Materials and Methods
Subjects
This cross-sectional survey study was reviewed and approved by the Northwestern University Institutional Review Board. A convenience sample was recruited from attendees of a community fair in Chicago, IL. A designated area existed in which women could approach and receive a description of the study. Verbal consent was obtained from all study participants. Eligibility criteria included English-speaking women who self-identified as African American and were 18-70 years old. Study participants were compensated for their time with $5.00 gift cards.
Surveys
Surveys were developed based on The Awareness of HPV and Cervical Cancer Questionnaire, which is a validated HPV knowledge and awareness tool that was developed by Ingledue et al in 2004 to assess knowledge and beliefs related to HPV and cervical cancer. Participants completed self-administered paper surveys, which included 28 items that assessed knowledge of female anatomy, HPV and HPV vaccination, and demographic questions. Knowledge was assessed by answers to multiple-choice response questions (eg, There is a vaccine that protects against HPV: [A] Yes; [B] No; [C] I don’t know; A Papanicolaou test is a screening test for [A] ovary cancer; [B] lung cancer; [C] breast cancer; [D] colon cancer; [E] cervix cancer; [F] I don’t know.) Surveys contained no personal identifying information.
Statistical analyses
Study results were entered into a database; data entry accuracy was confirmed by 2 of the investigators. A cumulative HPV knowledge score was determined for each participant based on survey responses. Survey responses were dichotomized; each correct answer received a score of 1, whereas incorrect responses, including “I don’t know,” received a score of 0. HPV knowledge was categorized as “adequate” if there were ≥18 correct responses (approximately 2/3 or 64%) of the 28 knowledge questions. Chi-square analysis was used to test the association between categoric variables in this cross-sectional survey study. A probability value of < .05 was considered statistically significant. All statistical analyses were performed with SPSS software (Predictive Analytics SoftWare [PASW] version 18; SPSS Inc, Chicago, IL).
Results
A total of 322 surveys were distributed, and 242 were completed, for a 75.2% response rate. Two hundred fifteen women met eligibility criteria. Of the 27 participants who were excluded, 19 surveys had missing data; 7 participants did not identify themselves as African American; and 1 participant did not meet the age criteria. The mean age of participants was 48.2 years (SD, 12.1 years). Eighty-seven percent of participants had an education level of high school or above; and 32% of participants had household income levels of >$40,000/year. We had 26 participants eligible for the vaccine; 9 of them had been offered the vaccine, which accounted for a total of 34.6% participants who were eligible for the vaccine personally being offered the vaccine. Furthermore, of those who had children, only 28% of the children had been offered the HPV vaccine. Tables 1, 2, and 3 provide additional details regarding participant demographic, personal health, and women’s health information.
| Variable | Measure |
|---|---|
| Age, y a | 50 (18-70) |
| Children, n a | 2 (1–6) |
| Grandchildren, n a | 4 (1–18) |
| African American/black, n (%) | 215 (100) |
| Ethnicity, n (%) | |
| Hispanic/Latina | 4 (1.9) |
| Non-Hispanic/non-Latina | 156 (72.6) |
| Education, n (%) | |
| High school graduate | 56 (26) |
| Some college courses | 75 (34.9) |
| College graduate | 56 (26) |
| Postgraduate courses | 15 (7) |
| Other | 12 (5.6) |
| Partnering status, n (%) | |
| Single | 118 (54.9) |
| Married | 48 (22.3) |
| Widowed | 12 (5.6) |
| Divorced | 31 (14.4) |
| Living with significant other | 3 (1.4) |
| Income level, n (%) | |
| <$20,000 | 89 (41.4) |
| $21,000–40,000 | 57 (26.5) |
| $41,000–60,000 | 33 (15.3) |
| $61,000–80,000 | 20 (9.3) |
| >$80,000 | 8 (3.7) |
| Variable | n (%) |
|---|---|
| Health insurance | |
| No Insurance | 57 (26.5) |
| Health maintenance organization | 35 (16.3) |
| Medicaid/Medicare | 64 (29.8) |
| Private insurance | 45 (20.9) |
| Not sure | 9 (4.2) |
| Last doctor visit | |
| Within the last year | 164 (76.4) |
| 2-3 y | 26 (12.1) |
| 4-5 y | 11 (5.1) |
| 6-10 y | 5 (2.3) |
| >10 y | 5 (2.3) |
| Papanicolaou test ever | |
| Yes | 200 (93) |
| No | 12 (5.6) |
| Last Papanicolaou test | |
| Within the last year | 122 (56.7) |
| 2-3 y | 53 (24.7) |
| 4-5 y | 15 (7) |
| 6-10 y | 13 (6) |
| >10 y | 8 (3.7) |
| Abnormal Papanicolaou test result | |
| Yes | 74 (34.4) |
| No | 128 (59.5) |
| Variable | n (%) |
|---|---|
| Offered vaccine | |
| Yes | 33 (15.3) |
| No | 163 (75.8) |
| I don’t know | 13 (6.0) |
| Children offered vaccine | |
| Yes | 47 (28.7) |
| No | 85 (51.8) |
| I don’t know | 26 (15.9) |
| Received vaccine | |
| Yes | 15 (7.0) |
| No | 173 (80.5) |
| I don’t know | 17 (7.9) |
| Children received vaccine | |
| Yes | 29 (17.7) |
| No | 100 (61.0) |
| I don’t know | 30 (18.3) |
| Reason child did not get vaccine | |
| Concern over side-effects | 8 (4.9) |
| Costs | 13 (7.9) |
| Not enough information to make decision | 17 (10.4) |
| Not offered | 27 (16.5) |
| Concerns about sexual promiscuity | 3 (1.8) |
| Other | 12 (7.3) |
Of 28 knowledge questions regarding HPV, cervical cancer, and HPV vaccines, the mean knowledge score was 12.3 ± 4.2. Overall knowledge scores ranged from 3–23. Three-fourths of the participants scored <65% on the knowledge score portion of the survey. The Figure shows the distribution of knowledge scores by participants.
Although 93% of participants were able to identify the cervix correctly when presented with a drawing, 33% of them were unable to correctly identify that a Papanicolaou test is performed on the cervix, and only 58% of them recognized a Papanicolaou test as a screening test for cervical cancer.
The percentage of participants who knew that there is a vaccine that protects against HPV was 61%; however, only 37% of participants correctly answered that a virus is the cause of cervical cancer. Seventy-four percent of the participants knew that cervical cancer can be diagnosed by a Papanicolaou test; only 35% of the participants could correctly identify factors that can prevent cervical cancer, including vaccination, Papanicolaou tests, and delayed onset of sexual activity. When asked to identify risk factors for cervical cancer, participants identified risks factors correctly <50% of the time. Further, only 2% were able to identify women who were at highest risk of getting cervical cancer (Hispanic); 42% of participants were able to identify African American as the group at highest risk of dying of cervical cancer.
Using a cutoff score of 18 of 28 as an adequate knowledge score, 73% of participants demonstrated low knowledge scores regarding HPV, cervical cancer, and the HPV vaccine. χ 2 analysis demonstrated that education level ( Χ 2 [4, n = 175] = 13.96, P = .007), household income ( Χ 2 [4, n = 169] = 13.18, P = .010), and having a child who had been offered the HPV vaccine ( Χ 2 [2, n = 131] = 13.96, P = .041) were factors that were associated positively with adequate knowledge scores. Having had a Papanicolaou test or having seen a doctor within the past year was not associated significantly with adequate knowledge scores.
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