A review of cervical cancer screening intervention research: implications for public health programs and future research

Interventions to increase cervical screening uptake among immigrant women: A systematic review and meta-analysis

Numerous intervention studies have attempted to increase cervical screening uptake among immigrant women, nonetheless their screening participation remains low. This systematic review and meta-analysis aimed to summarise the evidence on interventions to improve cervical screening among immigrant women globally and identify their effectiveness. Databases PubMed, EMBASE, Scopus, PsycINFO, ERIC, CINAHL and CENTRAL were systematically searched from inception to October 12, 2021, for intervention studies, including randomised and clinical controlled trials (RCT, CCT) and one and two group pre-post studies. Peer-reviewed studies involving immigrant and refugee women, in community and clinical settings, were eligible. Comparator interventions were usual or minimal care or attention control. Data extraction, quality appraisal and risk of bias were assessed by two authors independently using COVIDENCE software. Narrative synthesis of findings was carried out, with the main outcome measure defined as the cervical screening uptake rate difference pre- and post-intervention followed by random effects meta-analysis of trials and two group pre-post studies, using Comprehensive Meta-Analysis software, to calculate pooled rate ratios and adjustment for publication bias, where found. The protocol followed PRISMA guidelines and was registered prospectively with PROSPERO (CRD42020192341). 1,900 studies were identified, of which 42 (21 RCTS, 4 CCTs, and 16 pre-post studies) with 44,224 participants, were included in the systematic review, and 28 with 35,495 participants in the meta-analysis. Overall, the uptake difference rate for interventions ranged from -6.7 to 96%. Meta-analysis demonstrated a pooled rate ratio of 1.15 (95% CI 1.03-1.29), with high heterogeneity. Culturally sensitive, multicomponent interventions, using different modes of information delivery and self-sampling modality were most promising. Interventions led to at least 15% increase in cervical screening participation among immigrant women. Interventions designed to overcome logistical barriers and use multiple channels to communicate culturally appropriate health promotion messages are most effective at achieving cervical screening uptake among immigrant women.

'No to unnecessary caesarean sections': Evaluation of a mass-media campaign on women's knowledge, attitude and intention for mode of delivery

Introduction

Improvement of women’s knowledge and attitude toward vaginal birth is recognized as an important strategy to control caesarean sections (CS) on maternal request. This study aimed to evaluate the effectiveness of a mass-media campaign in improving knowledge, attitude and intention of women for vaginal birth.

Methods

This was a population-based study carried out in Tehran, Iran. A national ‘No to unnecessary caesarean sections’ campaign was launched in April 2016 and was televised for ten days. A random sample of pregnant women from all defined geographical areas of Tehran were recruited and assessed for knowledge about the benefits of vaginal birth and the risk of CS, attitude and intention toward mode of delivery at two points in time: before and after the campaign. A comparison was made to evaluate outcome measures among those who had seen the campaign and those who had not.

Results

In all, 37 public and private maternity care centers were selected randomly and 702 eligible pregnant women attending these centers were entered in the study. Pre- and post-intervention data for 466 women were available for analysis. Of these, 194 women indicated that they had seen the campaign and the remaining 272 women said that they had not. A comparison of the outcome measures between the two study groups showed that there were significant differences between those who had seen the campaign and those who had not. Those who had seen the campaign reported increased knowledge, had a more positive attitude and indicated increased behavioral intention toward vaginal birth.

Conclusions

In general, the findings indicated that the mass-media campaign improved pregnant women’s knowledge, attitude and intention towards vaginal birth. However, the long-term effects of such campaigns need further investigation.

Australian women's cervical cancer screening attendance as a function of screening barriers and facilitators

RATIONALE

Cervical cancer screening registry data indicate that 43% of eligible Australian women did not screen in the latest reporting period (2014-2015). However, few prior empirical studies have examined whether the screening barriers and facilitators experienced by women can affect their screening attendance. Such information is required to inform the development of future tailored health promotion strategies.

OBJECTIVE

This study examined whether the cervical cancer screening barriers and facilitators identified by women were related to their screening history, from November 2015 and January 2016. At this time, Australian women typically undertook a Pap test every two years. They were deemed overdue for screening if they have not screened in the past 27 months (i.e., overdue by more than three months).

METHOD

In this study, a large sample (N = 338) of women were asked about their screening history including screening status (i.e., up-to-date vs. overdue) and prior screening (i.e., never screened vs. screened), and the psychological and practical screening barriers or facilitators they had experienced.

RESULTS

Logistic regression analysis indicated that screening status was related to a greater number of psychological barriers, but not practical barriers or facilitators. In contrast, prior screening was related to more practical and psychological screening barriers and fewer practical facilitators, but not psychological facilitators. Some individual psychological screening barriers (e.g., anxiety, embarrassment), practical barriers (e.g., lack of time) and practical facilitators (e.g., low cost of test) were related to women's screening status and prior screening.

CONCLUSIONS

Results suggest that addressing practical cervical cancer screening facilitators (e.g., reminder prompts) and psychological screening barriers may help to optimize screening attendance in women who have never screened or are overdue for cervical cancer screening.

Women's experiences with cervical cancer screening in a colposcopy referral clinic in Cape Town, South Africa: a qualitative analysis

OBJECTIVE

The aim of this study was to explore and understand women's experience with cervical cancer screening and with the referral pathways for abnormal Papanicolau (Pap) smears.

DESIGN AND SETTING

Focus group discussions were conducted with first time colposcopy clinic attendees at a tertiary hospital colposcopy clinic in Cape Town, South Africa during November 2014. A thematic analysis was conducted to identify key themes. Initial coding categories were drawn from the interview guide.

PARTICIPANTS

27 women participated in 4 focus group discussions.

RESULTS

Participants mean age was 34 years, most did not complete secondary level education and were unemployed. Negative community opinions relating to Pap smears and colposcopy referral might deter women from seeking treatment. Having a gynaecological symptom was the most commonly cited reason for having a Pap smear. Fear of having a HIV test performed at the same time as Pap smear and low encouragement from peers, were factors identified as potential access barriers. Participants commented on insufficient or lack of information from primary providers on referral to the colposcopy clinic and concerns and apprehension during waiting periods between receiving results and the colposcopy appointment were discussed.

CONCLUSIONS

There is a strong and urgent need to improve current knowledge about cervical cancer and Pap smears and the necessity and benefits of timely access to screening programmes, results and treatment. Strategies such as community health education programmes and mass media interventions could be employed to disseminate cervical cancer information and address negative community perceptions. Better training and support mechanisms to equip healthcare providers with the skills to convey cervical cancer information to women are needed. The use of short message service (SMS) to deliver Pap smear results and provide patients with more information should be considered to improve waiting times for results and alleviate apprehension during waiting periods.

Melanoma Disparities among US Hispanics: Use of the Social Ecological Model to Contextualize Reasons for Inequitable Outcomes and Frame a Research Agenda

Cutaneous melanoma is a significant public health concern, accounting for thousands of deaths annually in the US. Early detection and diagnosis are critical given the poor prognosis and limited treatment options of advanced-stage disease. While non-Hispanic whites have higher incidence rates of melanoma, Hispanics are typically diagnosed at later disease stages and suffer higher morbidity and mortality. Currently, there is a paucity of literature investigating the root causes underlying these trends among Hispanics. Given that Hispanics are the most rapidly expanding demographic segment in the US, it is essential for cancer control efforts to elucidate the major determinants of their poor melanoma outcomes. Herein, we use the social ecological model as a framework to explore the multitude of influences on melanoma disparities among Hispanics and provide recommendations for planning future studies and interventions.

Using Intervention Mapping to Develop a Breast and Cervical Cancer Screening Program for Hispanic Farmworkers: Cultivando La Salud

This article describes the development of the Cultivando La Salud program, an intervention to increase breast and cervical cancer screening for Hispanic farmworker women. Processes and findings of intervention mapping (IM), a planning process for development of theory and evidence-informed program are discussed. The six IM steps are presented: needs assessment, preparation of planning matrices, election of theoretic methods and practical strategies, program design, implementation planning, and evaluation. The article also describes how qualitative and quantitative findings informed intervention development. IM helped ensure that theory and evidence guided (a) the identifiction of behavioral and environmental factors related to a target health problem and (b) the selection of the most appropriate methods and strategies to address the identified determinants. IM also guided the development of program materials and implementation by lay health workers. Also reported are findings of the pilot study and effectiveness trial.

Community Members' Input into Cancer Prevention Campaign Development and Experience Being Featured in the Campaign

BACKGROUND

Colorectal cancer (CRC) incidence and mortality rates are increased and CRC screening rates are lower among Appalachia Ohio residents.

OBJECTIVES

We sought to describe 1) a partnership of cancer researchers and community members that developed county-specific media campaigns to improve CRC screening rates (intervention) and fruit and vegetable consumption (control) and 2) the experience of community members featured in the campaigns.

METHODS

Community members assisted with campaign development, were featured in campaigns, identified locations for materials, and promoted the campaigns. Campaigns included billboards, posters, and information in local newspapers. A mailed survey assessed featured community members' experiences in the campaigns.

LESSONS LEARNED

Ongoing communication among members of the partnership was critical to successful community-level campaigns. Featured community members had mostly positive experiences about being included in the campaigns.

CONCLUSIONS

Having a shared vision, ongoing trust, and good communication are essential elements to maintaining a viable academic-community partnership.

Who's Missing? Predictors of Attrition Following Participation in Culturally Targeted Educational Breast and Cervical Cancer Outreach Programs for Latinas

Rates of breast and cervical cancer screening among Latinas are suboptimal. The Esperanza y Vida program was developed to increase awareness of screening methods among Latinas. Lay health advisor cancer survivors are trained to deliver the program and use a narrative communication approach to promote breast and cervical cancer awareness and screening. This study aimed to identify characteristics of participants, within the larger study, who were lost, due to attrition, for follow-up assistance. Participants (N = 908) completed questionnaires that assessed knowledge, perceptions, and beliefs about breast and cervical cancer and were contacted after the program to assess screening and offer assistance in obtaining screening exams. Latinas who were younger than 40 years of age and who felt that the survivor's story would prompt them to make an appointment for screening were more likely to be lost to follow-up at 2 months. These findings have implications for future breast and cervical cancer outreach programs and interventions.

The development of a brief jail-based cervical health promotion intervention

The primary objective of this article was to describe the development and pilot implementation of a brief jail-based cervical health promotion intervention. The intervention was guided by a preliminary study of incarcerated women's cervical health knowledge, awareness, and health literacy, as well as a social and feminist approach to intervention development. We developed and conducted a pilot implementation of the Sexual Health Empowerment Project to increase cervical health knowledge, reduce barriers related to beliefs about cervical cancer, and improve self-efficacy and confidence in navigating health systems. This article offers a framework for how empirically and theory-based interventions are developed and tailored for a jail setting. Future work should include the evaluation of the long-term effects of such a disease-specific program on health behaviors and outcomes among high-risk and vulnerable groups of women as they leave jails and enter communities.

Cost of services provided by the National Breast and Cervical Cancer Early Detection Program

BACKGROUND

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) is the largest cancer screening program for low-income women in the United States. This study updates previous estimates of the costs of delivering preventive cancer screening services in the NBCCEDP.

METHODS

We developed a standardized web-based cost-assessment tool to collect annual activity-based cost data on screening for breast and cervical cancer in the NBCCEDP. Data were collected from 63 of the 66 programs that received funding from the Centers for Disease Control and Prevention during the 2006/2007 fiscal year. We used these data to calculate costs of delivering preventive public health services in the program.

RESULTS

We estimated the total cost of all NBCCEDP services to be $296 (standard deviation [SD], $123) per woman served (including the estimated value of in-kind donations, which constituted approximately 15% of this total estimated cost). The estimated cost of screening and diagnostic services was $145 (SD, $38) per women served, which represented 57.7% of the total cost excluding the value of in-kind donations. Including the value of in-kind donations, the weighted mean cost of screening a woman for breast cancer was $110 with an office visit and $88 without, the weighted mean cost of a diagnostic procedure was $401, and the weighted mean cost per breast cancer detected was $35,480. For cervical cancer, the corresponding cost estimates were $61, $21, $415, and $18,995, respectively.

CONCLUSIONS

These NBCCEDP cost estimates may help policy makers in planning and implementing future costs for various potential changes to the program.

Prompting asthma intervention in Rochester-uniting parents and providers (PAIR-UP): a randomized trial

IMPORTANCE

A disproportionate number of impoverished and minority children have asthma and receive suboptimal preventive care.

OBJECTIVE

To evaluate whether the Prompting Asthma Intervention in Rochester-Uniting Parents and Providers (PAIR-UP) intervention, administered in primary care offices, improves the delivery of preventive care and reduces morbidity for urban children with asthma.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized trial in which 12 urban primary care practices were matched based on size and type and randomly allocated to the PAIR-UP intervention or usual care (UC). We enrolled 638 children aged 2 to 12 years with persistent or poorly controlled asthma in the waiting room prior to a visit with a clinician for any reason from October 2009 to January 2013. Blinded interviewers called caregivers within 2 weeks to inquire about preventive measures taken at the visit and called them 2 and 6 months later to assess symptoms.

INTERVENTIONS

Children enrolled at PAIR-UP practices received prompts for the caregiver and clinician at the time of the visit that outlined the child's asthma severity or control as well as specific guideline-based recommendations to enhance preventive care. These practices also received educational resources and periodic feedback on their asthma care performance. The UC practices received copies of the asthma guidelines.

MAIN OUTCOMES AND MEASURES

The primary outcome was symptom-free days (SFDs) per 2 weeks at the 2-month follow-up.

RESULTS

We enrolled 638 children (participation rate of 80%; 36% were black, 36% were Hispanic, and 68% had Medicaid insurance). Groups were similar in demographic characteristics and asthma severity at baseline. At the index visit, more children in the PAIR-UP group received a preventive medication action (new medication, increased dose, recommendation to restart preventive medication) than in the UC group (58% vs 33%; odds ratio [OR] = 2.8; 95% CI, 1.9 to 3.9). More children in the PAIR-UP group than in the UC group received an asthma action plan (61% vs 23%; OR = 8.3; 95% CI, 3.7 to 18.7), discussions regarding asthma (93% vs 78%; OR = 4.5; 95% CI, 2.8 to 7.2), and secondhand smoke counseling (80% vs 63%; OR = 2.6; 95% CI, 1.2 to 5.5). At the 2-month follow-up, children in the PAIR-UP group had more SFDs per 2 weeks than those in the UC group (mean difference, 0.78 days; 95% CI, 0.29 to 1.27). At 6 months, the improvement in SFDs was no longer statistically significant (mean difference, 0.56; 95% CI, -0.14 to 1.25).

CONCLUSIONS AND RELEVANCE

The PAIR-UP intervention improved the delivery of preventive asthma care and reduced asthma morbidity for high-risk urban children with persistent asthma at 2 months, but the improvement in SFDs was no longer significant at 6 months.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01105754.

Cervical cancer prevention in Malawi: a qualitative study of women's perspectives

Researchers posit that cervical cancer knowledge is central to participation in prevention behaviors. However, of the many barriers to cervical cancer prevention in low- and middle-income countries, cervical cancer knowledge remains severely limited among communities at great risk for the disease. Malawi is one such country where the burden of cervical cancer is considerably high. Formative research targeting cervical cancer prevention is needed, particularly research that explores ways to deliver cervical cancer information efficiently and effectively to Malawian women. In this study, the authors aimed to garner Malawian women's understanding of cervical cancer and to shed light on preferences for health information delivery, including community health advocacy. Qualitative, in-depth interviews were conducted with 30 Malawian women and analyzed for recurring themes. In general, women had limited cervical cancer knowledge, which supported misperceptions about the disease, including factors pertaining to risk and prevention. Nonetheless, women reported that receiving cervical cancer information from trusted sources would help promote preventive behaviors. Women noted that they received most of their health information from hospital personnel, but distance was a barrier. Women also expressed interest in community health advocacy. Perspectives from Malawian women may be vital toward informing efforts to increase cervical cancer knowledge and prevention.

A large cross-sectional survey investigating the knowledge of cervical cancer risk aetiology and the predictors of the adherence to cervical cancer screening related to mass media campaign

Objectives. The aims of this study were to compare the characteristics of women who got a Pap-test during the mass media campaign, carried out in an Italian region by broadcasts advertising, and two years later and to identify the determinants of knowledge of cervical cancer etiology and of the adherence to the mass media campaign. Methods. A cross-sectional survey was carried out through a self-administered questionnaire. Results. A total of 8570 randomly selected women were surveyed, 823 of these had a Pap-test during the mass media campaign period and 7747 two years later. Higher educational level, being not married, and living in urban areas were the main independent characteristics associated with a higher level of knowledge of cervical cancer etiology, although a previous treatment following a Pap smear abnormality was the strongest predictor (OR = 2.88; 95% CI: 2.43–3.41). During the campaign period women had the Pap-test more frequently as a consequence of the mass media campaign (OR = 8.28; 95% CI; 5.51–12.45). Conclusions. Mass media campaign is a useful tool to foster cervical screening compliance; however, its short-term effect suggests repeating it regularly.

Ethics and Community Involvement in Syntheses Concerning American Indian, Alaska Native, or Native Hawaiian Health: A Systematic Review

BACKGROUND

The objective of the research was to review reporting of ethical concerns and community involvement in peer-reviewed systematic reviews or meta-analyses concerning American Indian, Alaska Native, or Native Hawaiian (AI/AN/NH) health.

METHODS

Text words and indexed vocabulary terms were used to query PubMed, Embase, Cochrane Library, and the Native Health Database for systematic reviews or meta-analyses concerning AI/AN/NH health published in peer-reviewed journals, followed by a search through reference lists. Each article was abstracted by two independent reviewers; results were discussed until consensus was reached.

RESULTS

We identified 107 papers published from 1986-2012 that were primarily about AI/AN/NH health or presented findings separately for AI/AN/NH communities. Two reported seeking indigenous reviewer feedback; none reported seeking input from tribes and communities. Approximately 7% reported on institutional review board (IRB) approval of included studies, 5% reported on tribal approval, and 4% referenced the sovereignty of AI/AN tribes. Approximately 63% used evidence from more than one AI/AN/NH population study, and 28% discussed potential benefits to communities from the synthesis research.

CONCLUSIONS

Reporting of ethics and community involvement are not prominent. Systematic reviews and meta-analyses making community-level inferences may pose risks to communities. Future systematic reviews and meta-analyses should consider ethical and participatory dimensions of research.

Tailored telephone counseling to improve adherence to follow-up regimens after an abnormal pap smear among minority, underserved women

OBJECTIVE

The present study explored the impact of a tailored telephone counseling intervention on increasing follow-up adherence after an abnormal Pap smear result among low-income, minority women, which may reduce cervical cancer disparity.

METHODS

Participants (N=211) were randomly assigned to receive: (1) a telephone reminder that included an assessment of barriers to adherence, as well as counseling tailored to the barriers elicited; (2) telephone reminder and barriers assessment, followed by a mailed home tailored barriers print brochure; or (3) enhanced standard care comprising telephone reminder and barriers assessment. Assessments were obtained at initial contact and 1-week later, as well as at 6- and 12-months after the initial colposcopy.

RESULTS

The telephone counseling group showed greater adherence to follow-up recommendations than did the combined other two groups (p<0.05). For the initial colposcopy, tailored telephone barriers counseling was more effective among women with a high school education or less.

CONCLUSION

Tailored telephone barriers counseling improves adherence to initial colposcopy, as well as to longer-term medical follow-up, among low-income, inner-city women.

PRACTICE IMPLICATIONS

Dissemination of barriers counseling into ongoing telephone reminder calls and contacts may decrease disparities in cancer outcomes, especially among women with less than post-secondary education.

Promoting cervical screening after introduction of the human papillomavirus vaccine: the effect of repeated mass media campaigns

Objectives

In 2007, Australia implemented an ongoing, school-based human papillomavirus (HPV) vaccination programme for school-aged girls, and a catch-up programme for 18–26-year-old women that ran until the end of 2009. The availability of what is widely known as the ‘cervical cancer vaccine’ means there is the potential for women to believe, incorrectly, that they no longer require regular cervical screening, and this risk needs to be addressed. The current study aimed to assess the effect of three mass media campaigns to promote cervical screening on the rate of cervical screening tests in the Australian state of Victoria, after HPV vaccine became available.

Methods

Seasonal time series assessed the effect of media campaigns broadcast in 2007, 2009 and 2010 on the rate of weekly cervical screening tests in Victorian women from 2006 to 2010, stratified by time since last screening test.

Results

The 2007 and 2009 media campaigns significantly increased the number of cervical screening tests per week. The 2007 campaign had a significant impact on lapsed screeners (>36 months since last test), overdue screeners (28–36 months since last test), and women never previously screened. The 2009 campaign significantly increased screening tests for overdue screeners, and the 2010 media campaign was associated with a significant increase in screening tests for lapsed screeners.

Conclusions

A well-researched and carefully pretested television advertising campaign with accurate, actionable messages can elicit appropriate screening behaviour among some of the appropriate groups even in a changed environment of complex, and potentially competing, messages.

Interventions for improving population health literacy: insights from a rapid review of the evidence

The promotion of health literacy is critical to active and informed participation in health promotion, disease prevention, and health care. This article reports on a rapid review of the evidence concerning effective strategies for improving health literacy. This review was undertaken as part of a series of evidence reviews commissioned by the European Centre for Disease Prevention and Control through the Translating Health Communications Project. The authors searched a range of electronic databases and identified six evidence reviews published between 2000 and 2011. A narrative synthesis of the findings was then conducted. The majority of the published research originated in the United States, and the studies reviewed mainly focused on functional health literacy interventions that occurred in clinical settings. Considerable gaps in the evidence exist regarding the most effective population-level health literacy interventions, particularly with regard to communicable diseases. There is a paucity of intervention studies conducted on this topic in Europe. Implications of the findings for improving population health literacy on the prevention and control of communicable diseases in Europe are considered.

The Impact of a Media Campaign on Cervical Screening Knowledge and Self-efficacy

A three-phase cross-sectional face-to-face interview study (n= 1571) was conducted to investigate the impact of the PapScreen Victoria media campaign conducted in English, and the extent to which a media campaign can influence women's perceived self-efficacy associated with having a Pap test. In total, 1571 women aged between 25 and 69 years were interviewed about prompted and unprompted recall of media messages, intention to have a Pap test and perceived self-efficacy associated with having Pap tests, and barriers to cervical screening. Chi-square and logistic regression analyses revealed that women's awareness of Pap testing messages and priority of this health issue was greater at the first follow-up, and was maintained at the second. Multivariate analyses of variance indicated that it was perceived as more difficult to choose a practitioner and ring for results at the first follow-up, and perceived self-efficacy was lower then than at baseline. Results suggest that the cognitive processes at work are more complex than previously thought.

Performance of papanicolaou testing and detection of cervical carcinoma in situ in participants of organized cervical cancer screening in South Korea

Background

The present study measured the performance of the Papanicolaou (Pap) test and detection of cervical carcinoma in situ (CIS) and cancer in participants of organized cervical cancer screening in South Korea, and examined differences in the proportion of CIS according to socio-demographic factors.

Methods

Data were obtained from the National Cancer Screening Program and National Health Insurance Cancer Screening Program databases. We analyzed data from 4,072,997 screenings of women aged 30 years or older who underwent cervical cancer screening by Pap test between January 1, 2005 and December 31, 2006. We calculated the performances of the Pap test and compared that according to socio-demographic factors.

Results

The positivity rate for all screenings was 6.6%. The cancer detection rate (CDR) and interval cancer rate (ICR) were 0.32 per 1,000 screenings, and 0.13 per 1,000 negative screenings, respectively. About 63.4% of screen-detected CIS+ cases (CIS or invasive cervical cancer) were CIS. The CDR and ICR, and percentage of CIS among all CIS+ were significantly different by age group and health insurance status. The odds ratios of CDR and ICR were higher for Medical Aid Program (MAP) recipients compared with National Health Insurance (NHI) beneficiaries. The likelihood of a detected CIS+ case to be CIS was significantly lower among MAP recipients than among NHI beneficiaries.

Conclusions

The difference in performance of cervical cancer screening among different socio-demographic groups may indicate an important influence of socio-demographic factors on preventive behavior. The findings of the study support the critical need for increasing efforts to raise awareness and provide more screening in at-risk populations, specifically low-income groups.

Barriers to cervical cancer screening among lesbians

OBJECTIVE

To evaluate cervical cancer screening practices and barriers to screening in a sample of lesbians.

METHODS

Cross-sectional survey data were collected from 225 self-identified lesbians who completed an online questionnaire.

RESULTS

Of the respondents, 71% reported receiving a Pap screening test in the past 24 months (routine screeners), and 29% reported receiving a Pap screening test >24 months ago or never (nonroutine screeners). Routine screeners were more likely to be older (p < 0.01), white (p = 0.04), and college graduates (p < 0.01) than nonroutine screeners. Nonroutine screeners were more likely to delay seeking healthcare because of fear of discrimination (p < 0.01) and were less likely than routine screeners to disclose orientation to their primary care physician (p < 0.01). After adjusting for age, race, and education, nonroutine screeners perceived fewer benefits from (p < 0.01) and more barriers (p < 0.01) to Pap screening tests and were less knowledgeable about screening guidelines (p < 0.01) than routine screeners, but there was no difference in perceived susceptibility (p = 0.68), perceived seriousness (p = 0.68), or risk factor knowledge (p = 0.35) of cervical cancer.

CONCLUSIONS

Many lesbians do not screen for cervical cancer at recommended rates. Nonroutine screeners perceive fewer benefits, more barriers, and more discrimination and are less knowledgeable about screening guidelines than routine screeners.

Impact of media reporting of cervical cancer in a UK celebrity on a population-based cervical screening programme

Objectives

To determine the impact of media reporting of cervical cancer in a UK celebrity on cervical screening uptake, response time and colposcopy referral and attendance.

Setting

Population-based national cervical screening programme for women in Wales, UK.

Methods

A time series regression analysis of the Welsh national cervical screening and colposcopy databases was used to examine the number of smear tests carried out between 2000 and 2010, stratified by age group and deprivation indicators. Logistic regression was used to analyse colposcopy attendance.

Results

Over 33,000 more cervical screening tests than expected were carried out in the year of media reporting (2008/9), 11,539 (35%) of which were in the month of Jade Goody's death. The largest increase was evident in women aged 35–39 years (475 additional tests per month, 95% CI 331–619). Impacts were similar across deprivation quintiles. Colposcopy referrals increased by 18% during the year of media reporting. Increases were observed for all smear test results in 2008/9, particularly among younger women, and further rises were evident in 2009/10 for smear tests showing borderline changes and mild dyskaryosis. The proportion of women attending colposcopy appointments rose in the year of media reporting (χ 2 = 45.8, P < 0.001).

Conclusions

Mass media reporting of cervical cancer in a UK celebrity was associated with a significant, but transient, increase in screening uptake and colposcopy referral and attendance. Mass media reporting can play a role in enhanced detection of abnormalities, but public health messages must be communicated effectively to minimize anxiety whilst maximizing case-finding and uptake among non-responders.

Awareness and uptake of the Pap smear among market women in Lagos, Nigeria

Our study evaluates the effect of an educational programme on awareness and uptake of the cervical cancer screening test (Pap smear) by women in a model market in Lagos, Nigeria. This was a quasi-experimental study using a multistage sampling technique. A total of 350 women were divided into two groups. A baseline survey on awareness of the Pap test and screening practices was carried out using pre-tested, interviewer administered, structured questionnaires. Participants in the intervention group received sessions of community based health information on cervical cancer screening tests while participants in the control group received health information on hypertension. Subsequently, participants in both groups were reassessed to evaluate the effect of the educational programme on the Pap test and cervical screening uptake. Data were analysed with the Epi-info version 6.04. Awareness about the Pap test was low at baseline; only 6.9% and 12.0% of participants in the intervention and control groups, respectively, had heard of Pap smears. Furthermore, less than 10% had correct information on the use of the Pap test. Post-intervention, there was a significant and proportional increase in the knowledge of the Pap test in the intervention group (P<0.05). However, uptake of the test was quite low in the intervention and control groups both pre- and post-intervention and there was no significant change in uptake. We concluded that essential schemes are required to enhance access to screening, as knowledge alone is insufficient to promote acceptance and use of cervical cytological screening tests.

Perspectives on Pap test follow-up care among rural Appalachian women

Approximately one- to three-quarters of women notified of abnormal Pap test results do not receive appropriate follow-up care, dramatically elevating their risk for invasive cervical cancer. We explored barriers to and facilitators of follow-up care for women in two counties in Appalachian Kentucky, where invasive cervical cancer incidence and mortality are significantly higher than the national average. In-depth interviews were conducted among 27 Appalachian women and seven local health department personnel. Those who had been told of an atypical Pap test result tended to have one of three reactions: (1) not alarmed and generally did not obtain follow-up care; (2) alarmed and obtained follow-up care; or (3) alarmed, but did not obtain care. Each of these typologies appeared to be shaped by a differing set of three categories of influences: personal factors; procedure/provider/system factors; and ecological/community factors. Recommendations to increase appropriate follow-up care included pursuing research on explanations for these typologies and developing tailored interventions specific to women in each of the response types.

Evaluation of a multifaceted social marketing campaign to increase awareness of and screening for oral cancer in African Americans

OBJECTIVES

A 2-year social marketing media campaign and community education activities were organized to promote screening for oral cancer in a high-risk population in Detroit/Wayne County, Michigan. Long-term goals of the campaign were to reduce the oral cancer death rate, increase the proportion of oral cancers detected at an early stage, and increase the proportion of adults who report having been screened. The intermediate goals of the campaign were to increase awareness of oral cancer and of oral cancer screening. This article presents outcomes related to the intermediate goals of the campaign.

METHODS

The intermediate goals of the campaign were assessed by the number of calls to a toll-free hotline, which media venues led to calls, number of screenings conducted by the free screening clinic, number of precancers and cancers detected, and the number of sessions conducted, organizations involved, and persons participating in the community education program. The costs per screened case and cancers detected were also evaluated. The media campaign promoted screening using billboards, radio and newspaper ads, and a toll-free hotline. Culturally relevant messages were developed collaboratively with focus groups representing the target audience. Billboards were placed in highly visible locations around Detroit, Michigan. Sixty-second messages on the impact of oral cancer and that screening is 'painless and free' were aired on radio stations popular with the target audience. Ads displaying the hotline were placed in two local newspapers. Callers to the hotline were scheduled for a free screening with a clinic operated by the project. Referral to an oral surgeon was scheduled if a suspicious lesion was found. Free education sessions were also conducted with community-based organizations. Costs associated with the campaign and hotline were totaled, and the cost per screening and cancer detected were calculated.

RESULTS

During the campaign, 1327 radio spots aired; 42 billboards were displayed; two newspaper ads were printed; and 242 education sessions were conducted. The hotline received 1783 calls. The majority of callers reported that their call was prompted by a radio ad (57%). The clinic screened 1020 adults and referred 78 for further examination. Three cancers, two precancers, and 12 benign tumors were detected. The total cost associated with the campaign and toll-free hotline was $795,898.

CONCLUSIONS

A multifaceted social marketing campaign including radio ads, billboards, and education sessions can effectively target a high-risk population and that given an outlet could result in a significant number of people getting screened at a relatively low cost.

Improving health outcomes with better patient understanding and education

A central plank of health care reform is an expanded role for educated consumers interacting with responsive health care teams. However, for individuals to realize the benefits of health education also requires a high level of engagement. Population studies have documented a gap between expectations and the actual performance of behaviours related to participation in health care and prevention. Interventions to improve self-care have shown improvements in self-efficacy, patient satisfaction, coping skills, and perceptions of social support. Significant clinical benefits have been seen from trials of self-management or lifestyle interventions across conditions such as diabetes, coronary heart disease, heart failure and rheumatoid arthritis. However, the focus of many studies has been on short-term outcomes rather that long term effects. There is also some evidence that participation in patient education programs is not spread evenly across socio economic groups. This review considers three other issues that may be important in increasing the public health impact of patient education. The first is health literacy, which is the capacity to seek, understand and act on health information. Although health literacy involves an individual's competencies, the health system has a primary responsibility in setting the parameters of the health interaction and the style, content and mode of information. Secondly, much patient education work has focused on factors such as attitudes and beliefs. That small changes in physical environments can have large effects on behavior and can be utilized in self-management and chronic disease research. Choice architecture involves reconfiguring the context or physical environment in a way that makes it more likely that people will choose certain behaviours. Thirdly, better means of evaluating the impact of programs on public health is needed. The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework has been promoted as one such potential approach.

Use of mass media campaigns to change health behaviour

Mass media campaigns are widely used to expose high proportions of large populations to messages through routine uses of existing media, such as television, radio, and newspapers. Exposure to such messages is, therefore, generally passive. Such campaigns are frequently competing with factors, such as pervasive product marketing, powerful social norms, and behaviours driven by addiction or habit. In this Review we discuss the outcomes of mass media campaigns in the context of various health-risk behaviours (eg, use of tobacco, alcohol, and other drugs, heart disease risk factors, sex-related behaviours, road safety, cancer screening and prevention, child survival, and organ or blood donation). We conclude that mass media campaigns can produce positive changes or prevent negative changes in health-related behaviours across large populations. We assess what contributes to these outcomes, such as concurrent availability of required services and products, availability of community-based programmes, and policies that support behaviour change. Finally, we propose areas for improvement, such as investment in longer better-funded campaigns to achieve adequate population exposure to media messages.

Factors in quality care--the case of follow-up to abnormal cancer screening tests--problems in the steps and interfaces of care

To achieve the benefit of cancer screening, appropriate follow-up of abnormal screening test results must occur. Such follow-up requires traversing the transition between screening detection and diagnosis, including several steps and interfaces in care. This article reviews factors and interventions associated with follow-up of abnormal tests for cervical, breast and colorectal cancers. We synthesized 12 reviews of descriptive and intervention studies published between 1980 and 2008. There was wide variability in definition of follow-up, setting, study population, and reported prevalence rates. Correlates of follow-up included patient characteristics (eg, knowledge and age), social support, provider characteristics, practice (eg, having reminders systems), community and professional norms (eg, quality measures), and policy (eg, federal programs). Effective interventions included patient education and support; delivery systems design changes, such as navigation; and information system changes, most notably patient tracking and physician reminders. Few studies focused explicitly on interfaces and steps of care, such as communication between primary care and specialists, or simultaneously targeted the multilevel factors that affect care. Future practice and research priorities should include development of clear operational definitions of the steps and interfaces related to patients, providers, and organizations; reflect evolving guidelines and new technologies; determine priorities for intervention testing; and improve measures and apply appropriate study designs.

Timeliness and follow-up patterns of cervical cancer detection in a cohort of medically underserved California women

INTRODUCTION

This study examines factors associated with timely follow-up after Pap test in a program providing cervical cancer detection services to medically underserved California women.

METHODS

Data between 01 January 1992 and 30 June 2007 were analyzed. Cox proportional hazard regression was used to identify subgroups of women with delayed time to diagnosis or treatment scheduling. The probability of being scheduled for final diagnosis and treatment was assessed using logistic regression analysis. Demographic and clinical characteristics of the women lost to follow up were examined.

RESULTS

Time from screening to final diagnosis scheduling differed according to age group, race/ethnicity, and Pap test result. Race/ethnicity and age were associated with whether treatment was scheduled or not. While loss to follow up among those scheduled for final diagnosis was associated with certain patients' characteristics, no such association was found among those who were scheduled for treatment.

CONCLUSIONS

Patient's demographic characteristics determine the odds of being scheduled for final diagnosis and treatment as well as timeliness of follow-up from screening to final diagnosis. Findings suggest that the dual goal of reducing health disparities and cost-effective detection and treatment of precancerous disease to prevent cervical cancers cannot be achieved without consideration of racial/ethnic differences and needs.

Association of knowledge, anxiety, and fear with adherence to follow up for colposcopy

OBJECTIVES

To evaluate the association of pre-visit anxiety with pre- and post-visit knowledge, satisfaction, and adherence to colposcopy follow-up visits.

METHODS

A group of 122 women presenting for colposcopy between July 1999 and May 2000 were studied. Immediately prior to their appointment, 98% of eligible patients participated in a self-administered questionnaire. Patients were sent a follow-up questionnaire within two weeks of the appointment. Statistical analyses included Chi-Square and Fisher's exact tests for categorical variables.

RESULTS

The mean follow up was 112 days (SE 9.47). Although the mean fear score was 7.3 (SE 3, range 1-10) and mean anxiety score was 7.8 (SE 2.8, range 1-10), there was no significant association with pre-visit fear and adherence to follow up. Pre-evaluation knowledge was positively associated with fear, anxiety, post-visit knowledge, and adherence to follow up.

CONCLUSIONS

Pre-visit intervention may improve adherence and reduce anxiety associated with colposcopy.

Mass media campaign improves cervical screening across all socio-economic groups

Low socio-economic status (SES) has been associated with lower cervical screening rates. Mass media is one known strategy that can increase cervical screening participation. This study sought to determine whether a mass media campaign conducted in Victoria, Australia, in 2005 was effective in encouraging women across all SES groups to screen. Data were obtained from the Victorian Cervical Cytology Registry for each Pap test registered during 2005 and categorized into SES quintiles using the Index of Socio-Economic Advantage/Disadvantage. Negative binomial regression was used to determine the impact of the campaign on the weekly number of Pap tests and whether the media campaign had a differential effect by SES, after adjusting for the number of workdays per week, age group and time since previous test. Cervical screening increased 27% during the campaign period and was equally effective in encouraging screening across all SES groups, including low-SES women. Mass media campaigns can prompt increased rates of cervical screening among all women, not just those from more advantaged areas. Combining media with additional strategies targeted at low-SES women may help lessen the underlying differences in screening rates across SES.

Some signals cannot wait: effects of a national campaign on early detection of cancer among Dutch adults (>55 years)

BACKGROUND

The present study examined the effects of the campaign "early detection of cancer" on knowledge, attitudes, awareness, and intention to perform passive detection and timely seeking medical help. Further, the campaign was evaluated on recall and recognition and the various campaign components were evaluated.

METHODS

A longitudinal study using a Solomon four-group design among 784 Dutch adults aged 55 years and older was conducted. Data was gathered by means of telephone interviews.

RESULTS

The results showed moderate levels of campaign awareness. After the campaign, solely respondents who received a pre-test questionnaire and were aware of the campaign had significant higher cancer knowledge levels regarding passive detection. Respondents who were only aware of the campaign were significantly more willing to perform passive detection behavior and to timely seek medical help in the future. Further, they were more aware that paying attention to cancer warning signs can lead to early detection of cancer.

CONCLUSIONS

It can be concluded that solely the combination of the pre-test questionnaire and exposure to the campaign had a significant positive impact on respondents' cancer knowledge levels. The effects of the campaign on intention and awareness are indistinct and could be a consequence of (the results of) a self-selection bias. It seems that the dose, frequency, and duration of the campaign should be increased in order to substantiate the effects of the campaign.

A theory-based approach to understanding follow-up of abnormal Pap tests

We applied a general theoretical framework to understand intentions to attend recommended follow-up for abnormal Pap results. Participants were 338 women attending university-affiliated clinics. Intention was associated with favorable attitudes toward follow-up (OR = 5.3); perceiving attending follow-up as consistent with one's self-concept (OR = 3.0); self-efficacy (OR = 1.8); and believing one would be told exactly what is wrong (OR = 1.3). Intention was negatively associated with believing the problem could be avoided by not returning for follow-up (OR = 0.75). Beliefs, affect and attitudes differed by race and ethnicity (all p < .05). Attendance at follow-up was related to attitude and self-concept (both p < .05). Results have implications for theory development and patient education.

Effectiveness of Cultivando la Salud: a breast and cervical cancer screening promotion program for low-income Hispanic women

OBJECTIVES

We tested the effectiveness of a lay health worker intervention to increase breast and cervical cancer screening among low-income Hispanic women.

METHODS

Participants were women 50 years and older who were nonadherent to mammography (n = 464) or Papanicolaou (Pap) test (n = 243) screening guidelines. After the collection of baseline data, lay health workers implemented the Cultivando la Salud (CLS; Cultivating Health) intervention. Data collectors then interviewed the participants 6 months later.

RESULTS

At follow-up, screening completion was higher among women in the intervention group than in the control group for both mammography (40.8% vs 29.9%; P < .05) and Pap test (39.5% vs 23.6%; P < .05) screening. In an intent-to-treat analysis, these differences remained but were not significant. The intervention increased mammography self-efficacy, perceived susceptibility, perceived survivability, perceived benefits of mammography, subjective norms, and processes of change. The intervention also significantly increased Pap test self-efficacy, perceived benefits of having a Pap test, subjective norms, and perceived survivability of cancer. It did not change Pap test knowledge, perceived susceptibility, or perceptions about negative aspects of Pap test screening.

CONCLUSIONS

Our results add to the evidence concerning the effectiveness of lay health worker interventions for increasing Pap test screening and mammography. Future research should explore the effectiveness of CLS in other Hispanic groups, the mechanisms through which interpersonal communication influences decisions about screening, and how effective interventions such as CLS can best be adopted and implemented in community-based organizations or other settings.

Impact of ASC-H terminology on the detection of HSILs in medically underserved California women

In this study we evaluated CDP: EWC, a large public health screening program for low-income women to determine whether the ASC-H term, introduced in the 2001 revision to the Bethesda System, has facilitated the detection of the most serious precancerous cervical lesions such as CIN-II-III/CIS, including accuracy of detection and minimizing diagnostic delays. Pap test and biopsy data from the period 2003-2006 were compared with those from 1995-1999, and included analysis of a subset of rarely and never-screened for each study period. More ASC-H Pap tests were followed by CIN-II+ biopsies (20%) than ASCUS Pap tests (5%). Thirteen percent of ASC-H showed CIN-III/CIS on follow-up biopsy. Following the introduction of ASC-H, negative and LSIL Pap tests followed by CIN-III/CIS biopsies decreased from 5.6% to 0.37% and 9.2% to 4.4%, respectively. Fewer CIN-III/CIS cases were preceded by Pap tests with negative and ASCUS results in 2003-2005 as compared with 1995-1999. The number of days from screening to diagnosis for women aged 25-39 years with ASC-H Pap test results (58 days) was less than for ASCUS results (78 days) for the current study period. In this high-risk multi-ethnic population, ASC-H more effectively communicates equivocal findings likely to represent HSIL leading to more rapid follow-up. The incidence of CIN-II or CIN-III/CIS following ASC-H Pap tests is lower than generally appreciated for this population, including for rarely or never-screened high-risk women. Fewer CIN-III/CIS lesions were detected following negative and ASCUS Pap results. Compliance with follow-up is less than ideal for this population.

Weaving meaning? An exploration of the interplay between lay and professional understandings of cervical cancer risk

In line with the increasing emphasis on informed choice, women invited for cervical cancer screening in England receive a leaflet containing information on the risk factors and causation of the condition. However, data from a qualitative interview study with 35 women suggest that the ways in which women make sense of this information can vary and frequently do not correspond to the causal pathways and explanations which characterise contemporary professional medical explanations. This paper examines the complex interplay between lay and professional understandings that takes place as women attempt to weave the information they receive, their prior understandings and contextual factors together into some kind of coherent framework, in which each piece of information makes sense in relation to everything else. We conclude by arguing that, while presenting full and accurate information about orthodox medical understandings of cervical cancer causation in an accessible way maybe challenging, partial presentation of 'the facts' is likely to be ineffective.

Cost analysis of the National Breast and Cervical Cancer Early Detection Program: selected states, 2003 to 2004

BACKGROUND

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was established by the U.S. Congress in 1990. In recent years, there has been an emphasis on ascertaining the NBCCEDP's costs of delivering screening and diagnostic services to medically underserved, low-income women. The objective of this report was to address 3 economic questions: What is the cost per woman served in the program, what is the cost per woman served by program component, and what is the cost per cancer detected through the program?

METHODS

The authors developed a questionnaire to systematically collect activity-based costs on screening for breast and cervical cancer from 9 participating programs. The questionnaire was developed based on well established methods of collecting cost data for program evaluation. Data were collected from July 2003 through June 2004.

RESULTS

With in-kind contributions, the cost of screening services to women in 9 programs was estimated at $555 per woman served. Without in-kind contributions, this cost was $519. Among the program components, screening and coalitions/partnerships accounted for the highest and lowest cost per woman served, respectively. The median cost of screening a woman for breast cancer was $94, and the cost per breast cancer detected was $10,566. For cervical cancer, these costs were $56 and $13,340, respectively.

CONCLUSIONS

Costs per woman served, screened, and cancers detected are needed for programs to accurately determine the resources required to reach and screen eligible women. With limited program resources, these cost estimates can provide useful information to assist programs in planning and implementing cost-effective activities that could maximize the allocation of program resources.

Acceptability of reminder letters for Papanicolaou tests: a survey of women from 23 Family Health Networks in Ontario

OBJECTIVE

To explore women's perspectives on the acceptability and content of reminder letters from the family physician for Papanicolaou (Pap) test screening and the effect of reminder letters on compliance with screening recommendations.

METHODS

A population-based survey was conducted in 23 Family Health Networks and Primary Care Networks participating in a demonstration project to increase the delivery of preventive services in Ontario. Questionnaires were mailed to randomly selected women aged 35 to 69 years who had received a reminder letter for a Pap test from their family physician within the previous six months. Two focus groups were conducted with a volunteer sample of respondents.

RESULTS

The usable response rate was 54.3% (406/748). Two-thirds (65.8%, 267/406) of women who completed the survey recalled receiving the reminder letter. Overall, 52.3% (212/405) reported having a Pap test in the past six months. Among women who recalled the reminder letter and scheduled or had a Pap test, 71.4% (125/175) reported that the letter influenced their decision to be screened. The majority of respondents (80.8%, 328/406) wanted to continue to receive reminder letters for Pap tests from their physician, and 34.5% (140/406) wanted to receive additional information about cervical screening. Focus group interviews indicated that women who have had a Pap test may still be unsure about screening recommendations, what the test detects, and the rationale for follow-up procedures.

CONCLUSIONS

Reminder letters in family practice were viewed as useful and influenced women's decisions to undergo Pap test screening. Women who have had a Pap test may still need additional information about the test.

Cervical Cancer Incidence in the United States by Area of Residence, 1998–2001

OBJECTIVES

To examine differences in cervical cancer incidence rates among women in rural, suburban, and metropolitan areas of the United States.

METHODS

This study examined invasive cervical cancer incidence among women in United States counties classified as rural, suburban, and metropolitan for the period 1998-2001. We examined differences in incidence by age, race, Hispanic ethnicity, stage at diagnosis, and poverty level, using the Center for Disease Control and Prevention National Program of Cancer Registries, National Cancer Institute's Surveillance, Epidemiology, and End Results Program and 2000 U.S. Census data.

RESULTS

A total of 39,946 cases of cervical cancer were included. Overall, the rates increased among younger women, peaked at ages 40-44 years, remained relatively constant in middle age, and decreased after age 69 years. Incidence rates were lower among residents of metropolitan areas than residents of rural areas, both overall and across groups defined by race, ethnicity, (localized) stage, and poverty level.

CONCLUSION

Rural women in the United States have higher cervical cancer incidence rates. Among older women (aged 45-80 years) in whom half of cervical cancers occur, geographic differences largely disappear after controlling for poverty and race.

LEVEL OF EVIDENCE

III.

Process of care failures in invasive cervical cancer: systematic review and meta-analysis

OBJECTIVE

As invasive cervical cancer is preventable when screening and treatment of pre-invasive lesions are timely and appropriate, several past studies attempted to enumerate the quality of preventive care invasive cervical cancer subjects received before diagnosis. Objectives of the present study were to review and to summarize the findings of these studies in a meta-analysis.

METHOD

Data from 42 studies were used to estimate DerSimonian and Laird random effects models for the various failures in care along the cancer care continuum. Analyses were also conducted within strata characterized by variables deemed to account for heterogeneity in meta-regression analyses.

RESULTS

Poor Pap screening frequency was the primary factor attributable to development of invasive cervical cancer. On average, 53.8% (95% confidence interval: 43.6-66.3) of invasive cervical cancer subjects had inadequate screening histories and 41.5% (95% confidence interval: 35.4-48.7) were never screened. There was significant temporal improvement in the proportion of women screened at least once over a lifetime but not in the proportion with overall deficient histories. An estimated 29.3% (95% confidence interval: 21.2-40.4) of failures to prevent invasive cervical cancer can be attributed to false-negative Pap smears and 11.9% (95% confidence interval: 9.0-15.6) to poor follow-up of abnormal results.

CONCLUSION

Appropriate assessment of the effect of combined failures in the process of care must be done in comprehensive audit studies.

Do cervical cancer screening rates increase in association with an intervention designed to increase mammography usage?

OBJECTIVES

To assess cervical cancer screening behaviors among underserved women participating in an intervention designed to increase mammography use.

METHODS

This was a randomized trial of 897 women from three racial groups (white, African American, Native American) living in a rural county in North Carolina. Baseline and followup surveys were completed by 815 women; 775 women provided data to be included in these analyses. The intervention group received an educational program focused on mammography delivered by a lay health advisor, and the control group received a physician letter/brochure focusing on Pap tests.

RESULTS

Women in both the intervention (OR 1.70; 1.31, 2.21, p < 0.001) and control groups (OR 1.38; 1.04, 1.82, p = 0.025) significantly increased cervical cancer screening rates within risk appropriate guidelines. No differences by racial group were documented. Women categorized in the high-risk group for developing cervical cancer (>2 sexual partners, age <18 years at first sexual intercourse, smoker; treated for sexually transmitted disease [STD] or partner with treated STD) significantly (OR 1.88; 1.54, 2.28, p < 0.001) increased Pap test completion. However, a nonsignificant increase (OR 1.25; 0.87, 1.79, p = 0.221) in Pap test completion was demonstrated in women categorized as low risk for cervical cancer.

CONCLUSIONS

This study suggests that women in an intensive behavioral intervention designed to increase mammography use may also increase Pap test completion, similar to a minimal intervention focused only on increasing Pap test completion. These results have implications for the design and evaluation of behavioral intervention studies.

Health literacy as a predictor of follow-up after an abnormal Pap smear: a prospective study

BACKGROUND

Low literacy influences cervical cancer screening knowledge, and is a possible contributor to racial disparities in cervical cancer.

OBJECTIVE

To examine the hypothesis that literacy predicts patient adherence to follow-up recommendations after an abnormal Pap smear.

DESIGN

A prospective, continuity clinic-based study.

PARTICIPANTS

From a sample of 538 women undergoing literacy testing at the time of Pap smear screening, we studied 68 women with abnormal Pap smear diagnoses.

MEASUREMENTS

Literacy was assessed using the Rapid Evaluation of Adult Literacy in Medicine (REALM). We also measured other proxies for literacy, including educational attainment and physician estimates of patients' literacy level. Outcome measures included on-time and 1-year follow-up and duration of time to follow-up after an abnormal Pap smear.

RESULTS

Only one-third of the cohort adhered to follow-up recommendations. At 1 year, 25% of the women had not returned at all. Patients with inadequate literacy (as assessed by the REALM) were less likely to follow up within 1 year, although this result was not statistically significant (adjusted odds ratio [OR]=3.8, 95% confidence interval [CI]: 0.8 to 17.4). Patients subjectively assessed by their physician to have low literacy skills were significantly less likely to follow up within 1 year (adjusted OR=14, 95% CI: 3 to 65). Less than high school education (hazard ratio (HR)= 2.3; 95% CI: 1.2, 4.6) and low physician-estimated literacy level (HR=3.4, 95% CI: 1.4, 8.2), but not objective literacy level, were significant predictors of duration of time to follow-up, adjusting for recommended days to follow-up and other factors.

CONCLUSIONS

Among women with an abnormal Pap smear, those perceived by their physician to have low literacy were significantly more likely to fail to present for follow-up.

Public Education and Cancer Control

OBJECTIVES

To provide an overview of public education efforts in tobacco, obesity, environmental health, and cancer screening.

DATA SOURCES

Cochrane, AHRQ, the CDC's Guide to Community Preventive Services, and other reviews.

CONCLUSION

Major changes in rates of smoking and cancer screening attest to the effectiveness of public education efforts. Diet and physical activity have more resistant behaviors. Communication technologies offer possibilities for connecting people with the education they need.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can play important roles in public education by helping to overcome people's misperceptions and biases related to cancer. There also may be an important role for nurses as information brokers.

Follow-up of abnormal or inadequate cervical smears using two guidance systems: RCT on effectiveness

BACKGROUND

To improve follow-up compliance after an initial inadequate or abnormal cervical smear, two follow-up guidance systems were tested for effectiveness. A comprehensive system (cytopathology laboratory monitored the follow-up of all abnormal and inadequate smears) was compared to a selective system (monitoring was left to the smear taker; laboratory acted as a safety net).

METHODS

In an RCT on all family practices (N = 171) in the catchment areas of two cytopathology laboratories (Nijmegen region, The Netherlands, 1998-2000), practices were allocated at random to one of the follow-up guidance systems. All women included were registered at the practices, invited to the national screening program and had abnormal or inadequate smears. Measurements comprised of (1) follow-up compliance at baseline and 1 year after the initial smear and (2) diagnostic outcome of the follow-up smear.

RESULTS

During the study period, 132 practices sent their cervical smears to the laboratories. The comprehensive system covered 1226 women, the selective 1034. In the comprehensive system, the increase in follow-up compliance for initial inadequate and slightly abnormal smears was significantly higher (8.9%) than in the selective one, which implied an extra detection of eleven, more serious, abnormalities per 1000 women.

CONCLUSION

The comprehensive system was more effective than the selective and is suitable for use on a larger scale.

Science and society: the communications revolution and cancer control

Advances in communications technology, particularly with regards to computer-based media, have opened up exciting possibilities to intervene and influence the trajectory of cancer control, from disease prevention to survivorship, and to reduce the cancer burden. The resulting explosion in cancer information in the mass media and on the Internet, however, also offers challenges in terms of equality in access to information and the ability to act on it, as well as in making sure that it is accurate, readily available and easy to use.