Knowledge of cervical cancer risk factors among Chinese immigrants in Seattle

Chinese American immigrants are a growing part of the United States population. Cervical cancer is a significant cause of morbidity and mortality among Chinese Americans. Pap smear testing is less common in Chinese American immigrants than in the general population. During 1999, we conducted a community-based survey of Chinese American women living in Seattle. We assessed knowledge of cervical cancer risk factors and history of Pap smear testing along with socioeconomic and acculturation characteristics. The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample included 472 women. Most cervical cancer risk factors were recognized by less than half of our participants. Factors independently associated with knowledge of cervical cancer risk factors included marital status, employment, and education. Respondents with the highest knowledge had greater odds of ever receiving a Pap smear, compared to those respondents with the lowest knowledge (OR 2.5; 95% CI: 1.1,5.8). Our findings suggest a need for increased recognition of cervical cancer risk factors among Chinese American immigrants. Culturally and linguistically appropriate educational interventions for cervical cancer risk factors should be developed, implemented and evaluated.     

Rate of Cervical Cancer Screening Associated with Immigration Status and Number of Years Since Immigration in Ontario, Canada

Cervical cancer screening is a vital public health measure intended to reduce the morbidity and mortality from what is a largely preventable cancer. Previous Canadian studies have documented that immigrants have significantly lower Papanicolaou (Pap) testing rates than women born in Canada. However, the impact of number of years since immigration is less clear. Data were taken from the 2007–2008 Canadian Community Health Survey. Responses from 16, 706 women living in Ontario, Canada were included. The focus was on self-reported Pap testing rates within the last 3 years, immigrant status and number of years since immigration. A robust Poisson regression model was used to determine prevalence ratios (PR) with 95 % confidence intervals (CIs) after adjustment for covariates. The results demonstrated that recent immigrant women (less than 10 years in Canada) were less likely to have had a Pap test in the past 3 years than those who were Canadian-born (PR = 0.77; 95 % CI: 0.71, 0.84). In contrast, immigrants who had lived in Canada for 10 years or longer showed similar compliance with recommended Pap testing intervals as non-immigrants. Higher income, higher level of education, younger age and being married were independently associated with better Pap testing rates. A strategy targeting recent immigrants to Canada is needed to promote Pap testing in this population and reduce their risk of invasive cervical cancer.     

An examination of sociocultural factors associated with cervical cancer screening among low-income Latina immigrants of reproductive age

The purpose of this study was threefold: 1) to examine whether low-income Latina immigrants were less likely to receive a Pap smear than low-income non-Latinas; 2) to examine ethnic differences regarding cervical cancer knowledge; and 3) to examine the sociocultural factors associated with cervical cancer screening among low-income Latina immigrants. Participants included 225 low-income women of reproductive age attending a WIC (Women, Infants, and Children) clinic (50% Latina immigrants and 50% non-Latinas). Latina immigrants were less educated, less likely to have health insurance, and more likely to be married or living with a partner than non-Latinas (ps < 0.05). All non-Latinas had a Pap smear in the past compared to 81.3% of Latina immigrants (p < 0.001). Latina immigrants displayed significantly less knowledge regarding cervical cancer than non-Latinas (ps < 0.01). Latina immigrants tended to display culturally based knowledge and beliefs regarding cervical cancer and screening that may influence getting a Pap smear.     

Perceptions of cervical cancer threat, benefits, and barriers of Papanicolaou smear screening programs for women in Iran

OBJECTIVES: The main purpose was to assess associations between HBM variables and participation in cervical cancer screening programs in a sample of Iranian women. METHODS: A total of 333 married women of childbearing age were recruited with cluster sampling. The study was conducted from spring 2002 to spring 2003 and a self-report questionnaire and structured interview were designed to measure the four HBM constructs and Iranian women's knowledge about Pap smear screening. RESULTS: A total of 68.5% reported having undergone at least one Pap test. Women were more likely to participate in Pap smears when they had access to knowledge about cervical cancer and screening programs. Furthermore, the perceived benefit and barrier variables of the Health belief model were two factors related to participation in Pap smear testing. CONCLUSIONS: Health care professionals must provide women with more information about cervical cancer and the benefits of participating in cervical cancer screening programs.     

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.     

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.     

Facilitators and barriers to cervical cancer screening among Chinese Canadian women

BACKGROUND: Chinese Canadian women have higher cervical cancer incidence, and lower Pap testing, rates than the general Canadian population. Predisposing, enabling and reinforcing factors associated with ever having a Pap test, and having a recent Pap test within the last 2 years, were assessed in Chinese women in British Columbia using the PRECEDE-PROCEED model. METHOD: Chinese women (n=512) between the ages of 20 and 79 years and residing in Greater Vancouver were interviewed about Pap testing, health care, traditional health beliefs, acculturation and sociodemographic characteristics. Two analyses were done, comparing women who had ever and never had a Pap test, and comparing women who had and had not received a recent Pap test. Focus groups and qualitative interviews ensured cultural sensitivity in the survey questionnaire. RESULTS: Seventy-six percent reported ever having a Pap test and 57% reported having a Pap test within the last 2 years. Traditional health beliefs were not associated with ever or recent Pap testing. However, belief that Pap testing prevented cancer and general knowledge about the Pap test were associated with screening. Concern about pain/discomfort with the test, availability of time, culturally sensitive health care services and recommendation for Pap testing by a physician were also associated with screening. Factors differed for ever, and recently, having a Pap test. INTERPRETATION: Pap testing is less common among Chinese Canadian women. Continuing education about Pap testing is recommended for physicians serving underscreened Chinese women. Culturally and linguistically appropriate educational materials are needed for the Chinese community.     

Hispanic acculturation and utilization of cervical cancer screening in the US

BACKGROUND: Hispanic women have an incidence rate of invasive cervical cancer that is twice as high as that of non-Hispanic White women. Previous investigations have reported that Hispanics are less likely to utilize cancer screening services. Using data from the 2000 National Health Interview Survey, this study examined whether acculturation of Hispanic women was associated with cervical cancer screening. METHODS: The subjects included 2307 Hispanic women aged 21-70 who did not have a history of cervical cancer or a hysterectomy. Women were analyzed by acculturation level according to whether or not they ever had a Pap smear and had one in the previous year and previous 3 years. RESULTS: Acculturation levels tended to be inversely correlated with no Pap smear. Compared to lower acculturated women, women who were more acculturated were less likely to never had a Pap smear (OR = 0.86; 95% CI = 0.58-1.27 for moderate acculturated women and OR = 0.51; 95% CI = 0.29-0.89 for higher acculturated women). Similar results were found for having no Pap smear within the past 3 years (OR = 0.83; 95% CI = 0.61-1.13 for moderate acculturated women and OR = 0.73; 95% CI = 0.49-1.08 for higher acculturated women). CONCLUSION: The findings show that lower acculturation was associated with the under use of cervical cancer screening and suggest that these women might have barriers in accessing and utilizing Pap smears.     

Is a history of trauma associated with a reduced likelihood of cervical cancer screening?

OBJECTIVE: We tested the hypothesis that a history of trauma (especially sexual trauma) was associated with a reduced likelihood of having had medically appropriate cervical cancer screening. STUDY DESIGN: A case-control study using mailed self-report questionnaires. POPULATION: The questionnaires were completed by an age-stratified random sample of adult women members of a large health maintenance organization. The sample included 364 women who had received medically appropriate cervical cancer screening and 372 who had not. OUTCOMES MEASURED: We defined cases as women who, according to their medical record, had not had cervical cancer screening within 2 years before the study. Controls were defined as women who had been screened. We evaluated exposures to trauma that we hypothesized to be associated with the case/control state. RESULTS: Women who had been sexually abused in childhood were less likely to have had a Pap smear within the past 2 years (36.0% vs. 50.4%, P =.050). Other traumatic events were associated with Pap testing in bivariate analyses but not when demographic characteristics and clinic location were controlled. Childhood sexual abuse remained associated with reduced odds of Pap screening in logistic regression analyses that controlled for clinic location, demographics, attitudes about Pap screening, and posttraumatic stress disorder symptoms (adjusted OR = 0.56, 95% CI 0.34 to 0.91). CONCLUSIONS: These findings suggest that childhood sexual abuse may lead to decreased probability of screening for cervical cancer, potentially contributing to the poorer health seen in other studies of women who have been sexually abused.     

Inadequacy of cervical cancer screening among urban recent immigrants: a population-based study of physician and laboratory claims in Toronto, Canada

OBJECTIVE: In Canada, Pap smears are recommended from 18 to 69. Self-reported socioeconomic gradients in screening have been documented in North America but there have been few direct measures of Pap smear use among immigrants or socially disadvantaged groups. Our purpose was to investigate whether socioedemographic factors are related to cervical cancer screening in Toronto, Canada. METHOD: Pap smears were identified using fee and laboratory codes in Ontario physician service claims for 3 years (2000-2002 inclusive) for women aged 18-66. Area-level socioeconomic factors were derived from the 2001 census. At the individual level, recent registrants for health coverage, over 80% of whom are expected to be recent immigrants, were identified as women first registering after January 1, 1993. RESULTS: Among 724,584 women, 55.4% had Pap smears within 3 years. Recent immigration, visible minority, foreign language, low income and low education were all associated with significantly lower area rates. Recent registrants had much lower rates than non-recent registrants (36.9% versus 60.9%). CONCLUSION: Pap smear rates in Toronto fall below those dictated by evidence-based practice. Recent registrants, a largely immigrant group, have particularly low rates. Efforts to improve coverage need to emphasize women who recently immigrated and those with socioeconomic disadvantage.     

Increasing women's compliance with opportunistic cervical cancer screening: a randomized trial.

Our objective was to evaluate the efficacy and acceptability of two interventions designed to increase opportunistic cervical cancer screening. We designed a randomized trial of two interventions additional to usual care. We recruited 17 male general practitioners selected at random from the inner metropolitan region of Sydney, Australia. The patients were 202 women, between 20 and 65 years of age, eligible for a Pap smear. We allocated minimal and maximal interactional interventions to obtain consent for a Pap smear. Our main outcome measure was women's having a Pap smear during the consultation or within one month. We also measured acceptability of interventions to practitioners and women. These were our results: minimal: 55% of women had a Pap smear; maximal: 67% of women had a Pap smear; total when both approaches are combined: 61%. We conclude that brief advice is as effective as maximal persuasion in increasing women's compliance with opportunistic screening in routine consultations. Both interventions were acceptable to women. Practitioners preferred the minimal intervention. We demonstrate opportunistic screening is an effective and acceptable way to encourage women at risk to have a Pap smear.     

Perceptions of Cervical Cancer Threat,Benefits, and Barriers of Papanicolaou Smear Screening Programs for Women in Iran

ABSTRACT

Objectives: The main purpose was to assess associations between HBM variables and participation in cervical cancer screening programs in a sample of Iranian women.

Methods: A total of 333 married women of childbearing age were recruited with cluster sampling. The study was conducted from spring 2002 to spring 2003 and a self-report questionnaire and structured interview were designed to measure the four HBM constructs and Iranian women's knowledge about Pap smear screening.

Results: A total of 68.5% reported having undergone at least one Pap test. Women were more likely to participate in Pap smears when they had access to knowledge about cervical cancer and screening programs. Furthermore, the perceived benefit and barrier variables of the Health belief model were two factors related to participation in Pap smear testing.

Conclusions: Health care professionals must provide women with more information about cervical cancer and the benefits of participating in cervical cancer screening programs.     

Pap Testing, Awareness, and Acceptability of a Human Papillomavirus (HPV) Vaccine Among Chinese American Women

Little is known about the knowledge and opinions of human papillomavirus (HPV) vaccine among Chinese immigrants, nor the impact of framing HPV as a sexually transmitted infection in this population. A cross-sectional survey was conducted focusing on knowledge and experience with HPV, HPV vaccine, cervical cancer and Pap testing, and attitudes toward HPV vaccine in response to different message frames. Chinese American women were recruited in a community setting (n?=?162). Only 19?% had heard of HPV and 38?% had had a Pap test in the last 3?years. Multivariate logistic regression showed that English proficiency was associated with vaccination acceptance and insurance status was associated with HPV awareness; there was no observed correlation with message framing. Chinese American women with limited English proficiency have low HPV awareness. Community-based, culturally appropriate education about cervical cancer and HPV vaccine should be directed toward limited-English proficient Chinese American women.     

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.     

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.     

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.     

What Australian women want and when they want it: cervical screening testing preferences,decision‐making styles and information needs

Background New testing technologies and human papillomavirus (HPV) vaccines have recently brought changes to cervical cancer screening. In 2006, the Australian government also changed the protocol for managing abnormal Pap smears. Australian women’s attitudes and preferences to these changes are largely unknown. Quantitative data on information needs and community attitudes to informed decision making in screening in Australia are also limited. Objective This national study measures women’s preferences for testing and management of abnormal screening results, preferred decision‐making styles and information needs for cervical cancer screening. Design A randomly selected sample of Australian women aged 18–70 participated in a structured telephone questionnaire, exploring testing preferences, information and decision‐making needs. Results A total of 1279, of 1571 eligible women, participated in the study with an overall response rate of 81.4%. Half of the women (n = 637) preferred having their Pap smears at least annually, and 85% wanted concurrent HPV testing. A large proportion of women preferred to be involved in decision making for both routine Pap smears (87%) and follow‐up for abnormal results (89%). The majority of women wanted information on screening risks (70%) and benefits (77%); of these 81 (85%) wanted this information before screening. However, 63% of women only wanted information about follow‐up examinations if they had an abnormal Pap test result. Conclusion Australian women want to be involved in decision making for cervical cancer screening and require information on the risks and benefits of Pap testing prior to undergoing any screening.     

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.     

Physical Activity and Cervical Cancer Testing Among American Indian Women

Purpose: Studies have shown that women who engage in high levels of physical activity have higher rates of cancer screening, including Papanicalaou (Pap) tests. Because American Indian (AI) women are at high risk for cervical cancer morbidity and mortality, we examined Pap screening prevalence and assessed whether physical activity was associated with screening adherence among AI women from 2 culturally distinct regions in the Northern Plains and the Southwest. Methods: A total of 1,979 AI women at least 18 years of age participating in a cross‐sectional cohort study reported whether they received a Pap test within the previous 3 years. Physical activity level was expressed as total metabolic equivalent (MET) scores and grouped into quartiles. We used binary logistic regression to model the association of Pap testing and MET quartile, adjusting for demographic and health factors. Findings: Overall, 60% of women received a Pap test within the previous 3 years. After controlling for covariates, increased physical activity was associated with higher odds of Pap screening (OR = 1.1 per increase in MET quartile; 95% CI = 1.1, 1.2). Conclusions: This is the first study to examine physical activity patterns and receipt of cancer screening in AIs. While recent Pap testing was more common among physically active AI women, prevalence was still quite low in all subgroups. Efforts are needed to increase awareness of the importance of cervical cancer screening among AI women.