annual screening for women 3 years after sexual debut, but no later than age 21. Screening was not recommended for women under age 21 who had never had sex [8]. A total of 363 women were recruited. Of those 363 women, 43 women under age 21 and 5 women 21 or older reported never having sex. Only women who reported having sex or who were 21 years or older were included in the study, leaving a final sample size of 320 (36343). Once written informed consent was obtained, participants completed an anonymous 52-item paper and pencil self-report questionnaire that assessed their awareness, knowledge, and behaviors related to HPV and cervical cancer prevention and control. The questionnaire was developed based on a review of the literature [9-11], existing items, and/or previously used items. A more detailed explanation of the study design can be found elsewhere [7, 12, 13]. The study was approved by the University of South Carolina and participating HBCU's institutional review boards. Measures Pap Test Knowledge Pap test knowledge was assessed using six items (e.g., "A Pap smear checks for changes in the cells of a woman's uterus, also called the womb"). The response options for knowledge items were "true," "false," and "don't know." Correct responses were given a score of 1 and incorrect or "don't know" responses a score of 0. Items were summed to create a Pap test knowledge index score with a maximum of six points. Pap Test History Pap test history was assessed using three items. The first item was about lifetime Pap test use, "Have you ever had a Pap smear also known as a Pap test?" (yes/no). The second item was, "How long has it been since you had your last Pap smear?" Response options for this item were "less than 12 months ago," "1-2 years," "2-3 years," "3-5 years," "5 or more years," and "don't know." The responses were categorized into two categories, "less than 1 year ago" and "one or more years ago." As noted, at the time of the study, cervical cancer screening guidelines recommended annual screening for women 3 years after sexual intercourse, but no later than age 21 [8]. As such, the responses were categorized based on the cervical cancer screening guidelines at the time of data collection. The third item was, "Have you ever had an abnormal Pap smear result?" (yes/no). It is important to note that the term Pap smear was used rather than Pap test for the knowledge and screening history questions because more women were familiar with the term. However, the term Pap test is used throughout the paper to reference cervical cancer screening. Data Analysis Descriptive statistics summarized sociodemographic characteristics of the sample. T-tests were used to compare differences in Pap test knowledge between participants who reported ever versus never having a Pap test, those who had a Pap test less than 1 year ago versus one or more years ago, and those who reported ever having an abnormal Pap test result versus never having an abnormal result. Chi-square tests were used to compare differences in Pap test knowledge by abnormal Pap test history. All analyses were conducted using SPSS 20 (SPSS, Chicago, IL). Statistical tests were two-tailed, with alpha level of .05. Results Of the 320 women, all were non-Hispanic, African-American/ Black; mean age was 20.241.63 years. Nearly all participants (99 %; n =318) attended school full time and the largest proportion were classified as freshmen (26 %; n =84) followed by sophomore (25 %; n =81). About 80 % (n =253) were single and 97 % (n =311) reported ever having sex. Roughly 76 % (n =243) reported ever having a Pap test. Of those, 54 % (n =174) had a Pap test less than 1 year ago, 23 % (n =73) had their last Pap test one or more years ago, and 25 % (n =79) reported ever having an abnormal Pap test result. The overall mean score on the Pap test knowledge scale was 4.46 1.11. Women who reported ever having a Pap test scored slightly higher (4.631.02) on the Pap test knowledge scale than women who never had a Pap test (3.981.11), but this J Canc Educ (2014) 29:478-481 479 difference was not statistically significant. Women who received a Pap test less than 1 year ago (4.670.96) compared to those who had a Pap test one or more years ago (4.551.08) did not have significantly different Pap test knowledge scores. Women who reported having an abnormal Pap result scored significantly higher on the Pap test knowledge scale compared to women who did not report having an abnormal result (4.96 0.82 vs. 4.491.04), p <0.01 (see Table 1 for Pap test knowledge items and statistically significant differences in percent responding correctly by abnormal Pap test result). Discussion The study revealed mixed findings on the influence of knowledge on Pap test screening history. Knowledge influenced some, but not all cervical cancer screening history. Our results showed that young African-American women with a history of abnormal Pap tests were significantly more knowledgeable about the Pap test compared to those with no prior history. This finding is not surprising, but contrasts with some research which suggests no difference in Pap test knowledge between women with and without an abnormal Pap test history [5]. One possible reason for the current finding is that women with a history of abnormal Pap tests may have been exposed, to a greater degree, to Pap test information and were more engaged in such discussions with their healthcare provider after receipt of their test result. Surprisingly, Pap test knowledge had no influence on other screening behaviors such as having a Pap test and time since last Pap test. Some research supports these findings while other research does not [5, 6]. These finding are discouraging and may suggest that women who reported ever engaging in screening were not adequately informed about the procedure prior to or after utilization. Efforts to increase understanding of the Pap test and its benefits are critical to sustained screening engagement. The overall Pap test knowledge score among women in the current study was moderate. Head et al. found lower levels of Pap test knowledge among a predominantly White sample of young women aged 18-24 [14]. The marginal level of Pap test knowledge found in this study highlights the need for continued efforts that increase awareness and knowledge of cervical cancer and emphasize the benefits of screening if the unequal distribution of cervical cancer, among minority women is to be curtailed. Creating Pap test information that is easily understood and provides women with the necessary information to make informed decisions regarding their cervical health is paramount. Given the recent modifications to cervical cancer screening recommendations (e.g., beginning screening at age 21, increased screening intervals) [15], efforts to inform women of screening recommendations as part of early educational efforts might provide promise. Daley et al. suggest that cervical cancer educational efforts be incorporated into routine sexual health education classes starting in primary and secondary school [4]. Engaging young women in discussions about their reproductive health may prove most beneficial in promoting recommended cervical cancer screening. This study has limitations that should be considered when interpreting the results. First, the study was conducted among a nonprobability sample of college students; therefore, results may not be representative of the larger college population. Second, all data were selfreported, which may have introduced recall bias or produced socially desirable responses. Lastly, information on health insurance status was not collected. Such information is important to assess in cancer screening studies.