Pap smear receipt among Vietnamese immigrants: the importance of health care factors

Objective. Recent US data indicate that women of Vietnamese descent have higher cervical cancer incidence rates than women of any other race/ethnicity, and lower levels of Pap testing than white, black, and Latina women. Our objective was to provide information about Pap testing barriers and facilitators that could be used to develop cervical cancer control intervention programs for Vietnamese American women.

Design. We conducted a cross-sectional, community-based survey of Vietnamese immigrants. Our study was conducted in metropolitan Seattle, Washington, DC. A total of 1532 Vietnamese American women participated in the study. Demographic, health care, and knowledge/belief items associated with previous cervical cancer screening participation (ever screened and screened according to interval screening guidelines) were examined.

Results. Eighty-one percentage of the respondents had been screened for cervical cancer in the previous three years. Recent Pap testing was strongly associated (p<0.001) with having a regular doctor, having a physical in the last year, previous physician recommendation for testing, and having asked a physician for testing. Women whose regular doctor was a Vietnamese man were no more likely to have received a recent Pap smear than those with no regular doctor.

Conclusion. Our findings indicate that cervical cancer screening disparities between Vietnamese and other racial/ethnic groups are decreasing. Efforts to further increase Pap smear receipt in Vietnamese American communities should enable women without a source of health care to find a regular provider. Additionally, intervention programs should improve patient–provider communication by encouraging health care providers (especially male Vietnamese physicians serving women living in ethnic enclaves) to recommend Pap testing, as well as by empowering Vietnamese women to specifically ask their physicians for Pap testing.     

Knowledge about Cervical Cancer Risk Factors,Traditional Health Beliefs,and Pap Testing Among Vietnamese American Women

Introduction: The objective of this paper was to examine knowledge about cervical cancer risk factors and traditional health beliefs in relation to Papanicolaou (Pap) testing among Vietnamese women. Methods: A population-based survey was conducted in Seattle (n<352, response rate=82%) during 2002. Results: The proportions of women who knew that older age, not getting regular Pap tests, and Vietnamese ethnicity are associated with an elevated cervical cancer risk were only 53%, 62%, and 23%, respectively. The majority (87%) incorrectly believed poor women’s hygiene is a risk factor for cervical cancer. Approximately two-thirds (68%) of the women had received a Pap test during the preceding three years. Knowing that lack of Pap testing increases the risk of cervical cancer was strongly associated (p<0.001) with recent Pap smear receipt. Conclusion: Our results confirm that Vietnamese women have lower levels of cervical cancer screening than non-Latina white women. Intervention programs addressing Pap testing in Vietnamese communities should recognize women’s traditional beliefs while encouraging them to adopt biomedical preventive measures into their daily lives.     

Pap smear screening among women >/=40 years residing at the United States-Mexico border

Invasive cervical cancer is a preventable disease due to screening for precursor lesions using the Papanicolaou cytological testing (Pap smear). Participants were assessed regarding their access to and utilization of health care services, prevention orientation, history of chronic disease screening, and reproductive health history. Factors independently positively associated with Pap smear screening were age, clinical breast exam (CBE) in the last year, doctor recommendation of a Pap test, living in the United States, and checkup in the past year. Having a regular source of health care, as well as a doctor's recommendation for a Pap smear, appears to have a positive effect on women's Pap smear screening rates in U.S.-Mexico border communities.     

Pap Smear Screening Among Women ≥40 years Residing at the United States–Mexico Border

Invasive cervical cancer is a preventable disease due to screening for precursor lesions using the Papanicolaou cytological testing (Pap smear). Participants were assessed regarding their access to and utilization of health care services, prevention orientation, history of chronic disease screening, and reproductive health history. Factors independently positively associated with Pap smear screening were age, clinical breast exam (CBE) in the last year, doctor recommendation of a Pap test, living in the United States, and checkup in the past year. Having a regular source of health care, as well as a doctor's recommendation for a Pap smear, appears to have a positive effect on women's Pap smear screening rates in U.S.–Mexico border communities.     

Evaluation of a Cervical Cancer Control Intervention Using Lay Health Workers for Vietnamese American Women

Objectives. We conducted a trial to evaluate the effectiveness of a cervical cancer control intervention for Vietnamese American women that used lay health workers.Methods. The study group included 234 women who had not received a Papanicolaou (Pap) test in the last 3 years. Experimental group participants received a lay health worker home visit. Our trial endpoint was Pap test receipt within 6 months of randomization. Pap testing completion was ascertained through women''s self-reports and medical record reviews. We examined intervention effects among women who had ever received a Pap test (prior to randomization) and women who had never received a Pap test.Results. Three quarters of the women in the experimental group completed a home visit. Ever-screened experimental group women were significantly more likely to report Pap testing (P < .02) and to have records verifying Pap testing (P < .04) than were ever-screened control group women. There were no significant differences between the trial arms for women who had never been screened.Conclusions. Our findings indicate that lay health worker–based interventions for Vietnamese American women are feasible to implement and can increase levels of Pap testing use among ever-screened women but not among never-screened women.Over 10% of Asian Americans are of Vietnamese descent, and the Vietnamese American population now exceeds 1 250 000.¹ The majority of Vietnamese Americans came to the United States as refugees or immigrants over the last 3 decades.² Cancer registry data show that in the United States, the incidence rate of cervical cancer among Vietnamese women is over twice that among non-Hispanic White women (16.8 vs 8.1 per 100 000).³ Further, the President''s Advisory Commission on Asian Americans recently identified cervical cancer among Vietnamese women as one of the most important health disparities experienced by Asian American populations.⁴According to American Cancer Society guidelines, women should be screened for cervical cancer every 1 to 3 years, depending on their risk factors for disease and previous screening history.⁵ Additionally, national cervical cancer screening goals for the year 2010 specify that at least 97% of women should have received a Papanicolaou (Pap) test on at least 1 occasion, and 90% of women should have received a Pap test within the previous 3 years.⁶ However, California survey data for 2003 indicated that only 70% of Vietnamese women aged 18 years and older had received Pap testing in the previous 3 years, compared with 84% of White, 87% of Black, and 85% of Hispanic women.⁷Lay health workers are community members who are not certified health care professionals, but have been trained to promote health or provide health care services within their community. The Cochrane Database for Systematic Reviews recently concluded that interventions based on lay health workers represent a promising approach to disease prevention, and recommended further research on the effectiveness of approaches using lay health workers for different health topics and demographic population subgroups.⁸ We have previously described our development of a cervical cancer control intervention for Vietnamese American women that used lay health workers.⁹ In this report, we provide findings from our randomized controlled trial to evaluate the effectiveness of the lay health worker–based intervention in improving levels of Pap test receipt among Vietnamese immigrants in Washington State.     

Effect of provider status on preventive screening among Korean-American women in Alameda County,California

BACKGROUND: Previous research suggests that having a doctor of the same ethnicity may be associated with lower rates of breast and cervical cancer screening in some Asian-American women. This study analyzes the effect of having a Korean, non-Korean, or no regular doctor upon several measures of screening among Korean-American women. METHODS: A random sample of 339 Korean-American women in Alameda County, California, were surveyed by telephone. Contingency tables and multivariable logistic regression were used to evaluate the association between provider status and six measures of recent screening, controlling for insurance and demographics. RESULTS: Having a non-Korean doctor was associated with an increased likelihood of having a Pap smear (odds ratio = 2.19, 95% confidence interval = 1.00, 4.80), mammogram (odds ratio = 7.63, 95% confidence interval = 2.35, 24.84), and clinical breast examination (odds ratio = 3.76, 95% confidence interval = 1.54, 9.20) in the past 2 years, compared to having a Korean doctor. This relationship is less apparent for nonfemale specific screening tests like cholesterol exams and routine checkups. CONCLUSIONS: Women who have a Korean doctor have less than optimal rates of breast and cervical cancer screening compared to women who have a non-Korean doctor. Having a Korean doctor may indicate less access to preventive health services, and programs to increase screening should target both Korean physicians and their female patients.     

Breast and cervix cancer screening among multiethnic women: role of age, health, and source of care

OBJECTIVE: The aim of this study was to evaluate the relationships between age, health status, access to care, and breast and cervical cancer screening among multiethnic elderly and nonelderly women. METHODS: A structured telephone survey of a quota sample of 1,420 New York City women from four Hispanic groups (Columbian, Dominican, Puerto Rican, Ecuadorian) and three black groups (U.S., Caribbean, and Haitian) was performed. Outcome measures included "ever" and "recent" self-reported use of mammography, clinical breast examination (CBE), and Pap smears. Logistic regression models assessed the predictors of screening use. RESULTS: Having a regular source of care significantly predicted all screening use for both elderly and nonelderly, controlling for ethnicity, sociodemographics, health status, access to care, proportion of life in the United States, and cancer attitudes. Elderly women (>/=65 years) were significantly less likely to have ever had (OR = 0.79, 95% CI 0.65-0. 96) and to have recently had (OR = 0.67, 95% CI 0.57-0.79) Pap smears than younger women, controlling for the other variables; being elderly also tended to be an independent predictor of ever and recent mammography and CBE use. Interestingly, there was a trend for health status to act differently in predicting Pap smear use for the two age groups. For younger women, being in poor health increased the odds of Pap smear screening, while for elderly women, being in good health increased the odds of screening. CONCLUSIONS: Elderly women reported being screened less than younger women; interactions between health status and age need further exploration.     

Pap smear rates among Haitian immigrant women in eastern Massachusetts

OBJECTIVE: Given limited prior evidence of high rates of cervical cancer in Haitian immigrant women in the U.S., this study was designed to examine self-reported Pap smear screening rates for Haitian immigrant women and compare them to rates for women of other ethnicities. METHODS: Multi-ethnic women at least 40 years of age living in neighborhoods with large Haitian immigrant populations in eastern Massachusetts were surveyed in 2000-2002. Multivariate logistic regression analyses were used to examine the effect of demographic and health care characteristics on Pap smear rates. RESULTS: Overall, 81% (95% confidence interval 79%, 84%) of women in the study sample reported having had a Pap smear within three years. In unadjusted analyses, Pap smear rates differed by ethnicity (p=0.003), with women identified as Haitian having a lower crude Pap smear rate (78%) than women identified as African American (87%), English-speaking Caribbean (88%), or Latina (92%). Women identified as Haitian had a higher rate than women identified as non-Hispanic white (74%). Adjustment for differences in demographic factors known to predict Pap smear acquisition (age, marital status, education level, and household income) only partially accounted for the observed difference in Pap smear rates. However, adjustment for these variables as well as those related to health care access (single site for primary care, health insurance status, and physician gender) eliminated the ethnic difference in Pap smear rates. CONCLUSIONS: The lower crude Pap smear rate for Haitian immigrants relative to other women of color was in part due to differences in (1) utilization of a single source for primary care, (2) health insurance, and (3) care provided by female physicians. Public health programs, such as the cancer prevention programs currently utilized in eastern Massachusetts, may influence these factors. Thus, the relatively high Pap rate among women in this study may reflect the success of these programs. Public health and elected officials will need to consider closely how implementing or withdrawing these programs may impact immigrant and minority communities.     

Pap smear use in a population of older Mexican-American women

BACKGROUND: Hispanic women and older women (age > or = 50 years) in general have been identified as populations of women who often underutilize Papanicolaou (Pap) smears. OBJECTIVE: To report the rates of cervical cancer screening in a group of older Mexican American women and to identify the correlates of having a Pap smear in the past three years. DATA SOURCE: The Mammography Use by Older Mexican-American Women Survey, a stratified area probability sample of 452 women ages 50-74 from three southeast Texas counties. Self-report data was collected with in-person interviews from 1997 to 1999. RESULTS: We found that 93.1% of the women reported at least one Pap smear in their lifetime and that 64.1% reported a Pap smear in the past three years. Odds of reporting a recent Pap smear was lower for older women (OR 0.51, 95% CI 0.32-0.82) and those below the poverty line (OR 0.52, 95% CI 0.33-0.82). The odds were higher for women who had a regular doctor for female care (OR 6.49, 95% CI 2.96-14.23) or a regular clinic or hospital source for female care (OR 5.50, 95% CI 2.55-11.89). Among these older Mexican-American women, cultural factors (language of interview, acculturation, fatalism) did not have a significant effect on screening use. CONCLUSION: Recent Pap smear use (64.1%) falls well below the year 2010 goal of 90%. Efforts need to be made to overcome barriers to Pap smear utilization for these women, such as providing access to female medical care.     

Predictors of cervical Pap smear screening awareness,intention, and receipt among Vietnamese-American women

BACKGROUND: Compared with white women, Vietnamese women in the United States have a higher rate of cervical cancer and lower Papanicolau (Pap) test utilization. We evaluated factors associated with awareness of the Pap test, intention to obtain it, and its receipt in Vietnamese-American women. METHODS: In 2000, we conducted a telephone survey of Vietnamese-American women aged >or=18 years living in Santa Clara County, California, and Harris County, Texas. We collected data on sociodemographics, healthcare system access and attitudes, as well as Pap test awareness, attitudes, intentions, and practices. RESULTS: Of 1566 subjects, 74% had heard of the Pap test, and 76% had had at least one. Only 42% of those who never had a Pap test had considered obtaining one. There were no significant differences between the two sites. Women aged >or=65 had the lowest rates for all three outcomes. For all women, younger age, being married, having requested a Pap test, physician recommendation, and preferring a female standby if the doctor was male were associated with Pap test intention. Being married, higher level of education, having a female doctor, having a respectful doctor, having requested the test, and physician recommendation were associated with Pap test receipt. CONCLUSION: Vietnamese-American women have low rates of Pap test awareness, intention, and receipt. The patient-doctor interaction is an important determinant. Efforts to increase Pap test utilization in this population need to be directed at encouraging physicians to offer the Pap test and empowering women to ask for the test.     

Young Asian Americans’ Knowledge and Perceptions of Cervical Cancer and the Human Papillomavirus

Cervical cancer is a major health disparity among Asian Americans, with cervical cancer rates of Vietnamese women being significantly higher than for the general US female population and low screening rates reported for Asian American females. Focus groups and interviews were conducted with young Vietnamese, Filipino, and Korean adults (ages 18–29) to collect information on knowledge, perceptions and sources of information regarding cervical cancer, Pap tests and the human papillomavirus. 16 Korean, 18 Vietnamese, and 18 Filipino (50% female) adults participated in the study. Many participants had never heard of HPV, cervical cancer and Pap testing. Cervical cancer screening rates were low for Korean and Vietnamese females and were influenced by moral beliefs and lack of awareness. Culturally relevant education materials that consider specific Asian ethnicity and language are needed to increase awareness of cervical cancer, Pap testing, and HPV among Asian American young adults     

Pap smear use in California: are we closing the racial/ethnic gap?

BACKGROUND: Minority women continue to be disproportionately affected by cervical cancer. Minority population groups at high risk for cervical cancer may be failing to fully comply with screening recommendations. The use of Pap smears among women in California was evaluated to identify ethnic groups at higher risk for noncompliance with cervical cancer screening. METHODS: Cross-sectional analysis of 2001 California Health Interview Survey data. Logistic regression was used to assess the independent contribution of race/ethnicity to the use of Pap smears. RESULTS: Hispanic (aPR = 1.03, 95% CI 1.02-1.05) and Black (aPR = 1.03, 95% CI 1.001-1.06) women are more likely to report a Pap smear in the past 3 years as compared to White women. Asians were the least likely to report cervical cancer screening despite a more favorable sociodemographic profile. Screening rates varied among Hispanic or Asian subgroups; Mexicans, Vietnamese, Chinese, and South Asians are particularly underserved. CONCLUSIONS: In contrast to the country as a whole, Hispanic women in California are more likely to report a recent Pap smear as compared to White women. However, racial/ethnic disparities in Pap smear use persist; Asian women are the least likely to report cervical cancer screening as compared to any other group.     

Papanicolaou testing among Vietnamese Americans: results of a multifaceted intervention

BACKGROUND: Vietnamese-American women have the highest incidence of cervical cancer of any ethnic group, and they underutilize Papanicolaou (Pap) tests. DESIGN: Development and implementation of a multifaceted intervention using community-based participatory research (CBPR) methodology and evaluated with a quasi-experimental controlled design with cross-sectional pre-intervention (2000) and post-intervention (2004) telephone surveys. Data were analyzed in 2005. SETTING: Santa Clara County, California (intervention community) and Harris County, Texas (comparison community). PARTICIPANTS: Vietnamese-American women aged 18 and older (n =1566 at pre-intervention and 2009 at post-intervention). INTERVENTION: A community-academic coalition developed and implemented six components: Vietnamese-language media campaign, lay health worker outreach, Vietnamese Pap clinic, patient registry/reminder system, restoration of a government-funded low-cost screening program, and continuing medical education for Vietnamese physicians. OUTCOME MEASURE: Pap test receipt. RESULTS: Overall response rate was 56%. Pap test receipt increased in the intervention (77.5% to 84.2%, p <0.001), but not in the comparison community (73.9% to 70.6%, p >0.05). In multivariate analyses, the intervention was associated with increased Pap test receipt (odds ratio [OR]=2.02, 95% confidence interval [CI]=1.37-2.99). Other factors associated with increased Pap testing included longer U.S. residence, having health insurance, having a regular site of care, having a respectful physician, having a non-Vietnamese or a female Vietnamese physician, and recalling exposure to Vietnamese-language media about Pap testing. Factors associated with reduced likelihood of Pap test receipt were age 65 years and older, never married, less than high school education, and income below poverty level. CONCLUSIONS: A multifaceted CBPR intervention was associated with increased Pap test receipt among Vietnamese-American women in one community.     

Correlates of cervical cancer screening among underserved Hispanic and African-American women

BACKGROUND: Substantial subgroups of American women, specifically those of ethnic minorities, have not been screened for cervical cancer or are not screened at regular intervals. The rates for receipt of female-related cancer screening tests remain far below the goals set forth in Healthy People 2010. OBJECTIVE: This study applied a well-known, recently revised theoretical model of health care access and utilization, the Behavioral Model for Vulnerable Populations, to examine the correlates of the adherence to cervical cancer screening guidelines among publicly housed Hispanic and African-American women, two of the most vulnerable segments of our population. METHODS: This study conducted a cross-sectional survey of a community-based random sample of 230 African-American and Latino female heads of household, from a geographically defined area, the three urban public housing communities in Los Angeles County, CA. RESULTS: Only 62% of our sample had received a screening for cervical cancer within the past year. Yet, 29% of the sample claimed that no health care provider had ever told them that they needed a screening test for cervical cancer. Hispanic and older women are by far less likely to adhere to screening guidelines; in this study, 51% of Hispanics and 22% of African-Americans reported no screening within the last year. Multivariate analysis shows that affordability, continuity of care, and receiving advice from health care providers regarding a Papanicolaou (Pap) smear were significant predictors of up-to-date to cervical cancer screening. CONCLUSION: This study documents a significant disparity in screening for cervical cancer among underserved minorities, particularly Hispanic, uninsured, and older women. The continuity of obtaining medical services and receiving recommendations from physicians remain the core factors that are significantly associated with obtaining cervical cancer screening. These results underscore the need for continued efforts to ensure that medically underserved minority women have access to cancer screening services.     

Inequalities in Pap smear screening for cervical cancer in Brazil

Objective

To examine the risk factors associated with never being screened for cervical cancer (CC) in Brazil.

Methods

Using the National Household Sample Survey 2008 (PNAD), we analyzed data from 102,108 Brazilian women ages 25–64 years. The patients were analyzed as having been or never having been screened with a Pap smear (Yes/No). Age-adjusted prevalence of never-screening was analyzed using a Chi-squared test. Crude and adjusted models using Poisson regression were performed.

Results

The prevalence of never-screened women for CC was 12.9%, 11.5% and 22.2% in Brazil in general, urban and rural areas, respectively. The Brazilian region with the highest prevalence of never-screening was the North (17.4%, 14.7% and 27.3% in general, urban and rural areas, respectively). The factors associated with a higher risk for never being screened were the following: poverty, younger age, lower educational level, non-white skin color, a greater number of children, no supplemental health insurance and not having visited a doctor in the past 12 months.

Conclusion

Socioeconomic and demographic conditions lead to inequalities in access to Pap smear screening in Brazil. Public health policy addressing these risk groups is necessary.     

Age and Pap smear history as a basis for intervention strategy

As a means of developing effective intervention strategies for promoting Pap smear screening, we analyzed data from a population-based women's health survey (N=603) in a 36-county area in southeastern Kentucky. The cervical cancer mortality rate for white women in this area is one of the highest in the United States. By using selected sociodemographic, health-care utilization, health knowledge, and health behavior variables in age-specific logistic regression models, we discriminated between women who had had a Pap smear within 3.5 years and those who had not. Several variables predicted Pap screening status regardless of the woman's age. Women of all age groups who had not been recently screened had encounters with the medical-care system. A key variable that affected use of screening services was ever use of birth control pills. The main differences between the three age groups were as follows: the 18–44 age group was less likely to see a private physician and less likely to seek medical care of any type, except for care related to pregnancy; only the 45–59 age group believed that cost of medical care was a problem; and only for the 60 or older age group were socioeconomic variables associated with not having recently had a Pap test.Carl Spurlock is planning and research advisor, Division of Epidemiology, Kentucky Department for Health Services. Marion Nadel is an epidemiologist, Division of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control. Edward McManmon is project director, Barabdos Eye Study, Division of Epidemiology, Department of Community and Preventive Medicine, State University of New York at Stony Brook.     

Cervical cancer screening among Latinas recently immigrated to the United States

BACKGROUND: Little is known about the cancer screening practices of women whose behavior may place them at a high risk for cervical cancer. We explored factors that influence repeated Pap smear screening among recently immigrated Latinas working in bars also called cantinas. METHODS: Face-to-face interview were administered to 360 women working in 60 cantinas. Participants provided information about their cancer screening practices including the number of Pap smears completed in the 5 years before the interview. A theory-based model proposing that demographic characteristics, cancer screening barriers and facilitators, and psychosocial factors influence repeated Pap smear screening was tested with a hierarchical linear regression. RESULTS: Facilitators of cancer screening (recent visit to a physician and receiving a Pap smear in a clinic) and psychosocial variables (Pap smear beliefs, cancer screening intentions and lack of encouragement) were significantly associated with the total number reported Pap smears (adjusted R2 = 0.31, P < 0.0001). Cervical cancer risk behaviors were not significantly associated with repeated screening. CONCLUSIONS: While risk behaviors did not act as barriers, access to health care measures facilitated repeated Pap smear screening. Psychosocial factors hypothesized to function as antecedents of Pap smear screening appear instead to follow from repeated experience with the examination.     

Cervical cancer screening among Lebanese women

Background

Cervical cancer is a very common malignancy amongst women worldwide. Pap smear is an effective and inexpensive screening test in asymptomatic women. The aim of this paper was to assess the prevalence of Pap smear screening for cervical cancer among Lebanese women and to determine associated sociodemographic and psychosocial characteristics.

Measuring Sustained Mammography Use By Urban African-American Women

Although the numbers of African-American women who are ever screened for breast cancer has increased, sustaining regular screening over a lifetime remains a problem. Face-to-face interviews about breast cancer screening were conducted with 576 African-American women from an east coast city. The well-screened index measuring adherence to breast cancer screening guidelines was developed and tested. This index incorporated a womans past and present use of mammography plus her future intent to be screened. Respondents were dichotomized into well-screened and not well-screened groups. Social and psychological factors associated with sustained screening as measured by this index were then explored. In bivariate analyses, education, health insurance, usual source of care, chronicity and preference for provider ethnicity and gender were significantly different for the two groups. In the multivariate model, women who were well-screened were significantly more likely to report recent physician contact, Pap smear, dental visit, history of breast problems, and beliefs that screening should be done annually and that early detection improves outcomes. Women reporting poor health were less likely to be well-screened. The well-screened index can potentially be used for assessment by clinicians and for program evaluation; however further validation studies need to be conducted. Despite limited resources, the majority of these urban African-American women are building lifetime patterns of regular breast cancer screening. Focused efforts are needed to achieve sustained screening patterns in the 25% who are not regularly screened.This work was supported in part by awards to Dr. Klassen from the National Cancer Institute (investigator-initiated grant R01 CA66065) and the AVON Foundation (AVON Foundation Gift to the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins).     

Improving adherence to regular pap smear screening among Asian women: a population-based study in Singapore.

This study addresses the issue of adherence to regular screening for cervical cancer in Asian women and factors that would promote this. A community-based cross-sectional survey was carried out among 726 women (30-59 years) in Singapore. Although the overall screening prevalence was 62.4%, only 42% reported having regular smears. Women in the irregular group were more likely to have a Pap smear as part of postnatal or family planning visits, whereas the primary reason for attendance among the regular group was likely to be screening or a health checkup. Chief barriers to regular screening were low perceived susceptibility (46.5%) and low accessibility (37.1%). One third of women who have ever had a smear do not return for regular screening. Appropriate windows of opportunity in contact between women and the health care services should be used to convey the importance of adherence to screening.