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Factors Associated With Pap Test Screening Among South Korean Women Aged 20 To 39 Years
Factors Associated With Pap Test Screening Among South Korean Women Aged 20 To 39 Years
Factors Associated With Pap Test Screening Among South Korean Women Aged 20 To 39 Years
Abstract
The number of hospital visits with cervical cancer as the chief complaint among South Korean women aged 20 to 39 has
increased by 1.2 times between 2016 and 2020, indicating a need for active screening for the disease. This study aimed to
investigate the status of the Papanicolaou (Pap) test and identify factors influencing Pap test experience among South Korean
women aged 20 to 39 years. An online questionnaire survey was conducted over 5 days starting from November 19, 2021. A total
of 338 participants who were randomly sampled by age completed the survey. Data were analyzed using descriptive statistics, t
test, χ2 test, and logistic regression. The mean age of the participants was 29.9 years, and participants with and without Pap test
experience accounted for 60.7% and 39.3% of the total, respectively. There were significant differences in age, marital status,
employment status, smoking status, experience of coitus, awareness of the National Cancer Screening Program, and human
papillomavirus (HPV) vaccination status according to the Pap test experience (P < .05) of the participants. Pap test attitude, Pap
test self-efficacy, cervical cancer knowledge, HPV knowledge, and cancer prevention behavior scores were significantly higher
in the Pap test experience group than in the no Pap test experience group (P < .05). Logistic regression analysis showed that
experience of coitus (odds ratio [OR] = 10.46, 95% confidence interval [CI]: 4.54–24.11), marital status (OR = 5.96, 95% CI: 2.25–
15.77), awareness of the National Cancer Screening Program (OR = 4.39, 95% CI: 1.66–11.58), HPV vaccination (OR = 2.62,
95% CI: 1.35–5.09), employment status (OR = 2.22, 95% CI: 1.08–4.59), and self-efficacy (OR = 1.09, 95% CI: 1.01–1.19) were
the influencing factors in the Pap test experience group. To improve the Pap test screening rate among South Korean women
aged 20 to 39, reinforcement strategies and intervention programs that involve age-specific approaches must be established.
Abbreviations: CC = cervical cancer, CI = confidence interval, HPV = human papillomavirus, NCSP = National Cancer Screening
Program, non-PT = no Pap test experience, OR = odds ratio, Pap = Papanicolaou, PT = Pap test experience.
Keywords: cancer screening test, cervical cancer, knowledge, Pap test, self-efficacy, women
This work was supported by the Basic Science Research Program through the Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.
National Research Foundation of Korea (NRF) funded by the Ministry of Education This is an open-access article distributed under the terms of the Creative
(no. NRF-2020R1I1A3065986). Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is
The authors have no funding and conflicts of interest to disclose. permissible to download, share, remix, transform, and buildup the work provided
it is properly cited. The work cannot be used commercially without permission
The datasets generated during and/or analyzed during the current study are from the journal.
available from the corresponding author on reasonable request.
How to cite this article: Seo YA, Kim YA. Factors associated with Pap test
a
Department of Data Science, College of Natural Sciences, Jeju National screening among South Korean women aged 20 to 39 years. Medicine
University, Jeju-si, Jeju-do, Republic of Korea, b Department of Nursing, College 2023;102:30(e34539).
of Nursing, Jeju National University, Jeju-si, Jeju-do, Republic of Korea.
Received: 31 January 2023 / Received in final form: 26 June 2023 / Accepted:
*Correspondence: Young A Kim, Department of Nursing, College of Nursing, Jeju 11 July 2023
National University, 102 Jejudaehakno, Jeju-si, Jeju-do 63243, Republic of Korea
(e-mail: yakim@jejunu.ac.kr). http://dx.doi.org/10.1097/MD.0000000000034539
1
Seo and Kim • Medicine (2023) 102:30Medicine
feelings of shame can act as barriers to the screening in young attitude. The tool’s reliability was Cronbach α = 0.88 at the time
women.[8–11] of development and Cronbach α = 0.86 in this study.
Considering that most patients with sexually transmitted
diseases in South Korea are young people and that the aver- 2.4.3. Pap test self-efficacy The tool developed by Jo
age age of the first sexual experience has gradually decreased (unpublished dissertation) for measuring Pap test-related self-
to 13.6 years, efforts to prevent CC among young women are efficacy of women was used. The tool consists of 10 items,
essential.[12,13] Above all, management through regular screening each rated on a 4-point Likert scale from “Not at all” to “Very
is critical for CC prevention. Therefore, this study focused on much so.” The total score ranged between 10 and 40 points,
young adult women. with higher scores indicating higher self-efficacy for screening
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This study aimed to survey the Pap test experience among behavior. The tool’s reliability was Cronbach α = 0.93 at the
women aged 20 to 39 years, investigate the influencing factors, time of development and Cronbach α = 0.90 in this study.
and provide evidence-based data to raise awareness and encour-
wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 04/23/2024
age regular Pap screening as a means of preventing CC, espe- 2.4.4. Knowledge of CC This study used a tool developed by
cially among women in their 20s and 30s who are experiencing Kim and Park[14] for measuring CC knowledge among female
the NCSP for the first time. university students. The tool consists of 8 items, each answered
as “Yes,” “No,” or “Not sure.” Each correct answer was assigned
1 point, while a wrong or no answer was assigned 0 points. The
2. Methods total score ranged between 0 and 8 points, with higher scores
indicating higher CC knowledge. The tool’s reliability was
2.1. Study design Cronbach α = 0.83 at the time of development and Cronbach
This was a descriptive survey study investigating the status of α = 0.57 in this study.
Pap test screening and identifying the factors influencing the Pap 2.4.5. Knowledge of HPV This study used a tool developed
test experience among women aged 20 to 39 years. by Kim and Ahn[15] for measuring HPV knowledge. The tool
consists of 20 items, each answered as “Yes,” “No,” or “Not
sure.” Each correct answer was assigned 1 point, while a wrong
2.2. Ethics approval and consent to participate or no answer was assigned 0 points. The total score ranged
This study was performed in line with the principles of the between 0 and 20 points, with higher scores indicating higher
Declaration of Helsinki. The study was conducted after obtain- HPV knowledge. The tool’s reliability was Cronbach α = 0.87
ing approval from the Institutional Review Board (IRB; JJNU- at the time of development and Cronbach α = 0.88 in this study.
IRB-2021-078) for the objective and methods of the study,
confidentiality, data management, study information sheet, con- 2.4.6. Cancer prevention behavior To identify the level of
sent form, and questionnaire. Informed consent was obtained general cancer prevention practice, participants were instructed
from all the participants. to check the items they practice among the 10 national cancer
prevention practice rules presented by the National Cancer
Information Center.[16] Each “Yes” response was assigned 1
2.3. Participants and data collection point, and a “No” response was assigned 0 points. The total
score ranged between 0 and 10 points, with higher scores
Macromill Embrain Co., an online research firm, was hired indicating better cancer prevention behavior. The tool’s
for data collection, which was performed over 5 days starting reliability was Cronbach α = 0.73 in a previous study[17] and
from November 19, 2021. The sample size was calculated using Cronbach α = 0.70 in this study.
G*power 3.1.9.4 program (Universität Düsseldorf, Düsseldorf,
Germany). When the parameters for binomial logistic regression
analysis were set to 2 tails, odds ratio (OR) = 1.5, significance 2.5. Statistical analyses
level (α) = 0.05, and statistical power (1-β) = 0.9, the minimum
sample size required was 275. The email addresses of a panel of Collected data were analyzed using the SPSS 23.0/PC program
women aged 20 to 39 years who are registered with the online (IBM Corp., Armonk, NY). Descriptive statistics were used to
research firm were extracted using equal allocation by age. A present the sociodemographic characteristics, Pap test attitude,
request to participate in the survey was sent to the addresses, Pap test self-efficacy, CC knowledge, HPV knowledge, and can-
and ultimately 338 participants completed the survey. The sys- cer prevention behavior. Chi-square and t tests were performed
tem used for the survey was set up to close if the response time to compare the differences in sociodemographic characteristics,
was too short or some responses were missing. Women who Pap test attitude, Pap test self-efficacy, CC knowledge, HPV
did not consent to participate or dropped out during the survey knowledge, and cancer prevention behavior according to the
were excluded. Pap test experience of the participants. Binomial logistic regres-
sion analysis was performed to investigate the influencing fac-
tors according to the Pap test experience of the participants.
2.4. Study tools
2.4.1. Sociodemographic characteristics Age, marital status, 3. Results
education status, employment status, smoking status, experience
of coitus, family history of CC, Pap test experience, awareness 3.1. Sociodemographic characteristics
of the NCSP, and HPV vaccination status were investigated. According to the age distribution, there were 165 (48.8%)
and 173 participants (51.2%) aged 20 to 29 and 30 to 39
2.4.2. Attitude toward the Pap test This refers to the subjective years, respectively, with a mean age of 29.9 ± 5.1 years. The
awareness of the benefits of undergoing a Pap test and the number of married and unmarried participants was 107
consequences and barriers to not receiving one. In this study, (31.7%) and 231 (68.3%), respectively. With respect to edu-
a tool developed by Jo (unpublished dissertation) was used to cation level, most participants (n = 198, 58.6%) were univer-
measure the attitude toward the Pap test. The tool consists of sity graduates. Meanwhile, 227 participants (67.2%) were
14 items, each rated on a 4-point Likert scale from “Not at all” employed, and 111 (32.8%) were unemployed. There were
to “Very much so.” The total score ranged between 14 and 56 63 smokers (18.6%). In addition, 256 participants (75.7%)
points, with higher scores indicating a more positive Pap test had coitus experience, with the mean age of first coitus being
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Seo and Kim • Medicine (2023) 102:30www.md-journal.com
22.16 ± 3.89 years (min: 15, max: 36 years). The group with 3.4. Factors influencing Pap test experience
Pap test experience (PT group) consisted of 205 participants To identify the factors influencing Pap test experience, binomial
(60.7%), while the group with no Pap test experience (non-PT logistic regression was performed with factors that showed a
group) consisted of 133 participants (29.3%). Furthermore, 21 significant difference in univariate analysis (sociodemographic
participants (6.2%) had a family history of CC, 293 (86.7%) characteristics [age, marital status, employment status, smoking
were aware of the NCSP, and 129 (38.2%) had received HPV status, experience of coitus, awareness of the NCSP, and HPV
vaccination (Table 1). vaccination], Pap test attitude, Pap test self-efficacy, CC knowl-
edge, HPV knowledge, and cancer prevention behavior) as the
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The mean scores, as measured by the tools described above, Nagelkerke determination coefficient. Classification accuracy
were as follows: Pap test attitude = 44.20 ± 5.42 points; Pap test was 81.7%. The model in the present study was determined to
self-efficacy = 29.09 ± 4.69 points; CC knowledge = 3.49 ± 1.67 fit the data analyzed herein since the hypothesis that this model
points; HPV knowledge = 5.21 ± 3.18 points; and cancer pre- would show no difference between the measured and predicted
vention behavior = 7.55 ± 2.10 points (Table 1). values could not be rejected based on the Hosmer–Lemeshow
test results (χ2 = 5.30, P = .725).
The identified significant factors influencing Pap test expe-
3.3. Differences in characteristics according to Pap test rience were marital status, employment status, experience of
coitus, awareness of the NCSP, HPV vaccination, and Pap test
experience self-efficacy. Married individuals had a 5.96 times higher OR of
Differences in characteristics according to the Pap test experience having a Pap test compared to unmarried individuals. The odds
of the participants were investigated. Among the sociodemo- were 2.22 and 10.46 times higher for employed and individu-
graphic characteristics, age (P < .001), marital status (P < .001), als with coitus experience, compared to unemployed individu-
employment status (P < .001), smoking status (P = .026), expe- als and individuals without coitus experience, respectively. The
rience of coitus (P < .001), awareness of the NCSP (P < .001), odds were 4.39 times higher for individuals aware of the NCSP
and HPV vaccination (P < .001) showed significant differences and 2.62 times higher for individuals who received HPV vacci-
according to the Pap test experience. Furthermore, Pap test atti- nation, compared to those who were not aware and those who
tude (P < .001), Pap test self-efficacy (P < .001), CC knowledge did not receive the vaccination, respectively. Concerning the Pap
(P = .001), HPV knowledge (P = .038), and cancer prevention test self-efficacy, an increase of 1 point was associated with an
behavior (P = .027) all showed significant differences according increase of 1.09 times in the likelihood of Pap test experience
to the Pap test experience (Table 1). (Table 2).
Table 1
Differences in characteristics according to Pap test experience (N = 338).
Experience with Pap test
Yes (n = 205) No (n = 133)
Variables Categories Total n (%) or M ± SD χ2 (p) or t (p)
Age (yr) 20–29 165 (48.8) 72 (35.1) 93 (69.9) 39.10 (<.001)
30–39 173 (51.2) 133 (64.9) 40 (30.1)
Marital status Yes 107 (31.7) 97 (47.3) 10 (7.5) 59.06 (<.001)
No 231 (68.3) 108 (52.7) 123 (92.5)
Education status ≤High school 37 (10.9) 17 (8.3) 20 (15.0) 3.80 (.283)
College 75 (22.2) 47 (22.9) 28 (21.1)
University 198 (58.6) 124 (60.5) 74 (55.6)
≥Graduate school 28 (8.3) 17 (8.3) 11 (8.3)
Employment status Employed 227 (67.2) 155 (75.6) 72 (54.1) 16.87 (<.001)
Unemployed 111 (32.8) 50 (24.4) 61 (45.9)
Smoking status nonsmoker 275 (81.4) 159 (77.6) 116 (87.2) 4.96 (.026)
Smoker 63 (18.6) 46 (22.4) 17 (12.8)
Experience of coitus Yes 256 (75.7) 195 (95.1) 61 (45.9) 106.52 (<.001)
Age of first coitus (n = 256) 22.16 ± 3.89 22.36 ± 4.14 21.51 ± 2.88
No 82 (24.3) 10 (4.9) 72 (54.1)
Family history of CC Yes 21 (6.2) 12 (5.9) 9 (6.8) 0.12 (.734)
No 317 (93.8) 193 (94.1) 124 (93.2)
Awareness of the NCSP Yes 293 (86.7) 196 (95.6) 97 (72.9) 35.94 (<.001)
No 45 (13.3) 9 (4.4) 36 (27.1)
HPV vaccination Yes 129 (38.2) 94 (45.9) 35 (26.3) 13.05 (<.001)
No 209 (61.8) 111 (54.1) 98 (73.7)
Attitude toward the Pap test 44.20 ± 5.42 45.18 ± 5.44 42.69 ± 5.04 4.23 (<.001)
Pap test self-efficacy 29.09 ± 4.69 30.09 ± 4.68 27.54 ± 4.29 5.06 (<.001)
Knowledge of CC 3.49 ± 1.67 3.73 ± 1.67 3.12 ± 1.62 3.33 (.001)
Knowledge of HPV 5.21 ± 3.18 5.50 ± 3.19 4.77 ± 3.12 2.09 (.038)
Cancer prevention behavior 7.55 ± 2.10 7.76 ± 2.02 7.24 ± 2.20 2.22 (.027)
CC = cervical cancer, HPV = human papillomavirus, NCSP = National Cancer Screening Program.
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Seo and Kim • Medicine (2023) 102:30Medicine
Table 2
Factors affecting Pap test experience among South Korean women (20–39 years) by binary logistic regression (N = 338).
Variables B SE OR (95% CI) P value
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Seo and Kim • Medicine (2023) 102:30www.md-journal.com
age groups, the Pap test screening rate in this population may Formal analysis: Yun Am Seo.
increase. Funding acquisition: Young A Kim.
Finally, in the present study, a difference in the Pap test experi- Investigation: Yun Am Seo.
wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 04/23/2024
ence was evident between women in their 20s and 30s, although Methodology: Yun Am Seo, Young A Kim.
age was not found to be a significant determinant of the Pap test Project administration: Young A Kim.
experience (P = .729). The average age of the participants at the Supervision: Young A Kim.
time of their first sexual intercourse was 22.16 years, with the Validation: Yun Am Seo.
youngest reported age being 15 years. Moreover, even though 82 Writing – original draft: Yun Am Seo.
participants reported no history of sexual intercourse, Pap tests Writing – review & editing: Young A Kim.
were performed on 10 of them. Sexual experience at an early age
is a well-known risk factor for CC.[25,26] In Korean culture, the References
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