Learning About Pap Smears

J Pediatr Adolesc Gynecol (2002) 15:197-204

Original Studies Learning About Pap Smears: An Educational Skit for Hispanic Adolescents Reva A. Richardson, MD1, Wanjiku Njoroge, MD3, Graciela G. Wilcox, MD4, Mariam R. Chacko, MD5, and Albert C. Hergenroeder, MD 6 1

Jackson Memorial Medical Center Program, University of Miami, School of Medicine, Dept. of Pediatrics, Miami, Florida; 3University Hospital of Philadelphia, Dept. of Psychiatry, Philadelphia, Pennsylvania; 4University Medical Center, University of Arizona, Dept. of Pediatrics, Tucson, Arizona; and 5Adolescent Medicine and Sports Medicine Section, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas

Abstract. Purpose: To assess the efficacy of an educational skit on improving knowledge and decision making/ behavior toward obtaining a Pap smear. Methods: Ninety-two Hispanic high school female volunteers participated in an intervention, single-sample, preintervention/postintervention survey. Data were collected prior to (T0), immediately after (T1), and seven weeks after (T2) the intervention. The intervention was a live, 15-minute, English-language skit. Results: Fifty percent reported sexual intercourse. Viewing the skit was associated with 29% of those who needed a Pap smear done, actually scheduling or having a Pap smear done between T0 and T2. However, a causal relationship was not proven (P  0.09). Knowledge was greater at T1 and T2 compared to T0 (P  0.00001). However, there was a decrease in knowledge at T2 compared to T1. More subjects agreed that females their age were at risk for cancer at T2 compared to T0 (P  0.0001). Conclusions: There was an improvement in and retention of knowledge about Pap smears after viewing this educational skit. This study sets the stage for evaluating this educational skit on a larger sample with a comparison group.

Key Words. Patient education—Preventative services—Educational programs—Cervical dysplasia— Pap smears

Introduction Annual Papanicolaou (Pap) smear testing is recommended by numerous professional organizations for

Address reprint requests to: Albert C. Hergenroeder, MD, Texas Children’s Hospital, 6621 Fannin Street, cc610.01, Houston, TX 77030-2399; E-mail: [email protected] © 2002 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Science Inc.

sexually active females and females 18 yr of age or older.1,2 Less than half of adolescents who meet criteria for obtaining a Pap smear actually have one performed.3–5 This failure to adhere to the recommended guidelines is possibly due to lack of knowledge about these guidelines, an important factor in compliance.6 Najem et al surveyed 3980 inner-city, primarily minority high school students and reported that adolescents at risk for a sexually transmitted infection or those 18 yr of age or older perceived that major barriers to obtaining Pap tests were: 1) the belief that they were not at risk for cancer; 2) feeling that Pap tests are not accurate; and 3) lack of information about where to get Pap tests and how to make appointments.7 Forty-six percent did not believe the test was necessary for them, and 43% did not believe they were at risk for cancer. Because a significant number of these students also stated that they did not know how or where to obtain a Pap smear, an educational intervention at a schoolbased clinic was recommended by the authors. Other investigators have reported that adolescent females lack knowledge about the Pap smear.8 Fear of having a painful pelvic examination has been reported as a barrier to having a Pap smear performed. However, no primary reference supporting this was identified. Improving knowledge and self-efficacy (i.e., confidence in one’s ability to carry out a plan) are important goals of health promotion.9 Mexican-American women who are not compliant with cervical screening guidelines had a knowledge deficit, did not understand the Pap test, and had lower self-efficacy for understanding physicians.10 The intention to comply with cervical screening guidelines is associated with higher knowledge compared to women with no inten1083-3188/02/$22.00 PII S1083-3188(02)00155-9

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tion to comply with cervical screening.11 If self-efficacy can be improved with enhancing knowledge and skills, then self-efficacy for adolescent females to follow Pap smear guidelines could be improved by educational interventions that increase knowledge and skills. This would include knowing when and how to schedule a Pap smear. Adolescents enjoy theater as a medium for health education and promotion of healthy lifestyles, especially if they can relate to the characters and language.12–14 Although the positive effect of live theatre on adolescents’ attitudes about health behavior has been noted, the effect on behavior has not.13,14 The purpose of this study was to assess the efficacy of an educational skit on improving knowledge and decision making/behavior toward obtaining Pap smears among a group of primarily Hispanic female students at a high school. Methods Study Design An intervention, single-sample, preintervention/postintervention survey design was used. The intervention was a 15-minute English-language skit developed by the investigators with a survey administered immediately prior to the intervention (T0), immediately after the intervention (T1), and seven weeks after the intervention (T2). Study Population The subjects were recruited from a predominantly Hispanic public senior high school in Houston, Texas for the 1997–98 academic calendar. The sole eligibility criterion was that the subject was English speaking. An English-speaking skit was the first step taken towards developing the school program. The majority of Hispanic students (75%) in this school are bilingual or (only) English speaking. A convenience sample of females was recruited from Health and Physical Education and ROTC classes. There were 350 potentially eligible subjects. Consent forms were provided at a recruitment session held during classes. A signed parental consent form was required if the subject was less than 18 yr of age. Subjects 18 yr of age or older signed their own consent form. The final study sample was 92 female students. The Baylor College of Medicine Institutional Review Board and the Houston Independent School District Review Board approved the study. Pilot Study A pilot test of the survey was conducted with 10 Hispanic adolescent females, ages 13–15, recruited from the local Association for the Advancement of Mexican Americans. These subjects were separate from the

study group, and the methods of administration of the survey and the survey content were revised based on their suggestions. Specifically: 1) emphasis was placed on each subject sitting in their own chair to complete the questionnaire, as the pilot group sat around a circular table and some attempted to complete the survey collaboratively, rather than individually; 2) key teaching points were written on a flip chart during the intervention to address visual learners; 3) the questionnaire was reduced from three to two pages; and 4) key points regarding risk factors for an abnormal Pap smear were repeated in the dialogue. Survey A survey to assess knowledge and attitudes about and behavior toward obtaining a Pap smear was designed for the ninth-grade reading level. Content validity of the survey was reviewed by the authors and other interdisciplinary adolescent medicine faculty at Baylor College of Medicine. There were two types of questions: 1) open-ended; and 2) forced choices with a 5-point Likert Scale, including the responses “strongly agree with statement,” “agree with statement,” “neutral,” “disagree with statement,” and “strongly disagree with statement.” At the conclusion of the educational skit, the survey included the open-ended comment: “Please feel free to give us any comments about this presentation.” To ensure confidentiality, each subject was given a study number written on the survey form. The survey was administered by study number at T0, T1, and T2 during class time. Intervention The intervention was a 15-minute English-language skit that was presented during Health and Physical Education and ROTC classes (see Appendix). The script was written by the investigators and involved three Hispanic female medical students acting as adolescents discussing Pap smears. The content of the skit was determined using current recommended guidelines for obtaining a Pap smear and included potential barriers (i.e., fear of a painful examination and others discussed earlier), and the skit was assessed for content validity by the investigators. Modeling skills for scheduling an appointment to obtain a Pap smear were performed. The skit was presented to the same pilot group of 10 Hispanic females that reviewed the survey. Time was allotted for questions and comments from the subjects after the skit. Outcome Variable Definitions There were knowledge, attitude, and decision making/ behavioral outcome variables. Knowledge variables were dichotomous and were assessed using open-ended questions. Knowledge variables included:

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1. What a Pap smear detects. A correct answer was defined as including the word “cancer.” An answer that did not include the word cancer was considered incorrect. 2. Risks for an abnormal Pap smear. Correct answers included having sexual intercourse, multiple partners, infection with human papilloma virus, or smoking cigarettes. 3. The indications to obtain a Pap smear. A correct answer was defined as being 18 yr of age or older or having had sexual intercourse and having not obtained a Pap smear in the past 12 months.

the past 12 months; or 2) a subject who had no history of sexual intercourse and was less than 18 yr of age who had not obtained or scheduled a Pap smear. Examples of incorrect behavior or decision making included: 1) subjects scheduling or having a Pap smear done if the subject had no history of sexual intercourse or was less than 18 yr of age; or 2) not scheduling or having a Pap smear done if the subject had a history of sexual intercourse or was at least 18 yr old and had not had a Pap smear done; or 3) if the subject had a Pap smear done or scheduled one to be done within 12 months of the last Pap smear.

Attitude variables were assessed using statements followed by the subjects rating their response on the 5-point Likert Scale discussed above. The attitude questions are listed in Table 1. These variables were chosen based on the senior authors’ experience with reasons why Hispanic adolescents defer pelvic examinations and Pap smears and a report on the association with anxiety about cancer as a detriment to compliance with cancer screening guidelines.15 The decision making/behavior outcome variable included appropriate decision making or behavior, based on age and sexual history, about having a Pap smear done or having scheduled an appointment to have a Pap smear done. Specifically, correct decision making/behavior included: 1) a subject who had a history of sexual intercourse or was 18 yr of age or older and having a Pap smear done in the past 12 months, or scheduling a Pap smear if one had not been done in

Data Management and Analysis To observe a 20% increase in the percentage of students giving correct answers to a knowledge question, with 80% power and an  level of 0.05 with a twosided t-test, 90 subjects were needed. Data were analyzed using the Statistical Package for Social Sciences, version 9.0 (SPSS, Inc., Chicago, IL, USA, 1999) and the Statistical Analysis System, version 6.1 (SAS Institute, Inc. Cary, NC, USA, 1997). The subjects’ demographic characteristics are described in the text as mean values. The subjects’ knowledge about Pap smears is presented as the percentage of subjects correctly answering a knowledge question. Subjects’ attitudes about Pap smears are presented as the percent agreeing with a statement. To facilitate detecting change in attitudes, the 5-point Likert scale answers were recoded into a 3-point scale

Table 1. Outcome Variables Measured Across Three Times, T0 (Baseline), T1 (Immediately After Intervention), and T2 (Seven Weeks Postintervention) Outcome Variable Knowledge (% correct answers) What does a Pap smear detect? When should a female start having a Pap smear done? Reasons why a female would be at risk for an abnormal Pap smear Attitudes (% agreeing with statement) Afraid of having a Pap smear done Afraid of having an abnormal Pap smear Pap smears are painful Having a Pap smear is embarrassing Intend to schedule a Pap smear Females my age at risk for cancer Decision making/behavior % correct decision making/ behavior (see Outcome Variable definitions)

T0

T1

T2

P value*

41.3

83.7*

73.9**

 0.00001

71.7

95.7*

84.8**

 0.00001

19.6

75.0*

51.6**

 0.00001

47.7

65.2

44.8

0.7

65.2 29.9 56.2 61.0 64.1

80.4* 38.0 68.1 71.7 92.4*

78.2 27.6 52.3 70.1 83.7**

0.04 0.4 0.6 0.14 0.0001

37.0

N/Aa

46.5

0.09

* Significantly higher than T0 ** Significantly higher than T0 and significantly lower than T1 a This could not change between T0 and T1 as they were immediately pre- and postintervention.

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by combining “strongly agree” and “agree” into “agree,” with “neutral” remaining unchanged and “disagree” and “strongly disagree” combined into “disagree.” Knowledge and attitude were compared at T0, T1, and T2 using weighted-least squares to model repeated measurements of categorical outcome variables.16) Outcome variables are listed in Table 1. Analyses of some outcome variables were stratified as a function of sexual history (i.e., those who did/did not report a history of sexual intercourse) and a history of having/not having a previous Pap smear done using Chi-square analysis. Significance was defined as a P value  0.05.

Results Study Sample Ninety-two subjects participated in the program at T0 and T1 and 87 followed up at T2. Ninety-five percent of the subjects were Hispanic. Their mean age was 17.0  1.4 yr. Seventy-eight percent of the sample was 18 yr of age or older and 83% were in the 12th grade. Fifty percent of the sample reported a history of sexual intercourse. Of those who reported a history of sexual intercourse, the mean age of first sexual intercourse was 15.9  1.4 yr. Baseline knowledge and attitude are presented in Table 1. Subjects who reported prior sexual intercourse, compared to those who did not report prior intercourse, were more likely to have spoken to a physician or nurse about a Pap smear (P  0.001). Seventy percent of the subjects who reported no prior sexual intercourse had neither received information about nor spoken to a health care provider about Pap smears; however, 93% wanted more information about Pap smears. Decision Making/Behavior In the group of subjects who had an indication to obtain a Pap smear at T0 (i.e., a history of sexual intercourse or age greater than or equal to 18 yr), 36% (n  27) reported having a prior Pap smear. In the subgroup of subjects with a history of sexual intercourse, 58% (n  26) reported having a previous Pap smear. Having a previous Pap smear was related to having a history of sexual intercourse (P  0.001).

Knowledge about indications for Pap smears applied to the individual subjects is presented below under “Decision Making/Behavior.” Attitudes. The distribution of correct answers is shown in Table 1. The percent of subjects agreeing with the statement that females their age were at risk for cancer increased at T1 and T2 compared to T0. The percent agreeing that they were afraid of having an abnormal Pap smear increased at T1, yet this increase did not persist at T2. Decision Making/Behavior. Fifty-six subjects needed a Pap smear at T0 based on age or a history of sexual intercourse. Five of these subjects were not available at T2. Fifteen of the remaining 51 patients (29%) either scheduled or had a Pap smear done in the interim. The percentage of subjects exhibiting correct decision making behavior at T2 compared to T0 did not reach statistical significance (P  0.09). Subjects Who Reported No History of Sexual Intercourse Ever at T2. There were 44 subjects at T2 with no history of sexual intercourse. Twenty-nine of these were 18 yr of age or older. Fourteen of these twenty-nine correctly agreed with the statement that the skit had taught them that they needed a Pap smear, and five obtained or scheduled a Pap smear in the interim. Fifteen of the 44 subjects were under age 18. Seven of these 15 agreed with the statement that the skit taught them that they did not need a Pap smear. Eight incorrectly agreed with the statement that the skit had taught them that they needed a Pap smear, and 3 scheduled a Pap smear. Thus 21 of the 44 subjects with no history of sexual intercourse reported learning correctly about their need or lack of need for a Pap smear. Qualitative Comments about the Skit. Forty-three subjects wrote comments regarding the educational skit. Thirty-six wrote positive comments and 8 wrote neutral comments. Examples are listed in Table 2. There were three negative comments, each of which came from students who also made a positive comment: “Don’t treat us like little kids,” “Need to learn how to act in front of people like us,” and “The male in the group made my friend uncomfortable.” (The senior investigator was a male and was present to facilitate the collection of surveys and stood in the back of the room during the presentation.)

Table 2. Qualitative Comments about the Skit

Impact of the Skit on Knowledge, Attitudes, and Decision-Making/Behavior Knowledge. The distribution of correct answers about the knowledge variables are listed in Table 1. Percent correct answers for knowledge variables increased between T0 and T1, and between T0 and T2.

Positive comments “This gave us good information.” “This presentation was great.” “Even though I had a Pap smear before, I learned a lot.” Neutral comments “The presentation was OK.” “How can an abnormal Pap smear be taken care of?”

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Discussion The most significant finding of this study is that there was an improvement in and retention of knowledge about Pap smears after viewing the educational skit in this group of Hispanic adolescents. For nearly onethird of subjects who needed a Pap smear at T0, viewing the skit was associated with having or scheduling to have a Pap smear done at seven weeks. However, the proportion of those reporting improved decision making/behavior did not reach significance. A longer period of follow-up may have detected more of the desired decision making/behavior so the effectiveness of the intervention on decision making reported here is a minimum. Our definition of incorrect decision making/behavior included scheduling or having a Pap smear sooner than 12 months since the previous Pap smear. Possibly some had dysplasia and were told to return at earlier than 12 months, in which case their decision making was correct. However, we did not query for this information and this is a limitation of the study: the instrument may not be valid in determining correct decision making as it did not address reasons why a subject would have to return for a Pap smear earlier than 12 months. However, we did not collect this information as we knew we would not be able to corroborate the answers and we were concerned about the validity of self-report about cervical dysplasia and advice about follow-up Pap smears. In addition, obtaining a Pap smear at earlier than 12 months is a desirable outcome as it represents patients taking initiative for their reproductive health care. This is especially important to Hispanic women who have lower rates of obtaining preventive reproductive health care than non-Hispanic women.17 The majority of subjects who gave written comments liked the presentation, and the neutral/negative comments suggest areas for improvement. We were unable to identify another published educational intervention in adolescents that improved knowledge about and compliance with Pap smear guidelines. This intervention has the potential to improve compliance with Pap smear guidelines on a broad scale if it is evaluated in a larger sample, including a comparison group, and demonstrated to be effective in improving knowledge, attitudes, and behavior. Scheduling or having a Pap smear done at seven weeks was associated with a history of sexual intercourse, independent of whether or not the subjects needed the Pap smear at T0. This educational intervention needs to be improved so those adolescents with a normal Pap smear are more likely to wait 12 months for a repeat Pap smear. This point deserves more repetition in the presentation. Although the majority of subjects reported the intent to schedule a Pap smear, many did not. Barriers to

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obtaining services for adolescents may include the lack of confidential services, the fear of having a pelvic examination, anxiety about having cancer, and the concerns that the pelvic examination may compromise a female’s virginity status.15 Compliance with cervical screening guidelines in Mexican-American women has been reported to be inversely related to anxiety about having cancer, controlling for knowledge.15 Knowledge about cancer and anxiety about having cancer were related in these adult women and in our subjects after the intervention. Because of the increase in fear of having an abnormal Pap smear immediately after the skit, we will change the skit content to emphasize that some adolescents are at risk for an abnormal Pap smear, which can lead to cancer in adults, although cervical cancer in adolescents is rare. We acknowledge that a potential untoward effect of this educational intervention was to increase some subjects’ anxiety about susceptibility to cancer. Cancer screening programs could be impeded if there is not a mechanism to recognize and address an individual’s anxiety. We did not allow for this on an individual basis in this study and would suggest that it be made available in subsequent interventions. Another barrier to obtaining Pap smears may be a lack of information about how to make an appointment.7 Our skit attempted to address this latter potential barrier. Handouts with telephone numbers, maps, and the appointment making procedure for specific clinics accessible to the students will be part of subsequent educational interventions. The decrease in knowledge at T2 compared to T1 points out the importance of repeating key points. A fact sheet with key points and clinic phone numbers, given to subjects in the weeks after the intervention, might increase the desired behavior and will be included in subsequent educational interventions. At T0, the percentage of subjects with a history of sexual intercourse who had obtained a Pap smear was similar to that reported by Thrall et al5 and higher than that estimated by Igra et al.3 The latter study included 15- to 19-yr-old subjects, and the majority of our sample was 18 yr of age or older. The percentage of sexually active subjects who have a Pap smear done increases from 15 to 19 yr of age,4 possibly explaining some of the difference between the studies. Limitations The absence of a comparison group precluded testing the independent effect of exposure to the educational skit on correct decision making/behavior. Subjects may have scheduled or had a Pap smear done in the interim, independent of the intervention. However, there was no other mechanism (i.e., a health class or public education campaign about Pap smears) through which all the students would have received this information.

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Subsequent studies could explore the effectiveness of the material presented by skit vs. another method such as a lecture or a photo novella, used for education of Hispanic consumers. The percentage of subjects enrolled in the study was 26% of the potential subjects and suggests recruitment bias. There was recruitment bias, however, not by design. At the outset we intended to enroll all ninth through twelfth grade students in the Health and Physical Education and ROTC classes. However, parental consent for participation was required for students less than 18 yr of age. The result was that 87% of the sample was 18 yr of age or older. Our results should be interpreted primarily for Hispanic students 18 yr of age and older, and acknowledging this recruitment bias we see the limitation as one imposed by the institutional review board requirement rather than unsuccessful recruitment methods. The outcome variable, scheduling or obtaining a Pap smear, was self-reported, and this method has limitations. In 61% of adult women who reported having a Pap smear in the past three years, pathology reports confirming this test could be found.18 Adolescents’ reports about their sexual history and health-related behaviors are not always consistent.19,20 Future studies could establish methods wherein the report of obtaining a Pap smear could be corroborated without violating the subjects’ confidentiality. For instance, the subject could have a card signed and dated by the staff where the Pap smear was obtained, similar to immunization record cards. The school’s academic schedule precluded doing the intervention sooner or the follow-up later. It is possible that the skit may have favorably affected behavior that manifested after T2. Finally, this group was primarily twelfth-grade Hispanic females, and the findings may not be applicable to other demographic groups. The questions assessing knowledge, attitude, and behavior used in this study were developed for this study, and validity and reliability have not been established.

Summary There was an improvement in and retention of knowledge about Pap smears after viewing the educational skit in this group of primarily Hispanic females. Viewing the skit was associated with some subjects scheduling or obtaining a Pap smear, although causality between this behavior and the educational intervention was not proven. A follow-up study with a comparison group may help address this issue of causality. Secondary educational reinforcers are necessary, as the improved knowledge about Pap smears decreased

over seven weeks. The next steps will be to improve the intervention content and delivery to test the effect on other audiences with a longer follow-up time and to use comparison groups with the same material presented in a more conventional format. In addition, an information brochure will be included as an intervention method. This study has identified specific next steps toward improving the delivery of information about this important health problem in young Hispanic women. Acknowledgments: We are grateful to the actresses in the educational skit, Elizabeth Sanchez, Krista Huerta, and Nicole Flores, and the students and staff at the Stephen F. Austin High School, especially Vice Principal Patricia Russo. Drs. Chacko and Hergenroeder are supported by HRSA/ MCHB Leadership Education in Adolescent Health (LEAH) program #5T71MC00011-03.

Appendix Script for Skit 1: Hello— 2: Hi— 1: What’s up? You look like you are stressed out. 2: Well, not really; it’s just that I’m getting older, and my Mom thinks I should visit the clinic to get a well woman check-up and a Pap smear. I have never had one before, but I’ve heard that it hurts and is really embarrassing, I guess I’m just scared about the whole thing. 1: Oh, I got my first Pap smear a couple of months ago. 2: You did? 1: Yeah. My sister had one when she was 16 because she was having sex, and she told me that I should get one since I started having sex. 2: Was it awful? Did it hurt? 1: To tell you the truth it really wasn’t as bad as I thought it would be. Honestly, I was nervous when I got there, but the nurse talked to me about what Pap smear was and why it was a good thing that I was getting one. When the doctor came in the room she explained everything she would be doing before we started, which made me feel more comfortable. 2: I don’t understand why I need a Pap smear, I’ve never had sex. 1: Yeah, but Pap smears are for sexually active females as well as any female over the age of 18. 2: Oh, so what exactly is a Pap smear? 1: A Pap smear is a test to check for precancerous cells. 2: Cancer! Why do I have to worry about cancer?! I thought you couldn’t get that until you were a lot older!

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1: I thought that way too, but the doctor told me that young females are at risk for getting cervical cancer, especially if we or our partner has had sex with more than one person. 2: Why is that? 1: Part of it is because we have an increased risk of getting sexually transmitted diseases when we have multiple partners, and cervical cancer is caused by a sexually transmitted virus called HPV or human papilloma virus. 2: Isn’t that the one that causes genital warts? 1: Some types can. The problem with this STD is that you might not even know you have it. 2: That’s scary. 1: Yeah that’s why it is a good idea to get a Pap smear. With this test the doctor can look at cells on your cervix and see anything abnormal, and treat it before it develops into cancer. We should have a Pap smear every year for at least 3 years at the beginning. If those cells are all normal we can talk with the doctor and find out if they would like us to come in less often. 2: You said the doctor will look at cells from my cervix, what’s that? 1: There’s a picture over there, let’s go over there and I’ll show you where it is. 2: OK. (Move over to the diagram of the female reproductive organs. 1 and 2 are in the room chatting and 3 walks over.) 3: Hi. What are you two talking about? 2: Oh, I’m gonna have to get a Pap smear. (1) is showing me what will happen. 3: Do you mind if I come in? I’ve never gotten one of those but I heard I should. 2: Yeah, sure, it’s fine with me. 1: It’s fine with me too. Alright. See this (points to reproductive organs on diagram)? Females have these organs inside them right about here (indicates suprapubic area). This is the uterus—this organ that is shaped like an upside-down pear here. And this lower part of the uterus here is the cervix. Your doctor can actually see it when she does the Pap smear. 3: How is that possible, isn’t that inside my vagina? 1: They use something called a speculum. Ms. Garcia had one here for one of the classes she teaches. Let me see if I can find it. (Looks through a few drawers.) The doctor runs some warm water over it and then puts it into your vagina—this area here (points to diagram). 3: But that looks so big! Does it hurt? 1: I felt some pressure and it was a little uncomfortable, but it didn’t really hurt. They are various sizes, even a very small one for virgins. And the whole thing is really quick.

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3: You know what I’m worried about? I’m planning on waiting until I’m married to have sex, so if I get one of these when I turn 18, does that mean I’ll no longer be considered a virgin? 1: No, this is just a medical procedure to help you stay healthy. Being a virgin just refers to whether you’ve actually had sex before or not. So don’t worry about that. 3: That’s cool. 2: So what do they do once they can see the cervix? 1: They use a little brush and brush it across the cervix, as well as a spatula, which they move across the cervix; they smear these cells on a slide and spray it so the cells stay on the slide. The slide is then sent to a lab to be evaluated for abnormal cells. 2: So, if they find abnormal cells, does that mean you have cervical cancer? 1: No! It might mean that, but usually if you get them annually, this abnormality means that you have cells that are at risk of developing into cancer if not treated. 3: Well, what do you do if they tell you they found something abnormal? 1: Your doctor or nurse should call you to tell you if your Pap smear was normal or abnormal. If he or she does not get in contact with you, make sure you call the clinic and ask for the results of the test. If they do find something abnormal, they will want you to return for a follow-up appointment. If you have something they call “precancerous condition” or cancer in the early stages your physician can take the “bad” cells out. 2: Are there certain people who are more at risk for having an abnormal Pap smear? 1: Yes, the things that put you more at risk for having an abnormal Pap smear are: (she writes on the board—just the words that are in quotes) 1) Sex at an “early age” 2) Sex with “multiple partners” or having a partner who has had sex with many people 3) Infection with “HPV” (Human Papilloma Virus), which is a sexually-transmitted disease (STD) 4) And some other things like cigarette smoking. 2: Well thank you so much for explaining about Pap smears. I’m still a little scared but I feel a lot better now that I understand more about what a Pap smear is all about. 1: So do you want to go schedule a Pap smear now? 2: Me? Right now? 3: Yeah, why not? You might as well get it over with; I have Dr. Miranda’s card with me, I think you’ll like her. 2: But what do I say? Are they gonna ask me embarrassing questions?

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Richardson et al: Pap Smears, Education, and Hispanic Adolescents

1: No! The only thing I didn’t know when I called the first time was our insurance company. Do you know that? 2: Actually I have Medicaid, will the doctor take that? 1: I’m not sure, but most doctors do. If she doesn’t I’m sure she can refer you to another doctor who will. Here’s (hands to 2) her card. 3: Here’s the phone. 2: (dials) . . . Person at the clinic picks up 4: Hello. ____ clinic. May I help you? 2: Yeah, I need to schedule a Pap smear. 4: OK, what is your name? 2: ______. 4: Do you have insurance or Medicaid? 2: Medicaid. 4: Dr. Miranda has an opening for March 25th at 2 p.m. Try to arrive 15 minutes earlier so you can complete questionnaires for your record. Make sure you walk in with your Medicaid card. 2: OK, thank you. (hangs up) 1  actress #1 2  actress #2 3  actress #3 4  character #4 (actress #1) References 1. United States Department of Health and Human Services Public Health Service: Clinician’s Handbook of Preventive Services: Put Prevention Into Practice. Washington, DC: United States Government Printing Office; 1994 2. U.S. Preventive Services Task Force: Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions (2nd ed.). Baltimore, Williams and Wilkins, 1996 3. Igra V, Millstein SG: Current status and approaches to improving preventive services for adolescents. JAMA 1993; 269(11):1408 4. Wilcox LS, Mosher WD: Factors associated with obtaining health screening among women of reproductive age. Public Health Rep 1993; 108:76 5. Thrall JS, McCloskey L, Spivak H, et al: Performance of Massachusetts HMOs in providing Pap smear and sexually transmitted disease screening to adolescent females. J Adolesc Health 1998; 22:184

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