The feasibility of risk-based cervical cancer screening

OBJECTIVE: This study examined the feasibility of risk-based cervical cancer screening in primary care practices in Lansing, Michigan (United States). METHODS: We recruited adult women regardless of the reason for visit from March to June of 2001. Women completed a risk factor questionnaire including number of current and lifetime sexual partners, history of sexually transmitted diseases and smoking. We also explicitly extracted from the patients' medical records: Pap smear results, presence of a sexual history, and screening for sexually transmitted infections (STI). RESULTS: Of 1271 eligible women, 809 (64%) completed the questionnaire and 601 agreed to have their records reviewed. Women of minority race represented 28.6% of the sample and one-third were insured through Medicaid. The mean number of lifetime partners was 9 and average age of first intercourse was 17. Eighty-six percent of women provided complete information. Most women (83%) had at least one risk factor for cervical cancer. We found low rates of documented sexual history taking (54%) and STI testing (4%). CONCLUSION: Women seeking care from a primary care clinician will provide, if asked, sensitive information, making risk-based cervical cancer screening feasible. However, since so many women had at least one identifiable risk factor, multivariate models or alternative approaches to assessing risk need to be developed.     

Cervical cancer screening beliefs among young Hispanic women

OBJECTIVES: This study examined beliefs, attitudes, and personal characteristics that correlated with self-reported cervical cancer screening history among Hispanic women aged 18 to 25 years old in El Paso, TX, a large metropolitan area on the U.S.-Mexico border. METHODS: Data were collected through a cross-sectional, face-to-face survey. The study questionnaire was based primarily on the Health Belief Model, and included scales that measured perceived susceptibility and seriousness of cervical cancer, and perceived benefits and barriers to Pap test screening. The study questionnaire also included measures of acculturation, Pap test history, pregnancy and sexual history, use of birth control, type of medical insurance, and educational attainment. RESULTS: Sixty-nine percent reported ever having had a Pap test and 56% reported having had a test in the past year. Eighty percent reported that they were sexually active, and of these, 63% reported using birth control. Respondents understood the seriousness of cervical cancer, their susceptibility to cervical cancer, and the benefits of Pap testing; however, only 61% agreed that most young women whom they know have Pap tests. Greater acculturation and the belief that most young unmarried women have Pap tests were positively associated with ever having screening. The perception that the test would be painful and not knowing where to go for the test were negatively associated with ever having a Pap test. CONCLUSIONS: This study found suboptimal rates of screening for cervical cancer in a sample of young Hispanic women residing along the U.S.-Mexico border. Although women may understand the seriousness of cervical cancer and the benefits of screening, perceptions about Pap tests may pose barriers to undergoing screening. Efforts to increase screening also may need to focus specifically on women who are least acculturated, as they also were least likely to have had prior Pap tests.     

Breast and Cervical Cancer Screening Among South Asian Women in New York City

The purpose of this paper is to document the breast and cervical cancer screening practices of a community sample of South Asian women living in the New York City area. A convenience sample of 98 women was engaged in face-to-face interviews regarding their socio-demographic characteristics and cancer screening utilization. Sixty-seven percent of women had ever had a Pap test; 54% had one in the last 3 years. Seventy percent of women over 40 had ever had a mammogram; 56% had one in the last 2 years. Sixty-six percent of women had knowledge of breast self-exam (BSE); 34% of women ever practiced BSE. Multiple logistic regression analysis indicated that insurance status was a significant predictor of ever having a Pap test or mammogram, receiving timely Pap tests, and ever practicing BSE. Education was a significant predictor of ever having a Pap test and having knowledge of BSE. Marital status was a predictor of receiving timely Pap tests, and having spent more time in the U.S. was a predictor of ever practicing BSE. The study concludes that increased educational efforts must be developed targeting immigrant South Asian women of low socioeconomic status with limited access to healthcare.     

Junior High School Students' Perceptions Regarding Nonconsensual Sexual Behavior

ABSTRACT: This study assessed early adolescents' attitudes and perceptions regarding nonconsensual sexual activity. A total of 371 surveys (94% return rate) was completed. More than one-third of respondents (35%) reported they had engaged in sexual intercourse; 17% reported having been sexually coerced by a teen-ager; 19% reported feeling pressure from their friends to have intercourse; 7% reported having been sexually coerced by an adult; and 6% reported having sexually coerced someone else. Students also demonstrated lack of knowledge regarding nonconsensual sexual behaviors. Analysis of variance tests determined if knowledge (KN), attitudes (AT), behavioral intentions (BI), and locus of control (LC) changed across specific background and demographic variables. One background variable (having been sexually coerced by a teen-ager) was associated with high risk orientation (lower scores) on all four subscales. Lower scores also were associated with being male (KN, AT, BI), having sexually coerced someone else (KN, AT, BI), having been sexually coerced by an adult (AT, BI), and having engaged in sexual intercourse (AT, BO).     

Knowledge,Attitudes, and Practices for Cervical Cancer Screening Among the Bhutanese Refugee Community in Omaha,Nebraska

Cervical cancer is the second most common cause of cancer mortality among women with the vast majority of patients in developing countries. Bhutanese refugees in the United States are from South Central Asia, the 4th leading region of the world for cervical cancer incidence. Over the past few years, Bhutanese refugees have increased significantly in Nebraska. This study evaluates current knowledge of cervical cancer and screening practices among the Bhutanese refugee women in Omaha, Nebraska. The study aimed to investigate cervical cancer and screening knowledge and perceptions about the susceptibility and severity of cervical cancer and perceived benefits and barriers to screening. Self-administered questionnaires and focus groups based on the Health Belief Model were conducted among 42 healthy women from the Bhutanese refugee community in Omaha. The study revealed a significant lack of knowledge in this community regarding cervical cancer and screening practices, with only 22.2 % reporting ever hearing of a Pap test and 13.9 % reporting ever having one. Only 33.3 % of women were in agreement with their own perceived susceptibility to cervical cancer. Women who reported ever hearing about the Pap test tended to believe more strongly about curability of the disease if discovered early than women who never heard about the test (71.4 vs. 45.0 %, for the two groups. respectively). Refugee populations in the United States are in need for tailored cancer education programs especially when being resettled from countries with high risk for cancer.     

Sexual Orientation Differences in Cervical Cancer Prevention among a Cohort of U.S. Women

BackgroundAlthough much has been published in recent years on differences in Papanicolaou (Pap) tests across sexual orientation, other aspects of cervical cancer prevention remain underexplored, such as human papillomavirus (HPV) vaccination, HPV co-tests, or abnormal Pap tests.MethodsData came from participants (aged 24–54 years) enrolled in an ongoing, longitudinal, U.S.-based cohort study, the Nurses’ Health Study 3 (N = 12,175). Analyses were restricted to participants who met the current guidelines for care (e.g., ≥21 years of age for Pap tests).ResultsMostly heterosexual women were more likely to initiate HPV vaccination than completely heterosexual women with no same-sex partners. All other comparisons across sexual orientation for HPV vaccination initiation and completion and the age of initiation were not statistically significant. Compared with completely heterosexual women with no same-sex partners, mostly heterosexual and lesbian women had lower odds of having a Pap test within the past 2 years. Completely heterosexual women with same-sex partners, mostly heterosexual women, and bisexual women had their first Pap test at an earlier age, had higher odds of having an HPV co-test, and had higher odds of having a positive HPV or abnormal Pap test compared with completely heterosexual women with no same-sex partners. In contrast, lesbian women had lower odds of having positive HPV or abnormal Pap results (odds ratio, 0.65; 95% confidence interval, 0.49–0.86) than completely heterosexual women with no same-sex partners.ConclusionsThere are significant differences across sexual orientation groups in cervical cancer prevention for Pap test timing and positive HPV and abnormal Pap tests, but few differences in HPV vaccination initiation, completion, and age at initiation. Interventions should focus on increasing routine Pap testing among mostly heterosexual and lesbian women.     

Coverage and focus of a cervical cancer prevention program in southern Brazil.

OBJECTIVE: To determine the coverage and focus of cervical cancer screening (Pap smears) in a population-based sample in Brazil. METHODS: Cross-sectional cluster survey covering 1730 women aged 20 years or older with a history of sexual activity. Information was collected on social, demographic and behavioral variables, knowledge of and use of the Pap test. RESULTS: Of women aged 25-59 years, who are the target population of the national cervical cancer screening program, 78.7% had had at least one Pap test in their lifetime, and 68.8% had had a Pap test in the last 3 years. Statistics for focus of the program showed that of the 637 women who reported having a Pap test in the last year, only 20.6% actually required one. The remainder were either outside the age range or had had another test less than 30 months previously. Prevalence of not having been tested in the previous 3 years was highest among black (41.7%) and low-income women (64.3%), and among those at greatest risk for cervical cancer (62.3% for women with three or more risk factors). Focus was inversely related to socioeconomic status. CONCLUSION: Coverage rates were similar to those reported in other national studies, but this is the first report to examine the focus of the national program. We show that 8 of every 10 Pap tests were not necessary. Coverage levels remain unacceptably low among women of low socioeconomic status and those at greatest risk for cervical cancer.     

Cervical Cancer Screening and Sexual Risky Behaviors among a Population of Hispanic Origin

ObjectiveTo assess the prevalence of cervical cancer screening through Papanicolaou (Pap) test utilization and its association with sexual behaviors among a population-based sample of Hispanic women in Puerto Rico (PR).MethodsThis study was a secondary data analysis of the database of a cross-sectional study of HPV infection in PR (2010–2013; n = 554 women). Pap test utilization (past 3 years) was self-reported and sexual risky behavior was defined as an index that considered the following sexual behaviors: early age of sexual debut (≤16 years), 11 or more lifetime sexual partners, and 2 or more sexual partners in the last year. Multivariable logistic regression was used to estimate the magnitude of the association between sexual risk behavior and Pap test utilization, after adjusting for socioeconomic and lifestyles characteristics.ResultsThe overall prevalence of Pap test utilization was 78.0%. Pap test screening varied with sexual behavior, with women with none or one risky sexual behavior having higher odds of Pap test utilization in the past 3 years (odds ratio [OR], 1.74; 95% CI, 1.03–2.93) compared with those with two or three risky sexual behaviors. This difference remained marginally significant (p < .10) after adjusting for age, educational attainment, smoking status and STI history (OR, 1.72; 95% CI, 0.96–3.08).ConclusionsThe prevalence of cervical cancer screening in this population (78%) is still below Healthy People 2020 recommendations (93%). Also, women with risky sexual behaviors are less likely to have been screened. Efforts to promote cervical screening programs should focus on these high-risk women as a method for cervical cancer prevention and control.     

Variation in the duration of protection given by screening using the Pap test for cervical cancer

The duration of protection offered by Pap screening for cervical cancer was examined using data on 101 cases of invasive cervical cancer and 396 controls from a Maryland case-control study. Receipt of a Pap test up to 4 years ago afforded significant protection, compared to women screened 11 or more years ago, or never screened. Smoking, intercourse before age 19, and a history of sexually transmitted disease were significant risk factors for cervical cancer; barrier contraception use was protective. Variation in protection from Pap screening was examined by age, race, age at first intercourse, barrier contraception use, and source of last Pap test (obstetrician-gynecologist vs other provider type). Results showed older women, women with earlier age of first intercourse, and non-users of barrier contraception received slightly less protection from Pap tests, while women who received their last Pap test from an obstetrician-gynecologist received significantly more protection than women who did not. Issues of quality of screening and follow-up are discussed in regard to these results.     

Inner-city women at risk for cervical cancer: behavioral and utilization factors related to inadequate screening

This study investigated the relationships between health care utilization, knowledge, attitudes, sociodemographic characteristics, and adequacy of cervical cancer screening among a random sample of women from inner-city neighborhoods with high rates of cervical cancer mortality. Of 416 women interviewed, 30.3% reported hysterectomies; women with intact uteri (N = 290) are the subjects of this analysis. Over two-fifths (44.1%) reported not receiving adequate Pap testing during the previous 4 years. Compared with adequately screened women, they were more likely to be 45 years or older, have no medical insurance, report never having been to an obstetrician-gynecologist, recall never having been told by a medical provider how often to get a Pap test, rely on providers for adequate screening, report not seeking care as often as they think they should, have less knowledge of risk factors for cervical cancer, and believe that women should get Pap tests less than yearly. Separate models for younger and older women showed that these factors vary by age, demonstrating the need for interventions to be sensitive to age subgroups. These findings suggest that cancer control activities should place more emphasis on motivating women as well as influencing the health care delivery system to maximize reductions in cervical cancer.     

Cross-sectional survey on the knowledge, attitude and practice of male Filipino seafarers on sexual health

The Philippines is currently the world's leading supplier of seafarers aboard foreign vessels, accounting for nearly a quarter of the world's maritime industry. Seafarers, being mobile, have a significant contribution impact on the worldwide spread of infectious diseases such as sexually transmitted infections (STIs). This study aims to determine the level of knowledge, as well as the attitudes and practices (KAP) of male Filipino seafarers regarding sexual health. A cross-sectional survey was administered through convenience sampling of male Filipino seafarers. The respondents showed the least knowledge about prevention, followed by transmission of STIs. The respondents showed adequate knowledge about risk factors such as multiple sex partners, and about transmission such as vertical spread. In addition, the respondents indicated their attitude and level of responsibility in informing their sexual partners in case they contract STIs and avoidance of high-risk partners. They also showed attitudes that predispose them to high-risk behaviour such as decreased sexual sensation caused by use of condoms and added pleasure in having intercourse with strangers. The majority of respondents were sexually active. Most have STI/HIV screening as part of their pre-employment medical exam. Positive practices include use of condoms, voluntary medical evaluation for STI's, and avoidance of high-risk partners. Negative practices include going to bars closely linked with prostitution, and most of the respondents had had sexual intercourse with sex workers overseas. Male seafarers appear to have double standards regarding women as sexual partners - about half had intercourse outside their stable relationships. They perceive protection as their sole discretion.     

Perceptions of cervical cancer risk and screening among transmasculine individuals: patient and provider perspectives

Transmasculine people (individuals assigned a female sex at birth who identify as male or masculine) are at risk of cervical cancer. Despite low rates of Pap test use in this population, research examining the determinants of cervical cancer screening among transmasculine individuals is scarce. We conducted in-depth interviews and focus groups with 49 participants (32 transmasculine patients and 17 healthcare providers) in order to examine transmasculine individuals’ and healthcare providers’ perceptions of cervical cancer risk and screening among individuals on the transmasculine continuum. Overall, patients believed that transmasculine individuals should receive regular Pap tests, especially in the event of gynaecological concerns. While healthcare providers’ views varied, many perceived transmasculine individuals to be at low risk of cervical cancer. Contrary to existing screening guidelines, several providers believed that transmasculine individuals who did not engage in penile-vaginal intercourse with cisgender men, expressed discomfort about Pap testing or intended to obtain a hysterectomy might not need to be screened regularly or at all. Our findings underscore the importance of educating patients and providers about cervical cancer risk among transmasculine individuals and establishing evidence-based guidelines for cervical cancer screening in this underserved population.     

Cervical Cancer Risk as a Predictor of Pap Smear Use in Rural North Carolina

Risk for invasive cervical cancer is reported to be higher in rural areas than urban ones, and cervical cancer-related mortality is higher in rural women due to poorer utilization of preventive services and subsequent presentation at late stages of the disease. This cross-sectional study examined the relationship between prevalence of risk factors for cervical cancer and the degree of compliance with risk-appropriate screening guidelines for cervical cancer. Secondary data were analyzed for 614 women from Robeson County, NC, aged 40 and older, and of mainly rural and low socioeconomic status. High-risk status was determined by the presence of any of the following five risk factors: a history of more than two sexual partners, age at first sexual intercourse under 18 years, history of sexually transmitted disease, history of sexually transmitted disease in sexual partner(s), and smoking. Low-risk status was the absence of all factors. A high-risk participant was considered compliant if she had had at least three Pap smears in the 3 years prior to the interview, while a low-risk participant was considered compliant if she had had at least one Pap smear within the previous 3 years. Overall, 82% of the participants were at high risk for cervical cancer. However, only 41% of all participants were compliant with the risk-appropriate screening guidelines. Low-risk status was significantly associated with compliance with cervical cancer screening guidelines (adjusted OR = 6.7; 95% CI = 3.7 to 11.1, p = .0001). Findings in this study population suggest rural women at high risk for cervical cancer are less likely to be compliant with appropriate Pap smear screening guidelines, indicating the need to target educational programs.     

Factors associated with inadequate cervical cancer screening among lower income primary care patients

This study identified factors associated with cervical cancer screening patterns among lower income primary care patients. One hundred forty-one women completed a self-administered questionnaire before their medical visit. The results indicated that 71 percent had a Papanicolaou (Pap) test in the past year, 14 percent had one between 1 and 3 years ago, and 15 percent had not had a Pap test for 3 or more years. Advanced age was associated with a reduced likelihood of adequate screening; 21 percent of women aged 50-64 years and 39 percent of those aged 65 years and older had not had a Pap test in the past 3 years. Factors positively associated with screening included perceived susceptibility to cervical cancer and the belief in the efficacy of Pap tests and benefits of screening. Fear of finding cancer was a significant barrier to cervical screening in this population. Of those women who had not been screened adequately, 58 percent were interested in obtaining Pap tests in the primary care setting. The implications for promoting cervical cancer screening in primary care practices are discussed.     

Relative and attributable risk for cervical cancer: a comparative study in the United States and Italy

The attributable risk for invasive cervical cancer in the US and Italian populations has been estimated in relation to main 'aetiological' factors (number of sexual partners, age at first intercourse, parity, oral contraceptive use and smoking) and history of Pap smear using data from two case-control studies conducted in the US (466 cases and 788 controls) and Italy (528 cases and 456 controls). The risk of cervical cancer increased in both studies with multiple sexual partners, decreasing age at first intercourse, higher parity, oral contraceptive use and smoking. Levels of exposure to various risk factors were markedly different in the two countries (ie number of sexual partners, frequency of oral contraceptive use and smoking were greater in the US). Multiple Pap smears and a short interval since last Pap smear strongly reduced risk of cervical cancer in both populations, although screening was much more widespread in the US study population, with only 9% of controls reporting no previous smear versus 38% of the Italian control series. The combined population attributable risk for the five 'aetiological' risk factors was slightly greater in the US study (76%) than in the Italian one (69%), chiefly because of a higher prevalence of exposure to sexual factors in US study women. A substantially larger proportion of Italian cases were due in part to deficiency in screening (46% in US and 84% in Italy). Thus, further inclusion of the effect of screening programmes (number of Pap smears and time since last Pap) led to an overall proportion of cases attributable to the examined risk factors of 87% in the US and 95% in Italy.     

Cervical cancer screening: knowledge of Pap smear benefits and utilization in Mexico

OBJECTIVE: To identify and evaluate the predisposing factors regarding the utilization of the Pap smears in the population seen in the Cervical Cancer Screening Program in Mexico METHODS: A cross-sectional study was conducted from January 1997 through December 1998 in Mexico city. A questionnaire was applied to a total of 2,107 women of reproductive age who attended a family planning program and data was collected regarding the following topics: social-demographics, reproductive risk factors associated with cervical cancer, sexual behavior and partner history, birth control, knowledge about Pap smear' benefits, and its utilization. Statistic analysis was conducted using Student' s test and non-conditional multiple logistic regression model for determining significance. RESULTS: The predisposing factors were: knowledge about Pap smear's benefits (OR=6.00, CI 95% 4.70-7.67), history of using at least two birth control methods (OR=2.38, CI 95% 1.75-3.24), previous history of vaginal infection (OR=2.18, CI 95% 1.73-2.75), sexual partner's approval of gynecological examinations (OR=1.56, CI 95% 1.07-2.29). CONCLUSIONS: Educational programs on cancer prevention in this population should include the benefits of screening tests. Pap smears for Mexican women of reproductive age are mostly offered opportunely. The previous use of health services is a determinant factor for the utilization of the Cervical Cancer Screening Program. These results show the need to strengthen health promotion programs to women at high risk of cervical cancer and their sexual partners.     

Pap screening and knowledge of risk factors for cervical cancer in Chinese women in British Columbia, Canada

Objective. Cervical cancer is a significant cause of mortality and morbidity for Chinese Canadian women, due in part to inadequate Pap screening. A community‐based survey was conducted involving 528 Chinese immigrant women residing in British Columbia, Canada, in order to identify barriers and facilitators to Pap testing. This paper addresses the relationship between knowledge level about cervical cancer risk factors and Pap screening practices.

Design. Female trilingual Chinese interviewers conducted personal at‐home interviews about knowledge of cervical cancer risk factors, history of Pap screening, sociodemographic and acculturation factors.

Results. The average summary score for knowledge about cervical cancer risk factors was 5.2/10, and knowledge level was significantly associated with the woman's educational level and the gender of the doctor providing usual care. Seventy‐four per cent of respondents reported ever having received a Pap test, and 56% reported having received a test within the last two years. Respondents with the highest knowledge were more likely to have ever received a Pap test (OR 6.4, 95% CI: 2.6, 15.9), and to have recently received a test (OR 3.1, 95% CI: 1.4, 6.7).

Conclusion. The average knowledge level about cervical cancer risk factors is low in Chinese Canadian women, especially among those with less education and who receive their usual care from a male doctor. Knowledge of these risk factors influences Pap screening behaviour. Culturally and linguistically appropriate education interventions addressing Pap testing and risk factors for cervical cancer are needed in the Canadian Chinese community. Educational resources are also needed for their primary care givers.     

Factors associated with obtaining health screening among women of reproductive age.

Death and disability associated with breast and cervical cancer and hypertension can be reduced by early detection and treatment. The authors examined the rates for having obtained a Papanicolaou (Pap) test or pelvic examination, a breast physical examination, and a blood pressure test within the last 12 months among women of reproductive age in the United States in 1988, as reported by the 8,450 women interviewed for the 1988 National Survey of Family Growth. Overall, the annual rates of screening for women ages 15-44 years for those tests were 67 percent for a Pap test or pelvic examination, 67 percent for a breast examination, and 82 percent for a blood pressure test. Standard recommendations for the frequency of screening and survey data were examined to see whether actual screening practice was consistent with those recommendations. More than 90 percent of women who had a family planning service visit within 12 months received each of the tests, regardless of who provided the service or who paid for the visit. Women who were not sexually active, women with little education or low income, American Indian women, Hispanic women, and women of Asian or Pacific Islander descent had lower rates of screening than others, regardless of their risk status. These findings strongly suggest that the likelihood of having obtained screening among women 15-44 years old is determined primarily by how often a woman uses health care, rather than by her risk of disease.     

Receipt of preventive health care services by lesbians

BACKGROUND: We measured receipt of age-appropriate preventive health services by lesbians and assessed whether provider and individual characteristics, including disclosure of sexual orientation, are independently associated with receipt of these services. METHODS: A questionnaire was printed in a national biweekly gay, lesbian, and bisexual news magazine, and self-identified lesbians living in all U. S. states (N =6935) responded to the survey. Main outcome variables were receipt of a Pap smear within the preceding 1 and 2 years and, for women aged > or= 50, receipt of a mammogram within the past 1 and 2 years. RESULTS: Fifty-four percent had Pap smears within 1 year and 71% within 2 years, with increasing rates among older and more educated respondents. Seventy percent of respondents aged > or = 50 had a mammogram in the past year, and 83% within 2 years; rates did not vary significantly controlling for education. Sixty percent had disclosed their sexual orientation to their regular health care provider. Controlling for patient and provider characteristics, disclosure was independently associated with receipt of Pap smears, but not mammograms. CONCLUSIONS: It is important for providers to identify their lesbian patients' unmet needs for preventive health care. Additionally, it is important for providers to provide complete and appropriate preventive health care for their lesbian patients. Further research is needed to determine why lesbians are not receiving Pap smears at the recommended rate and whether this disparity is reflective of aspects of cervical cancer screening or indicates a more general problem with access to health care including receipt of preventive services.     

Sociodemographic predictors of pap test receipt,currency and knowledge among Australian women

BACKGROUND: Knowledge of sociodemographic variations in cervical cancer screening can help identify population groups at risk of underutilization of cervical cancer procedures and practices. The aim of this research was to examine sociodemographic predictors of receipt, currency (being up-to-date for), and knowledge of Pap test. METHODS: We used data from the 1995 National Health Survey. A subsample of women was given self-administered questionnaires that included questions about the Pap test. The sample size was 7,572. Using multiple logistic regression, we examined the association of age, marital status, region of residence, country of birth, Index of Relative Socioeconomic Disadvantage (IRSD), and education with Pap test receipt, currency, and knowledge. RESULTS: Women under 30 and over 49 years of age, those not presently married, those with lower levels of education, and those born in the Middle East or Asia (compared with the Australian/New Zealand-born women) were at a greater risk of not receiving and having no knowledge of Pap test. CONCLUSIONS: The results of this study suggest that, as part of a comprehensive cancer screening strategy, women who are unlikely to obtain a Pap smear might benefit from targeted interventions to improve adherence to cervical cancer screening programs.