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Increasing Pap Uptake and HPV 
Vaccination Knowledge and Acceptability 
among Black Women 
Kimlin Ashing1*, Camille Ragin2, Ndifreke Etim1,3 

1City of Hope Beckman Research Institute – Division of Health Equities, 1500 E Duarte Rd, Duarte, CA 
91030, USA. 2Fox Chase Cancer Center, Philadelphia, PA 19111 3Claremont Graduate University, School of 
Global Health 

*Corresponding Author: Email: kashing@coh.org 

ABSTRACT 
Women were recruited from two socioeconomically and ethnically similar regions to participate in the 
intervention. Regions were assigned to one of two conditions: print only or print plus media-based 
social marketing. Baseline and follow-up data were collected and analyzed using univariate and 
bivariate statistical approaches. There was a statistically significant relationship between intervention 
condition and reporting a Pap test at follow up (p = .013). Compared to women in the print only 
condition, women in the print plus media-based social marketing condition reported significantly 
increased Pap testing. Across both conditions, intention to receive Pap testing was high. In the print only 
condition, 37 out of 40 (92.5%) participants reported intention to receive Pap screening within two 
years, while 47 out of 57 (82.5%) participants in the print and media condition reported intention to 
have a test within two years. HPVV knowledge increased among all participants with no differences 
across intervention condition. The print only group reported no change in Pap test completion at follow 
up. However, the enhanced trial condition showed a 25% increase in Pap testing from baseline to 
follow-up. Therefore, in both intervention conditions, HPV knowledge and HPVV acceptability 
significantly increased from baseline to follow-up among all participants. This study suggests a 
multicomponent media-based social marketing strategy may be useful in promoting Pap testing and 
knowledge about HPVV among Black women. 

KEYWORDS: Kindly add. 

Citation: Ashing K et al (2021) Testing a Multicomponent Intervention to Increase Pap Uptake and HPV 
Vaccination Knowledge and Acceptability among Black Women. Cancer Health Disparities 5: e1-e10 
doi:10.9777/chd.2020.1006 
 
 
 



 
 
 
 
 

 
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INTRODUCTION 
Black women in the United States suffer the 
greatest cervical cancer disparity. Blacks have the 
highest cervical cancer incidence – 41% higher 
than white women – and are twice as likely to die 
from the disease than their white counterparts 
(DeSantis et al., 2016). Although Pap test and 
human papillomavirus vaccination (HPVV) offer the 
potential to prevent and even eradicate cervical 
cancer, Black women continue to be 
disproportionately burdened. Therefore, the 
reduction and elimination of persistent and 
troubling HPV-related cancer disparity among 
Black women ought to be prioritized. 

The current guidelines for cervical cancer 
screening recommend women begin Pap testing 
at age 21 and continue screening every three years 
until age 29. From age 30-65, women can 
continue screening every three years or at five 
year intervals if their Pap test also includes an HPV 
test and there is no past positive screening result. 
The guideline for HPVV is the two vaccine series 
administered 6 to 12 months apart for individuals 
starting the series before age 15, and the three 
vaccine series for teens and young adults 15 to 26 
years old. The second dose of the three vaccine 
series is administered 1-2 months after initiation 
and the third dose at 6 months (Centers for 
Disease Control and Prevention, 2016). Despite the 
recommendations, Pap-testing and HPVV uptake 
among Blacks fall short of Healthy People 2020 
goals of 93% and 85%, respectively. Blacks’ HPV 
vaccination coverage is 37.4%,which is lower than 
the national coverage of 44.8%, and their Pap 
testing rate is 74% (Arnett et al., 2016). Low HPV 
vaccine uptake and underutilization of Pap 
screening in this population may be partly a 
function of lack of knowledge (Ashing et al., 2017; 
Blackman et al., 2013; Galbraith et al., 2016), 
absence of medical homes, and non-

recommendation by providers of these cancer 
prevention and control strategies (Centers for 
Disease Control and Prevention, 2016; Galbraith et 
al., 2016). Blacks’ knowledge of HPV and Pap 
testing lags behind non-Hispanic Whites (Ashing 
et al., 2017), and Blacks are less likely to have a 
medical home or utilize primary care (Arnett et al., 
2016). 

Many of the barriers to uptake in this population 
will need broader social and policy level 
interventions, but issues such as acceptability and 
lack of knowledge can be successfully addressed 
at the community and individual level. For 
example, an educational intervention among 
African American college students reported a 
statistically significant increase in participants’ 
knowledge post-intervention and high participant 
affirmation of intention to get regular Pap smears 
(94%) and the HPV vaccine (87%) (Staples et al., 
2018). Other strategies that have proved 
efficacious in increasing Pap test uptake and 
knowledge and acceptability of HPVV among 
minorities include access-enhancing programs, 
community interventions, approaches directed at 
individuals, culturally and ethnically tailored 
materials, and mass media campaigns (Chan et al., 
2015; Han et al., 2011). 

Mass media have been used extensively in social 
marketing campaigns for various types of health 
behavior change ( Hall et al., 2015; Wakefield et al., 
2010). This form of intervention offers a cost-
effective way to reach large, dispersed populations 
and is particularly useful in realizing episodic or 
one-time behaviors. In the context of cervical 
cancer prevention, the evidence suggests 
combining mass media and social marketing with 
other types of tailored interventions such as 
reminder letters results in increases in pap 
screening (Wakefield et al., 2010). In one 
intervention, researchers used social marketing 



 
 
 
 
 

 
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that combined radio public service 
announcements, doctor's recommendation, 
posters, and brochures targeting parents and 
providers to increase HPVV among preteen boys 
(Cates et al., 2014). Social marketing is a program 
planning and implementation process that applies 
commercial marketing concepts and techniques to 
promote voluntary attitude and behavior change 
(Nowak et al., 2015). 

While these strategies have proven efficacious, 
only a few interventions have attempted to 
increase HPVV acceptability (Galbraith et al., 2016), 
and even fewer simultaneously attempt to increase 
Pap uptake and HPVV knowledge and 
acceptability among African American women. 
Within the Black culture, women, including 
grandmothers, play a central role in health 
decision-making (Kennedy et al., 2007). Therefore, 
targeting women of all ages for the intervention 
seems an efficient approach to increase Pap 
testing among women and concurrently influence 
HPVV acceptability and uptake within families. 

The purpose of this study was to assess the 
efficacy of a multicomponent trial intervention to 
increase Pap testing and HPVV knowledge and 
acceptability among African American women in 
two California counties. 

METHODS 
This behavioral trial was conducted in 
collaboration with community partners to enhance 
cultural and community relevance. We readily 
gained community buy-in because of the 
documented elevated cervical cancer prevalence 
and mortality in California. Our community 
partners formed an active advisory council made 
up of health leaders from community-based 
health organizations. The advisory council guided 
the overall trial including the recruitment and 
intervention protocol. They also advised on best 

platforms for the intervention, hosted health fairs, 
and posted fliers at their community sites. The 
intervention strategies were informed by an 
effective Pap testing media campaign conducted 
by the Los Angeles County Office of Women’s 
Health (Stone-Francisco et al., 2003). Thus, our 
intervention integrated a community engaged 
approach and a social marketing intervention to 
increase Pap testing and HPVV knowledge and 
acceptability. 

Setting 
The study was conducted across sub-urban cities 
within the San Gabriel Valley area of Los Angeles 
County, which served as the mailed intervention 
region; and sub-urban cities in Riverside County, 
which served as the enhanced intervention region. 
The targeted regions, each of which was treated as 
a cluster, have similar demographics including 
ethnicity (40% Latino, 5% Black); median age 
(36.4); median household income ($65,744); high 
school graduation rate (about 70%); and number 
of foreign born residents (about 35%). These 
regions are approximately 55 miles apart. The 
distance reduces the likelihood of intervention 
contamination. 

Participants 
Inclusion Criteria and Justification. African 
American women 18 years or older living in these 
two socioeconomically and ethnically similar 
regions were invited to participate in the study. 
Women were excluded if they had any type of 
cancer diagnosis history because the medical 
characteristics (e.g. disease progression, prognosis) 
and perceptions (e.g. health care seeking 
behaviors) are significantly different for these 
women. Additionally, women with other major 
medical conditions (e.g. stroke and degenerative 
illness) who are likely to present with distinct 
medical and quality of life issues were excluded. 



 
 
 
 
 

 
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Procedures 
Participant Recruitment and Enrollment. We used a 
multi-method recruitment approach that 
combined passive strategies – posting fliers at 
community centers and health clinics – and active 
strategies – distributing invitation fliers via 
community health networks, and direct participant 
invitation at various community cultural and health 
events. Study advertisements included contact 
details for the research team. Recruitment, 
enrollment and participation followed all 
Institutional Review Board (IRB) and other 
regulatory procedures. All participants signed an 
informed consent form to participate in the study. 

We send pre-intervention study packets to all 
women who expressed an interest in participating. 
The packets contained a letter of invitation that 
described the study; an informed consent form; 
the questionnaire; and a self addressed, stamped 
envelope. Three weeks after initial mailing, a 
research assistant (RA) made a follow-up 
telephone call if no response was received. When 
a call was received from a potential participant 
and/or when the RA called, the RA described the 
study, reviewed the consent form, and answered 
any questions regarding the study. The preferred 
method of survey completion was mail; however, 
potential participants who were slow to respond 
were given the choice of completing the survey by 
mail or by telephone. The telephonic means of 
data collection allowed for the inclusion of women 
with low literacy. Additionally, participants 
recruited at community events were given the 
choice to return the completed survey the same 
day or to return the survey via mail. Recruitment 
and enrollment were conducted over a three-
month period. Study participants were provided 
with a $20 gift card. 

Trial Intervention Conditions. This trial was 
informed by the social marketing approaches and 

materials from the CDC; NIH; and a successful 
social marketing CCA prevention initiative 
launched by the Los Angeles County Department 
of Public Health, Office of Women’s Health (The 
Multiethnic Cervical Cancer Prevention and 
Education Initiative). The County’s Multiethnic 
initiative resulted in 17,747 CCA screenings, 10% of 
which were abnormal. 

Our social marketing strategy used traditional 
media outlets (e.g., local TV and radio, ethnic 
newspapers, and circulars) and direct mailing to 
deliver the intervention. The study was titled “End 
Stigma, End Fear, and End Cervical Cancer”. Each 
study region was assigned to one of two 
intervention conditions: 1) The enhanced 
intervention using traditional media plus direct 
mailing of printed materials with Pap test and 
HPVV resources and 2) Direct mailing of printed 
materials with Pap test and HPVV resources, only. 

Women in the enhanced intervention region were 
exposed to public service announcements (PSAs) 
on public access TV and radio, and printed 
information posted in community circulars and 
newspapers distributed in the targeted region. 
PSAs, developed by the study team in 
collaboration with community partners, were aired 
each day at 11a.m. and 8p.m. for three months. 
This schedule was intended to increase exposure 
while reducing cost. The intervention content 
included information about Pap Testing, HPV and 
HPVV, and health clinics and facilities that offered 
free or low-cost Pap testing and HPVV. 

At three months post intervention (6 months post 
baseline), we mailed post-intervention packets that 
contained a “thank you” letter, the questionnaire, 
and a self-addressed, stamped envelope to all 
enrolled participants. Two follow-up phone calls 
were made to encourage participants to return the 
questionnaires. 



 
 
 
 
 

 
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Measure 
Participants were assessed at two time points: 
baseline and post-intervention. Participants 
completed a self-report assessment comprised of 
standardized measures (e.g., MOS social support), 
items drawn from related studies, and new items 
generated from the lead author’s previous 
research with multiethnic samples (Ashing et al., 
2017; Blackman et al., 2013; Lim and Ashing-Giwa, 
2011; Ragin et al., 2017). The questionnaire 
included items that queried medical history, Pap 
test completion, HPV knowledge, HPV vaccine 
attitude, stigma, life stress, health care utilization, 
quality of health care, sexual practices, and 
demographic variables. One item queried Pap test 
intention and completion (When do you plan to 
have your next pap test?); three items queried Pap 
test knowledge (e.g. Can Pap test find abnormal 
cervical cancer cells early?); three items queried 
HPV knowledge (e.g. Do you think you can get 
HPV through sexual contact? Can HPV cause 
certain cancers?); and three items queried HPV 
vaccine acceptability (e.g. Would you/have you 
ever recommended that a relative or friend get the 
HPV vaccine?). The questionnaire took about 35-
45 minutes to be completed. 

Outcome measures 
Primary outcome measures in the analysis were 
knowledge and beliefs about pap testing and HPV 
vaccine, intention to receive Pap test, Pap test 
completion, and HPVV acceptability. Pap test 
knowledge was examined using three questions 
that examined participants’ knowledge about the 
benefit of regular pap tests, where to get more 
information about PAP testing, and where to refer 
someone to receive the Pap test. Pap test 
acceptability items asked about their perceptions 
of the cost and safety of Pap test, and willingness 
to recommend Pap testing to a friend. Pap test 
completion was assessed by asking participants if 
they intend to receive a pap test within the next 

year. HPV vaccine knowledge was examined using 
two questions that examined participants’ 
knowledge of ever hearing of HPV vaccine to 
prevent cervical cancer and knowledge that you 
can get HPV through sexual contact. HPV vaccine 
acceptability was measured from participants’ 
responses to three items that asked participants if 
they would recommend HPV vaccine to a relative 
or friend, if the vaccine cost too much, and if they 
believed the HPV vaccine is safe. The items for 
knowledge and acceptability were summed to 
obtain a composite score measuring knowledge 
and acceptability of HPV vaccine and pap test. 

Data Analysis 
Data analysis was conducted using SPSS version 
24. An alpha level of .05 was chosen for all 
statistical tests. To check for differences between 
experimental conditions at baseline, t-tests were 
used for scales and chi-square tests or Fishers 
Exact Tests were performed for categorical data as 
needed. Chi-square test was used to examine if 
there was a relationship between plan to receive 
the Pap test within two years between intervention 
groups. Analysis was conducted separately for 
those who had reported having had a Pap test 
and those who did not report a Pap test at 
baseline. Repeated measure ANOVA was used to 
examine changes in HPV vaccine knowledge and 
acceptability between intervention groups from 
pretest to posttest. 

RESULTS 
The study sample consisted of 141 participants 
aged 18 years and above, with a mean age of 
46.13 (SD= 14.09). Overall, 35.8% of participants 
were between 40-54 years old; 49.3% had some 
college/Associate degree education; 61% reported 
having private insurance; 44% had over $45K 
yearly income; 27% lived with a partner and 
children; and 42% were partnered. Our analysis 
showed a significant difference in educational 



 
 
 
 
 

 
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status between intervention conditions (χ2 (2) 
=9.77, p =.008). Those in the enhanced 
intervention condition were more likely to report 
having a college degree or more (49.1%) 
compared to the direct mailing only condition 
(24.1%). There were no significant differences 
mean age (t = -0.61, p =.541), marital status (χ2 (1) 
=0.002, p = .963), income (χ2 (2) =0.09, p = .954) 
or having private insurance (χ2 (1) =3.39, p = .066). 
For the enhanced intervention delivery, we used of 
multiple channels – radio, TV, newspapers, and 
circulars. Eight-seven percent of the enhanced 
intervention trial participant indicated that they 
were exposed to at least two of the intervention 
condition. 

Pap test knowledge and completion 
There was no overall significant increase in 
knowledge from baseline to follow up (p=.956); 
and no significant difference between groups in 
Pap knowledge at follow up (p=.632). Fisher’s 
exact test was used to examine the relationship 
between trial conditions and Pap testing 
completion at follow up among 44 African 
American women who did not report having had a 
Pap test. There was a significant relationship 
between intervention group and reporting a Pap 
test at follow up, (p = .013). None of the 
participants in the print only group reported a pap 
test at follow up. However, the enhanced trial 
condition showed a 25% increase in Pap testing 
from baseline to follow-up with 4 out of 16) 
participants in the enhanced intervention reported 
having had a pap test at follow up. 

Intent to receive Pap test in the future 
Chi-square tests and Fisher’s Exact tests were used 
to compare demographic, knowledge and beliefs 

for those who reported an intention to test within 
two years and those who did not. There were no 
significant difference between both groups at 
p<.05 level. For those who did not report a Pap 
test at baseline, there was a non-significant trend 
when comparing the relationship between 
intervention group condition and intention to have 
a Pap test within two years (χ2 (1) =2.45, p =.107). 
In the print only condition, 9 out of 28 (32%) 
participants reported an intention to receive Pap 
screening within two years, while 9 out of 16 (56%) 
of participants in the enhanced intervention 
condition reported an intention to have a test 
within two years. 

Among those who had reported a Pap test at 
baseline, there was a significant relationship 
between intervention trial group and intention to 
have a Pap test within two years (χ2 (1) =19.83, p 
<.001). In the print only group, 28 out of 56 (50%) 
participants reported an intention to receive Pap 
screening within two years, while 38 out of 41 
(92.6%) of participants in the print and media 
group reported an intention to have a test within 
two years. 

HPV Vaccine knowledge 
A mixed-design repeated-measure ANOVA 
revealed no significant effect of the enhanced 
intervention group (F(1, 95)=1.57, p=.213 ) or time-
by-group interaction (F(1, 95)=0.18, p=.674) on 
HPV knowledge. However, there was a significant 
effect of time on HPV knowledge, F(1, 95) = 5.79, p 
= .018, η2 = .06. This indicates both intervention 
conditions showed increases on HPV knowledge. 
Therefore, in both intervention conditions, HPV 
knowledge significantly increased from baseline to 
follow-up among all participants. 

 

 



 
 
 
 
 

 
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Figure 1. Results of mixed-design repeated-measure ANOVA showing change in HPV knowledge 
between groups 

HPV Vaccine Acceptability 
There was no significant effect of enhanced 
intervention condition on HPV acceptability F(1, 95) 
= 0.51, p < .478. Similarly, no time-by-intervention 
interaction was found (P = .497, η2 = 0.005). 
However, there was a statistically significant effect 
of time on HPV acceptability, F (1, 95) = 53.37, p < 
.001, η2 = 0.36. Both intervention conditions 
improved on HPV acceptability. Follow-up 

univariate analyses using paired t-test confirmed 
significant increases in acceptability between the 
pretest and posttest for both the direct mailing 
condition (t = -4.64, p <.001), and the enhanced 
intervention condition (t = -5.95, p <.001). 
Therefore, in both trial conditions, HPV 
acceptability significantly increased from baseline 
to follow-up. 

 
Figure 2. Results of paired t-test showing increase in HPV Acceptability from baseline to follow-up. 



 
 
 
 
 

 
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Table 1. Mean and standard deviations for HPV knowledge and acceptability. 

 Print only Print and media 

 Baseline Follow up Baseline Follow up 

HPV Knowledge 1.18 
(0.12) 

1.40 
(0.11) 

1.37 
(0.10) 

1.53 
(0.09) 

HPV Acceptability 1.05 
(0.18) 

1.85 
(0.17) 

1.11 
(0.15) 

1.07 
(0.14) 

 

DISCUSSION 
HPVV vaccination and early detection through Pap 
screening are critical to cervical cancer prevention 
and control, but only 39% of African American 
women receive an early cervical cancer diagnosis 
compared to 48% of non-Hispanic whites (Ashing 
et al., 2017). African American women also have a 
poorer prognosis and higher mortality than their 
white counterparts. In addition, despite this greater 
HPV related cancer burden, African Americans 
have unacceptably low HPVV. There is an urgent 
need to reduce cervical cancer disparities among 
African Americans by implementing and 
disseminating interventions that increase 
knowledge and timely uptake of HPV vaccination 
and Pap testing. 

The results of this study suggest a multicomponent 
approach has the potential to increase Pap testing 
in this population. At follow up, more participants 
in enhanced intervention reported having a Pap 
test than participants assigned to the direct 
mailing condition. Adding the enhanced media-
based social marketing component, therefore, 
increased the effectiveness of the intervention in 
boosting Pap test uptake. This finding adds to the 
growing evidence in support of interventions that 
use multiple strategies versus a single-focus 
approach (Han et al., 2011). Is also suggests there 
is utility in fusing media, community-based 
approaches, and social marketing strategies in 

interventions to increase Pap testing among 
African American women. 

In African American populations, mass media and 
in particular Black media have been identified as 
an effective health promotion communication tool 
(Hall et al., 2015). The Centers for Disease Control 
(CDC), for example, used radio advertisements and 
small media to enhance the reach and impact of 
the agency’s African American Women and Mass 
Media (AAMM) campaign (Hall et al., 2015). 
Evaluation of the AAMM showed the program 
reached target audience and resulted in increased 
awareness of breast cancer screening services. 
Based on the preliminary results of our study, it is 
worth exploring further how adding a social 
marketing component can make media 
interventions even more appealing to African 
American women and reduce barriers to Pap 
uptake. 

The added benefit of the enhanced intervention 
was not realized for HPVV outcomes. Specifically, 
regarding HPVV knowledge and acceptability, 
adding the social marketing component did not 
result in statistically significant differences across 
trial conditions. Comparison of baseline and follow 
up results shows, overall, the trial was effective in 
significantly increasing African American/Black 
women’s knowledge and acceptability of HPVV. 
Therefore, among African Americans in our 
sample, targeted, media-based social marketing 



 
 
 
 
 

 
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did not provide added value in reducing HPVV 
hesitance and improving HPVV. This finding is a 
little surprising. Considering the success of social 
marketing in health promotion (Stead et al., 2007), 
we anticipated the enhanced intervention would 
show greater efficacy in increasing HPVV 
knowledge and acceptability. 

As this study focused on HPVV acceptability 
relevant to adolescent vaccination, it is plausible 
that cultural factors relevant to sexual beliefs and 
practices may be potent barriers. Therefore, 
research to increase HPVV among Blacks may 
need to closely attend to and address cultural and 
health system factors. 

LIMITATIONS AND CONCLUSION 
The findings reported here should be interpreted 
within the limitations of this study. First, the study 
relied on self-report. However, the responses and 
scores on the outcome measures seem reasonable 
and realistic. It would be useful for future studies 
to also include objective measures, such as 
medical chart reviews for Pap testing and HPVV, 
as complements for subjective assessments. For 
the enhanced intervention delivery, we used 
multiple channels – radio, TV, newspapers, and 
circulars. Eight-seven percent of the enhanced 
intervention trial participant indicated that they 
were exposed to at least two of the intervention 
condition. However, we did not measure 
frequency and duration of exposure. Also, our 
media channels were limited to local outlets, only. 
This may have limited the impact compared to 
using larger outlets with broader foothold in 
African American/Black markets. However, utilizing 
larger media outlets would have disseminate the 
enhanced intervention to women in regions 
assigned to the direct mailing condition. 

Despite the limitations, this study makes an 
important contribution to the small but growing 

research on intervention strategies to increase Pap 
and HPVV. Overall, this study suggests a 
multicomponent, media-based social marketing 
strategy that is informed by the community may 
be useful in promoting Pap testing and providing 
information about HPVV. Both the direct mail of 
the printed resources and the enhanced approach 
showed the potential to significantly boost 
knowledge and acceptability of HPVV among 
African American women. 

In summary, studies targeting women for both 
HPVV and Pap testing improvements are critical 
since women are often the health decision-makers 
for themselves and adolescents within families. 
There is need for greater understanding of multi-
level (including health systems and providers) and 
multi-channel best practices targeting behavior 
change to increase Pap testing and HPVV. Further, 
since the vaccine is now approved for individuals 
9-45 years old, giving an opportunity for HPV-
related cancer prevention among youth to middle-
adulthood, future studies will need to develop and 
disseminate effective strategies for targeting 
African Americans/Blacks and other groups to 
vaccinate their adolescents and themselves. 

Acknowledgement 
This research received funding from the City of 
Hope Excellence Award, and did not receive any 
support from funding agencies in the public or 
commercial sectors. The authors wish to thank the 
participants for the study for sharing their 
experiences. We thank Dr Lenna Dawkins-Moulton 
for her assistance in formatting this manuscript for 
submission. 

Conflicts of interest 
The authors declare that they have no conflict of 
interest. 



 
 
 
 
 

 
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Authors' contributions 
Kimlin Ashing led the overall study and writing. 
Camille Ragin and Ndifreke Etim contributed to 
the conceptualization and writing. Dr Etim 
contributed to the data analyses. 

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	INTRODUCTION
	METHODS
	Setting
	Participants
	Procedures
	Measure
	Outcome measures

	Data Analysis

	RESULTS
	Pap test knowledge and completion
	Intent to receive Pap test in the future
	HPV Vaccine knowledge
	HPV Vaccine Acceptability

	DISCUSSION
	LIMITATIONS AND CONCLUSION
	Acknowledgement
	Conflicts of interest
	Authors' contributions

