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.
kae33@drexel.edu
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)
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&
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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Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O.
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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
JOGNN, 39, 238-249; 2010. DOI: 10.1111/j.1552-6909.2010.01136.x
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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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E S E A R C H
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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E S E A R C H
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.
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
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
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/
Zia, H. (2000). Asian American dreams: The emergence of an American
people. New York: Farrar, Straus & Giroux.
JOGNN 2010; Vol. 39, Issue 3
249
Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O.
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