A presentation to the American Congress of Obstetrics and Gynecology Annual Scientific Meeting May 2015

1. Women’s understanding of the term
‘Pap smear’: A comparison of Spanish
speaking versus English speaking
women.
David L Howard, Beth Soulli, Nicole Johnson, Saladin Cooper
University of Missouri Kansas City

2. Cervical Cancer Rates in U.S.
All Women
The American Cancer Society's estimates for cervical cancer in the United
States for 2015:
 About 12,900 new cases of invasive cervical cancer will be diagnosed.
 About 4,100 women will die from cervical cancer.
 Cervical Cancer #14 cause of cancer deaths in women in U.S.
American Cancer Society. Cancer Facts & Figures 2015. Atlanta: American Cancer
Society; 2015.

3. Why are we talking about cervical cancer screening?
 RESULTS FROM A NATIONAL SURVEY IN 2012 [2012 Behavioral Risk Factor
Surveillance System survey—133,851 women.]
 Benard VB, Thomas CC, King J, Massetti GM, Doria-Rose VP, Saraiya M; Centers for Disease Control
and Prevention (CDC). Vital signs: cervical cancer incidence, mortality, and screening - United
States, 2007-2012. MMWR Morb Mortal Wkly Rep.2014 Nov 7;63(44):1004-9.
Race/ethnicity Percent NOT screened in the past 5 years
Overall Those with NO Insurance
White 10.8 28.8
Hispanic 11.7 16.7

4. Why are we talking about cervical cancer screening?
 Benard VB, Thomas CC, King J, Massetti GM, Doria-Rose VP, Saraiya M; Centers for Disease Control and Prevention (CDC).
Vital signs: cervical cancer incidence, mortality, and screening - United States, 2007-2012. MMWR Morb Mortal Wkly
Rep.2014 Nov 7;63(44):1004-9.
REGION Cervical cancer
Incidence rate
2007-2011
(age adjusted)
Cervical cancer
Death rate
2007-2011
(age adjusted)
Percent of women
21-65 not screened
in past 5 year
2012
Northeast 7.5 2.1 10.9
South 8.5 2.7 12.3
Midwest 7.4 2.2 10.6
West 7.3 2.1 11.5

5. Hispanic women in the US and cervical cancer
 Between 2000 and 2010 the Hispanic population in the US grew by 43%, four times the growth
of the total population (1)
 In the U.S Hispanic women have the highest incidence of cervical cancer (2)
 11.1 per 100,000 [2005-2009] vs. 7.2 per 100,000 for non Hispanic white women
 Incidence ratio of 1.6 [statistically significant]
 Hispanic non-adherence to follow up after abnormal cytology results have also been reported
to range between 20 and 90% [3]
(1) Ennis SR, Ríos-Vargas M, Albert NG. The Hispanic Population: 2010. U.S. Census Bureau;2011 (2) American Cancer Society. Cancer Facts &
Figures for Hispancis/Latinos 2012-2014. Atlanta: American Cancer Society, 2012. (3) Engelstad LP, Stewart SL, Nguyen BH, et al. Abnormal Pap
smear follow-up in a high-risk population. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer
Research, cosponsored by the American Society of Preventive Oncology. 2001;10(10):1015-1020.

6. Hispanic women in the US and cervical cancer
 Given the
 Lower uptake of cervical cancer screening
 Poorer adherence to follow up after abnormal cytology
 Higher incidence of cervical cancer
 We thought it was important to re-assess understanding of the purpose of a Pap
smear among this group, especially after the most recent and dramatic changes
to cervical cancer screening guidelines.

7. Pilot study
 An initial pilot study was conducted among 174 women (164 English speaking;
10 Spanish speaking)
 We developed and administered two versions of our survey
 73 women completed Version A
 94 women completed Version B
 Survey directly adapted from survey used in two prior studies:
 Head SK, Crosby RA, Moore GR. Pap smear knowledge among young women following the
introduction of the HPV vaccine. Journal of pediatric and adolescent gynecology.
2009;22(4):251-256.
 Blake DR, Weber BM, Fletcher KE. Adolescent and young adult women's misunderstanding of
the term Pap smear. Arch Pediatr Adolesc Med. 2004;158(10):966-970.

8. Pilot study
 We then analyzed the internal consistency of responses to the primary
research questions within each survey.
 One version (version A) was superior to the other in terms of internal
consistency of responses.
 This version was then exclusively administered to participants in the second
phase of the study(exclusively Spanish speaking)

9. Pilot study
 In our pilot study we found that
 74% of women completing version A could identify at least one correct
descriptor for the term Pap smear
 Women who could identify at least one correct descriptor for the term
'Pap smear' were on average older than those who could not (mean =
36.9 vs. 28.7 years; p = 0.012).
 67% of women completing version B of the survey could not distinguish
between a pelvic exam and a pap smear.

10. Study Objectives
 To assess and quantify Spanish-speaking women’s ability to identify correct
descriptors for the term “Pap smear”
 To directly compare the ability of Spanish speaking women to that of English
speaking women to identify correct descriptors for the term “Pap Smear”
 To determine whether age is associated with Spanish-speaking women’s
understanding
 (as was found in our pilot study among primarily English speaking women)

11. Hypotheses (developed based on our pilot study
among English Speaking women)
 1. A majority of Spanish speaking women would be able to
identify at least one correct synonym for the term 'Pap smear'
 2. Similar to English speaking women, Spanish speaking women
able to identify at least one correct descriptor for the term 'Pap
smear' would be significantly older than those unable to do so
 3. Similar to English speaking women, a majority of Spanish
speaking women would not be able to distinguish between a
pelvic exam and a Pap smear

12. Research Design/Subjects
 Single institution study—urban teaching hospital in Kansas City Missouri
 Anonymous, voluntary, cross-sectional survey
 Survey was translated into Spanish by certified medical translator and was
designed, per IRB requirements, to read at an 8th grade level.
 Predominantly low-income women on either Medicaid or uninsured
 Pregnant patients included
 Excluded: cannot speak or read Spanish, have legal guardians, <18 y.o

13. Survey (as approved by IRB)
ENGLISH SPANISH

14. Survey, cont.

15. Survey, cont.

16. Statistical Analysis
 We compared characteristics between Spanish-speaking women who could
versus those who could not identify at least one correct descriptor for the
term ‘Pap Smear.’
 We compared the proportion of Spanish speaking women choosing each
possible descriptor for the term Pap smear to the proportion of English
speaking women choosing that same response.
 Continuous variables compared using the Student’s T test and categorical
variables compared using the chi square test
 All analyses done using STATA version 8 (College St. TX)

17. Results
 123 Spanish speaking women
 116 answered all questions
 Compared to English speaking participants, Spanish speaking
participants were:
 older age at sexual debut
 significantly less likely to report ever being tested for an STI,
 Significantly less likely to report having one or more sexual partners in
the past year
 Significantly less likely to report ever having an abnormal pap smear.
 Significantly MORE likely to be pregnant at the time of the survey.

18. Detailed breakdown of participants’ responses to the survey question asking them to identify synonyms/descriptors for the term Pap smear.
Correct synonym or descriptors for term Pap Smear Spanish Speaking women
N=116
English speaking women
N=66
p-value
Test for HPV 29(25) 30(45.5) 0.005
Test for cervical cancer 64(55.2) 43(65.2) 0.19
Test for early changes in the cervix that might lead to
cervical cancer
55(47.4) 41(62.1) 0.06
Test for pre-cancer cells in the cervix 55(47.4) 37(56.1) 0.26
Total identifying at least one correct descriptor 86(74.1) 51(77.3) 0.63
Incorrect synonym or descriptors for term Pap Smear
Pelvic exam 53(45.7) 52(78.8) 0.001
Test for STD 29(25) 40(60.6) 0.001
Checkup 25(21.6) 37(56.1) 0.001
Test for pregnancy 21(18.1) 24(36.4) 0.006
None of the above 2(1.7) 0(0) 0.28
I really have no idea. 15(12.9) 8(12.1) 0.88

19. Characteristics of participants who identified at least one correct synonym or descriptor for the term Pap smear, stratified by primary language (Spanish versus
English).
English Speaking women Spanish speaking women
Identified at least one
correct synonym or
descriptor
N=54
Did not identify at least
one correct synonym or
descriptor
N=19
p-value1 Identified at least one correct
synonym or descriptor
N=86
Did not identify at least
one correct synonym or
descriptor,
N=30
p-value1
Age
(mean, 95% CI)
37.6 (34.1-41.2) 27.1(23.1-31.1) 0.004 35.7(33.1,38.2) 29.5(26.1,32.9) 0.011
Age at first sexual
encounter (mean,
95% CI)
15.8(15.2,16.3) 16.5(14.1,18.9)
0.33
17.9(17.3,18.4) 17.5 (17.1,17.9) 0.55
Ever had abnormal Pap
Yes 27(52.9) 5(33.3) 0.18 18(21%) 6(20%) 0.93
No 24(47.1) 10(66.7) 66(77%) 23(77%)
Ever had HPV vaccine
Yes 8 (15.6) 1 (6.7) 0.35 16(19%) 2 (7%) 0.17
No 41(80.4) 14(93.3) 67(78%) 24 (80%)
Ever had STI
Yes 26(51) 8(53.3) 0.87 16 (19%) 6(20%) 0.78
No 25(49) 7(46.7) 68 (79%) 22(73%)
Ever been tested for STI
Yes 47(92.2) 12(80.0) 0.10 13(15%) 2 (7%) 0.25
No 3(5.9) 3(20.0) 72(84%) 27 (90%)

20. Summary of Results
 For both English speaking and Spanish speaking women a majority (77% and 74%
respectively) were able to identify at least one correct descriptor for the term 'Pap
smear'.
 For both English speaking and Spanish speaking women, those who could identify at
least one correct descriptor for the term Pap smear were significantly older than
those who could not.
 Combining the pilot study with the current study 170 out of 283 women (60%) could
not differentiate a Pap smear from a pelvic exam
 Unexpectedly, Spanish speaking women were significantly less likely to choose
incorrect descriptors.

21. Conclusions
 Majority of US women still conflate a Pap smear with a pelvic exam
 Age and primary language(English vs. Spanish) appear to be associated with
understanding of the term ‘Pap smear’
 There is a clear need for more research into the factors behind this association
and how we can improve understanding (of the purpose of Pap smears)
specifically among younger women.

22. END TALK

23. Why are we talking about cervical cancer screening?
 Nearly all cases of cervical cancer could be prevented with regular
screening.
 ½ of cervical cancers diagnosed in the US are in women never screened.
 An additional 10% of cancers occur among women not screened within the
past 5 yrs.
 Rates are much higher in low-resource, medically underserved populations vs
the general US population.

24. Why are we talking about cervical cancer screening?
 5 year relative Survival rates by stage at diagnosis(2004-2010):
 All stages-68% [10 year=64%]
 Locally invasive—91% [uterine 95%, ovarian 92%]
 47% of cervical cancers diagnosed at this stage
 Regional mets—57% [ovarian=72%, uterine=68%]
 Distant mets—16% [ovarian=27%]
 Reference: American Cancer Society. Cancer Facts & Figures
2015. Atlanta: American Cancer Society; 2015.

25. EXTRA SLIDES

26. Further discussion
 Understanding women’s misperceptions of what a pap smear entails can help shape
educational programs that focus on increasing awareness of cervical cancer and the need for
screening.
 For instance, women seen in the ED for pelvic complaint may undergo pelvic exam and STI
screening, but think they had pap smear. This belief may prevent them from scheduling a
well woman exam if they think they have undergone their necessary cervical cancer
screening.
 It is important to educate women on what tests are being performed at time of pelvic exam.
 Also, important to educate on current cervical cancer recommendations and when next pap
smear is due.

27. Barriers to Screening
 It is important to identify other barriers that prevent women, especially
Hispanic women, from obtaining cervical cancer screening
 Common barriers include:
 knowledge of cervical cancer screening and etiology, acculturation, lack of access, and
cultural beliefs
 Lower acculturated Hispanic women, often characterized by limited education, low literacy
levels, and the use of Spanish language, are less likely to utilize cervical cancer screening
services than highly acculturated or bicultural women.
 Punishment, or castigo, from a higher being is more prevalent in Hispanic women. Widely
held belief that God can punish people by giving them cancer.
 Belief health care only needed in the presence of symptoms. Belief screening only
necessary if at risk or cancer runs in the family
 Misperceptions about development of cervical cancer: poor hygiene, abortion, fate, vaginal
trauma, antibiotics and having intercourse during menses

28. Embarrassment as a Screening Barrier
 gender differences between women and their providers
 exposure of private body parts
 discussions about sexual activity (especially to someone
other than their partners)
 view cervical cancer may imply immoral behavior

29. Shelton et. al. Cervical Cancer Screening Among Immigrant Hispanics: An
Analysis of Country by Origin,
J Immig Minor Health, 2012;14:715-720
 Non-adherence to pap screening
is associated with:
 For women born in Mexico,
married/partnered women were
more likely to be adherent,
while increasing age (41+) was
associated with decreased
adherence.
Older age Alcohol use
Unmarried Language barriers
Lower education Less acculturation
Low income Male physician
No children Embarrassment
Last Dr visit >1 yr Low knowledge
No insurance Poor communication
with clinic staff
No other cancer
screens

30. Behavioral Theories
 1. Health belief model: preventive health behavior depends on the desire to
avoid illness and the belief that a specific health action will prevent illness.
Dimensions: perceived susceptibility to illness, perceived severity of an illness or
of leaving it untreated, perceived benefits of recommended actions to prevent or
treat a disease, and perceived barriers to following recommendations
 2. Social cognitive theory: based on assumption that an individual’s behavior is
determined by the interaction between behavior, personal factors, and
environmental influences. Constructs include: individual’s capacities to learn by
observing others, to have confidence in performing a behavior (self-efficacy), to
anticipate the outcomes of a behavior, and to self-regulate behavior.
 3. Theory of planned behavior: assumes that behavioral beliefs, normative
beliefs (perceptions of whether important individuals approve or disapprove of
performing the behavior), and perceived control over behaviors predict behavioral
intentions, which in turn predict behaviors.
 4. Transtheoretical model: behavioral change is a process involving progress
through 5 stages: precontemplation, contemplation, preparation, action and
maintenance. Processes of change are activities that people use to progress
through the stages, and include consciousness raising and helping relationships.

31. Principles for Culturally Proficient Health Services for
Hispanic/Latino Families and Communities
 Involve family members.
 Show respect – Always be respectful, and explain without being condescending.
 Get personal – Hispanics typically prefer being closer to each other in space than non-Hispanic
whites do.
 Ask about their life (family, friends, and work), and share life stories and pictures.
 Encourage them to ask questions.
 Take seriously the responsibility and respect conferred on the provider.
 Reach out to the community – Community-based organizations within Hispanics
neighborhoods, barrios, colonias, and other ethnic enclaves provide a significant point of
entry and opportunity to expand on any outreach effort in which you may be involved.
 Respect traditional healing approaches – Hispanic patients may combine respect for the
benefits of mainstream medicine, tradition, and traditional healing with a strong religious
component.
American Cancer Society. Cancer Facts & Figures for Hispancis/Latinos 2012-2014. Atlanta: American Cancer Society, 2012.

32. Thank you!
 David Howard MD, PhD
 Saladin Cooper, MD
 Gerard Malnar, MD, MBA
 Nicole Johnson, MD
 ***All clinic nurses and staff for helping with distribution and collection
of surveys***

33. References1. Watts L, Joseph N, Velazquez A, Gonzalez M, Munro E, Muzikansky A, Rauh-Hain J, Carmen M. Understanding barriers to cervical cancer screening among Hispanic women. Am J Obstet Gynecol. 2009;201:199.e1-8.
2. Allison K, Duran M, Pena-Purcell N. Cervical cancer screening practices among Hispanic women: theories for culturally appropriate interventions. Hisp Health Care Int. 2005;3(2):61-67.
3. Shelton R, Jandorf L, King S, Thelemaque L, Erwin O. Cervical cancer screening among immigrant Hispanics: an analysis by country of origin. J Immig Minor Health. 2012;14:715-720.
4. Austin L, McNally M, Stewart D. Breast and cervical cancer screening in Hispanic women: a literature review using the heath belief model. Women Health Iss. 2002;12(3):122-128.
5. Flores B, Acton G. Older Hispanic women, health literacy, and cervical cancer screening. Clin Nurs Res. 2013;22(4):402-415.
6. Tung W. Cervical cancer screening among Hispanic and Asian American women. Home health care management & practice. 2011;23(6):480-483.
7. Calvo A, McCormack K, McDermott R, Bryant C, Coreil J, Loseke D. Social construction of cervical cancer screening among Panamanian women. Am J Health Educ. 2012;43(3):153-163.
8. Williams-Brennan L, Gastaldo D, Cole D, Paszat L. Social determinants of health associated with cervical cancer screening among women living in developing countries: a scoping review. Arch Gynecol Obstet. 2012;286:1487-1505.
9. Waller J, McCaffrey K, Forrest S, Szarewski A, Cadman L, Wardle J. Awareness of human papillomavirus among women attending a well women clinic. Sex Transm Infect. 2003;79:320-322.
10.Blake D, Weber B, Fletcher K. Adolescent and young adult women’s misunderstanding of the term pap smear. Arch Pediatr Adolesc Med. 2004;158(10)966-970.
11.Kahn J, Chiou V, Allen J, Goodman E, Perlman S, Emans J. Beliefs about papanicolaou smears and compliance with papanicolaou smear follow-up in adolescents. Arch Pediatr Adolesc Med. 1999;153(10):1046-1054.
12.Radecki C, Pearson H, Breitkopf D. Poor knowledge regarding the pap test among low-income women undergoing routine screening. Perspect Sex Reprod Health. 2005;37(2):78-84.
13.Pirzadeh A, Mazaheri M. The effect of education on women’s practice based on the health belief model about pap smear test. Int J Prev Med. 2012;3(8):585-590.
14.Saslow D, Solomon D, et al. American cancer society, American society for colposcopy and cervical pathology, and American society for clinical pathology screening guidelines for the prevention and early detection of cervical
cancer. J Low Genit Tract Dis. 2012;16(3):1-29.
15.Head S, Crosby R, Moore G. Pap smear knowledge among young women following the introduction of the HPV vaccine. J Pedatr Adolesc Gynecol. 2009;22:251-256.
16.Massad S, Meyer P, Hobbs J. Knowledge of cervical cancer screening among women attending urban colposcopy clinics. Cancer Detect Prev. 1997;21(1):103-109.
17.American Cancer Society. Cancer Facts & Figures for Hispancis/Latinos 2012-2014. Atlanta: American Cancer Society, 2012.
18.American Cancer Society. Global Cancer Facts & Figures 2nd Edition. Atlanta: American Cancer Society; 2011.
19.Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the
SEER web site, April 2014.
20.Howard D, Smith S, Hunter J, Johnson N, Cooper S, Malnar G. Women’s understanding of the term “pap smear”. Manuscript unpublished. 2014.

34. Comparison Among Race/Ethnicity

35. American Cancer Society. Cancer Facts & Figures for Hispancis/Latinos 2012-2014. Atlanta: American Cancer Society, 2012.

36. Hispanic Implications
 There has been a 43% increase in the Hispanic population in the U.S. in
the past decade
 Estimated that by 2050, 30% of the U.S. Population will be Hispanic
 Cancer is the leading cause of death among Hispanics (Heart disease #1
for Whites, Blacks)
 Cervical cancer incidence rates among Hispanic women are about 60%
higher than those among non-Hispanic whites.
 The highest incidence of cervical cancer among Hispanic women is in the
Midwest, likely due to large numbers of new immigrants in this region.

37. Does the General Public Understand What
a Pap Smear Is?
 Many women cannot differentiate a pap smear from a Pelvic
exam.
 In the English version of study, 74% of women thought pap smear
and pelvic exam were synonymous.
 Because women are no longer undergoing annual pap smears, the
ability to differentiate between a pap smear and a pelvic exam
are now important.
 Think pap smear occurred during ED visit
 May not schedule well woman exam if think obtained all
necessary screening