TEN-STEP STUDY PLAN1. Statement of the problem and its significa.docx

TEN-STEP STUDY PLAN
1. Statement of the problem and its significance
2. Theoretical or conceptual framework
3. Research questions to be answered by the study
4. List of hypotheses to be tested
5. Definitions of key terms and variables
6. Description of the research design
7. Description of the sample and how it was obtained
8. Description of the planned statistical analysis
9. Statement of assumptions and limitations
10. Dissemination plan.
obesity pdf.pdf
NCHS Data Brief ■ No. 219 ■ November 2015
Prevalence of Obesity Among Adults and Youth:
United States, 2011–2014
Cynthia L. Ogden, Ph.D.; Margaret D. Carroll, M.S.P.H.; Cheryl
D. Fryar, M.S.P.H.;
and Katherine M. Flegal, Ph.D.
Figure 1. Prevalence of obesity among adults aged 20 and over,
by sex and age: United States,
2011–2014
P
er
ce

nt
0
10
20
30
40
50 60 and over40–5920–3920 and over
WomenMenAll
36.3
32.3
140.2
137.0
234.3
230.3
1,238.3
34.9
38.3
34.4
142.1
138.8
1Significantly different from those aged 20–39.
2

Key findings
Data from the National
Health and Nutrition
Examination Survey
● In 2011–2014, the
prevalence of obesity was just
over 36% in adults and 17% in
youth.
● The prevalence of obesity
was higher in women (38.3%)
than in men (34.3%). Among
all youth, no difference was
seen by sex.
was higher among middle-aged
(40.2%) and older (37.0%)
adults than younger (32.3%)
adults.
was higher among non-
Hispanic white, non-Hispanic
black, and Hispanic adults and
youth than among non-Hispanic
Asian adults and youth.
● From 1999 through 2014,
obesity prevalence increased
among adults and youth.
However, among youth,
prevalence did not change
from 2003–2004 through
2013–2014.

U.S. DEPA
Obesity is associated with health risks (1,2). Monitoring the
prevalence
of obesity is relevant for public health programs that focus on
reducing
or preventing obesity. No significant changes were seen in
either adult or
childhood obesity prevalence in the United States between
2003–2004 and
2011–2012 (3). This report provides the most recent national
data on obesity
prevalence by sex, age, and race and Hispanic origin, using data
for 2011–
2014. Overall prevalence estimates from 1999–2000 through
2013–2014 are
also presented.
Keyword: National Health and Nutrition Examination Survey
What was the prevalence of obesity among adults in
2011–2014?
The prevalence of obesity was 36.5% (crude estimate) among
U.S. adults
during 2011–2014. Overall, the prevalence of obesity among
middle-aged
RTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Center for Health Statistics
Significantly different from women of the same age group.
NOTES: Totals were age-adjusted by the direct method to the
2000 U.S. census population using the age groups 20–39, 40–
59,
and 60 and over. Crude estimates are 36.5% for all, 34.5% for

men, and 38.5% for women.
SOURCE: CDC/NCHS, National Health and Nutrition
Examination Survey, 2011–2014.
adults aged 40–59 (40.2%) and older adults aged 60 and over
(37.0%) was higher than among
younger adults aged 20–39 (32.3%). No significant difference in
prevalence was observed
between middle-aged and older adults (Figure 1).
Overall, the prevalence of obesity among women (38.3%) was
higher than among men (34.3%).
For adults aged 20–39 and 40–59, the prevalence of obesity was
higher among women than
among men, but the difference between older women and men
aged 60 and over was not
significant.
Among both men and women, the prevalence of obesity
followed a similar pattern by age. Men
aged 40–59 (38.3%) had a higher prevalence of obesity than
men aged 20–39 (30.3%). Women
aged 40–59 (42.1%) had a higher prevalence of obesity than
women aged 20–39 (34.4%). The
prevalence of obesity among men and women aged 20–39 was
lower than among men and
women aged 60 and over, except the difference for men was not
significant.
Were there differences in the prevalence of obesity among
adults by race
and Hispanic origin in 2011–2014?

The prevalence of obesity was lowest among non-Hispanic
Asian adults (11.7%), followed by
non-Hispanic white (34.5%), Hispanic (42.5%), and non-
Hispanic black (48.1%) adults. All
differences were significant. The pattern among women was
similar to the pattern in the overall
adult population. The prevalence of obesity was 11.9% in non-
Hispanic Asian, 35.5% in non-
Hispanic white, 45.7% in Hispanic, and 56.9% in non-Hispanic
black women. The prevalence
■ 2 ■
Figure 2. Prevalence of obesity among adults aged 20 and over,
by sex and race and Hispanic origin: United States,
2011–2014
P
er
ce
nt
0
10
20
30
40
50
60
HispanicNon-Hispanic AsianNon-Hispanic blackNon-Hispanic

white
WomenMenAll
134.5
1,2,348.1
11.7
1,242.5
133.6
1,437.5
11.2
1,2,439.0
135.5
1,2,356.9
11.9
1,245.7
1Significantly different from non-Hispanic Asian persons.
2Significantly different from non-Hispanic white persons.
3Significantly different from Hispanic persons.
4Significantly different from women of the same race and
Hispanic origin.
NOTE: All estimates are age-adjusted by the direct method to
the 2000 U.S. census population using the age groups 20–39,
40–59, and 60 and over.

of obesity was lower in non-Hispanic Asian (11.2%) men
compared with non-Hispanic white
(33.6%), non-Hispanic black (37.5%), and Hispanic (39.0%)
men. No difference in obesity
prevalence was observed between non-Hispanic black and non-
Hispanic white men, nor was there
a difference between non-Hispanic black and Hispanic men
(Figure 2).
The only differences by sex were found among non-Hispanic
black and Hispanic adults. The
prevalence of obesity among non-Hispanic black women was
56.9% compared with 37.5%
in non-Hispanic black men. The prevalence of obesity was
45.7% among Hispanic women
compared with 39.0% in Hispanic men.
What was the prevalence of obesity among youth aged 2–19
years in
2011–2014?
The prevalence of obesity among U.S. youth was 17.0% in
2011–2014. Overall, the prevalence
of obesity among preschool-aged children (2–5 years) (8.9%)
was lower than among school-aged
children (6–11 years) (17.5%) and adolescents (12–19 years)
(20.5%). The same pattern was seen
in both males and females (Figure 3).
■ 3 ■
Figure 3. Prevalence of obesity among youth aged 2–19 years,

by sex and age: United States, 2011–2014
P
er
ce
nt
0
5
10
15
20
25
30
12–19 years6–11 years2–5 years2–19 years
FemalesMalesAll
17.0
8.9
117.5
120.5
16.9
9.2

117.6
120.1
17.1
8.6
117.5
121.0
1Significantly different from those aged 2–5 years.
Were there differences in the prevalence of obesity among
youth aged 2–19
years by race and Hispanic origin in 2011–2014?
The prevalence of obesity among non-Hispanic Asian youth
(8.6%) was lower than among
non-Hispanic white (14.7%), non-Hispanic black (19.5%), and
Hispanic (21.9%) youth. The
prevalence of obesity among non-Hispanic white youth was
lower than in non-Hispanic black
and Hispanic youth, but no significant difference was observed
between non-Hispanic black and
Hispanic youth.
The pattern among females was similar to the pattern in the
overall population, except the

prevalence was not significantly different in non-Hispanic white
females compared with non-
Hispanic black females. The prevalence of obesity was 5.3% in
non-Hispanic Asian, 15.1% in
non-Hispanic white, 20.7% in non-Hispanic black, and 21.4% in
Hispanic females.
Among males, the prevalence of obesity was lower in non-
Hispanic Asian (11.8%) males
compared with non-Hispanic black (18.4%) and Hispanic
(22.4%) males, but no significant
difference was seen between non-Hispanic Asian (11.8%) and
non-Hispanic white (14.3%)
males. Differences between non-Hispanic white, non-Hispanic
black, and Hispanic males were
statistically significant (Figure 4).
The only difference by sex was found among non-Hispanic
Asian youth—the prevalence was
11.8% in non-Hispanic Asian males and 5.3% in non-Hispanic
Asian females.
■ 4 ■
Figure 4. Prevalence of obesity among youth aged 2–19 years,
by sex and race and Hispanic origin: United States,
2011–2014
P
er
ce
nt
0
5

10
15
20
25
30
FemalesMalesAll
HispanicNon-Hispanic AsianNon-Hispanic blackNon-Hispanic
white
114.7
1,219.5
8.6
1,221.9
14.3
1,218.4
311.8
115.1
1,2,422.4
120.7
5.3

1,221.4
1Significantly different from non-Hispanic Asian persons.
2Significantly different from non-Hispanic white persons.
3Significantly different from females of the same race and
Hispanic origin.
4Significantly different from non-Hispanic black persons.
What are the trends in adult and childhood obesity?
From 1999–2000 through 2013–2014, a significant increase in
obesity was observed in both
adults and youth. Between 2003–2004 and 2013–2014, however,
no change in prevalence was
seen among youth. No change in obesity prevalence among
youth was noted between 2011–2012
and 2013–2014, and the observed change in adults between
2011–2012 and 2013–2014 was not
significant (Figure 5).
Figure 5. Trends in obesity prevalence among adults aged 20
and over (age-adjusted) and youth aged 2–19 years:
United States, 1999–2000 through 2013–2014
Youth1,2
Adults1
P
er

ce
nt
0
10
20
30
40
2013–20142011–20122009–20102007–20082005–20062003–
20042001–20021999–2000
Survey years
13.9
30.5 30.5
15.4
32.2
17.1
34.3
15.4
33.7
16.8

35.7
16.9
34.9
16.9
37.7
17.2
1Significant increasing linear trend from 1999–2000 through
2013–2014.
2Test for linear trend for 2003–2004 through 2013–2014 not
significant (p > 0.05).
NOTE: All adult estimates are age-adjusted by the direct
method to the 2000 U.S. census population using the age groups
20–39, 40–59, and 60 and over.
Examination Survey.
Summary
More than one-third of adults and 17% of youth in the United
States were obese in 2011–2014.
The prevalence of obesity was higher among women than among
men overall and higher among
non-Hispanic black and Hispanic adults compared with other
racial and Hispanic origin groups.
Among youth, no difference in obesity prevalence was seen
between males and females, except
among non-Hispanic Asian youth.
Obesity prevalence was lower among non-Hispanic Asian adults
compared with other racial and
Hispanic origin groups. No difference in obesity prevalence was

observed between non-Hispanic
black and Hispanic men. However, the prevalence was higher
among non-Hispanic black women
compared with Hispanic women. Among youth, the prevalence
of obesity was lowest among non-
Hispanic Asian youth, but no significant difference in
prevalence was seen between non-Hispanic
white and non-Hispanic Asian males. Among males, the
prevalence of obesity was lower among
■ 5 ■
non-Hispanic black compared with Hispanic youth. However,
among females, no difference in
prevalence was observed between non-Hispanic black and
Hispanic youth.
Trends in obesity prevalence show no increase among youth
since 2003–2004, but trends do
show increases in both adults and youth from 1999–2000
through 2013–2014. No significant
differences between 2011–2012 and 2013–2014 were seen in
either youth or adults.
Obesity is defined using cut points of body mass index (BMI).
BMI does not measure body
fat directly, and the relationship between BMI and body fat
varies by sex, age, and race and
Hispanic origin (4,5). Morbidity and mortality risk may vary
between different racial and
Hispanic origin groups at the same BMI. Some studies suggest
that among some Asian
subgroups, health and mortality risks may begin at a lower BMI
compared with other racial

and Hispanic origin groups (6–8).
The definition of obesity is based on BMI for both youth and
adults, but the definitions are not
directly comparable. Among adults, there is a set cut point
based on health risk, while among
children the definition is statistical and is based on a
comparison to a reference population (9).
The prevalence of obesity among U.S. adults remains higher
than the Healthy People 2020 goal
of 30.5% (10). Although the overall prevalence of childhood
obesity is higher than the Healthy
People 2020 goal of 14.5%, the prevalence of obesity among
children aged 2–5 years is below the
goal of 9.4%.
Definitions
Non-Hispanic Asian: Primarily comprises persons of Chinese,
Asian Indian, Korean, Filipino,
Vietnamese, and Japanese descent.
Obesity: BMI was calculated as weight in kilograms divided by
height in meters squared, rounded
to one decimal place. Obesity in adults was defined as a BMI of
greater than or equal to 30.
Obesity in youth was defined as a BMI of greater than or equal
to the age- and sex-specific 95th
percentile of the 2000 CDC growth charts (9).
Data source and methods
Data from the National Health and Nutrition Examination
Surveys (NHANES) for survey years
1999–2000, 2001–2002, 2003–2004, 2005–2006, 2007–2008,

2009–2010, 2011–2012, and
2013–2014 were used for these analyses. Data from NHANES
2011–2014 (4 years of data) were
used to test differences between demographic subgroups, thus
increasing the sample size and the
ability to detect a difference in the prevalence. In testing for
trends in obesity, eight 2-year cycles
were used: 1999–2000, 2001–2002, 2003–2004, 2005–2006,
2007–2008, 2009–2010, 2011–2012,
and 2013–2014. Because previous research found no increase in
obesity prevalence from 2003–
2004 through 2011–2012 (3), analyses of linear trends were also
conducted between 2003–2004
and 2013–2014.
NHANES is a cross-sectional survey designed to monitor the
health and nutritional status of the
civilian noninstitutionalized U.S. population (11). The survey
consists of interviews conducted
in participants’ homes and standardized physical examinations
conducted in mobile examination
centers.
■ 6 ■
The NHANES sample is selected through a complex, multistage
probability design. In 2011–2012
and 2013–2014, non-Hispanic black, non-Hispanic Asian, and
Hispanic persons, among other
groups, were oversampled to obtain reliable estimates for these
population subgroups. Race- and
Hispanic origin-specific estimates reflect individuals reporting
only one race; those reporting
more than one race are included in the total but are not reported

separately.
Examination sample weights, which account for the differential
probabilities of selection,
nonresponse, and noncoverage, were incorporated into the
estimation process. All variance
estimates accounted for the complex survey design by using
Taylor series linearization. Pregnant
females were excluded from analyses.
Prevalence estimates for the adult population aged 20 and over
were age-adjusted using the direct
method to the 2000 U.S. census population using the age groups
20–39, 40–59, and 60 and over.
Differences between groups were tested using a univariate t
statistic at the p < 0.05 significance
level. All differences reported are statistically significant unless
otherwise indicated. Adjustments
were not made for multiple comparisons. Statistical analyses
were conducted using the SAS
System for Windows, release 9.3 (SAS Institute Inc., Cary,
N.C.) and SUDAAN, release 11.1
(RTI International, Research Triangle Park, N.C.).
About the authors
Cynthia L. Ogden, Margaret D. Carroll, Cheryl D. Fryar, and
Katherine M. Flegal are with CDC’s
National Center for Health Statistics, Division of Health and
Nutrition Examination Surveys.
References
1. Clinical guidelines on the identification, evaluation, and
treatment of overweight and obesity
in adults—The evidence report. Obes Res 6 Suppl 2:51S–209S.

1998.
2. U.S. Department of Health and Human Services, Office of the
Surgeon General. The surgeon
general’s vision for a healthy and fit nation. Rockville, MD:
2010.
3. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of
childhood and adult obesity in the
United States, 2011–2012. JAMA 311(8):806–14. 2014.
4. Flegal KM, Ogden CL, Yanovski JA, Freedman DS, Shepherd
JA, Graubard BI, Borrud LG.
High adiposity and high body mass index-for-age in US children
and adolescents overall and by
race-ethnic group. Am J Clin Nutr 91(4):1020–6. 2010.
5. Deurenberg P, Deurenberg-Yap M, Guricci S. Asians are
different from Caucasians and from
each other in their body mass index/body fat per cent
relationship. Obes Rev 3(3):141–6. 2002.
6. Nguyen TT, Adair LS, Suchindran CM, He K, Popkin BM.
The association between body
mass index and hypertension is different between East and
Southeast Asians. Am J Clin Nutr
89(6):1905–12. 2009.
7. Jafar TH, Islam M, Poulter N, Hatcher J, Schmid CH, Levey
AS, Chaturvedi N. Children
in South Asia have higher body mass-adjusted blood pressure
levels than white children in the
United States: A comparative study. Circulation 111(10):1291–
7. 2005.
■ 7 ■

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Suggested citation
Ogden CL, Carroll MD, Fryar CD, Flegal
KM. Prevalence of obesity among adults
and youth: United States, 2011–2014. NCHS
data brief, no 219. Hyattsville, MD: National
Center for Health Statistics. 2015.
Copyright information
All material appearing in this report is in
the public domain and may be reproduced
or copied without permission; citation as to
source, however, is appreciated.
National Center for Health
Statistics
Charles J. Rothwell, M.S., M.B.A., Director

Nathaniel Schenker, Ph.D., Deputy Director
For more NCHS Data Briefs, visit:
http://www.cdc.gov/nchs/products/databriefs.htm.
8. Zheng W, McLerran DF, Rolland B, Zhang X, Inoue M,
Matsuo K, et
al. Association between body-mass index and risk of death in
more than 1
million Asians. N Engl J Med 364(8):719–29. 2011.
9. Ogden CL, Flegal KM. Changes in terminology for childhood
overweight and obesity. National health statistics reports; no
25. Hyattsville,
MD: National Center for Health Statistics. 2010.
10. U.S. Department of Health and Human Services, Office of
Disease
Prevention and Health Promotion. Healthy People 2020 topics
and
objectives: Nutrition and weight status. Washington, DC.
Available from:
http://www.healthypeople.gov/2020/topics-
objectives/topic/nutrition-and-
weight-status?topicid=29.
11. Johnson CL, Dohrmann SM, Burt VL, Mohadjer LK.
National Health
and Nutrition Examination Survey: Sample design, 2011–2014.
National
Center for Health Statistics. Vital Health Stat 2(162). 2014.
ISSN 1941–4927 Print ed.
ISSN 1941–4935 Online ed.
DHHS Publication No. 2016–1209
CS260465
Jennifer H. Madans, Ph.D., Associate

Director for Science
Division of Health and Nutrition
Examination Surveys
Kathryn S. Porter, M.D., M.S., Director
Ryne Paulose-Ram, Ph.D., Associate
Director for Science
For e-mail updates on NCHS publication
releases, subscribe online at:
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http://www.cdc.gov/nchs/products/databriefs.htm
objectives/topic/nutrition-and-weight-status?topicid=29
objectives/topic/nutrition-and-weight-status?topicid=29Key
findingsWhat was the prevalence of obesity among adults in
2011–2014?Were there differences in the prevalence of obesity
among adults by race and Hispanic origin in 2011–2014?What
was the prevalence of obesity among youth aged 2–19 years in
2011–2014?Were there differences in the prevalence of obesity
among youth aged 2–19 years by race and Hispanic origin in
2011–2014?What are the trends in adult and childhood

obesity?SummaryDefinitionsData source and methodsAbout the
authorsReferences
Running head: RESEARCH PROPOSAL 1
RESEARCH PROPOSAL 13
Research Proposal
The Influence of Human Papillomavirus in the Occurrence of
Abnormal PAP Smear and Cervical Cancer in Women aged 21-
65 years
Johan Mary Jimenez
Turabo University
NURS 502
October 5, 2016
Abstract
Cervical cancer, also known as Carcinoma of Uterine Cervix, is

the fourth most common malignancy in the world according to
World Cancer Research Fund International. The establishment
of the Pap smear or Papa Nicolaus in the 1940s caused an
important reduction in the appearance of new cases of cervical
cancer. Despite the emergence of pap screening and the
different and extremely effective programs for the prevention of
this disease, and according with the National Cancer Institute
that incidence rates have reduced 45 percent and mortality rates
have declined, Cervical Cancer still remains a public health
problem in the United Stated. The purpose of this research is to
determine the influence of Human Papillomavirus in the
occurrence of abnormal PAP Smear and cervical cancer and
increase awareness of the population about this latent disease
through promoting talks about cervical cancer and the
prevention of HPV infection. The investigation to be conducted
will be an exempt study with the general objective of
determining the influence of Human Papillomavirus in the
occurrence of abnormal PAP Smear and Cervical Cancer in
women aged 21 to 65 years. The technique to be used will be
review medical records in order to identify existing data about
infections for Human Papilloma Virus associated with cervical
cancer, identify numbers of sexual partners, HPV vaccination
history, Abnormal PAP Smear history, and Papanicolaus
screening, including HPV/cytology co-testing regular check-up.
All information related with the identity of the participants will
be kept private and confidential and will be protected at all
times.
Key words: Human Papilloma Virus, Abnormal PAP Smear,
Cervical Cancer
Table of Content
I.
Introduction…………………………………………………………

……………………4
II. Statement of the
Problem………………………………………………………………
….5
III. Cervical Cancer
Background…………………………………………………………
…...6
IV.
Methodology…………………………………………………………
………………….10
V. Analysis of
data……………………………………………………………………
…...12
VI.
References……………………………………………………………
…………………13
VII.
Appendix………………………………………………………………
…………………15

The Influence of Human Papillomavirus in the Occurrence of
Abnormal PAP Smear and Cervical Cancer in Women aged 21-
65 years
I. Introduction
Cervical cancer, also known as Carcinoma of Uterine Cervix, is
the fourth most frequent malignancy in the world according to
World Cancer Research Fund International (Ferlaj J et al.,
2014). The establishment of the Pap smear or Papa Nicolaus in
the 1940s caused an important reduction in the appearance of
new cases of cervical cancer (Olusola Adegoke et al., 2012).
Despite the emergence of this and the different and extremely
effective programs for the prevention of this disease, and
according with the National Cancer Institute that incidence rates
have reduced 45 percent and mortality rates have declined,
Cervical Cancer still remains a public health problem in the
United Stated (NIH, 2014).
Although Carcinoma of the Uterine Cervix rates are generally
diminishing among women in developed countries because of
the availability of the PAP Smear and HPV vaccine, in 2013,
the most recent data according to the CDC, 11,955 women in
the United States were diagnosed with cervical cancer and 4,217
died from cervical cancer (CDC, 2016). The estimates for
cervical cancer in the United States for 2016 according with
The American Cancer Society's about 12,990 new cases of
invasive cervical cancer will be diagnosed and about 4,120
women will die from cervical cancer (Society, 2016).
After many years of research and different hypothesis, it was
established that the virus responsible for cellular changes that
precede cervical cancer is the Human Papilloma Virus (HPV).
Nowadays, it is known that the more than 100 types of HPV
mainly types 16 and 18 genotypes are responsible for the
development of cervical cancer. HPV 16 and 18 are the most
frequent oncogenic types causing approximately 70% of all
cervical cancers worldwide. Another types genotypes like 6 and

11can also be responsible of genital warts. Human Papilloma
Virus is a highly transmissible in most populations. Women
with continual high-risk HPV infections have a high possibility
to develop cervical cancer. Since the discovery of the HPV as
mainly cause of cervix uterine cancer, HPA’s screening become
an important step in the early detection of cervical cancer.
With the development and approval of the vaccine by the FDA,
Gardasil in 2006 and Cervarix in 2009, in adolescent girls and
young woman, cancer cervical could be eradicated if the
protocols are widely and wisely implemented (Castellsagué,
2008).
II. Statement of the Problem
Does affect Human Papillomavirus in the occurrence of
abnormal PAP Smear and Cervical Cancer in women 21 to 65
years?
Research Objectives
General Objective
Determine the influence of Human Papillomavirus in the
occurrence of abnormal PAP Smear and cervical cancer in
women aged 21 to 65 years.
Specific Objectives
1. Identify infections for Human Papilloma Virus associated
with cervical cancer.
2. Identify numbers of sexual partners.
3. HPV vaccination history.
4. Abnormal PAP Smear history.
5. Papanicolaus screening, including HPV/cytology co-testing.
6. Provide educational talks about cervical cancer and HPV
prevention.
Purpose of the Investigation
Despite that Cervical Cancer incidence rates have reduced
about 45 percent and mortality rates have declined, Cervical
Cancer still remains a public health problem in the United
Stated.
The purpose of this research is to determine the influence of
Human Papillomavirus in the occurrence of abnormal PAP

Smear and cervical cancer, and increase awareness of the
population about this latent disease through promoting talks
about cervical cancer and prevention of HPV infection. Even
though cervical cancer is among the cancers that can be
prevented, it is very important to continue screening tests and
providing vaccination for protection. Nurses play an important
role in the screening programs by providing educative talks and
training mainly to high risk groups, with the purpose of
increasing the awareness of the people about cervical cancer
and HPV prevention. Furthermore, this research will serve as a
reference for future research.
III. Cervical Cancer Background
Cervical cancer is a global health problem for all women
because of the alarming number that has been a victim of this
disease claiming many lives. For many decades, the cause of
cervical cancer was unknown. It was not until the twentieth
century that researchers found it that the disease was caused by
exposure to human papillomavirus (HPV). Nowadays, vaccines
against some forms of the virus are widely available.
Cervical cancer begins in the patient’s cervix. The portion of
the uterus that it is exposed into the vagina and has a healthy
pink color covering with squamous cells is called ectocervix,
and the endocervix or cervical canal is called columnar cells.
Where these cells merge is called the transformation zone (T-
zone). This transformation zone is the location for abnormal or
precancerous cells to develop (NCCC, 2016).
The disease has been known since many years ago. In 400 A.C.,
the Greek physician Hippocrates wrote about the disease and
even tried to treat cancer with a procedure known as
Trachelectomy o Cervicectomy, but he found nothing
completely eradicated cancer. This procedure was used later for
a brief period in the 1940s, it involves the removal of the cervix
and direct linking the vaginal canal to the uterus.
In the 1980s, Zur Hausen and Gissmann provided the first solid
documentation that specific Human Papillomavirus (HPV) types
were linked to cervical cancer. More than 2000 years have

passed since Hippocrates gave the first explanation about
cervical cancer. Epidemiologists researching in the early 20th
century recognized that cervical cancer was frequent in female
sex workers and in women whose husbands had a high number
of sexual partners or visited regularly prostitutes women, and
also that this kind of cancer was rare in Jewish women (Panatto,
2008). Other important achievement in the prevention of
cervical cancer were: the creation of the Colposcope in 1925,
the development of the Pap technique by Papanicolaou, the
launch of Pap screening by Papanicolaou and Traut and the
development of a specific spatula to scrape the cervix by Ayre.
Nevertheless, Zur Hausen and Gissmann in 1976 brought in
HPV DNA in cervical cancer and warts (Panatto, 2008).
In 1983, Zur Hausen, Gissmann and their collaborators
recognized HPV 16 in genital cancer lesions, and in 1985, they
showed the presence of HPV DNA in cervical cancer cells. The
discoveries created the primary steps for further studies leading
to the development of two preventive vaccines: Gardasil® and
Cervarix®. Both vaccines protect against cervical lesions
caused by HPV 16 and 18. Furthermore, Gardasil® also
defends against HPV 6 and 11. These genotypic are responsible
for 90% of genital warts (Panatto, 2008). Investigations have
been demonstrated that both vaccines are a powerful tool to
fight mild and severe cervical lesions. Furthermore, both
vaccines are safe and well tolerated by patient.
Nevertheless, important questions remain open, the
establishment of the vaccines were an historic moment in
medical science pointing a new beginning in cancer prevention.
Background of the Study
In 19th century Verona, Dr. Domenico Rigoni-Stern noticed that
uterine cancer, while relatively frequent in women living in the
city, was very infrequent in the Catholic religious woman who
lived in the convents in the countryside. Further researches
demonstrated a more conventional explanation: the risk of
cervical cancer was linked with the number of sexual partners,
prostitutes had a high risk of getting the disease, married

women had a moderate risk, and religious woman were spared.
This epidemiological frame strongly indicated that a sexually
transmitted agent had an important piece in the development of
cervical cancer (DiMaio, 2015). Researching the principal
causes of cervical cancer took many years of investigations
leading false results. Many infectious agents like syphilis,
chlamydia, herpes simplex virus, and gonorrhea were falsely
accused (DiMaio, 2015).
In the early 20th century, hunters in the Midwest observed
and reported seeing rabbits with horns. Later, some of them
were captured and sent it from Kansas to the Rockefeller
Institute in New York City for investigation. The researchers
isolated the cells and inoculated them in healthy rabbits. Thru
out the microscopic, they could observe that these lesions were
not horns at all if not keratinized warts or papillomas. The
microscope also showed a large numbers of virus cells. Due to
this investigation, the papillomavirus was discovered for the
first time (DiMaio, 2015).
In early 1980, Papillomaviruses were first linked with
cancer of the cervix. Harald Zur Hausen after unsuccessful
experiments to prove a relation between herpes simplex virus
type 2 and cervical cancer turned his studies to
papillomaviruses. His first studies showed that the HPV types
that cause plantar and common warts were not observed in
cervical cancer. For those reasons, Zur Hausen looked for
viruses that infect the genital area. He began studying HPV
type 6. This type 6 is responsible of external genital warts, or
condyloma. But, this virus was rarely present in cervical
cancers. After several investigations, HPV types 16 and 18
were identified. 70 % of woman with cervical cancer contained
HPV-16 or HPV-18 DN. Furthermore, he also concluded that
HPV-negative cervical cancer was a diagnostic mistake
(DiMaio, 2015).
These findings discoveries revolutionized the biomedical
community. Very soon, they produced solid proof that HPV
plays an essential role in the development of cervical cancer.

The most solid evidence came from using the vaccines to
prevent HPV infection (DiMaio, 2015). HPV vaccination
potentially aims to diminish the morbidity and mortality rates
from cervical cancer. Nevertheless, promoting Papanicolaou
smear or PAP smear screening test, educating parents and
children, and infection control measures are still important part
to fight this malignancy (Greener, 2014).
Quantitative studies in United Stated indicated many
factors linked with woman’s participation in cervical cancer
screening among certain ethnic groups. In USA, Hispanic
population have high incidence and mortality rates of cervical
cancer. Qualitative investigations found many factors that
constitute barriers for a Pap smear like cultural norms and
beliefs, individual perceptions about cancer, language
difficulties, limited knowledge about HPV, and cervical cancer
(M Grandahl et al., 2015).
A British study indicated a reduce awareness of HPV and a
reduce acceptability of the vaccine among ethnic minorities.
Similar conclusions were recently found among woman from
other countries with low income in the United States: Only 11%
accepted HPV vaccination for their daughters. In those cases,
lack of knowledge was the main problem. Parents wanted to
have more information to make a decision about HPV
vaccination. As a result of this quantitative study, the
investigators concluded that: woman would like to participate in
cervical cancer prevention programs and accept HPV
vaccination for their daughters, but do not have enough
knowledge about it, and have difficulties understanding all
aspects of the program from primary care providers.
Furthermore, even though the women were available and agree
to participate in the prevention of cervical cancer, several
obstacles were identified: language problems, reduce knowledge
about the relation between sexual transmission of HPV and
cervical cancer, and lack of regular health check-ups (M
Grandahl et al., 2015).
IV. Methodology

Hypothesis
H- Human Papillomavirus affects the occurrence of abnormal
PAP Smear and cervical cancer in women 21 to 65 years.
Definition of Terms
Cervical Cancer: is a type of cancer that develops in the cells of
the cervix, more specifically in the lower part of the uterus that
connects to the vagina (Staff, 2016). See appendix A.
Human Papillomavirus: it is the most frequent sexually
transmitted infection (STI). There are many different types of
HPV (FDA, 2016).
Pap Smear Test: it is performed to screen for cervical cancer.
Cells are obtained from the cervix and are examined under a
microscope (NIH, 2016). See appendix B.
Variables
Independent Variable: Human Papilloma Virus.
Dependent variable: Cervical Cancer.
Dependent variable: Abnormal PAP Smear
Type of Research
The investigation to be conducted will be an exempt study
with the general objective of determining the influence of
Human Papillomavirus in the occurrence of abnormal PAP
Smear and Cervical Cancer in women aged 21 to 65 years.
This exempt study will involve medical records, existing data,
documents and pathological samples. The source of information
is not available to the general public so that the participants
cannot be identified directly or through personal identifiers.
All information related with the identity of the participants will
be kept private and confidential and will be protected at all
times.
Study Population
The population will be all women between 21 to 65 years
meeting the following criteria:
Inclusion criteria:
1. Women between 21 and 65 years.
2. Sexually active.
3. Women with cervical cancer.

4. Woman with abnormal PAP Smear.
Exclusion criteria:
1. Women <21 years and > 65 years.
2. Woman not sexually active
3. Women without cervical cancer.
4. Women without abnormal PAP Smear.
Research Technique
The technique to be used will be review medical records in
order to identify existing data about infections for Human
Papilloma Virus associated with cervical cancer, identify
numbers of sexual partners, HPV vaccination history, Abnormal
PAP Smear history, and Papanicolaus screening, including
HPV/cytology co-testing regular check-up.
All information related with the identity of the participants
will be kept private and confidential and will be protected at all
times.
V. Analysis of data
Data collected from the medical record will be processed in
Microsoft Excel and Microsoft Word.
Microsoft Excel is a spreadsheet program used to keep and
recovery numerical data in a framework format of columns and
rows. Microsoft Excel will use to make a statistical analysis of
the data obtained after processing the data from our source of
investigation: medical records, existent data, and pathological
samples. During the investigation, data related with the
specific objectives of the study will be collected, and the
numerical data will be stored in Microsoft Excel to identified
the number of case where the Human Papillomavirus are present
in abnormal PAP Smear and Cervical Cancer giving effect to
our overall objective. Microsoft word will be used to process
the information collected during the study in form of text.
VI. References
Castellsagué, X. (2008, September). Natural history and
epidemiology of HPV infection and cervical cancer. Retrieved

October 1, 2016, from
https://www.ncbi.nlm.nih.gov/pubmed/18760711
CDC. (2016, June 20). Gynecologic Cancers . Retrieved from
Cervical Cancer Statistics:
http://www.cdc.gov/cancer/cervical/statistics/index.htm
DiMaio, D. (2015, June 1). Nuns, Warts, Viruses, and Cancer.
Retrieved from Yale Journal of Biology and Medicine:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4445434/
FDA. (2016, May 23). HPV (human papillomavirus). Retrieved
from U.S. Food and Drug Administration:
http://www.fda.gov/ForConsumers/ByAudience/ForWomen/ucm
118530.htm
Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers
C, Rebelo M, Parkin DM, Forman D, Bray, F. (2014).
Worldwide data. Retrieved September 29, 2016, from WCRF
International: http://www.wcrf.org/int/cancer-facts-
figures/worldwide-data
Greener, M. (2014, October 1). Tackling HPV and cervical
cancer: Looking at the whole picture. Retrieved from
https://eds.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=790
69509-7b48-411a-b497-
e1acc2587037%40sessionmgr103&vid=8&hid=114
Maria Grandahl, Tanja Tyden, Maria Gottvall, Ragnar
Westerling, Marie Oscarsson. (2015, June 1). Immigrant
women's experiences and views on the prevention of cervical
cancer: a qualitative study. Retrieved from EBSCO:
https://eds.a.ebscohost.com/ehost/detail/detail?vid=3&sid=7cf2c
91b-5b3a-469a-9b5f-
b9006e088df2%40sessionmgr4007&hid=4105&bdata=JnNpdGU
9ZWhvc3QtbGl2ZQ%3d%3d#AN=103792250&db=c8h
NCCC. (2016). National Cervical Cancer Coalition. Retrieved
from Cervical Cancer Overview: http://www.nccc-
online.org/hpvcervical-cancer/cervical-cancer-overview/
NIH. (2014, November 5). A Snapshot of Cervical Cancer.
Retrieved from
https://www.cancer.gov/research/progress/snapshots/cervical

NIH. (2016, April 05). Retrieved from
https://medlineplus.gov/ency/article/003911.htm
Olusola Adegoke, Shalini Kulasingam, Beth Virnig. (2012,
October 1). Cervical Cancer Trends in the United States: A 35-
Year Population-Based Analysis. Retrieved from Journal of
Women's Health :
https://eds.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=627
85b43-b934-464a-b3c6-
c5df4254ba46%40sessionmgr102&vid=4&hid=113
Panatto, D. (2008). Cervical cancer: From Hippocrates through
Rigoni-Stern to zur Hausen. Retrieved October 1, 2016, from
http://www.hu.ufsc.br/projeto_hpv/Cervical%20cancer%20From
%20Hippocrates%20through%20Rigoni-
Stern%20to%20zur%20Hausen.pdf
Society, A. C. (2016, January 29). What are the key statistics
about cervical cancer? Retrieved from Cervical Cancer :
http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervi
cal-cancer-key-statistics
Staff, M. C. (2016). Cervical cancer. Retrieved from Mayo
Clinic: http://www.mayoclinic.org/diseases-conditions/cervical-
cancer/home/ovc-20210887
Appendix A
Pap test (2016) Retrieve from:
http://www.mayoclinic.org/diseases-conditions/cervical-
cancer/home/ovc-20210887
Appendix B

Pap test (2016) Retrieve from:
https://medlineplus.gov/ency/article/003911.htm

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