Knowledge and Practices Regarding Human Papillomavirus and Cervical Cancer Screening Among Women in low-income areas of China: A Cross-Sectional Study

doi:10.21203/rs.3.rs-3594045/v1

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Knowledge and Practices Regarding Human Papillomavirus and Cervical Cancer Screening Among Women in low-income areas of China: A Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-3594045/v1

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Background

Persistent human papillomavirus (HPV) infection is the primary cause of cervical cancer. However, this can be prevented through vaccination and screening. This study aimed to clarify the relationship between behavior, knowledge, and attitude toward cervical cancer and regular screening and HPV infection among women in Lueyang County.

Methods

Women who underwent cervical cancer screening at the outpatient department of a maternal and child health center between September and December 2021 were invited to participate. In total, 2,326 women completed the questionnaire. Women who underwent regular or irregular screening were 1:1 matched for age. Differences in knowledge of HPV and attitudes toward HPV vaccination among different populations were assessed. Logistic regression analysis was performed to identify the factors influencing HPV infection.

Results

In total, 417 pairs of women who underwent regular and irregular screening were successfully matched. Age was a risk factor for HPV infection, whereas regular screening was a protective factor against HPV infection. In the regular screening group, 84 individuals tested positive for HPV, which was lower than the 216 individuals in the irregular screening group. Additionally, compared with the irregular screening group, the regular screening group had a higher level of knowledge about HPV and a greater willingness to receive the HPV vaccination.

Conclusions

Women in Lueyang County have low levels of knowledge regarding HPV and cervical cancer. Regular screening is a protective factor against HPV infection. The regular screening group demonstrates a higher level of HPV knowledge compared with the irregular screening group. These findings highlight the importance of regular screening and the need to strengthen public health education.

Human papillomavirus

cervical cancer

screening

cross-sectional

Cervical cancer is the only cancer with a definitive cause attributed to persistent infection by high-risk human papillomavirus (HPV)¹, Therefore, HPV vaccination and regular screening and effective measures for reducing the incidence and mortality of cervical cancer, as demonstrated in developed countries, are necessary.^2,3Thus, in 2009, under the auspices of the All-China Women’s Federation and the Ministry of Health, China launched a screening program for “two cancers” (cervical and breast cancers) and implemented free cervical cancer screening for rural women aged 35–64 years.⁴However, despite the widespread recognition of cervical cancer screening, it has low participation rates, especially in rural and western regions, compared with eastern regions. The disparity in participation rates across various socioeconomic and geographic provinces poses a significant challenge in preventing cervical cancer. ⁵Currently, China’s cervical cancer screening rate is far below the target of the World Health Organization of 70% screening coverage ⁶.

Various factors influence women’s participation in cervical cancer screening, including age, education, socioeconomic status, and cervical cancer⁷.Previous studies have demonstrated a significant correlation between cervical cancer knowledge and the rate of screening participation^8,9. An insufficient understanding of cervical cancer is considered one of the most important factors affecting participation rates¹⁰. That is, women who have participated in screening generally have greater knowledge of cervical cancer than those who have not undergone screening¹¹.

Lueyang County, which has high cervical cancer incidence and mortality rates, is a low-income region in China ¹².With an average educational level below the national standard, most of the residents live as farmers or migrant workers. Despite the initiation of annual cancer screenings in 2017, orchestrated by the local maternal and child health centers in collaboration with regional health centers and village doctors, the uptake of Lueyang County remains low. A limited number of women benefit from free screening, whereas several abstain from participation, which is potentially attributable to insufficient health awareness, financial constraints, and logistic complications. ¹³

This study aimed to examine the correlation between cervical cancer knowledge and adherence to regular screening practices. Additionally, we aimed to evaluate the effectiveness of regular screening for early detection of cervical cancer. Moreover, the present study aimed to understand women’s attitudes toward cervical cancer prevention in high-risk areas. The ultimate goal was to enhance the uptake of regular cervical cancer screening through the creation of evidence-based health education strategies designed to boost knowledge regarding cervical cancer and, consequently, its prevention.

Study Design and Ethical Considerations

This study used a cross-sectional design and was conducted at Lueyang County Maternal and Child Health Hospital in Hanzhong City, Shanxi Province. We collected information from women who underwent cervical cancer screening and invited them to complete our questionnaire. The content of our questionnaire was derived from a literature review and expert consultation. After obtaining informed consent from the participants, professional nurses provided guidance on completing the questionnaire. This study was approved by the Ethics Committee of Lueyang County Maternal and Child Health Hospital.

Data Collection and Inclusion Criteria

We invited all women who underwent cervical cancer screening from September to December 2021 to complete a paper-based questionnaire, and the completed questionnaires were subsequently entered into a data platform by professional personnel. Additionally, we registered the HPV test results of all patients on the data platform. Women aged < 20 years and those with missing important information on the questionnaire were excluded from the analysis. Ultimately, 2,326 women participated in our study.

Questionnaire

The questionnaire included demographic information, health-related knowledge about HPV, regular participation in cervical cancer screening, and attitudes toward HPV vaccination. We defined women who had been screened for cervical cancer in the last 3 years as regularly screened and women who had not been screened for cervical cancer in the last 3 years as not regularly screened. Notably, HPV health-related knowledge was mainly assessed by asking “Do you know about HPV”? and determining whether they were aware of the following information. “HPV is an important etiological factor of cervical cancer.” “HPV can cause genital warts in both men and women,” and “HPV can be transmitted through sexual contact.” “Most HPV infections can naturally regress without treatment.” “Men can also be infected with HPV.” “Condoms can prevent HPV infection.” Only if the answer to the question “Do you know about HPV” is “YES” can you continue to answer the next six questions. Attitude refers to the willingness to receive the HPV vaccine, with a positive attitude indicating willingness to receive the HPV vaccine and a negative attitude indicating unwillingness to receive the HPV vaccine.

Statistic analysis

We used SAS version 9.4 for descriptive analysis and SPSS for matching. Demographic and clinical characteristics of the participants were summarized using mean ± standard deviation for continuous variables and proportions (%) for categorical variables. Significant associations in contingency tables were tested using standard Pearson’s chi-squared test. If the P value calculated in these analyses was < 0.05, the difference was considered significant. We aimed to analyze the differences in HPV knowledge between the regular and irregular screening groups. To increase the effects of reducing confounding factors and enhance the comparability of the regularly and irregular screening groups, we established the regular and irregular screening groups using age as a matching variable, with 1:1 matching. Additionally, multivariate logistic regression was used to assess the influencing factors of HPV infection.

In total, 2,326 women participated in this study, 419 (mean age, 47.54 ± 8.48 years) in the regular screening group and 1884 (mean age, 49.26 ± 8.45 years) in the irregular screening group. Out of the participants, 468 (20.12%) tested positive for HPV.A total of 39.67% and 51.98% of women in the regular and irregular screening groups, respectively, were farmers. In the regular and irregular screening groups, 195 (47.33%) and 816 (43.54%) women, respectively, had secondary education (middle/high school). Furthermore, a greater proportion of women in the regular screening group had a university education than those in the irregular screening group. In the regular screening group, 56.12% of the women had an annual household income ranging from RMB 10,000 to 30,000.Notably, 2.94% and 0.86% of the women in the regular and irregular screening groups, respectively, received HPV immunization. A comprehensive summary of the participants’ characteristics is provided in Table 1.

Table 1

Characteristics of participants before and after matching in regular and irregular screening groups. (n = 2326)
Characteristics	Before		t/χ²	P	After		t/χ²	P
	Regular N = 419	Irregular N = 1884			Regular N = 417	Irregular N = 417
Age	47.54 ± 8.48	49.26 ± 8.45	-3.77	<0.001	47.65 ± 8.35	47.65 ± 8.35	0.00	1.00
HPV			0.0355	0.850			90.7092	<0.001
Positive	86(20.53)	379(20.12)			84(20.14)	216(51.80)
Negatives	333(79.74)	1505(79.88)			333(79.86)	201(48.20)
Occupation			33.8342	<0.001			6.1747	0.045
Farmers	165(39.76)	970(51.98)			165(39.95)	191(46.59)
Worker/Individual/Staff	169(40.72)	26.63(26.63)			168(40.68)	133(32.44)
Others	81(19.52)	21.38(21.38)			80(19.37)	86(20.98)
Education			31.5662	<0.001			7.0053	0.030
Primary or Illiterate	132(32.04)	832(44.40)			132(32.30)	166(39.90)
Middle/High school	195(47.33)	816(43.54)			195(47.56)	188(45.19)
Graduate	85(20.63)	226(12.06)			83(20.24)	62(14.90)
Annual income			82.9695	<0.001			42.1386	<0.001
≤ 10000	30(7.19)	300(15.98)			30(7.23)	50(12.80)
10000–30000	234(56.12)	629(33.51)			233(56.14)	141(34.06)
>30000	135(32.37)	758(40.38)			134(32.29)	188(45.41)
Unknown	18(4.32)	190(10.12)			18(4.34)	35(8.45)
Family history of cancer			0.8549	0.3552			1.3287	0.2490
YES	29(6.97)	156(8.34)			28(6.76)	37(8.92)
no	387(93.03)	1715(91.66)			386(93.24)	378(91.08)
Current gynecological symptoms			19.1545	<0.001			30.0013	<0.001
YES	137(32.70)	836(44.37)			135(32.37)	213(51.08)
NO	282(67.30)	1048(55.63)			282(67.63)	204(48.92)
Sex			2.0478	0.152			0.0147	0.903
YES	256(85.91)	1461(82.54)			254(85.81)	354(86.13)
NO	42(14.09)	309(17.46)			42(14.19)	57(13.87)
History of HPV vaccination			11.9414	0.0005			7.4675	0.0063
YES	12(2.94)	16(0.86)			12(2.96)	2(0.48)
NO	396(97.06)	1849(99.14)			394(97.04)	412(99.52)
Regular gynecological examinations			771.8798	<0.001			347.5194	<0.001
YES	362(86.40)	331(17.57)			362(86.81)	94(22.54)
NO	57(13.60)	1553(82.43)			55(13.19)	323(77.46)

Table 2 shows that age was a risk factor for HPV infection (odds ratio [OR] = 1.056, 95% confidence interval [CI]: 1.031–1.082). In contrast, regular screening was a protective factor for HPV infection (OR = 0.174, 95% CI: 0.117–0.259), suggesting that individuals who undergo regular screening have a lower likelihood of infection HPV compared with those who do not.

Table 2

Multivariable logistic regression analysis of HPV infection
Variables	β	SE	Wald χ2	p	OR	95% CI
age	0.054	0.012	19.787	<0.001	1.056	[1.031 1.082]
Worker/Individual/Staff	-0.841	0.264	10.135	0.001	0.431	[0.257 0.724]
Other occupations	-0.908	0.264	11.791	0.001	0.403	[0.240 0.677]
Middle/High school	-0.441	0.220	4.016	0.045	0.643	[0.418 0.990]
Graduate	-0.674	0.363	3.435	0.064	0.510	[0.250 1.039]
Regular screening	-1.749	0.203	74.237	<0.001	0.174	[0.117 0.259]
Known HPV	0.376	0.217	3.011	0.083	1.456	[0.952 2.226]

Table 3 shows that, among the individuals who had HPV knowledge (675), 314 (46.51%) underwent regular screening, whereas among the 1,642 participants who lacked HPV knowledge, 386 (23.50%) underwent regular screening (X² = 121.9331, P < 0.001).

Table 3

HPV awareness and regular screening among 2326 participants
	Regular screened	Irregular screened	Total
Knowledge of HPV	314(46.51%)	361(53.49%)	675
No knowledge of HPV	386(23.50%)	1265(76.50%)	1642
Total	700(30.09%)	1626(69.91%)	2326

To enhance the comparability between the two groups, we paired them according to age, resulting in 417 matched pairs with an equal number of participants in both groups after matching(Table 1). After matching, the two groups were of equal age. Compared with the irregular screening group, the regular screening group was more educated and had a higher annual household income (P < 0.05).There were 216(51.80%) positive HPV test results in irregular screening and 84(20.14%) in regular screening,(p < 0.001). After matching, 165(39.95%) and 191(46.59%) women in the regular screening group and irregular screening group were farmers by occupation respectively(p = 0.045). Overall the educational level of women in the matched regular screening group was higher than that of irregularly screened women. The number of regular gynecological check-ups was also higher in the regular plus cervical cancer screening group 362 (86.81%) than in the irregular screening group.(p < 0.001).

Table 4 shows the differences in HPV knowledge between the regular and irregular screening groups. Regarding the question “Do you know about HPV?” the number of individuals with HPV knowledge in the regular screening group (214 [51.32%]) was higher than that in the irregular screening group (107 [25.66%]) (P < .0001). Among the participants with HPV knowledge, no significant difference was found between the regular and irregular screening groups in terms of HPV-related diseases and transmission, prognosis, and prevention of HPV infection.

Table 4

Knowledge **of HPV between the regular screening group and the irregular screening group.**
Questions	Answer	Regular	Irregular	χ²	P
		N(%)	N(%)
Do you know about HPV?	YES	214(51.32)	107(25.66)	57.9844	< .0001
	NO	203(48.68)	310(74.34)	57.9844	< .0001
HPV is an important etiological factor of cervical cancer*	Know	195(90.28)	99(92.52)	0.4415	0.506
	Unknown	21(9.72)	8(7.48)	0.4415	0.506
HPV can cause genital warts in both males and females*	Know	145(67.13)	67(63.81)	0.3473	0.555
	Unknown	71(32.87)	38(36.19)	0.3473	0.555
HPV can be transmitted through sexual contact*	Know	172(79.26)	84(78.50)	0.0248	0.874
	Unknown	45(20.74)	23(21.50)	0.0248	0.874
Most HPV infections can naturally regress without treatment*	Know	119(57.77)	48(48.00)	2.5905	0.107
	Unknown	87(42.23)	52(52.00)	2.5905	0.107
Men can also infection HPV*	Know	133(61.57)	60(56.60)	0.7315	0.392
	Unknown	83(38.43)	46(43.40)	0.7315	0.392
Condoms can prevent HPV infection*	Know	164(76.28)	82(77.36)	0.0462	0.829
	Unknown	51(23.72)	24(22.64)	0.0462	0.829

*The number of respondents who answered “YES” to "Do you know about HPV?" question.

Table 5 shows attitudes toward HPV vaccine among regular screening group and the irregular screening group.In the regular screening group, 237 (56.83%) individuals were aware that “HPV infection can be prevented by vaccination,” whereas in the irregular screening group, 194 (46.52%) individuals had this knowledge (P = 0.0029). Regarding “willingness to receive HPV vaccination,” most of the participants in both the regular (348 [83.45%]) and irregular (345 [82.73%]) screening groups demonstrated a positive attitude toward HPV. Regarding the willingness to have their daughters vaccinated against HPV, mothers in the irregular screening group (17 [6.97%]) exhibited a higher level of hesitancy compared with mothers in the regular screening group (4 [1.70%], P = 0.004).

Table 5

Attitudes toward HPV vaccine among regular screening group and the irregular screening group.
Questions		Regular	Irregular	χ²	P
		N (%)	N (%)
HPV infection can be prevented by vaccination				8.8781	0.0029
	YES	237(56.83)	194(46.52)
	NO	180(43.17)	223(53.48)
Willingness to receive HPV vaccination				0.0768	0.781
	YES	348(83.45)	345(82.73)
	NO	69(16.55)	72(17.27)
Whether there are daughters				0.0171	0.896
	YES	246(60.59)	249(60.14)
	NO	160(39.41)	165(39.86)
Willingness to allow your daughter to receive HPV vaccination				7.9162	0.004
	YES	231(98.30)	227(93.03)
	NO	4(1.70)	17(6.97)

A total of 295 women provided reasons on not undergoing regular screening. Multiple reasons could be simultaneously selected. “Do not know how to check regularly” was the most frequently selected reason, followed by “Do not know the significance of screening.” The third reason was “No symptoms,” and a small percentage of reasons included feeling unnecessary and having no time. Figure 1 shows the reasons for not having regular screening.

This study mainly comprised women in underdeveloped areas, with the objective of assessing the patterns of regular screening behavior and the level of awareness regarding cervical cancer among this specific demographic. Our study demonstrated that women who were regularly screened were less likely to be infected with HPV than those who were irregularly screened, which suggests the importance of regular screening. Moreover, awareness of cervical cancer was higher in the regular screening group than in the irregular screening group. These results provide a basis for the development of grassroots public health work emphasizing the importance of cervical cancer screening and health education. This is particularly crucial in low-income areas where targeted efforts can significantly contribute to improving healthcare outcomes.

In our study, the percentage of women screened in the past 3 years was 18.01%, which is markedly lower than the regular screening rate among women in urban areas (82.14%), according to a previous study¹⁴.In 2009, China initiated the National Cervical Cancer Screening Program for Rural Areas, offering free cervical cancer screening services to registered rural women aged 35–64 years. Over the past decade, cervical cancer screening rates have increased in both urban and rural China¹⁵.However, these rates still fall below the WHO target of achieving 70% coverage for cervical cancer screening. Furthermore, disparities persist, revealing inequalities in screening rates between urban and rural areas and between the eastern and western regions of the country¹³.Factors such as inadequate or low income, elevated costs associated with attending screening (including transportation constraints and time commitments), and the absence of free employee checkups, can contribute to reduced willingness to undergo screening for cervical cancer¹⁶.Screening rates tend to be lower in older than in younger women. Specifically, women aged > 50 years exhibit significantly lower screening rates than those in the 35–49-year age group, as indicated in a previous study¹⁷.Our own study corroborates these findings, revealing that women in the regular screening group were generally younger than those in the irregular screening group. This phenomenon can be attributed to the effects of less awareness about cervical cancer and established traditional beliefs among older women.¹⁸

Another significant factor contributing to low cervical cancer screening rates is the lack of awareness about screening. This is a prevalent barrier, particularly in low- and middle-income countries. Several studies have consistently shown a positive correlation between cognitive awareness and the willingness to participate in screening^19,20.This aligns with findings from cervical cancer awareness surveys conducted in various regions^21,22.In line with these observations, our study also indicates that women in this economically disadvantaged area possess low knowledge about cervical cancer. A common belief among women is that screening is unnecessary if they are not experiencing symptoms²³. This lack of awareness regarding the early features and risk factors for cervical cancer can result in patients with early-stage cervical cancer missing an optimal window for treatment. Therefore, it is crucial to enhance awareness among women to promote screening and ensure timely intervention.

Health education is an effective method for raising awareness about cervical cancer. Providing education to women through lectures and video dissemination results in a substantial increase in their willingness to undergo cervical cancer screening. In Abera’s study, the intervention group demonstrated a remarkable and sustained increase of 46.4% in screening willingness during subsequent follow-up visits. This underscores the importance of health education in fostering women’s participation in screening initiatives.^24–26Nevertheless, notably, women in underdeveloped areas, particularly older women, may not have received systematic education, face challenges in reading and writing, or may have limited access to useful information via mobile phones. Additionally, owing to their geographical distance, they may encounter difficulties in accessing public health services. Undertaking health education initiatives for this demographic poses a significant challenge given these factors. Addressing these challenges requires innovative and targeted approaches to ensure the effective communication and education of women in underdeveloped areas.

HPV vaccination is considered the primary preventive measure against cervical cancer²⁷.Observations in the United States, Italy, and Norway among women who have received the vaccine indicate a decrease in HPV disease incidence rates, underscoring the necessity and effectiveness of the vaccine^28,29. However, in China, only a few cities with a high socioeconomic status have implemented free HPV vaccination programs³⁰.Residents of other areas who wish to receive vaccination must bear the costs. Furthermore, owing to high expenses, challenges in making appointments, and a lack of policy support, the overall HPV vaccination coverage rate in China is generally low³¹.The Lueyang County government recently devised a plan to implement a flat-rate subsidy for the cost of preventive HPV vaccination for girls aged 9–14 years within the county. This initiative aims to encourage HPV vaccination among girls of appropriate age and increase the local vaccination rate. However, notably, the vaccine has a limited timeframe and does not encompass all HPV strains. Even with vaccination, regular cervical cancer screening is essential for comprehensive prevention. The integration of vaccination and screening is crucial for the effective implementation of primary and secondary prevention measures against cervical cancer.

Limitations: This study has some limitations. First, our study specifically targeted women in less-developed regions to provide evidence of the importance of regular screening in economically disadvantaged areas. It is not intended for extrapolation to regions with higher economic levels and does not claim national applicability. Second, this was a cross-sectional study, and prospective observational studies are required to obtain the long-term outcomes in regularly and irregularly screened women. Third, although we identified an association between screening behavior and awareness, a causal relationship was not established. This underscores the need for further studies to provide evidence-based insights into subsequent cervical cancer prevention and management in Lueyang County. Continued investigation will enhance our understanding of the factors influencing screening behavior and aid in the development of more targeted and effective preventive strategies.

The proportion of women in Lueyang County who undergo regular cervical cancer screening is less than half. Women who undergo regular screening have a better understanding of HPV and HPV vaccine than those who do not undergo regular screening. Regular screening is a protective factor against HPV infection. The government should provide extensive free screening services, especially in economically disadvantaged areas. Additionally, targeted and effective public health education programs should be implemented to enhance women’s awareness of HPV and cervical cancer and the importance of regular cervical cancer screening.

Contributions

QS, JC, RZ and WX contributed to the study design. LB, DH, XZ, SY, RX,RZ,JC,DKand YN were involved in conducting the field work. JC performed the statistical analyses and wrote the manuscript text. QS and WX revised the draft. All authors have read and approved the final manuscript.

Availability of data and materials

All data pertaining to the findings are presented in this paper. However, the data can be obtained from the corresponding author any time on reasonable request.

Conflict of interest None declared.

Funding statement This project was funded by the Chongqing social Science Planning Project (No. 2022BS081); China Postdoctoral Science Foundation Funded Project (No.2022MD723732); Natural Science Foundation of Chongqing, China (No. 2023NSCQ-BHX0036);State Key Laboratory of Ultrasound Medical Engineering, Chongqing Medical University, China（No.2021KFKT007）

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki. All of the relevant approvals were obtained from the Ethics Committee of the Maternity Service Centre of Lueyang Maternal and Child Health Care Hospital (2021-001). The participants were informed that participation would be voluntary and that all data obtained from them would be kept confidential using codes instead of any personal identifiers.

Cohen PA, Jhingran A, Oaknin A, et al. Cervical cancer. Lancet 2019;393(10167):169-182, doi:10.1016/S0140-6736(18)32470-X
Haesebaert J, Lutringer-Magnin D, Kalecinski J, et al. French women's knowledge of and attitudes towards cervical cancer prevention and the acceptability of HPV vaccination among those with 14 - 18 year old daughters: a quantitative-qualitative study. BMC Public Health 2012;12(1034, doi:10.1186/1471-2458-12-1034
Giles M, Garland S. A study of women's knowledge regarding human papillomavirus infection, cervical cancer and human papillomavirus vaccines. Aust N Z J Obstet Gynaecol 2006;46(4):311-5, doi:10.1111/j.1479-828X.2006.00598.x
Women's health in rural China. Lancet 2009;374(9687):358, doi:10.1016/S0140-6736(09)61394-5
Li K, Li Q, Song L, et al. The distribution and prevalence of human papillomavirus in women in mainland China. Cancer 2019;125(7):1030-1037, doi:10.1002/cncr.32003
Zhang M, Zhong Y, Zhao Z, et al. Cervical Cancer Screening Rates Among Chinese Women - China, 2015. China CDC Wkly 2020;2(26):481-486, doi:10.46234/ccdcw2020.128
Li Q, Liu Q, Chen X, et al. Protection motivation theory in predicting cervical cancer screening participation: A longitudinal study in rural Chinese women. Psycho-oncology 2020;29(3):564-571, doi:10.1002/pon.5307
Donati S, Giambi C, Declich S, et al. Knowledge, attitude and practice in primary and secondary cervical cancer prevention among young adult Italian women. Vaccine 2012;30(12):2075-82, doi:10.1016/j.vaccine.2012.01.057
Jia Y, Li S, Yang R, et al. Knowledge about cervical cancer and barriers of screening program among women in Wufeng County, a high-incidence region of cervical cancer in China. PLoS One 2013;8(7):e67005, doi:10.1371/journal.pone.0067005
Di J, Rutherford S, Wu J, et al. Knowledge of Cervical Cancer Screening among Women across Different Socio-Economic Regions of China. PLoS One 2015;10(12):e0144819, doi:10.1371/journal.pone.0144819
Liu T, Li S, Ratcliffe J, et al. Assessing Knowledge and Attitudes towards Cervical Cancer Screening among Rural Women in Eastern China. International journal of environmental research and public health 2017;14(9), doi:10.3390/ijerph14090967
Yang S, Bai L, Xu W, et al. Profiling the real-world management status of high-risk human papillomavirus infection: a protocol to establish a prospective cohort of high-risk human papillomavirus-infected women in Lueyang County, China. BMJ Open 2022;12(9):e062678, doi:10.1136/bmjopen-2022-062678
You H, Gu H, Zhang N, et al. Why hasn't this woman been screened for breast and cervical cancer? - Evidence from a Chinese population-based study. Public health 2019;168(83-91, doi:10.1016/j.puhe.2018.12.007
Zhang B, Wang S, Yang X, et al. Knowledge, willingness, uptake and barriers of cervical cancer screening services among Chinese adult females: a national cross-sectional survey based on a large e-commerce platform. BMC women's health 2023;23(1):435, doi:10.1186/s12905-023-02554-2
Liu Y, Guo J, Zhu G, et al. Changes in rate and socioeconomic inequality of cervical cancer screening in northeastern China from 2013 to 2018. Frontiers in medicine 2022;9(913361, doi:10.3389/fmed.2022.913361
Li S, Liu S, Ratcliffe J, et al. Preferences for cervical cancer screening service attributes in rural China: a discrete choice experiment. Patient preference and adherence 2019;13(881-889, doi:10.2147/ppa.S201913
Guo M, Xu J, Du J. Trends in cervical cancer mortality in China from 1989 to 2018: an age-period-cohort study and Joinpoint analysis. BMC public health 2021;21(1):1329, doi:10.1186/s12889-021-11401-8
Wong LP. Knowledge and attitudes about HPV infection, HPV vaccination, and cervical cancer among rural southeast Asian women. International journal of behavioral medicine 2011;18(2):105-11, doi:10.1007/s12529-010-9104-y
Srinath A, van Merode F, Rao SV, et al. Barriers to cervical cancer and breast cancer screening uptake in low- and middle-income countries: a systematic review. Health policy and planning 2023;38(4):509-527, doi:10.1093/heapol/czac104
Setiawan D, Miranti I, Partiwi TD, et al. The willingness for cervical cancer screening among sexually active women in Indonesia: Lesson learned from two districts. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2022;159(1):145-151, doi:10.1002/ijgo.14113
Ning YE, Liu Y, Xu XY, et al. Knowledge of Cervical Cancer, Human Papilloma Virus (HPV) and HPV Vaccination Among Women in Northeast China. Journal of cancer education : the official journal of the American Association for Cancer Education 2020;35(6):1197-1205, doi:10.1007/s13187-019-01582-7
Hong Y, Zhang C, Li X, et al. HPV and cervical cancer related knowledge, awareness and testing behaviors in a community sample of female sex workers in China. BMC public health 2013;13(696, doi:10.1186/1471-2458-13-696
Yang H, Li SP, Chen Q, et al. Barriers to cervical cancer screening among rural women in eastern China: a qualitative study. BMJ open 2019;9(3):e026413, doi:10.1136/bmjopen-2018-026413
Abera GB, Abebe SM, Worku AG. Impact of health education intervention on demand of women for cervical cancer screening: a cluster-randomized controlled trial. Trials 2022;23(1):834, doi:10.1186/s13063-022-06765-0
Taylor VM, Hislop TG, Jackson JC, et al. A randomized controlled trial of interventions to promote cervical cancer screening among Chinese women in North America. Journal of the National Cancer Institute 2002;94(9):670-7, doi:10.1093/jnci/94.9.670
Fang CY, Ma GX, Tan Y, et al. A multifaceted intervention to increase cervical cancer screening among underserved Korean women. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology 2007;16(6):1298-302, doi:10.1158/1055-9965.Epi-07-0091
Ueda Y, Miyagi E. Importance of Education about Cervical Cancer and Its Preventive Measures for the Promotion of HPV Vaccine According to the WHO Strategies. Vaccines 2021;9(10), doi:10.3390/vaccines9101199
Carozzi FM, Ocello C, Burroni E, et al. Effectiveness of HPV vaccination in women reaching screening age in Italy. J Clin Virol 2016;84(74-81, doi:10.1016/j.jcv.2016.09.011
Feiring B, Laake I, Christiansen IK, et al. Substantial Decline in Prevalence of Vaccine-Type and Nonvaccine-Type Human Papillomavirus (HPV) in Vaccinated and Unvaccinated Girls 5 Years After Implementing HPV Vaccine in Norway. J Infect Dis 2018;218(12):1900-1910, doi:10.1093/infdis/jiy432
Zhou L, Gu B, Wang J, et al. Human papillomavirus vaccination at the national and provincial levels in China: a cost-effectiveness analysis using the PRIME model. BMC Public Health 2022;22(1):777, doi:10.1186/s12889-022-13056-5
Yin X, Zhang M, Wang F, et al. A national cross-sectional study on the influencing factors of low HPV vaccination coverage in mainland China. Front Public Health 2022;10(1064802, doi:10.3389/fpubh.2022.1064802

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Knowledge and Practices Regarding Human Papillomavirus and Cervical Cancer Screening Among Women in low-income areas of China: A Cross-Sectional Study

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