Human Papillomavirus and Cervical
Cancer Knowledge, Health Beliefs, and
Preventative Practices in Older Women

Kymberlee Montgomery, Joan Rosen Bloch, Anand Bhattacharya, and Owen Montgomery

Correspondence
Kymberlee Montgomery,
DrNP, WHNP-BC, Drexel
University College of
Nursing & Health
Professions, 245 N. 15th
Street, Bellet 1029,
Philadelphia, PA 19102.
[e-mail]

Keywords
human papillomavirus
HPV
cervical cancer
health beliefs
preventative practices

ABSTRACT

Objective: To explore knowledge of Human Papillomavirus (HPV) and cervical cancer, health beliefs, and preven-

tative practices in women 40 to 70 years.

Design: Cross-sectional descriptive.

Setting: Three urban ambulatory Obstetrics and Gynecology offices connected with a teaching hospital’s Depart-

ment of Obstetrics and Gynecology in the Mid-Atlantic section of the United States.

Participants: A convenience sample of 149 women age 40 to 70.

Methods: To assess HPV and cervical cancer knowledge, health beliefs, and preventative practices a self-admin-

istered survey, the Awareness of HPV and Cervical Cancer Questionnaire was distributed to women as they waited for

their well-woman gynecologic exam.

Results: The mean knowledge score was 7.39 (SD 5 3.42) out of 15. One third of the questions about the rela-

tionship of HPV and risks for cervical cancer were answered incorrectly by more than 75% of these women. Although

most appreciate the seriousness of cervical cancer, they believed themselves not particularly susceptible.

Conclusion: There is a need for HPV and cervical cancer awareness and education for women older than age 40.

Women’s health care professionals are well positioned to act as a catalyst to improve HPV and cervical cancer

knowledge, health beliefs, and preventative practice to ensure optimum health promotion for all women.

JOGNN, 39, 238-249; 2010.

DOI: 10.1111/j.1552-6909.2010.01136.x

Accepted December 2009

G

enital Human Papillomavirus (HPV) infection

is the most common sexually transmitted dis-

ease in the United States (Centers for Disease

Control [CDC], 2009). Approximately 25 million

American women are currently infected with one or

more strains of low risk (types 6 and 11) and/or high

risk (types 16 and 18) HPV, while more than 6 million

new infections are being reported every year (Dun-

ne et al., 2007; Parkin, 2006). HPV infection is the

leading cause of cervical cancer (CDC). Recent ad-

vances demonstrate that HPV, spread primarily

through skin-to-skin contact during sexual activity,

is the etiologic agent of genital warts and can be

isolated in 99.7% of cervical cancer cases (Dunne

et al.; Munoz et al., 2002; World Health Organization,

2008). Cervical cancer is responsible for signi¢cant

morbidity and mortality worldwide, including an es-

timated 4,000 deaths in the United States in 2009

alone (National Cancer Institute [NCI ], 2008).

Contrary to previous studies that demonstrate a de-

cline in HPV prevalence as women age, recent

evidence suggests HPV prevalence follows a

bimodal distribution with a ¢rst peak around age

20 years and a second smaller peak around age

40 to 50 years (Bosch & Harper, 2006; Chan et al.,

2009; Ferreccio et al., 2004; Molano et al., 2002;

Munoz et al., 2004: Reis et al., 2006). It is not clear if

the second peak around age 40 to 50 years is due

to new cases of HPV or HPV that was acquired

many years before but not previously identi¢ed. Yet

new incident cases at these years are certainly

plausible. Fluctuations in relationship infrastructure

with increased divorce rates and in¢delity disclo-

sures, and acceptance of nontraditional sexual

relationships place women at age 40 and older

at an increased risk of sexually transmitted dis-

ease exposures (Baay et al., 2004; Castle et al.,

2005).

Kymberlee Montgomery,
DrNP, CRNP, is a certified
women’s health nurse
practitioner at Drexel
University College of
Medicine; the Women’s
Health Nurse Practitioner
Program Track Coordinator
at Drexel University
College of Nursing and
Health Professions; a nurse
colposcopist; and the
director of the
transdisciplinary
colposcopy course at
Drexel University,
Philadelphia, PA.

(Continued)

JOGNN

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238

&

2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

http://jognn.awhonn.org

Previous research has demonstrated limited knowl-

edge and health beliefs related to HPV in the

adolescent and college age populations (Baer, All-

en, & Braun, 2000; Burak & Meyer,1997; Daley et al.,

2008; Dell, Chen, Ahmad, & Stewart, 2009; Fried-

man & Shepeard, 2007; Ingledue, Cottrell, &

Bernard, 2004). However, despite emerging data

showing every four out of ¢ve women that reaches

50 years of age will be infected with HPV and that

35% of women who die of cervical cancer are older

than age 65 (CDC, 2009), women older than age 40

are rarely the focus of any initiatives on HPV and

cervical cancer awareness (Montgomery & Bloch,

2010). The median age of diagnosis for cervical can-

cer is approximately 47 years ([7]CDC). It is possible

that these women do not believe themselves at risk

of HPV infections and are less likely to practice pre-

ventive measures that can potentially minimize the

transmission of HPV infection and the development

of cervical cancer. In keeping with the goals of

Healthy People 2010 (to help individuals of all ages

increase life expectancy and improve quality of

life, as well as reduce the number of new cancer

cases and illness, disability, and death caused by

cancer) (U.S. Department of Health and Human

Services, 2000), it is essential to understand HPV

and cervical cancer knowledge needs of women

older than age 40.

Background

More than 100 HPV genotypes are currently known,

and approximately 15 types of these potentially

cause cervical cancer (Gerberding, 2004; Roden

& Wu, 2006). Genotypes 16, 18, 31, and 45 are re-

sponsible for almost 80% of cervical cancer cases

worldwide, with genotype 16 accounting for almost

50% of these cases (Cli¡ord et al., 2006). Numer-

ous studies indicate that more than 90% of all HPV

infections in women clear within the ¢rst 2 years of

exposure (Gerberding Scheurer, Tortolero-Luna, &

Alder-Storthz, 2005; Schi¡man & Kjaer, 2003).

However, when the clearance of the virus is incom-

plete, HPV can progress to precancerous lesions

and cervical cancer (Koutsky et al., 2002; Jeurissen

& Makar, 2009; Schi¡man & Kjaer).

Acquisition of HPV infection of the genital tract usu-

ally occurs rapidly after sexual debut (Skinner et al.,

2008). Winer et al. (2003) showed a cumulative inci-

dence of HPV infection of about 40% in women

after ¢rst sexual intercourse or after sexual intimacy

with a new partner. Hence primary prevention strat-

egies in the preadolescent stage prior to HPV

exposure are optimal in eradicating cervical can-

cer. In 2006, the Food and Drug Administration

approved the ¢rst vaccine to prevent HPV acquisi-

tion and transmission for use in females age 9 to

26 years (CDC, 2009). After the Advisory Committee

on Immunization Practices (ACIP) put forth vacci-

nation recommendations in June of 2006, the CDC

began a multilevel national health campaign to ed-

ucate the targeted population of women in the

younger age group (Markowitz et al., 2007). In addi-

tion, the majority of cervical cancer cases and

deaths can be prevented through detection of pre-

cancerous changes in the cervix by cytology using

the Pap smear screening test.

The American College of Obstetricians and Gyne-

cologists (ACOG) (2009), the American Cancer

Society (ACS) (2007), and the U.S. Preventive Ser-

vices Task Force (USPSTF) (2007) have updated

Pap smear guidelines. ACOG recommends that cer-

vical cancer screening should begin at age 21 years

(regardless of sexual history), because women

younger than age 21 are at very low risk of cancer.

In addition, ACOG advises Pap smears every 2

years for women between age 21 and 29 years and

every 3 years for women age 30 and older who

have had three consecutive negative cervical cy-

tology screening test results and who have no

high-risk Pap smear history. The ACS suggests that

all women should begin cervical cancer testing 3

years after they start having sex (vaginal inter-

course). A woman who waits until she is older than

age 18 to have sex should start screening no later

than age 21. The USPSTF continues to recommend

a conventional Pap test at least every 3 years, re-

gardless of age. These three organizations agree

that co-testing using the combination of cytology

plus HPV DNA testing is an appropriate screening

test for women older than age 30 years.

Since the inception of these campaigns and new

Pap smear screening recommendations, aware-

ness of HPV improved in women age 18 to 26 years

but remains decreased in women age 27 to 49 years

(Jain et al., 2009). There is a persistent HPV and cer-

vical cancer knowledge gap of women older than

age 26. Pairing this gap with the emerging evidence

of a second peak in HPV prevalence in older wo-

men where the preponderance risk of cervical

cancer resides generates the compelling reason

for investigating HPV and cervical cancer knowl-

edge, health beliefs, and preventative practices in

women older than age 40 years.

Joan Rosen Bloch, PhD,
CRNP, is an assistant
professor in the doctoral
Nursing Department in the
College of Nursing and
Health Professions and in
the Department of
Epidemiology in the School
of Public Health at Drexel
University, Philadelphia,
PA.

Anand Bhattacharya, MHS,
is a research associate at
Drexel University’s College
of Medicine, Philadelphia,
PA.

Owen Montgomery, MD, is
the chairman of the
Department of Obstetrics
and Gynecology at Drexel
University College of
Medicine, Philadelphia, PA.

Four out of five women who reach age 50 years will be

infected with HPV; 35% of women who die of cervical

cancer are older than age 65.

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Theoretical Framework

This study was guided by the health belief model

(HBM). There are ¢ve core concepts: perceived

threat, perceived bene¢ts, perceived barriers, cues

to action, and self-e⁄cacy (Rosenstock, Strecher,

& Becker, 1994; Strecher & Rosenstock, 1997). The

HBM has been previously used to explain and pre-

dict health behaviors and health issues by focusing

on the knowledge, attitudes, and beliefs of individu-

als. As suggested by theories based on the HBM

(Strecher & Rosenstock), the likelihood that individ-

uals will take action to prevent illness depends on

their perception that they are personally vulnerable

to the condition, the consequences of the condition

would be serious, the precautionary behavior

e¡ectively prevents the condition, and the bene¢ts

of reducing the threat of the condition exceed

the costs of taking action (Redding, Rossi, Rossi,

Velicer, & Proschaska, 2000; Weistock et al., 2004).

Clinicians need to appreciate and understand their

patients’ health beliefs, especially in women age 40

and older who have not been the targets of the mar-

keting information about HPV, cervical cancer, and

the new vaccine.

Previous Studies of HPV
Knowledge

Knowledge related to HPV, its relationship to cervi-

cal cancer, and cervical cancer itself is improving

but continues to have de¢cits in younger and

older women (Denny-Smith, Bairan, & Page, 2006;

Holcomb, 2004; Ingledue et al., 2004; Montgomery

& Bloch, 2010; Jain et al., 2009). In the Denny-Smith

et al. study, the Awareness of HPV and Cervical

Cancer tool was distributed to a convenience

sample of 240 female nursing students, age 19 to

58 years with a mean age of 30 (SD

5 8.48) enrolled

in a baccalaureate nursing program. The results

indicated a lack of knowledge combined with

low perceptions of susceptibility and seriousness

of HPV and cervical cancer may make college

women more likely to contract sexually transmitted

infections (STIs) including HPV and therefore more

susceptible to cervical cancer. Numerous recent

studies that examined public knowledge of HPV

and this link to cervical cancer agree that public

awareness of HPV’s connection to cervical cancer

remains suboptimal (CDC, 2009; National Associa-

tion of Nurse Practitioners in Women’s Health

[NPWH][27][35][38], 2009; Sherris et al., 2006;

Vanslyke, Baum, Plaza, Otero, & Wheeler, 2008).

The most recent survey from the NPWH suggests

that women still do not have a clear understand-

ing about the relationship between HPV and

cervical cancer. Marlow, Waller, and Wardle (2009)

found that among the general public, few women

are aware that an STI potentially causes cervical

cancer.

The purpose of this exploratory descriptive study

was to describe knowledge of HPV and cervical

cancer, health beliefs, and preventative practices

of women age 40 to 70 years. In addition, the study

explored the relationships among knowledge of

HPV and cervical cancer and self-reported health

beliefs among women age 40 to 70 years.

Methods

Design

This study was a cross-sectional descriptive de-

sign. Anonymous data were collected over a 2-

month period in 2008 using a self-administered

pen-and-paper questionnaire.

Setting and Sample

A convenience sample of women age 40 to 70 years

was recruited from the waiting rooms of three am-

bulatory obstetrics and gynecology o⁄ces of a

large metropolitan university hospital in the Mid-At-

lantic section of the United States. All three o⁄ces

were used in an attempt to get a racially heteroge-

neous sample in this urban area that has rate of

cervical cancer 1.7 times higher than the national

rate (NCI, 2008). The inclusion criteria were women

age 40 to 70 years, presenting to their health care

provider for an annual checkup, and who did not

have a past or present history of HPV or cervical

cancer.

The sample size required for this study was guided

by a power analysis using the software program

G



Power (Version 3.0.10, Dusseldorf, Germany).

The power analysis was based on the correlation

analysis between the subscales knowledge, sus-

ceptibility, and seriousness. Small to medium e¡ect

size (Pearson’s r

5 0.23) was postulated in keeping

with Cohen’s (1992) recommendation for Pearson

correlation. Power was set to 0.80, meaning there

would be an 80% probability of reaching statistical

signi¢cance if the subscales were correlated. In

this study, for a signi¢cance level of

a 5 0.05

(two tailed), with an e¡ect size of 0.23, to achieve

a power of 0.80, a total sample size of 145 partici-

pants were required. To account for attrition due to

missing data, we recruited an additional 10% for a

total sample of 160. Out of 160 women who received

study packets, 149 completed questionnaires that

were returned in the sealed envelopes ; 11 question-

naires were incomplete and not used in these

analyses.

240

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Human Papillomavirus and Cervical Cancer Knowledge

Procedure

Following approval by the university Institution Re-

view Board (IRB), the study began by training a

research assistant (RA ; receptionist) at each of the

three o⁄ces. The training entailed using data on the

practice management program to identify potential

eligible participants when women are checked in

for their visits, inviting potential participants, and

keeping all data anonymous by sealing all enve-

lopes and placing them in the research bin in a

secured drawer or cabinet based on the speci¢c of-

¢ce. At each of the three sites, there were £yers

posted on the walls and a trained RA invited partic-

ipants if they met eligibility. If the patient met the two

requirements of age and the reason for the visit

(well-women check up), she was given a sheet to

read to further determine eligibility (exclusion crite-

ria if she had a history of HPV or cervical cancer).

After she read the sheet, the RA asked if she was el-

igible. If she said yes, she was given the survey

packet with a cover letter that accompanied the

packet. The cover letter contained a brief descrip-

tion

of

the

research

project,

assurance

of

anonymity, the voluntary nature of participation,

and IRB contact information. Completion of the sur-

vey acted as consent for participation. Once the

survey was completed, it was placed in a sealed en-

velope to be returned to the researcher such that no

identity was disclosed.

Measures

Sociodemographic variables collected included

age, race, education, health insurance status, relig-

ious a⁄liation, marital status, and income level.

HPV and Cervical Cancer Knowledge,
Health Beliefs, and Preventative Practices

With permission from the authors, the Awareness of

HPV and Cervical Cancer Questionnaire (Ingledue

et al., 2004) was used to measure knowledge and

beliefs, as well as preventative measures in regards

to HPV and cervical cancer. Ingledue et al. devel-

oped this self-administered 36-item questionnaire

based on the HBM (Glanz, Rimer, & Lewis, 2002) to

investigate HPV/cervical cancer knowledge, health

beliefs, and perception, and preventative measures

in college-age women. The tool was used in this

study because it was speci¢cally designed for HPV

and cervical cancer awareness and congruent

to the HBM that guided the study. Although

the questionnaire was originally used on college

age women, a panel of experts (obstetricians/gyne-

cologists, physicians, and nurse practitioners)

reviewed the questions concluding they were

generalizable to women of all age groups as dem-

onstrated by subsequent studies that used the

questionnaire on women from other age groups

(Denny-Smith et al., 2006). Using the same tool

allowed comparison of results from this study to

other published studies (Denny-Smith et al.; Ingle-

due et al ; McKeever, 2008).

The knowledge portion of the questionnaire con-

sists

of 15

multiple-choice

items,

with

each

question permitting only one response. The knowl-

edge score for this instrument ranges from 0 to 15

with higher scores indicative of more knowledge of

HPV and cervical cancer. The perceived threat por-

tion of cervical cancer consists of 15 questions,

using a 5-point Likert-type scale ranging from 1

(strongly agree) to 5 (strongly disagree). Nine of

the 15 questions relate to perceived susceptibility

and have a possible subtotal score range from 9 to

45. The remaining six questions relate to perceived

seriousness and have a potential score that ranges

from 6 to 30. Higher scores imply greater level of

perceived susceptibility and seriousness about

HPV and cervical cancer. The last six questions fo-

cus on individual sexual behaviors, risk factors,

and history of pap smears and are multiple-choices

categorical variables.

Ingledue et al. (2004) supported content validity of

the instrument by using consensual validity via a

panel of experts that represented several health

professionals including two gynecologists, two pro-

fessors of health

education,

and a medical

professional from the Breast and Cervical Cancer

program (Ingledue et al.). The authors also deter-

mined stability of the instrument over a 10-day

period through test^retest reliability procedure.

They reported that the instrument has high test^re-

test reliability for knowledge (r

5 0.90), perceptions

and beliefs (r

5 0.95), and preventative behaviors

(r

5 0.90) (Ingledue et al.). Internal consistency reli-

ability was not reported in the study by Ingledue et

al. For the current study, the internal consistency re-

liability for the Knowledge subscale was adequate

(Cronbach’s

a 5 0.77), but unacceptably low for

the Susceptibility subscale (

a 5 0.49) and Serious-

ness subscale (

a 5 0.20). This low reliability makes

any conclusions based on these subscales tenta-

tive at best. Quantitative data were coded and

entered into SPSS-PC 16.0 (SPSS Inc, Chicago, IL)

and stored on a secured computer used for re-

search

purposes

only.

Descriptive

statistics

including frequencies for categorical variables and

measures of central tendency (M) and variances

(SD) for continuous variables were used to describe

the HPV/cervical cancer knowledge, health beliefs,

and preventative practices in women age 40 to 70

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Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O.

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E S E A R C H

years. Pearson product^moment correlations were

calculated to describe the relationship among

HPV/cervical

cancer

knowledge,

susceptibility,

and seriousness in these women.

To further understand knowledge, health beliefs

(perceived susceptibility and perceived serious-

ness) and preventative practices in women age 40

to 70, these women were divided into age groups

by decade: 40 to 50, 51 to 60, and 61 to 70 years. Fol-

lowing testing for assumptions, a one-way analysis

of variance (ANOVA) was conducted to compare

knowledge and health beliefs among the three sub-

groups. If the ANOVAs were signi¢cant, post hoc

analyses were conducted using a Bonferroni ad-

justment. Preventative practices were compared

among the three subgroups using the chi-square

analysis. A Fishers Exact test was used when as-

sumptions of chi-square were not met. Level of

signi¢cance for all tests were set at

a 5 0.05.

Results

Sample Characteristics

The sociodemographics of the participants are de-

tailed in Table 1. The average age of the sample was

50.86 (SD

5 7.60) years old. Of the 149 women, one

half reported being married (n

5 75), more than

80% had private health insurance (n

5 126) and

more than 30% (n

5 47) had an annual household

income of $80,000 and more.

Knowledge

The mean score for knowledge, measured by the 15

items on the Awareness of HPV and Cervical Cancer

Questionnaire was 7.39 (SD

5 3.42) out of a possible

15.Table 2 represents the frequency of correct and in-

correct responses for each item of the Knowledge

subscale of the Awareness of HPV and Cervical

Cancer Questionnaire. It should be noted that more

than one half of the women responded incorrectly

to knowledge questions 1, 2, 3,10, 12, and 15.

Health Beliefs

Health beliefs were measured under the subdimen-

sions of perceived threat: perceived susceptibility

and perceived seriousness. For susceptibility, mea-

sured by nine items on the Awareness of HPV and

Cervical Cancer Questionnaire (Ingledue et al.,

2004) the mean score was 26.11 (SD

5 4.64) out of

a possible 45, and ranged from 18 to 44. Table 3 rep-

resents the frequency and percentage of responses

for each item for susceptibility in the questionnaire.

More than 50% of women in this age group report-

edly worry about getting cervical cancer, however

just more than 32% are concerned about being in-

Table 1: SocioDemographic
Characteristics of the Sample (N 5 149)

SocioDemographic

Characteristics

Mean (SD)

Ageçmean (SD)

50.86 (7.6)

Sexual partnersçmean (SD)

1.45 (1.4)

Race/ethnicity

n (%)

White (Caucasian/

Non-Hispanic)

92 (61.7)

African American/

Non-Hispanic

37 (24.8)

Asian/Hawaiian/Paci¢c

Islander

6 (4)

Hispanic/Latino

9 (6)

Other

5 (3.4)

Education

High School graduate

38 (25.5)

Some college courses

43 (28.8)

College graduate

64 (43)

Other

3 (2)

Missing

1 (0.7)

Marital status

Single

30 (20.1)

Married

75 (50.3)

Widowed

7 (4.7)

Divorced

24 (16.1)

Living w/signi¢cant other

12 (8.1)

Missing

1 (0.7)

Religion

Christian

41 (27.5)

Catholic

65 (43.6)

Jewish

18 (12.1)

Muslim

2 (1.3)

Other

22 (14.8)

Missing

1 (0.7)

Income level

0 to 20k

10 (7.0)

21 to 40k

20 (13.4)

41 to 60k

37 (24.8)

61 to 80k

24 (16.2)

242

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Human Papillomavirus and Cervical Cancer Knowledge

fected with HPV. Furthermore, only 23% consider

themselves at risk for developing cervical cancer,

while a mere 13% perceive themselves at risk of ac-

quiring HPV. More than 62% of the women

reportedly believe that they have the ability to avoid

getting a HPV infection, with another 50% believ-

ing that they can control whether they get cervical

cancer.

Similarly, the mean score for seriousness, mea-

sured by six items from the health belief subscale

from the same instrument was 19.73 (SD

5 2.87).

Scores ranged between 13 and 29. Details of fre-

quencies and percentage responses for items

measuring seriousness are presented in Table 4.

Approximately 33% of women view cervical cancer

as the most serious disease they could possibly

acquire and one that is life threatening. More than

60% incorrectly believe that HPV is curable.

Preventative Practices

Preventative practice behavior was pro¢led using

six questions. A summary of frequencies for re-

sponses to each question is presented in Table 5. A

majority of the women (n

5 100, 67.1%) reported

being active in a sexual relationship at the time of

participation. Just more than one half of the women

(n

5 78, 58.4) reported never using condoms. In ad-

dition, 84.5% (n

5 126) of the women revealed they

do not use any oral contraceptives. The majority of

women (n

5 118, 79.2%) polled were nonsmokers

with only 65.1% (n

5 97) of them receiving a Pap

smear test within the past year. Finally, almost three

out of every four women answered that they were

unaware of a family member who had been previ-

ously diagnosed with HPV or cervical cancer. Table

5 depicts preventative practices in women age 40 to

70 years classi¢ed into three subgroups (40^50, 51^

60, and 61^70 years).

Table 6 represents the Pearson product^moment

correlation (r) among knowledge, susceptibility

and seriousness. There was little, if any (r

5 0.06)

to low (r

5 0.38) positive relationship among knowl-

edge, susceptibility, and seriousness in women age

40 to 70 years (Portney & Watkins, 2010). Although

the correlation coe⁄cient was signi¢cant between

knowledge and seriousness (r

5 0.38, p

 .001),

the strength of the relationship was not. Caution in-

terpreting this relationship is warranted because

the subscale to measure seriousness in this popu-

lation had very low internal consistency reliability.

Subgroup Analysis

Table 7 presents the mean (SD) for knowledge, sus-

ceptibility, and seriousness and the results from the

ANOVA. The data met the assumptions of normal

distribution and homogeneity of variances be-

tween the groups. Signi¢cant di¡erences were

Table 1. Continued

SocioDemographic

Characteristics

Mean (SD)

80k or more

47 (31.6)

Missing

10 (7.0)

Health insurance

n (%)

Private

126 (84.6)

Public funded

13 (8.6)

No health insurance

4 (2.7)

Unsure

4 (2.7)

Missing

2 (1.4)

Table 2: Frequency of Correct Responses
for Multiple Choice Questions Regarding
HPV/Cervical Cancer Knowledge in
Women Age 40 to 70 Years (N 5 149)

Question

Correct

Multiple choice

n (%)

1. The virus associated with cervical cancer is

transmitted by:

66 (44.3)

2. Cervical cancer and pre cancer cells are

associated with the presence of:

40 (26.8)

3. Cervical cancer can be diagnosed by:

32 (21.5)

4. Prevention of cervical cancer may require:

84 (56.6)

5. HPV can cause:

98 (65.8)

6. HPV can live in the skin without causing growths

or changes:

82 (55.8)

Risk factors (yes or no)

7. Multiple sex partners

100 (67.1)

8. Having genital warts

76 (51.7)

9. Sexual intercourse before 18

75 (50.3)

10. Taking illegal drugs

27 (18.1)

11. Having contracted any STIs

85 (57.8)

12. Smoking cigarettes

33 (22.3)

13. Poor diet or nutrition

79 (53.4)

14. Using tampons

101 (67.8)

15. Use of oral contraceptives (birth control pills)

13 (8.8)

Note. Items from HPV Questionnaire (Ingledue et al., 2004).

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Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O.

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noted between the three subgroups (age 40^50,

51^60, 61^70 years) for seriousness scores only,

F(2,146)

5 4.14, p 5 .02; but not for knowledge,

F(2,146)

5 0.634,

p

5 .53;

and

susceptibility,

F(2,146)

5 2.92, p 5 .06. Post hoc analysis using

the Bonferroni adjustment revealed that the 61 to

70 years age group had signi¢cantly less percep-

tion of seriousness compared to the 51 to 60 year

(p

5 .02) and 40 to 50 years age groups (p 5 .05).

Preventative practices in women age 40 to 70 years

classi¢ed into the three subgroups (40^50, 51^60,

and 61^70 years) are presented in Table 5. Chi-

square/Fisher’s Exact analysis revealed signi¢cant

di¡erences in distribution of practice choices be-

tween the three subgroups for ‘‘use of condoms,’’

w

2

(10, N

5 148) 5 18.93, p 5 .02 and ‘‘use of oral

contraceptives’’

w

2

(4, N

5 148) 5 16.90, p 5 .001

only,

but

not

for

‘‘sexual

experience,’’

w

2

(4,

N

5 148) 5 7.81, p 5 .10, ‘‘cigarette smoking,’’

w

2

(2,

N

5 148) 5 1.16, p 5 .58, and ‘‘Pap smear test,’’

w

2

(4,

N

5 148) 5 0.90, p 5 .97. As evident from Table 5,

most women age 51 to 60 years (68%) and age

61 to 70 years (83.3%) indicated they did not use

Table 3: Likert-Type Scale Responses for Susceptibility Items

Question

Number

Question (Responses)

Strongly

Disagree,

n (%)

Disagree,

n (%)

Neutral,

n (%)

Agree,

n (%)

Strongly

Agree,

n (%)

16

I worry about getting cervical cancer.

16 (10.7)

25 (16.8)

33 (22.1)

46 (30.9)

29 (19.5)

17

I worry about getting HPV.

25 (16.8)

36 (24.2)

40 (26.8)

28 (18.8)

20 (13.4)

18

I believe that I am at risk for developing cervical

cancer.

25 (16.8)

46 (30.9)

41 (27.5)

29 (19.5)

7 (4.70)

19

I believe I am at risk for contracting HPV.

34 (22.8)

51 (34.2)

45 (30.2)

12 (8.1)

7 (4.7)

20

All women have an equal chance of developing

cervical cancer, it is beyond my control.

29 (19.5)

42 (28.2)

27 (18.1)

39 (26.2)

12 (8.1)

21

My chances of getting HPV are high.

34 (22.8)

56 (37.6)

43 (28.9)

10 (6.7)

5 (3.4)

22

My chances of getting HPV are low.

7 (4.7)

26 (17.4)

39 (26.2)

45 (30.2)

31 (20.8)

23

I have the ability to avoid cervical cancer.

7 (4.7)

37 (24.8)

36 (24.3)

45 (30.2)

24 (16.1)

24

I have the ability to avoid HPV infection.

9 (6.0)

20 (13.4)

26 (17.4)

60 (40.3)

33 (22.1)

Note. Items from HPV Questionnaire (Ingledue et al., 2004).

Table 4: Likert-Type Scale Responses of Seriousness

Question

Number

Question

Strongly

Disagree,

n (%)

Disagree,

n (%)

Neutral,

n (%)

Agree,

n (%)

Strongly

Agree,

n (%)

25

All women who develop cervical cancer must

have their uterus removed.

31 (20.8)

56 (37.6)

41 (27.5)

15 (10.1)

3 (2.0)

26

Among the diseases that I can imagine getting,

cancer of the cervix is the most serious.

24 (16.1)

55 (36.9)

21 (14.1)

32 (21.5)

16 (10.7)

27

I believe HPV is curable with proper medical

treatment.

10 (6.7)

16 (10.7)

32 (21.5)

73 (49.0)

17 (11.4)

28

Cervical cancer is often curable with early

detection and proper medical treatment.

1 (.7)

9 (6.0)

17 (11.4)

80 (53.7)

42 (28.2)

29

HPV is a life-threatening disease.

7 (4.7)

52 (34.9)

38 (25.5)

32 (21.5)

18 (12.1)

30

No one dies anymore from cervical cancer.

49 (32.9)

62 (41.6)

21 (14.1)

12 (8.1)

4 (2.7)

Note. Items from HPV Questionnaire (Ingledue et al., 2004).

244

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Human Papillomavirus and Cervical Cancer Knowledge

Table 5: Responses to Preventative Practices Characterized by Age (40–50, 51–60, and
61–70 Years of Age)

Preventative Practices

Total Sample

(Age 40

–70)

N

5 149

100%

Group 1

(Age 40

–50)

N

5 73

49%

Group 2

(Age 51

–60)

N

5 58

39%

Group 3

(Age 61

–70)

N

5 18

12%

Sexual experience: n (%)

Currently involved

100 (67.1)

56 (76.7)

33 (56.9)

11 (61.1)

Not currently involved

46 (30.8)

17 (23.3)

22 (37.9)

7 (38.9)

Never had sexual intercourse

2 (1.4)

0

2 (3.4)

0

Missing

1 (0.7)

Use of condoms: n (%)

Always

11 (7.4)

7 (9.6)

4 (6.9)

0

Usually

16 (10.7)

11 (15.1)

5 (8.6)

0

Sometimes

15 (10.1)

11 (15.1)

4 (6.9)

0

Occasionally

7 (4.7)

6 (8.2)

0

1 (5.5)

Rarely

11 (7.4)

4 (5.5)

5 (8.6)

2 (11.1)

Never

87 (58.4)

33 (45.2)

39 (67.2)

15 (83.3)

Missing

2 (1.3)

Use of oral contraceptives: n (%)

Yes

19 (12.8)

17 (23.3)

1 (1.7)

1 (5.5)

No

126 (84.5)

53 (72.6)

56 (96.5)

17 (94.4)

Don’t know

1 (0.7)

1 (1.4)

0

0

Missing

3 (2.0)

Cigarette smoking: n (%)

Yes

30 (20.1)

17 (23.2)

9 (15.5)

4 (22.22)

No

118 (79.2)

56 (76.7)

48 (82.7)

14 (77.8)

Missing

1 (0.7)

Pap smear: n (%)

Never

2 (1.40)

1 (1.36)

1 (1.72)

0

Within the past year

97 (65.10)

49 (67.12)

36 (62.06)

12 (66.7)

Had one but not within past year

47 (31.50)

22 (30.13)

19 (32.75)

6 (33.33)

Missing

3 (2.00)

Family member diagnosed with HPV: n (%)

Yes

22 (14.8)

14 (19.1)

7 (12.1)

1 (5.5)

No

108 (72.5)

52 (71.2)

43 (74.1)

13 (72.2)

Don’t know

16 (10.7)

7 (9.6)

5 (8.6)

4 (22.22)

Missing

3 (2.0)

Note. Items from HPV Questionnaire (Ingledue et al., 2004).

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condoms during sexual activity. In contrast, less

than one half (45.2%) of women age 40 to 50 years

selected never using condoms. The use of oral con-

traceptives was also less prevalent in the women

age 61 to 70 years (5.6%) and 51 to 60 years

(1.7%) compared to those age 40 to 50 years

(23.3%).

Discussion

Women age 40 to 70 years participating in this

study demonstrated low-level knowledge of HPV

and cervical cancer with more than one half of them

responding incorrectly to around 50% of the ques-

tions regarding knowledge of cervical cancer/HPV.

One third of the questions about the relationship of

HPV and risks for cervical cancer were answered in-

correctly by more than 75% of these women. As

evident from Table 2, most women in the study ex-

hibited

awareness

that

HPV

is

a

sexually

transmitted disease that could potentially cause

genital warts. They were however unaware of its re-

lationship to cervical cancer, its diagnosis, and the

clinical manifestations from the disease. As evident

in Table 3, more than one half of the respondents

were able to correctly identify risk factors of cervical

cancer that are associated with sexual behavior

and sexually transmitted diseases (multiple sex

partners, having STIs, having genital warts, and

sexual intercourse before age 18). However, these

women were unable to identify nonreproductive

system risk factors for cervical cancer (cigarette

smoking, use of illegal drugs, and use of oral con-

traception). Generally, the participants in the group

exhibited health-conscious behavior. The majority

of the women had a Pap smear within the last year,

do not smoke, and are seeing their provider for a

well-woman annual exam.

Regardless of their current marital status, the ma-

jority of this group does not use condoms. Almost

60% of women in this age group are married or liv-

ing with their signi¢cant other and the majority of

the group had only one sexual partner in the last 5

years. Most acknowledge HPV as a STI but did not

associate HPV with cervical cancer (see Table 5).

Likewise, the majority seemed unworried or per-

ceived themselves at low risk for acquiring HPV.

These women believe that cervical cancer is seri-

ous but curable with early detection and medical

treatment. However, a majority of this group incor-

rectly believed that HPV infection is curable with

proper medical treatment, and only one third

thought that the condition is life threatening. The

signi¢cant correlation between knowledge and

perceived seriousness revealed that the less

knowledge women had regarding HPV and cervical

cancer, the less they perceived the seriousness of

their risk for cervical cancer. With insu⁄cient

knowledge and understanding of the pathophysiol-

ogy of HPV and cervical cancer these women

remained worried about cervical

cancer de-

spite the fact that they were not worried about its

precursor.

Much of the knowledge associating HPV with cervi-

cal cancer has evolved within the past decade.

Moreover, despite the extensive public educational

Table 6: Pearson Correlations Among
Scores of Knowledge, Susceptibility, and
Seriousness

Variable (N

5 149)

Susceptibility

Seriousness

Knowledge

.06

.38



Susceptibility

ç

.15



p

o.001.

Table 7: Means and Standard Deviations Comparing Three Subgroups of Women Age 40
to 50, 51 to 60, and 61 to 70 Years for Knowledge, Susceptibility, and Seriousness
Scores

Group

N

Knowledge

Susceptibility

Seriousness

Mean (SD)

p Value

Mean (SD)

p Value

Mean (SD)

p Value

40 to 50 years

73

7.27 (3.31)

.53

27.01 (4.58)

.06

19.81 (2.92)

.02

51 to 60 years

58

7.74 (3.62)

25.38 (4.36)

20.17 (2.60)

61 to 70 years

18

6.77 (3.28)

24.77 (5.24)

18.00 (3.05)

More than 75% of the women answered one third of the

knowledge questions about the relationship of HPV and

risks for cervical cancer incorrectly.

246

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Human Papillomavirus and Cervical Cancer Knowledge

campaigns

through

media

and

educational

websites sponsored by reputable government orga-

nizations such as the CDC and the Food and Drug

Administration, and major international pharma-

ceutical companies over the past 5 years (CDC,

2009), women age 40 to 70 years continue to pos-

sess an inadequate knowledge base regarding

HPV and cervical cancer compared to women from

the original study by Ingledue et al. (2004) using

this tool.

In clinical practice, new technology enables health

care providers to appropriately stratify individuals’

perception of their susceptibility to cervical cancer.

The current American Society of Colposcopy and

Cervical Pathology (2006) guidelines encourages

practitioners to reassure women that they are less

susceptible to cervical cancer if they test negative

for high-risk HPV DNA and to appropriately identify

the subset of women in this group who are at an in-

creased susceptibility for cervical cancer.

Limitations

The ¢ndings of this study should be interpreted in

light of the several existing limitations. Participants

were primarily White, educated, and not of low in-

come. Consequently the ¢ndings may not be

generalized to other populations, especially urban

socioeconomically disadvantaged populations of

women of this age group. Secondly, this study relied

on self-report with no attempt to independently ver-

ify respondents’ information. In addition, although

this study used an anonymous questionnaire, limi-

tations of a survey study may apply. Surveys

provide only real-time descriptions of behaviors

and feelings of the respondents and responses

cannot always be taken as accurate descriptions

of what the respondents actually do or really feel.

This is true particularly for behavior that is contrary

to generally accepted norms of society, such as in-

formation regarding sexual activity (Zia, 2000).

Some of these women may have been unwilling to

indicate that they have engaged in controversial

behaviors, thus resulting in social desirability bias.

Although most women appreciated the seriousness

of cervical cancer, they believed themselves not

particularly susceptible. However, data were anon-

ymous and could not be veri¢ed by medical records

to validate their perceived HPV status and risk for

cervical cancer.

Data collected were limited to the items contained in

the Awareness of HPV and Cervical Cancer Ques-

tionnaire (Ingledue et al., 2004). Although the tool

was developed 5 years ago, some items need to be

revised for this age group, such as the question re-

garding yearly Pap smears. Practice guidelines

have been revised and Pap smear frequency for

women not at high risk for cervical cancer is every

3 years (U.S. Census Bureau, 2000). Moreover, inter-

nal reliability for the subscales of seriousness and

susceptibility were poor for this study. In women

older than age 40, the poor reliability may re£ect

that the subscales of seriousness and susceptibility

are actually measuring two dimensions: their health

beliefs about cervical cancer and their health be-

liefs about HPV (see Tables 3 and 4). Because this

population has an inadequate knowledge of the re-

lationship between HPV and cervical cancer, this

may be driving the poor reliability. The items in this

subscale may need to be revised to better represent

the construct of seriousness and susceptibility.

However, for the exploratory nature of this study,

using an existing tool with published data on HPV

knowledge and health beliefs adds strength to the

¢ndings.

Clinical Implications

Pap smear screening has been one of the most suc-

cessful public health interventions for cervical

cancer screening and prevention of the 20th cen-

tury (Markowitz et al., 2007). Only recently, in the

21st century, it has evolved into HPV screening and

diagnosis. Nurses need to be aware of the clinical

implications for women of this particular age group.

The ¢ndings of this study reveal obvious inconsis-

tencies and gaps in the knowledge, health beliefs,

and preventative practices regarding HPV and cer-

vical cancer in women age 40 to 70 years. Are they

adequately informed that their ‘‘routine Pap smear’’

also screens for HPV? Are they prepared to under-

stand what it means when they are told they have

HPV? Nurses and doctors must be prepared to ex-

plain the new consensus guidelines, if and why

they may have a HPV test, and especially the mean-

ing of a positive test. A focus-tailored approach to

appropriate educational and counseling is needed.

Implications for Future Research

Development of Ingledue’s tool is warranted to fur-

ther advance understandings of how knowledge,

health beliefs, and preventive practices interact

in all women, especially in populations with high

Nurses need to be aware that HPV and cervical cancer

are not just diseases infecting young women as portrayed

in the media.

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Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O.

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prevalence and risk of cervical cancer. Unclear is

the impact of di¡erences in women’s knowledge on

their health beliefs and preventative practices,

and how to best design e¡ective culturally sensi-

tive, age-appropriate educational awareness and

health promotion campaigns to better equip women

to minimize their chances and their daughters’

chances of acquiring HPV and cervical cancer.

Another area of research involves investigating cur-

rent practice patterns regarding HPV and cervical

cancer knowledge in health care professionals,

speci¢cally nurses that educate patients about this

health condition. New evidence on HPV and cervi-

cal cancer is emerging at an explosive pace, and it

is challenging for health care professionals to stay

current with the copious amount of information. De-

termining the level of HPV and cervical cancer

knowledge of healthcare professionals will help re-

searchers identify if patients have access to the

appropriate information and services.

Conclusion

More than 75% of the women answered one third of

the knowledge questions about the relationship of

HPV and risks for cervical cancer incorrectly. Al-

though most women appreciated the seriousness

of cervical cancer, they believed themselves not

particularly susceptible. Appropriate educational

materials are needed to increase HPV and cervical

cancer prevention for all women regardless of their

age.

REFERENCES

American Cancer Society. (2007). American Cancer Society recommen-

dations for human papillomavirus (HPV) vaccine use to prevent

cervical cancer and pre-cancers. Retrieved from http://www.

cancer.org/docroot/cri/content/cri_2_6x_acs_recommendations_for_

hpv_vaccine_use_to_prevent_cervical_cancer_and_pre-cancers_8.asp

American College of Obstetricians and Gynecologists. (2009). Cervical

cytology screening. Practice Bulletin, December 2009 #109,

ACOG.

American Society for Colposcopy and Cervical Pathology. (2006). 2006

consensus guidelines for the management of women with abnor-

mal cervical cancer screening tests. Retrieved from http://www.

asccp.org/consensus.shtml

Baay, M., Smits, E., Tjalma, W., Lardon, F., Weyler, J., Van Royen, P., et al.

(2004). Can cervical cancer screening be stopped at 50? The

prevalence of HPV in elderly women. International Journal of Can-

cer, 108, 258-261.

Baer, H., Allen, S., & Braun, L. (2000). Knowledge of human papillomavirus

infection among young adult men and women: Implications for

health education and research. Journal of Community Health, 25,

67-78.

Bosch, X., & Harper, D. (2006). Prevention strategies of cervical cancer in

the HPV vaccine era. Gynecologic Oncology, 103(1), 21-24.

Burak, L. J., & Meyer, M. (1997). Using the health belief model to examine

and predict college women’s cervical cancer screening beliefs

and behavior. Health Care for Women International, 18, 251-262.

Castle, P. E., Schi¡man, M., Herrero, R., Hildesheim, A., Rodriguez, A. C.,

Bratti, M. C., et al. (2005). A prospective study of age trends in cer-

vical human papillomavirus acquisition and persistence in

Guanacaste, Costa Rica. Journal of Infectious Disease, 191, 1808-

1816.

Center for Disease Control and Prevention. (2009). Human Papillomavi-

rus. Rockville, MD: National Prevention Network.

Chan, P., Chang, A., Yu, M., Li, W., Chan, M., Yeung, A., et al. (2009). Age dis-

tribution of human papillomavirus infection and cervical neoplasia

re£ects caveats of cervical screening policies. International Jour-

nal of Cancer, 26(1), 297-301.

Cli¡ord, G., Franceschi, S., Diaz, M., Munoz, N., & Villa, L. L. (2006). HPV

type-distribution in women with and without cervical neoplastic

diseases. Vaccine, 24, S26-S34.

Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155-159.

Daley, E. M., Perrin, K. M., Vamos, C., Webb, C., Mueller, T., Packing-Ebuen,

J. L., et al. (2008). HPV knowledge among HPV

1 women.

American Journal of Health Behavior, 32, 477-487.

Dell, D., Chen, H., Ahmad, F., & Stewart, D. (2009). Knowledge about

human papillomavirus among adolescents. Obstetrics and Gyne-

cology, 96, 653-656.

Denny-Smith, T., Bairan, A., & Page, M. (2006). A survey of female nursing

students’ knowledge, health beliefs, perceptions of risk, and risk

behaviors regarding human papillomavirus and cervical cancer.

Journal of the American Academy of Nurse Practitioners, 18(2),

62- 69.

Dunne, E. F., Unger, E. R., Sternberg, M., McQuillan, G., Swan, D. C., Patel, S.

S., et al. (2007). Prevalence of HPV infection among females in the

United States. Journal of the American Medical Association,

297(8), 813-819.

Ferreccio, C., Prado, R., Luzoro, A., Ampuero, S., Snijders, P., Meijer, C., et al.

(2004). Population based prevalence and age distribution of hu-

man papillomavirus among women in Santiago, Chile. Cancer

Epidemiology, Biomarkers and Prevention, 12, 2271-2276.

Friedman, A., & Shepeard, H. (2007). Exploring the knowledge, attitudes,

beliefs, and communication preferences of the general public

regarding HPV: Findings from CDC focus group research and im-

plications for practice. Health Education & Behavior, 34, 471- 484.

Gerberding, J. (2004). Report to Congress: Prevention of genital human

papillomavirus infection. Atlanta, GA: Centers for Disease Control

and Prevention, Department of Health and Human Services.

Glanz, K., Rimer, B. K., & Lewis, F. M. (2002). Health behavior and health

education. Theory, research and practice. San Fransisco: Wiley &

Sons.

Holcomb, B., Bailey, J. M., Crawford, K., & Ru⁄n, M. (2004). Adults’ knowl-

edge and behaviors related to human papillomavirus infection.

Journal of the American Board of Family Practice, 17(1), 26 -31.

Ingledue, K., Cottrell, R., & Bernard, A. (2004). College women’s knowledge,

perceptions, and preventative behaviors regarding HPV and cervi-

cal cancer. American Journal of Health Studies, 19(1), 28 -35.

Jain, N., Euler, G. L., Shefer, A., Lu, P., Yankey, D., & Markowitz, L. (2009).

Human papillomavirus (HPV) awareness and vaccination initia-

tion among women in the United States, National Immunization

Survey-Adult 2007. Preventative Medicine, 48(5), 426- 431.

Jeurissen, S., & Makar, A. (2009). Epidemiological and economic impact

of Human Papillomavirus vaccines. International Journal of Gyne-

cological Cancer, 19(4), 761-771.

Koutsky, L., Ault, K., Wheeler, C., Brown, D., Barr, E., Alvarez, F., et al. (2002).

A controlled trial of human papillomavirus type 16 vaccine: Proof of

principle study investigators. New England Journal of Medicine,

347, 1645-1651.

248

JOGNN, 39, 238-249; 2010. DOI: 10.1111/j.1552-6909.2010.01136.x

http://jognn.awhonn.org

R

E S E A R C H

Human Papillomavirus and Cervical Cancer Knowledge

Markowitz, L., Dunne, E., Saraiya, M., Lawson, H., Chesson, H., & Unger, E.

(2007). Quadrivalent human papillomavirus vaccine: Recommen-

dations of the Advisory Committee on Immunization Practices

(ACIP). Morbidity and Mortality Weekly Report, 56, 1-24.

Marlow, L., Waller, J., & Wardle, J. (2009). The impact of human papilloma-

virus information on perceived risk of cervical cancer. Cancer

Epidemiology Biomarkers and Prevention, 18, 373-378.

Molano, M., Posso, H., Weiderpass, E., van den Brule, A. J., Ronderos, M.,

Franceschi, S., et al. (2002). Prevalence and determinants of HPV

infection among Colombian women with normal cytology. British

Journal of Cancer, 87, 324-333.

McKeever, A. (2008). Female college students’ self-reported behavioral

change after an educational intervention to reduce behaviors as-

sociated with

cervical cancer

risk. Dissertation

Abstracts

International, 70 (4) (ProQuest document ID: 1731902691 or ATT

No. 3352986)

Montgomery, K., & Bloch, J. (2010). The human papillomavirus in women

over 40: The forgotten generation. Implications for practice and

recommendations for screening. Journal of the American Acad-

emy of Nurse Practitioners, 22, 92-100.

Munoz, N., Fransechi, S., Bosetti, C., Moreno, V., Herrero, R., Smith, J., et al.

(2002). Role of parity and human papillomavirus in cervical can-

cer: The IARC multicentric case-control study. Lancet, 359(9312),

1093-1101.

Munoz, N., Mendez, F., Posso, H., Molano, M., van den Brule, A., Ronderos,

M., et al. (2004). Incidence, duration, and determinants of cervical

human papillomavirus Infection in a cohort of Columbian women

with normal cytological results. Journal of Infectious Disease, 190,

2077-2087.

National Association of Nurse Practitioners in Women’s Health. (2009).

Cervical cancer awareness and knowledge survey: An executive

summary. Retrieved from http://www.npwh.org/i4a/pages/index.

cfm?pageid=1cervical%20cancer%20awareness%20and%20

knowledge%20survey

National Cancer Institute. (2008). Burden of cervical cancer prior to HPV

vaccine assessed. National Cancer Institute Bulletin, 5(23). Re-

trieved March 1, 2009, from http://www.cancer.gov

Parkin, D. (2006). The global health burden of infection-associated

cancers in the year 2002. International Journal of Cancer, 118,

3030-3044.

Portney, L., & Watkins, M. (2010). Foundations of clinical research: Appli-

cations to practice. New Jersey: Prentice Hall.

Redding, C. A., Rossi, J. S., Rossi, S. R., Velicer, W. F., & Proschaska, J. O.

(2000). Health behavior models. International Electronic Journal

of Health Education, 3(Special Issue), 180-193.

Reis, L., Harkins, D., Krapcho, M., Mariotto, A., Miller, B., Feuer, E., et al.

(2006). SEER cancer statistics review, 1975-2003. Bethesda, MD:

National Cancer Institute.

Roden, R., & Wu, T. (2006). How will vaccines a¡ect cervical cancer? Nat-

ure Reviews Cancer, 6, 753-763.

Rosenstock, I., Strecher, V., & Becker, M. (1994). The health belief model

and HIV risk behavior change. In R. J. DiClemente & J. L. Peterson

(Eds.), Preventing AIDS: Theories and methods of behavioral inter-

ventions (pp. 5-24). New York: Plenum Press.

Scheurer, M. E., Tortolero-Luna, G., & Adler-Storthz, K. (2005). Human

papillomavirus infection: Biology, epidemiology, and prevention.

International Journal of Gynecological Cancer, 15(5), 727-746.

Schi¡man, M., & Kjaer, S. K. (2003). Natural history of anogenital human

papillomavirus and neoplasia. Journal of the National Cancer In-

stitute Monographs, 31, 14-19.

Sherris, J., Friedman, A., Wittet, Davies, P., Steben, M., & Saraiya, M. (2006).

Education, training, and communication for HPV vaccines. Vac-

cine, 24(3), S210-S218.

Skinner, S. R., Garland, S. M., Stanley, M. A., Pitts, M., & Quinn, M. A. (2008).

Human papillomavirus vaccination for the prevention of cervical

neoplasia: Is it appropriate to vaccinate women older than 26?

Medical Journal of Australia, 188(4), 238-242.

Strecher, V. J., & Rosenstock, I. M. (1997). The health belief model. In

K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and

health education: Theory, research, and practice. San Francisco:

Jossey-Bass.

United States Census Bureau. (2000). Unites States Census 2000. Re-

trieved from http://www.census.gov/main/www/cen2000.html

United States Preventative Services Task Force. (2007). Screening for

cervical

cancer.

Retrieved

from

http://www.ahrq.gov/clinic/

3rduspstf/cervcan/cervcanrr.pdf

U.S. Department of Health and Human Services. (2000). Healthy People

2010. Retrieved from http://www.healthypeople.gov

Vanslyke, J., Baum, J., Plaza, V., Otero, M., & Wheeler, C. (2008). HPV and

cervical cancer testing and prevention: Knowledge, beliefs, and

attitudes among Hispanic women. Qualitative Health Research,

18(5), 584-596.

Weistock, H., Berman, S., & Cates, W. (2004). Sexually transmitted dis-

eases

among

American

youth:

Incidence

and

prevalence

estimates, 2000. Perspectives on Sexual Reproductive Health,

36(1), 6-11.

Winer, R. L., Hughes, J. P., Adam, D. E., Kiviat, N. B., & Koutsky, L. A. (2003).

Genital human papillomavirus infection: Incidence and risk factors

in a cohort of female university students. American Journal of Epi-

demiology, 157, 216-228.

World Health Organization. (2008). Human papillomavirus and cervical

cancer. Retrieved from http://www.who.int/immunization/topics/

hpv/en/

Zia, H. (2000). Asian American dreams: The emergence of an American

people. New York: Farrar, Straus & Giroux.

JOGNN 2010; Vol. 39, Issue 3

249

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