Thesis advisor: James Lubben / In 2011, an estimated 12,710 women suffered from cervical cancer and 4,290 died from it in the U.S. HPV vaccination (HPV-V) and PAP screening (PAP-S) could reduce this burden. Using 2010 National Health Interview Survey data, current disparities in the use of PAP-S and HPV-V in U.S. women aged 18-30 years were investigated. An adapted Behavioral Model of Health Care Utilization guided the study. Main outcomes were PAP-S in prior year and ever-HPV-V, both initiation and completion. Adjusted predictor estimates were obtained through multivariate logistic regressions with appropriate statistical procedures and weights for complex survey design. A sub-analysis focused on unvaccinated women. The sample had 3,129 women aged 18-30 years, representing about 27 million women of similar age in the U.S. PAP-S, HPV-V initiation and completion rates were 53.5%, 17.9%, and 10.3%, respectively. Hispanics were 33% less likely than Non-Hispanic-Whites to initiate HPV-V. Non-Hispanic-Blacks were 55% more likely and 57% less likely than Non-Hispanic-Whites to receive PAP-S and complete HPV-V, respectively. Non-Hispanic Asians were 36% less likely than Non-Hispanic-Whites to receive PAP-S, but this result was borderline significant. Younger age and being unmarried were predictors of lower PAP-S but higher HPV-V. Ever gave birth was a predictor of higher PAP-S but lower HPV-V. Preventative behaviors (PAP-S and flu vaccination) were predictors of higher HPV-V. STI-history was a predictor of higher HPV-V and PAP-S. Not having health insurance for over one year or recent health provider visit were predictors of lower PAP-S and HPV-V. Living in the South was a predictor of lower HPV-V. Household income was not a predictor of any outcomes. Most common reported reason for no HPV-V was "no need." Study findings indicate interventions to mitigate disparities in cervical cancer prevention are needed. Tailored education interventions for both women and health care providers along with opportunities associated with the 2010 Affordable Care Act, such as broader access to health care, emphasis on health information technology, and initiatives with PAP screening and adult vaccination as potential quality indicators for performance/payment, can reduce these disparities. Future research should focus on the feasibility of alternative venues for receiving HPV-V and PAP-S. / Thesis (PhD) — Boston College, 2013. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

The purpose of this dissertation was to explore the determinants of Pap screening completion among sub-Saharan African immigrant women. Cervical cancer is a public health problem globally. The risk of invasive cervical cancer remains high among sub- Saharan African immigrant women in the US despite being a preventable cancer. Early detection through Pap screening is crucial for prevention, treatment and prognosis. The specific aims of this dissertation were to 1) examine Pap screening practices among African immigrant women and to identify gaps to guide future research; 2) explore barriers and motivators that influence Pap screening decisions among African immigrant women; and 3) explore African immigrant men’s knowledge of Pap screening and attitudes about supporting their wives/female partners to utilize Pap screening, and 4) explore predictors of Pap screening use among sub-Saharan African immigrant women, Specific aim one was addressed by a review and synthesis of literature focused on Pap screening among African immigrant women. Common factors influencing Pap screening completion included immigration status, health care interactions, knowledge deficiency, religiosity, and certain personal characteristics. Specific aim two was addressed by the conduct of a qualitative descriptive study of barriers and motivators contributing to Pap screening decisions in 22 African immigrant women. Women experienced different barriers including low knowledge of screening, cultural beliefs, fear and communication issues. Addressing knowledge gaps and other barriers related to Pap screening may improve Pap screening participation in this group. Specific aim three was addressed by a qualitative descriptive study of men’s attitudes and beliefs regarding Pap screening and support for their wives for Pap screening participation. African immigrant men demonstrated suboptimal knowledge and awareness of cervical cancer screening. Most men had a lack of knowledge regarding HPV and its link with cervical cancer. Despite knowledge deficiency men showed significant interest in supporting their wife/female partners. Specific aim four was addressed by conducting an analysis of cross sectional data collected from 108 sub-Saharan African women. Predictors of Pap screening completion was determined using logistic regression while controlling for age and education. Pap screening awareness and provider’s recommendations were independent predictors of Pap screening. Given the unequitable burden of cervical cancer experienced by this population, the findings from this dissertation point to the need for a multilevel targeted health interventions directed toward African immigrant population are needed to increase the rates of Pap screening among African immigrant women. Prevention efforts should focus on individual level factors and develop culturally relevant strategies that will effectively provide educational outreach interventions and alleviate barriers to Pap screening. Engaging spousal support and addressing social norms related to spouses/partners’ roles that may influence partaking in cervical cancer screening is important among African immigrant women. Cervical cancer is preventable; Pap screening will lead to early detection of cervical cancer in female African immigrants.

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