Improving follow-up after an abnormal Pap smear: a randomized controlled trial

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology.

MAIN RESULTS

Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

Prevention of Adolescent Depression in Primary Care: Barriers and Relational Work Solutions

BACKGROUND AND PURPOSE

Depression affects millions of adolescents in the United States each year. This population may benefit from targeted preventive interventions. We sought to understand the internal factors that affect the ability of healthcare organizations to implement an intervention that involves mental health screening and depression prevention treatment of at-risk adolescents in primary care settings.

METHODS

From November 2011 to July 2016 we conducted a study of the implementation of a multisite (N=30) phase 3 randomized clinical trial of an Internet-based depression prevention intervention program (CATCH-IT). We describe the prevalence of internal barriers on the screening and enrollment process by reporting REACH (the proportion of target audience exposed to the intervention).

RESULTS

A total of 369 adolescents were randomized into the intervention or control program. Mean REACH values for the study clinics were 0.216 for screening and 0.181 for enrollment to CATCH-IT. Mean REACH enrollment lost due to internal barriers was 0.233. This translated to 4,691 adolescents lost at screening and 2,443 adolescents lost at enrollment due to internal barriers.

CONCLUSION

We propose a model of the implementation process that emphasizes the importance of positive relational work that assists in overcoming internal barriers to REACH. We also provide implications for policy and practice.

Effect of patient navigator program on no-show rates at an academic referral colposcopy clinic

BACKGROUND

Patient navigators have been used successfully to guide vulnerable patients through barriers to cancer care and reduce disparities in cancer outcomes. This study evaluated the effect of a patient navigator program on no-show rates at a tertiary care referral colposcopy center and explored factors associated with missed appointments.

METHODS

No-show rates prior and subsequent to implementation of the intervention were compared by chi-square test. We compared patient demographic, lifestyle, and diagnostic characteristics between patients who had ever and never missed appointments. We described patient-reported barriers to care.

RESULTS

Of 4,199 women evaluated in our clinic from January 2006 to December 2013, 2,441 (58%) had at least one missed appointment. African American, Hispanic, and publicly insured women tended to miss appointments more frequently than did white and privately insured women (p<0.0001). Patients who missed appointments tended to have more abnormal cytology (p<0.0001), cervical pathology (p=0.007), and vulvar pathology (p=0.001). No-show rates declined from 49.7% to 29.5% after implementation of the patient navigator program (p<0.0001). We found that 45% of patient no-shows were anticipated or a result of patient misunderstanding and could be mediated with targeted education by the patient navigator.

CONCLUSIONS

Patient navigator programs at referral centers reduce no-show rates, thus improving patient follow-up, which may reduce disparities in cervical cancer screening and treatment.

Analysis of patterns of patient compliance after an abnormal Pap smear result: the influence of demographic characteristics on patient compliance

OBJECTIVE

This study aimed to determine population characteristics that correlate to suboptimal follow-up after an abnormal cervical cytology result.

MATERIALS AND METHODS

Nonpregnant women, ages 21 to 65 years, with newly diagnosed abnormal cervical cytology result between January 2009 and January 2012 at an urban clinic were eligible for inclusion in this retrospective chart review. Cervical cytology data and demographic characteristics such as age, ethnicity, employment, marital and smoking status, health insurance and number of pregnancies were abstracted from electronic medical record. A log-linear model was used to determine which factors influenced patient compliance.

RESULTS

Of the total of 206 women, 78 (37.9%) had optimal follow-up and 128 (62.1%) had suboptimal follow-up. The 3 variables that were statistically significant in influencing patient follow-up after adjusted analyses included severity of cytology result (p = .0013), ethnicity (p = .02), and employment status (p = .0159). The risk ratio for optimal follow-up for those with severe cytology result was 1.81; for the non-whites, 1.77; and for the employed, 1.53.

CONCLUSIONS

Ethnicity, severity of cervical cytology result, and employment status play an important role in patient follow-up after an abnormal cervical cytology result. Detecting trends in our patient population that influence adherence to follow-up will help health care providers formulate strategies that target this problem.

Intervention to improve follow-up for abnormal Papanicolaou tests: a randomized clinical trial

OBJECTIVE

To evaluate the effect of a theory-based, culturally targeted intervention on adherence to follow-up among low-income and minority women who experience an abnormal Pap test.

METHOD

5,049 women were enrolled and underwent Pap testing. Of these, 378 had an abnormal result and 341 (90%) were randomized to one of three groups to receive their results: Intervention (I): culturally targeted behavioral and normative beliefs + knowledge/skills + salience + environmental constraints/barriers counseling; Active Control (AC): nontargeted behavioral and normative beliefs + knowledge/skills + salience + environmental constraints/barriers counseling; or Standard Care Only (SCO). The primary outcome was attendance at the initial follow-up appointment. Secondary outcomes included delay in care, completion of care at 18 months, state anxiety (STAI Y-6), depressive symptoms (CES-D), and distress (CDDQ). Anxiety was assessed at enrollment, notification of results, and 7-14 days later with the CDDQ and CES-D.

RESULTS

299 women were included in intent-to-treat analyses. Adherence rates were 60% (I), 54% (AC), and 58% (SCO), p = .73. Completion rates were 39% (I) and 35% in the AC and SCO groups, p = .77. Delay in care (in days) was (M ± SD): 58 ± 75 (I), 69 ± 72 (AC), and 54 ± 75 (SCO), p = .75. Adherence was associated with higher anxiety at notification, p < .01 and delay < 90 days (vs. 90+) was associated with greater perceived personal responsibility, p < .05. Women not completing their care (vs. those who did) had higher CES-D scores at enrollment, p < .05.

CONCLUSIONS

A theory-based, culturally targeted message was not more effective than a nontargeted message or standard care in improving behavior.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

World-wide, cervical cancer is the second most common cancer in women. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical cancer screening.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2009. MEDLINE, EMBASE and LILACS databases up to March 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible the data were synthesised in a meta-analysis.

MAIN RESULTS

Thirty-eight trials met our inclusion criteria. These trials assessed the effectiveness of invitational and educational interventions, counselling, risk factor assessment and procedural interventions. Heterogeneity between trials limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. Secondary outcomes including cost data were incompletely documented so evidence was limited. Most trials were at moderate risk of bias. Informed uptake of cervical screening was not reported in any trials.

AUTHORS' CONCLUSIONS

There is evidence to support the use of invitation letters to increase the uptake of cervical screening. There is limited evidence to support educational interventions but it is unclear what format is most effective. The majority of the studies are from developed countries and so the relevance to developing countries is unclear.

Healthcare use after screening for lung cancer

BACKGROUND

To evaluate the benefits of lung cancer screening, all effects of screening need to be considered. The aim of this study was to determine whether screening had an effect on healthcare use, specifically whether use increased for those with a false-positive or indeterminate screening result.

METHODS

Recruited were 400 individuals participating in a lung cancer screening study at the University of Pittsburgh. Self-reported outpatient healthcare use information was collected for the 6 months before, 0 to 6 months after, and 6 to 12 months after screening. The screening outcomes were negative, indeterminate, and suspicious. Repeated-measures Poisson regression models were used to examine changes in use over time and how changes over time varied among the screening outcome groups.

RESULTS

Approximately 58% of participants had a negative screening result, 36% had an indeterminate result, and approximately 6% had a suspicious result. The percentage of individuals who had any incidence of each type of outpatient use increased after screening, with the greatest increase noted for those with a suspicious screening result. Adjusted mean use significantly increased for nearly all types of use and for all 3 screening results categories in the 6 months after screening, but mostly declined to prescreening levels in the next 6 months.

CONCLUSIONS

Outpatient healthcare use was found to increase after screening for all individuals who were screened for lung cancer, regardless of the screening finding. The cost of the lung-related visits alone was substantial. Therefore, if lung cancer screening prevalence is increased, attendant follow-up healthcare costs are also likely to increase.

Tracking abnormal cervical cancer screening: evaluation of an EMR-based intervention

INTRODUCTION

System level barriers have been associated with inadequate follow-up of abnormal cervical cytology.

OBJECTIVE

The aim of this study was to develop and evaluate an electronic tracking system to improve follow-up of abnormal Pap tests.

PROGRAM DESCRIPTION

We implemented an electronic medical record (EMR)-based Pap test tracking system at two clinical practices at an inner-city academic health center. The system generated a provider-specific monthly report of all abnormal Pap results, and provided a patient-specific Pap tracking table embedded in the EMR for each subject.

EVALUATION

We compared abnormal Pap test follow-up rates for the 24 months pre-intervention with rates 12 months following its implementation (post-intervention). The evaluation followed all subjects for 12 months from the date of their abnormal Pap test, looking for diagnostic resolution.

RESULTS

Subjects were young women (mean age = 30.5) of primarily white (42%) and African American (37%) descent, who spoke English (88%). Forty-eight percent were insured through publicly subsidized insurance. Controlling for type of abnormality and practice location, the adjusted mean time to resolution decreased significantly from 108 days (confidence interval, CI 105-112 days) in the pre-intervention period to 86 days (CI 81-91 days).

CONCLUSION

Our study cannot demonstrate that with follow up, we directly avoided cases of invasive cervical cancer. However, we show that in an at-risk urban population, an automated, EMR-based tracking system reduced the time to resolution, and increased the number of women who achieved diagnostic resolution.

Women's experiences of having a colposcopic examination: self-reported satisfaction with care, perceived needs and consequences

This study was conducted in seven gynaecological clinics in New South Wales (NSW), Australia. The study aimed to assess the level of satisfaction with care, unmet needs and consequences following the procedure reported by women having a colposcopic examination. Of the 161 eligible women attending colposcopy clinics who were approached to take part, 156 (97%) gave written consent to participate and 138 (86%) completed interviews. Consenting women were telephoned within 1 week of their clinic visit to complete a computer-assisted telephone interview (CATI). The survey addressed a number of issues relating to the care they received during their colposcopic examination: satisfaction with care, satisfaction with the waiting time to have a colposcopy, preferences for provider gender, information and health care needs while waiting for the colposcopy, information and health care needs during the colposcopy, short-term physical consequences and shortterm psychosocial consequences of the procedure. Results indicate that satisfaction with care among women ranged from 69% to 96%. The highest expressed needs while waiting for the colposcopy were for information about risks of cancer (91%), reasons for needing a colposcopy (86%), and the colposcopy procedure (86%). Women reported that outcomes such as anxiety and disinterest in sex had further worsened or not been improved following the colposcopy. The results indicate that interventions to address specific concerns would need to be designed, implemented and evaluated.

Compliance After Loop Electrosurgical Excision Procedure or Cold Knife Cone Biopsy

OBJECTIVE

To examine rates and predictors of compliance with follow-up recommendations in low-income women from a county hospital clinic undergoing loop electrosurgical excision procedure (LEEP) and cone knife cone biopsy.

METHODS

A retrospective cohort study of 135 patients who underwent LEEP or cold knife cone biopsy was performed. Demographic data, results of cytology, colposcopy biopsy, excision specimen pathology, and indication for the LEEP or cold knife cone biopsy were collected. Compliance was determined by whether the patient adhered to the recommended follow-up within 1 year from the date of the procedure. Multivariable analysis was performed by using logistic regression.

RESULTS

A total of 135 patients were included for analysis (81 LEEP and 54 cold knife cone cases). Type of procedure was significant in predicting compliance: 74.1% of cold knife cone patients were compliant compared with 43.2% of LEEP patients (adjusted relative risk 1.64, 95% confidence interval 1.30-1.87). There was a trend for older patients to be more compliant than younger patients in the univariable analyses but not in multivariable analysis. After adjusting for age, LEEP patients were still significantly less compliant than cold knife cone patients. Pathologic indication (severity of disease), race, payor source, and gravidity were not significant predictors of compliance and not included in the multivariable analysis.

CONCLUSION

Compared with LEEP, cold knife cone patients were significantly more compliant with follow-up. Because LEEP is a less invasive in-office procedure, it may convey to patients the idea that their condition is less severe.

LEVEL OF EVIDENCE

II.

Adherence to recommendations for follow-up to abnormal Pap tests

OBJECTIVE

To evaluate whether timely adherence rates differ by race among women with abnormal Pap tests participating in a cost-free or reduced-cost program.

METHODS

Eligible subjects included women aged 47-64 years who received a referral for follow-up care after an abnormal Pap test from 1999 to 2002 in South Carolina (n=330). Adherence was measured as days to receipt of follow-up care after an abnormal Pap test. Cox proportional hazards modeling was used to estimate risk factors associated with time to adherence within 60 and 365 days by race.

RESULTS

African-American and non-Hispanic white women had similar adherence to follow-up. Among white women, those with high-grade lesions were less likely to adhere in a timely manner relative to those with low-grade lesions (hazard ratio 0.6, 95% confidence interval [CI] 0.4-1.0). For African-American women, rural residence (hazard ratio: 0.5, 95% CI 0.2-0.9) and history of abnormal Pap tests (hazard ratio 0.6, 95% CI 0.3-1.0) were associated with decreased adherence, whereas less education (hazard ratio 2.3, 95% CI 1.3-3.9) was associated with increased adherence.

CONCLUSION

Adherence rates do not differ by race. However, risk factors for adherence within race are variable. Interventions tailored to the differential needs of racial and ethnic groups may prove effective toward increasing timely adherence rates.

LEVEL OF EVIDENCE

II.

Understanding Barriers for Adherence to Follow-Up Care for Abnormal Pap Tests

OBJECTIVE

Approximately 4000 women annually will die from preventable and treatable cervical cancer. Failure to adhere to follow-up recommendations after an abnormal Pap test can lead to development of cervical cancer. This paper summarizes the body of literature on adherence to follow-up after an abnormal Pap test in order to facilitate development of interventions to decrease morbidity and mortality due to cervical cancer.

METHODS

We conducted a comprehensive search of published literature addressing risk factors for adherence or interventions to improve adherence following an abnormal Pap test as the outcome. We included peer-reviewed original research conducted in the United States from 1990 to 2005.

RESULTS

Fourteen analytical and twelve experimental studies that met our criteria were reviewed. Lesion severity and health beliefs were consistently associated with adherence rates. Communication interventions, including telephone reminders, counseling, and educational sessions, increased follow-up compliance across intervention studies. Inconsistent evidence for associations among race, income, and age were found.

CONCLUSIONS

Further research is needed to reinforce current studies addressing health beliefs and social support. Interventions that focus on the interplay among psychological, educational, and communication barriers are necessary. These interventions should be adapted and applied across various racial/ethnic and socioeconomic groups to reach all women with a high-risk profile for invasive cervical cancer.

Context of barriers to Pap testing in Korean women

Because efforts to increase the Papanicolaou (Pap) test rate have not been effective in Korea, there is an urgent need to identify the underlying context of the barriers to Pap testing. Twenty-three women aged 27-37 years were organized into four focus groups for a qualitative analysis of their attitudes and feelings about the Pap test. Five contextual themes of barriers were identified under the categories of "misconceptions attributable to women's experiences of Pap testing" and "issues related to the health care system." Educational and clinical implications in regard to women, health care professionals, and the health service environment were discussed to increase the Pap test rate.

Use of loop electrosurgical excision procedure specimens to provide tissue fractions for immunologic analyses

OBJECTIVE

To determine if dividing loop electrosurgical excision procedure (LEEP) specimens to provide tissue for research increases rates of LEEP specimen misdiagnosis and recurrent cervical intraepithelial neoplasia.

MATERIALS AND METHODS

In this chart review, 42 women with biopsy-confirmed cervical intraepithelial neoplasia (CIN) 2,3 had up to 20% of their LEEP specimens sectioned and used for immunologic analysis. The remainder of each specimen was assessed routinely. Follow-up cytologic analyses and cervical biopsies also were assessed. This cohort was compared with a control cohort of 80 patients with biopsy confirmed CIN 2,3 whose LEEP specimens were not divided. Statistical significance was defined as a p value of < .05.

RESULTS

There were no statistically significant differences between the groups with regard to histologic assessment of LEEP specimens or follow-up outcomes.

CONCLUSIONS

Use of up to 20% of LEEP specimens for research purposes neither adversely affects histologic evaluation of LEEP specimens nor leads to poorer follow-up outcomes.

Life Stressors Are an Important Reason for Women Discontinuing Follow-up Care for Cervical Neoplasia

Although studies have addressed psychosocial factors associated with obtaining follow-up care for an abnormal Pap test, none have explored the effect of stressful life events in predicting the receipt of follow-up care for an abnormal Pap test. Data from a program (1995-2001) that provided free follow-up care for women with low-grade cervical lesions (n = 601) was used to determine whether life stressors increased risk of study discontinuation. Women were interviewed at baseline and offered follow-up at 4- to 6-month intervals for up to 24 months. Of the 556 women recruited and interviewed (92% response rate), 53 were referred out because they had high-grade cervical lesions and 33 had a health condition precluding follow-up. Among 470 women who began follow-up, 175 (37.2%) discontinued before completing three visits. Women who discontinued were significantly more likely to report more stressful life events in the past year [age-adjusted relative risk (aRR), 1.19; 95% confidence interval (95% CI), 1.08-1.30; 17-item scale]. Events most strongly associated with discontinuation included having a problem with a boss (aRR, 1.9; 95% CI, 1.5-2.4), severe physical partner violence (aRR, 1.7; 95% CI, 1.3-2.2), being homeless (aRR, 2.1; 95% CI, 1.6-2.8), and having an unplanned pregnancy (aRR, 1.5, 95% CI, 1.2-2.1). Life stressors may be important predictors of discontinuation of free follow-up care among women in need of immediate follow-up care to prevent lesion progression.

Patient-based evaluation of a colposcopy information leaflet

A questionnaire survey of new patients attending the colposcopy clinic of a teaching hospital was carried out. The intention was to evaluate the information leaflet routinely sent to women who have been referred for colposcopy because of abnormal cervical smear results and use the findings to propose changes that will make the leaflet more suitable, effective and patient-friendly. The majority of the respondents received (90%), read (90%) and understood most or all (96%) of the information leaflet. Patients who received the leaflet performed better in the knowledge quiz than those who did not (P < 0.0001). Of the 111 patients who received and read the leaflet 50 (45%) found it reassuring or very reassuring and 58 (52%) thought it made them less anxious. On the contrary 20 (18%) patients found the leaflet worrying or very worrying and 33 (30%) thought it made them more anxious. Overall, 91 (82%) patients found the leaflet helpful or very helpful and 99 (89%) were satisfied with the information provided. The commonest difficulties with the leaflet identified by patients concerned the use of abbreviations and technical terms. We found the leaflet to be a useful method of providing information for patients before colposcopy. Whilst the leaflet appeared to have a major impact on patients' knowledge about abnormal smears and colposcopy, its effect in reducing anxiety was less pronounced.

Psychological and Sociocultural Perspectives on Follow-up of Abnormal Papanicolaou Results

OBJECTIVE

To understand women's motivation to attend follow-up of an abnormal Papanicolaou (Pap) test by applying a general theoretical framework for voluntary behavior.

METHODS

Semistructured, face-to-face interviews were conducted among 120 low-income, African-American, Caucasian, or Hispanic outpatients, aged 25-50 years, who presented for routine gynecologic care. Interview questions assessed social, cognitive, environmental, and emotional factors surrounding follow-up for an abnormal Pap test. Content analysis was performed.

RESULTS

The majority of women (74%) described their attitude toward returning for a follow-up visit as favorable. Overall, knowledge regarding the significance of an abnormal result was poor, and misconceptions were common. Perceived barriers, consequences, and social influences associated with attending follow-up were qualitatively different across the 3 racial/ethnic groups. For example, African-American and Hispanic women expressed embarrassment more frequently than Caucasian women and were less likely to anticipate obstacles to attending follow-up. Furthermore, African-American women were the least likely to be influenced by others' opinions and to perceive difficulty in adhering to follow-up recommendations. For nearly all women, adequate communication with their provider was a key component of anticipated adherence.

CONCLUSION

Clinicians may exert a positive influence on adherence among patients who experience an abnormal Pap test by engaging patients in a dialogue that accommodates the patient's sociocultural environment, explores concerns regarding the partner's reaction, emphasizes the importance of follow-up, provides a clear understanding of the process and timeline surrounding follow-up recommendations, and encourages the patient to anticipate obstacles to adherence and assists with solutions.

Interventions to improve follow-up of abnormal findings in cancer screening

The potential reduction in morbidity and mortality through cancer screening cannot be realized without receipt of appropriate follow-up care for abnormalities identified via screening. In this paper, the authors critically examine the existing literature on correlates of receipt of appropriate follow-up care for screen-detected abnormalities, as well as the literature on interventions designed to increase rates of receipt of follow-up care. Lessons learned describe what is known and not known about factors that are related to or predict receipt of follow-up care. Similarly, effective interventions to increase follow-up are described and gaps identified. A conceptual model is developed that categorizes the health care system in the United States as comprising four levels: policy, practice, provider, and patient. Some patient-level factors that influence follow-up receipt are identified, but the lack of data severely limit the understanding of provider, practice, and policy-level correlates. The majority of intervention studies to increase follow-up receipt have focused on patient-level factors and have targeted follow-up of abnormal Papanicolaou smears. Insufficient information is available regarding the effectiveness of provider, practice, or policy-level interventions. Standard definitions of what constitutes appropriate follow-up are lacking, which severely limit comparability of findings across studies. The validity of various methods of obtaining outcome data has not been clearly established. More research is needed on interventions targeting provider, system, and policy-level factors, particularly interventions focusing on follow-up of colorectal and breast abnormalities. Standardization of definitions and measures is needed to facilitate comparisons across studies.

Is the promise of cancer-screening programs being compromised? Quality of follow-up care after abnormal screening results

Cancer screening has increased dramatically in the United States, yet in some populations, particularly racial minorities or the poor, advanced disease at diagnosis remains high. One potential explanation is that follow-up of abnormal tests is suboptimal, and the benefits of screening are not being realized. The authors used a conceptual model of access to care and integrated constructs from models of provider and patient health behaviors to review published literature on follow-up care. Most studies reported that fewer than 75 percent of patients received some follow-up care, indicating that the promise of screening may be compromised. They identified pervasive barriers to follow-up at the provider, patient, and health care system levels. Interventions that address these barriers appear to be effective. Improvement of data infrastructure and reporting will be important objectives for policy makers, and further use of conceptual models by researchers may improve intervention development and, ultimately, cancer control.

Realizing the promise of breast cancer screening: clinical follow-up after abnormal screening among Black women

BACKGROUND

Delayed or incomplete follow-up after abnormal screening results may compromise the effectiveness of breast cancer screening programs, particularly in medically underserved and minority populations. This study examined the role of socioeconomic status, breast cancer risk factors, health care system barriers, and patient cognitive-attitudinal factors in the timing of diagnostic resolution after abnormal breast cancer screening exams among Black women receiving breast cancer screening at three New York city clinics.

METHODS

We identified 184 Black women as having an abnormal mammogram or clinical breast exam requiring immediate follow-up and they were interviewed and their medical records examined. Bivariate and multivariate logistic regression analyses were used to assess the association between patient and health care system factors and diagnostic resolution within 3 months of the abnormal finding.

RESULTS

Within 3 months, 39% of women were without diagnostic resolution and 28% within 6 months. Neither socioeconomic status nor system barriers were associated with timely diagnostic resolution. Timely resolution was associated with mammogram severity, patients asking questions (OR, 2.73; 95% CI, 1.25-5.96), or receiving next step information (OR, 2.6; 95% CI, 1.08-6.21) at the initial mammogram. Women with prior breast abnormalities were less likely to complete timely diagnostic resolution (OR, 0.42; 95% CI, 0.20-0.85), as were women with higher levels of cancer anxiety (OR, 0.50; 95% CI, 0.27-0.92).

CONCLUSIONS

Interventions that address a woman's prior experience with abnormal findings and improve patient/provider communication may improve timely and appropriate follow-up.

Factors affecting abnormal Pap smear follow-up among HIV-infected women

Women with HIV infection are at least 10 times more likely to have an abnormal Pap smear than women who are HIV negative. Unfortunately, many women with HIV do not return for care after an abnormal Pap smear. Through the use of focus groups and individual interviews, HIV-positive women's experiences with abnormal Pap smears and the factors that affected whether they returned for care were explored. Two thirds of the 18 participants were minority women, and the average age was 40. Using techniques of constant comparative analysis, five factors were identified that affected whether women came back for care. These factors included fear, the asymptomatic nature of the problem, life circumstances, the participant's perspectives on health, and the health care provider. The findings from this study have implications for clinical practice and future research regarding adherence and abnormal Pap smear follow-up among women with HIV.

Effect of health beliefs on delays in care for abnormal cervical cytology in a multi-ethnic population

CONTEXT

Women from racial and ethnic minorities in the United States have higher rates of cervical cancer and present with later stage disease compared to whites. Delays in care for abnormal Papanicolaou (Pap) smears can lead to missed cases of cervical cancer or late-stage presentation and may be one explanation for these differences.

OBJECTIVE

To determine if race and ethnicity, health beliefs, and cancer knowledge are associated with delays in care for abnormal Pap smears.

DESIGN, PARTICIPANTS, AND SETTING

We conducted a mailed survey with telephone follow-up of all women with an abnormal Pap smear who received care at Kaiser Permanente Los Angeles Medical Center between October 1998 and October 1999 (n = 1,049).

MEASUREMENTS AND MAIN RESULTS

A delay in care was defined as not attending the first scheduled clinic visit to follow up on an abnormal Pap smear, or requiring multiple contact attempts, including a certified letter, to schedule a follow-up visit. Our response rate was 70% (n = 733) and the sample was 51% Latina. Spanish-speaking Latinas and women of Asian descent were more likely to endorse fatalistic beliefs and misconceptions about cancer. Thirteen percent of the sample delayed follow-up on their abnormal Pap smear. Women who delayed care were more fatalistic and endorsed more misconceptions about cervical cancer. Delays in care were not independently associated with race and ethnicity.

CONCLUSIONS

Health beliefs and cancer knowledge differed by race and ethnicity among women in a large managed care organization. Fatalistic health beliefs and misconceptions about cancer, but not race and ethnicity, were independently associated with delays in care.

Abnormal cervical screen follow-up among low-income Latinas: Project SAFe

BACKGROUND

Cervical cancer incidence and mortality rates are dramatically higher among low-income women than in the general population, in part due to poor adherence to recommended diagnostic follow-up after an index Pap test. This report describes a pilot study of the Screening Adherence Follow-Up Program (SAFe), an individualized, structured case management program designed to assess for and intervene in response to a variety of potential personal and systems barriers to follow-up adherence. Interventions included health education, counseling, and systems navigation.

METHODS

A clinical decision-making algorithm was used to determine service intensity and level of intervention. Services were provided to 196 low-income women, predominantly Latinas, who had either a low-grade or high-grade squamous intraepithelial lesion (LGSIL or HGSIL) abnormal Pap result. Adherence rates to at least one follow-up appointment after enrollment and baseline intervention were 83% following LGSIL and 93% for HGSIL.

RESULTS

Over 1 year post-enrollment, 41% of women with LGSIL were fully adherent, with 42% partially adherent; 61% of women with HGSIL were fully adherent, with 32% partially adherent. In a comparison group of 369 nonenrollees (women who refused participation or could not be located for consent), adherence rates were 58% for LGSIL and 67% for HGSIL. A survey among a random sample of women served indicated that 93% were "mostly" or "very" satisfied, overall, with SAFe services.

CONCLUSIONS

The intervention team--a peer counselor and a master's degreed social worker--addressed multiple psychosocial and systems navigation problems to reduce potential barriers to adherence, including knowledge, attitudinal, psychosocial, psychological distress, systems communication, and resource access problems. SAFe appears highly acceptable to women and may significantly enhance medical care management following an abnormal cervical screen for a carefully targeted group of women at risk for suboptimal follow-up adherence.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

Cervical cancer is the third most common cancer world-wide. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at increasing uptake, and informed uptake of cervical cancer screening.

SEARCH STRATEGY

Twenty-three electronic databases (to March 2000) were searched with no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs), or quasi-RCTs of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Data on study characteristics and quality were extracted independently by two reviewers. Where data were available, relative risks and 95% CI were calculated and a chi-squared test for heterogeneity was performed.

MAIN RESULTS

Thirty-five studies were included (27 RCTs and eight quasi-RCTs). Heterogeneity between studies limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. The number and quality of included studies limited evidence regarding effectiveness of other interventions. Informed uptake of cervical screening was not considered by any studies.

REVIEWER'S CONCLUSIONS

There was some evidence to support the use of invitation letters to increase the uptake of cervical screening. There was limited evidence to support educational interventions but it was unclear what format was most effective. The majority of the studies were from developed countries and so the relevance to developing countries is unclear.

Can personal health record booklets improve cancer screening behaviors?

BACKGROUND

Despite the widespread use of written health education materials as interventions, relatively few studies have adequately evaluated the effectiveness of such materials on changing healthcare behaviors in the general population.

SETTING/PARTICIPANTS

The study consisted of ten matched pairs of small rural towns in New South Wales, Australia, with a total combined population of approximately 25,000 in both the intervention and control group towns. A randomized controlled trial was used.

INTERVENTION

Personal Health Record Booklets (PHRBs) that include the latest evidence-based recommendations for reducing risk of cancer and cardiovascular disease were developed using leading behavioral change theories to maximize effectiveness. The booklets included an explanatory letter, a gender-specific Better Health Booklet, and a gender-specific Better Health Diary. Following a media campaign, the PHRBs were mailed to all residents aged 20 to 60 years (about 12,600 people) in the ten intervention towns. Family practitioners in the intervention towns were recruited to support and encourage people to use the PHRBs.

MAIN OUTCOME MEASURES

Health Insurance Commission data for Papanicolaou (Pap) tests, mammograms, and skin operations were obtained for 5 years before the intervention, and 3 months and 1 year after the intervention.

RESULTS

No significant increases in the rates of Pap tests, mammograms, and skin operations were detected in either short- or long-term follow-ups.

CONCLUSIONS

While PHRBs may represent an inexpensive, easy-to-produce, and time-efficient method of communicating information to the general population, it appears unlikely that any significant behavioral change will result unless such materials are targeted toward high-risk groups or constitute the first intervention for a particular risk factor.

Adherence to recommendations for clinical follow-up after benign breast biopsy

PURPOSE

Women who undergo a benign breast biopsy are at elevated risk for the subsequent development of breast cancer (BC). Therefore, appropriate clinical follow-up of a benign breast biopsy is important. The present study examines the extent and correlates of nonadherence with follow-up recommendations after a benign breast biopsy.

METHODS

Women (n = 114) who had undergone a benign breast biopsy completed an initial telephone interview within 50 days of their biopsy (mean = 21 days). Additional telephone interviews were completed at 4 and 8 months post-biopsy. Measures of BC risk perception, general and BC-specific distress, BC-related attitudes and beliefs, social support, optimism, and informational coping style were completed. Specific recommendations for clinical follow-up and evidence of actual follow-up were obtained from medical records.

RESULTS

Of 103 women given a specific recommendation for clinical follow-up, 34% were classified as nonadherent with follow-up recommendations. Logistic regression analyses indicated that nonadherent women were characterized by younger age, recommendations for follow-up by clinical breast examination alone, greater confidence in their ability to perform breast self-examination properly, higher perceived personal risk for BC, and greater BC-specific distress.

CONCLUSION

Despite the importance of appropriate clinical follow-up of a benign breast biopsy, about one-third of women did not adhere to recommended follow-up. Risk factors for nonadherence suggest potential avenues for interventions to enhance participation in appropriate clinical follow-up.

Considerations in using tumor markers: what the psycho-oncologist needs to know

Tumor markers are measures of biological features of a cancer. By revealing important biological aspects of the tumor, tumor markers can be useful in staging patients, predicting cancer outcomes, and guiding treatments. The psychological consequences of using tumor markers are virtually unknown. In this review article, we draw on clinical studies involving the psychological impact of risk information, screening, prognostic information and surveillance of cancer. Such studies may be helpful in considering possible psychological reactions to tumor marker information in clinical practice.

Effectiveness of interventions to improve follow-up after abnormal cervical cancer screening

OBJECTIVE

The purpose of this study was to determine the effectiveness of interventions designed to improve follow-up after an abnormal Pap smear.

METHODS

We performed a qualitative meta-analysis of interventions designed to improve follow-up after an abnormal Pap smear and included studies that met the following criteria: randomized or concurrently controlled study design, defined outcomes, and data available for abstraction. Interventions were classified as behavioral, cognitive, sociologic, or combined strategies (e.g., behavioral and cognitive). Abnormal Pap smears were defined as any test result requiring additional follow-up. Effectiveness was measured by the rate of compliance with recommended follow-up.

RESULTS

Twenty-two interventions in 10 studies met the inclusion criteria. Cognitive interventions utilizing interactive telephone counseling were the most effective, improving compliance by 24 to 31%. Behavioral interventions, such as patient reminders, were also effective, increasing follow-up by up to 18%. Not all of these results achieved statistical significance. The single sociologic intervention we identified used video-taped peer discussions to provide a message about abnormal Pap smears and appropriate follow-up. This intervention was not associated with increased follow-up after an abnormal test. The effectiveness of interventions using multiple types of strategies to improve follow-up was inconsistent.

CONCLUSIONS

Cognitive strategies led to the greatest improvement in compliance with follow-up of abnormal Pap smear screening tests. Extension of similar interventions to follow-up of abnormal breast and colon cancer screening, development of physician- and system-targeted interventions, and evaluation of the cost-effectiveness of these strategies are important priorities for future research.

Improving follow-up after an abnormal pap smear: results from a quasi-experimental intervention study

The success of cervical cancer control programs depends on regular screening with the Pap smear test and prompt and appropriate treatment of early neoplastic lesions. Recognizing the potentially grave consequences of lack of follow-up for abnormal Pap smears, numerous intervention studies have tested the impact of a variety of strategies to increase return for follow-up. The majority of these studies were evaluated under controlled experimental conditions. Despite the encouraging findings of these trials, the next step in the research continuum requires that the effectiveness of these interventions be demonstrated in real world settings before full implementation is initiated. We report the results of an evaluation study assessing the combined effectiveness of three intervention modalities found effective in prior randomized studies: a tracking follow-up protocol, transportation incentives, and financial incentives. This study used a before-after, nonequivalent control group design to assess the impact of a multifaceted intervention that included a computerized tracking protocol with transportation and financial incentives. The study was implemented at two major hospitals, two comprehensive health centers (CHC), and nine public health centers (PHC) under the jurisdiction of the Los Angeles County Department of Health Services. One hospital, one CHC, and the four PHC located in the catchment area of the CHC were selected as experimental sites. The control sites - one hospital, one CHC, and five PHC - provided usual care. All women with an abnormal Pap smear at the intervention and control sites were included in the study. The study consisted of a 1-year period of baseline data collection (September 1989-August 1990), followed by a 2(1/2)-year intervention period (September 1990-February 1993). During the intervention period, the intervention protocol was implemented at the experimental sites, and the control sites provided usual care. Overall, we found that the rates of receipt of follow-up care were consistent with those found in similar studies. In contrast to results obtained in these prior randomized trials, we did not find strong and consistent evidence for intervention effects. Significant findings emerged only at the CHC and hospital levels and only for selected years. Results underscore the importance of testing interventions in real world conditions before large-scale implementation is initiated. In addition, this study highlights the challenge of detecting intervention effects in large-scale studies because of the greater measurement difficulties in field studies as compared with controlled experiments.

Follow-up of abnormal gynecologic cytology: a college of American pathologists Q-probes study of 16132 cases from 306 laboratories

OBJECTIVES

To measure the percentage of women with abnormal gynecologic cytology who have follow-up within 1 year and to identify patient and laboratory characteristics associated with higher percentages of follow-up.

DESIGN AND SETTING

Retrospective identification of patients with abnormal cervicovaginal cytology and identification of the initial clinical follow-up activity during the 12 months following the cytologic diagnosis.

MAIN OUTCOME MEASURE

Percentage of women receiving follow-up.

RESULTS

Three hundred six laboratories reported follow-up information on 16 132 patients with gynecologic cytology diagnoses of carcinoma, high-grade squamous intraepithelial lesion, low-grade squamous intraepithelial lesion, or glandular intraepithelial lesion. The following percentages of women received follow-up within 1 year: 85.6% of patients with cytologic diagnoses of carcinoma, 87.2% with diagnoses of high-grade squamous intraepithelial lesion, 82.7% with diagnoses of low-grade squamous intraepithelial lesion, and 84.9% with diagnoses of glandular intraepithelial lesion. Within 6 months, 82.2% of patients with cytologic diagnoses of carcinoma, 82.4% with diagnoses of high-grade squamous intraepithelial lesion, 71.9% with diagnoses of low-grade squamous intraepithelial lesion, and 74.7% with diagnoses of glandular intra-epithelial lesion received follow-up. Overall, 90. 8% of patients who received follow-up within the 1-year time frame of this study had their follow-up completed within 6 months. Specific follow-up activities and their frequencies are listed for each diagnostic category. Patients 30 years old or younger and pregnant patients had lower follow-up percentages.

CONCLUSIONS

With less than 83% of patients with high-grade squamous intraepithelial lesion or carcinoma cytology findings having available documentation of follow-up within 6 months, and less than 88% within 1 year, there is room for improvement in this area of health care. Monitoring and critical analysis of the follow-up process is a starting point for improvement.

Adolescents' knowledge of human papillomavirus and cervical dysplasia

STUDY OBJECTIVE

This study examined adolescents' knowledge of human papillomavirus (HPV) and cervical dysplasia (CD). Factors associated with knowledge and self-reported change in health-related behaviors were identified.

DESIGN

Interviews were conducted at an average of 2.5 years following the diagnosis of HPV/CD. Medical charts were reviewed.

SETTING

The study was conducted at a university-based adolescent dysplasia clinic.

PARTICIPANTS

Fifty females, ages 15-23 participated in the study: 88% African-American, 12% Caucasian.

RESULTS

On average, participants responded correctly to 86% of the questions regarding HPV/CD. However, the following key points were routinely missed: 52% did not know cigarette smoking increased the risk for cervical cancer; 42% believed that HPV/CD was always symptomatic; and 22% did not know condoms decreased the transmission of HPV. According to participants, their health care provider explained the diagnosis and treatment of HPV/CD using words they understood "some" or "most of the time." Higher academic skills significantly correlated with greater knowledge of HPV/CD. Forty-one percent of participants with a smoking history reportedly increased their smoking since the diagnosis, and only 40% used condoms "most of the time." However, 90% had maintained or increased their frequency of Pap tests.

CONCLUSIONS

Adolescent girls had knowledge of most factors related to HPV/CD, but many did not understand the risks of cigarette smoking and failure to use condoms. To improve understanding and compliance, health care providers should tailor educational strategies to the functional level of adolescents.

Anxiety and adherence to breast self-examination in women with a family history of breast cancer

OBJECTIVE

Previous research has indicated low rates of adherence to monthly breast self-examination (BSE) in women with a family history of breast cancer, and anxiety has been identified as a major factor that may interfere with regular self-examination. However, the direction of the relationship between anxiety and BSE frequency remains unclear, with some studies indicating that high anxiety promotes adherence and others indicating that it leads to avoidance. The aim of the present study was to clarify the relationship between anxiety and adherence to breast self-examination by comparing the impact of general anxiety with that of cancer-specific anxiety on BSE frequency.

METHODS

A sample of at-risk women (N=833) completed a questionnaire regarding BSE frequency, general anxiety, breast cancer worries, perceived risk of breast cancer, and family history of breast cancer. Women who self-examined infrequently (N=211), appropriately (N=462), or excessively (N=156) were compared on these variables.

RESULTS

Statistical analyses indicated that general anxiety differentiated only between excessive self-examiners and less frequent self-examiners, with excessive self-examiners reporting significantly higher general anxiety. Breast cancer worries differentiated between all three groups in a linear fashion, with increasing cancer worries associated with higher levels of BSE.

CONCLUSIONS

In some at-risk women, high cancer anxiety may lead to high general anxiety and precipitate hypervigilant breast self-examination rather than avoidance. These findings are discussed in relation to psychoeducational interventions and genetic counseling services for women with a family history of breast cancer.

Improving cervical screening in a remote aboriginal community

Improved cervical screening has been identified as a priority in reducing the incidence of cervical cancer among Aboriginal women. This paper discusses the cervical screening recommendations of a women's health project developed by Nganampa Health Council (NHC), the Aboriginal-controlled medical service meeting the health needs of the people of the Anangu Pitjantjatjara (AP) Lands. A community participation public health model was used in program development. A process including community and staff consultation, literature review and prioritisation informed the program development, ensuring strategies thereby derived were culturally acceptable as well as practical and scientifically valid. The epidemiology of cervical cancer and screening in this community is discussed. Strategies aimed at maximising patient participation, improving patient satisfaction, running an effective call and recall system, improving quality of cervical smears, improving management of women with abnormal smears and evaluating the program are suggested. The involvement of the community in a scientifically sound, public health approach may increase the likelihood that the strategies suggested will be effective in this community. Both the model of program development and the cervical screening strategies derived are likely to be of relevance for other Aboriginal communities.

Effectiveness of interventions to improve patient compliance: a meta-analysis

OBJECTIVES

This article summarizes the results of 153 studies published between 1977 and 1994 that evaluated the effectiveness of interventions to improve patient compliance with medical regimens.

METHODS

The compliance interventions were classified by theoretical focus into educational, behavioral, and affective categories within which specific intervention strategies were further distinguished. The compliance indicators broadly represent five classes of compliance-related assessments: (1) health outcomes (eg, blood pressure and hospitalization), (2) direct indicators (eg, urine and blood tracers and weight change), (3) indirect indicators (eg, pill count and refill records), (4) subjective report (eg, patients' or others' reports), and (5) utilization (appointment making and keeping and use of preventive services). An effect size (ES) r, defined as Fisher's Z transformation of the Pearson correlation coefficient, representing the association between each intervention (intervention versus control) and compliance measure was calculated. Both an unweighted and weighted r were calculated because of large sample size variation, and a combined probability across studies was calculated.

RESULTS

The interventions produced significant effects for all the compliance indicators (combined Z values more than 5 and less than 32), with the magnitude of effects ranging from small to large. The largest effects (unweighted) were evident for refill records and pill counts and in blood/urine and weight change studies. Although smaller in magnitude, compliance effects were evident for improved health outcomes and utilization. Chronic disease patients, including those with diabetes and hypertension, as well as cancer patients and those with mental health problems especially benefited from interventions.

CONCLUSIONS

No single strategy or programmatic focus showed any clear advantage compared with another. Comprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions.

Reducing loss-to-follow-up among women with abnormal Pap smears. Results from a randomized trial testing an intensive follow-up protocol and economic incentives

OBJECTIVES

This study evaluates the efficacy of two interventions designed to reduce loss-to-follow-up among women with abnormal Pap smears.

METHODS

The two interventions were evaluated in two large public hospitals using a randomized 2 x 2 factorial design. One intervention involved an intensive follow-up protocol that relied on multiple attempts (mail and telephone) to contact the patient. The second intervention provided patients with economic vouchers to offset out-of-pocket expenses associated with the follow-up visits. Loss-to-follow-up was addressed by medical chart reviews and telephone interviews.

RESULTS

The study population (n = 1453) was primarily Hispanic, married or otherwise living with a significant other, relatively young in age, and with no source of payment for health care. Overall, 30% of the total sample was loss-to-follow-up (i.e., no return visits). Among patients assigned to the control condition, loss-to-follow-up was 36.1% compared with 27.8% for the intensive follow-up condition, 28.8% for the voucher condition, and 29.0% for the intensive follow-up plus voucher condition. Both intervention conditions significantly improved follow-up rates. The odds ratio for intensive follow-up was 1.56 compared with 1.50 for the voucher intervention. The combined intervention condition (intensive follow-up x voucher program) did not have a significant effect after taking into account the main effects of the two interventions. Correlates of loss-to-follow-up included age (younger women had lower return rates), race/ethnicity (African American women had lower return rates), live-in relationship (women who were not married or living as married had lower return rates), and severity of the abnormal Pap smear (less severe abnormalities were associated with lower return rates).

CONCLUSIONS

Both interventions were associated with moderate reductions in loss-to-follow-up in this underserved population. The implications of these findings are discussed relative to implementing cervical cancer control programs within state and local health departments.

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

In this paper we review the published literature with respect to cervical cancer screening intervention research. Mass media campaigns appear to work best in promoting cervical cancer screening when multiple media are used, when they promote specific screening programs that eliminate or reduce access barriers, or when they are used in combination with other strategies. Many positive examples of using outreach staff to promote cervical cancer screening, as well as using mobile examination rooms in the community, were found. Substantial evidence that letters mailed to patient populations are efficacious was found, especially in promoting interval screening; however, bulk mailings to nonpatient populations have generally not been successful. Both physician and patient prompts have shown promise as well as opportunistic screenings in both the outpatient and the inpatient settings. In addition, several strategies for reducing loss to follow-up among women with abnormal test results were identified, including telephone follow-up, educational mailouts, audiovisual programs, clinic-based educational presentations and workshops, transportation incentives, and economic vouchers. Of special note is the success of other countries in establishing centralized recall systems to promote interval screening for cervical cancer. Ultimately, such systems could replace the need for opportunistic screening in underserved populations and perhaps many community outreach efforts. It is argued that health departments represent a logical starting point for developing a network of recall systems in the United States for underserved women.

The costs and effects of cervical and breast cancer screening in a public hospital emergency room. The Cancer Control Center of Harlem

OBJECTIVES

This study assessed the cost-effectiveness of cervix and breast cancer screening in a public hospital emergency room.

METHODS

Age-eligible women with nonurgent conditions and without recent screening were offered screening by a nurse. A decision analysis compared the costs and outcomes of emergency room screening and standard hospital screening efforts.

RESULTS

The undiscounted cost-effectiveness results for establishing new programs were $4050 (cervical cancer), $403,203 (breast cancer), and $4375 (joint cervix and breast cancer) per year of life saved. If screening is added to an existing program, results are more favorable ($429, $21,324, and $479 per year of life saved for cervix, breast, and joint screening, respectively). Results were most sensitive to volume and probability of receiving treatment after an abnormal screen.

CONCLUSIONS

Emergency room screening was cost-effective for cervical cancer; breast cancer screening was relatively expensive given the low number of women reached. More intensive recruitment and follow-up strategies are needed to maximize the cost-effectiveness of such programs.

Implementation of a breast and cervical cancer screening program in a public hospital emergency department. Cancer Control Center of Harlem

STUDY OBJECTIVE

To assess the feasibility and yields of screening for breast and cervical cancer in an urban public hospital emergency department.

METHODS

Women who presented to the ED of a large, urban public hospital during the study period with nonurgent conditions were eligible for a Papanicolaou test (Pap smear) and a clinical breast examination (CBE) if they were 18 years of age or older and for a mammogram if they were 40 years of age or older, provided they had not had the screening examination within the past year. The Pap smear and CBE were performed by a nurse, and mammography was scheduled for a later date. Women with gynecologic complaints were excluded.

RESULTS

On the basis of screening history, medical status, and age, 1,850 (32%) of the 5,830 women seen in the ER during the 23-month study period were eligible for both mammography and CBE, and 2,361 (41%) were eligible for Pap smears. Of these women, 116 (6%) completed mammography and CBE, and 644 (27%) received Pap smears. Among screened women, 10 (9%) and 20 (3%), respectively, had results that were suspicious or positive for breast or cervical cancer. Follow-up rates were low: 20% for breast screening and 50% for Pap smears. Among those receiving follow-up, 1 woman was found to have breast cancer and 8 were found to have cervical neoplasia.

CONCLUSION

ED cancer screening was feasible and yielded a high rate of cancer detection. Program efficiency was hampered by low volume and high numbers of patients lost to follow-up after abnormal screening results. Greater integration into the acute care setting and more intensive recruitment and follow-up strategies are needed to maximize the potential yield and cost effectiveness of such programs.

Barriers to follow-up of abnormal screening mammograms among low-income minority women. Cancer Control Center of Harlem

OBJECTIVE

To describe factors related to compliance diagnostic follow-up among minority women of low socioeconomic status with abnormal screening mammograms.

METHODS

A retrospective cross-sectional survey using a structured telephone interview. Three cancer screening clinics at an urban inner-city public hospital. All women with abnormal screening mammograms between September 1990 and January 1992 were eligible; women were interviewed in August 1992. Abnormal mammograms were those requiring specific, non-routine clinical follow-up; non-compliance was defined as delayed follow-up (four to six months after the date of the mammogram), or no follow-up at the time of interview (more than 6 months after abnormal).

RESULTS

Sixty-two of 442 screened women had abnormal results; the overall rate of non-compliance with follow-up was 50%. Among the 42 (68%) women who agreed to be interviewed, non-compliers were less likely to state that they had been told to receive follow-up than compliers (65% versus 100%; p = 0.008). Non-compliant women were less likely to have suspicious mammography interpretations (p = 0.05), and more likely to report barriers to follow-up, such as cost of lost wages and medical care, system barriers, or fears, than compliant women (61.9% versus 9%, p = 0.01). There were no differences between the two groups for age, education, insurance, source of care, family history, knowledge or attitudes.

CONCLUSIONS

These preliminary results suggest that follow-up of low income, minority women with abnormal screening mammograms could be enhanced by improved communication of results. Future studies should extend these findings with larger samples and in other settings and populations.

Multinational approaches to cervical cancer screening: a review

Worldwide, cervical cancer incidence is 75% higher than the projected ideal set by the World Health Organization. Despite an effective screen for in situ stage cancer, many women do not adhere to regular screening schedules. These delays raise mortality rates, since curative therapies are available only for the early stages of disease. Seeking to improve cancer control among women, investigators have developed a variety of methods to improve adherence rates. This article presents these methods as well as the cost-effectiveness of each when evaluative data are available. The article suggests that nurses may draw upon current knowledge to design and test the effectiveness of cancer control models in the catchment areas served by their institutions and agencies.

Walking the journey of womanhood: Yakama Indian women and Papanicolaou (Pap) test screening

Cervical cancer is the second leading cancer among Alaska Native, American Indian women, who have a high incidence of cervical cancer and low survival rates (Boss, 1991; Michalek & Mahoney, 1990; Page & Asire, 1985). The purpose of this Grounded Theory study was to gain a greater understanding of the meaning of the papanicolaou (Pap) test to the Yakama Indian women of eastern Washington to support the Tribe in the design of effective screening interventions. Data from 15 interviews, focus groups, and participant observation were included in the data analysis. The major theme was: Walking the Journey of Womanhood. Four phases of the journey were identified: (a) Starting the Journey, (b) Blooming, (c) Heading the Household, and (d) Becoming an Elder. In this study we found that interventions to influence Pap test screening among the Yakama women must address structures of care, provider-patient communications, and education for the women. Women heading the households and elders were identified as priority populations for education because they have negative attitudes from previous experiences and have a great influence on the younger women. Messages need to be wellness oriented and traditional methods of education, such as the talking circle, role model, and storytelling, need to be used.

A randomised controlled trial of strategies to prompt attendance for a Pap smear

OBJECTIVE

To assess the comparative efficacy, by randomised controlled trial, of three interventions designed to encourage "at risk" women to have a Pap smear: an educational pamphlet; letters inviting attendance at a women's health clinic; and letters from physicians.

METHODS

Subjects at risk for cervical cancer who had not been adequately screened were identified by a random community survey and randomly allocated to one of the intervention groups or a control group. Six months after intervention implementation, a follow up survey assessed subsequent screening attendance. Self report was validated by comparison with a national screening data base.

RESULTS

A significantly greater proportion of women (36.9%) within the group receiving a physician letter reported screening at follow up than in any other group (P = 0.012). The variables most strongly predicting screening attendance were: age, perceived frequency of screening required, use of oral contraceptives, and allocation to receive the physician letter intervention.

CONCLUSIONS

The relative efficacy of the GP letter in prompting screening attendance shows that this strategy is worthy of further investigation. There remains a need to examine the barriers to screening for older women, and to develop tailored strategies for this population.

Recall, retention, utilisation and acceptability of written health education materials

The effects of two distribution strategies on the recall of receipt, retention, utilisation and perceived acceptability of written health education materials were investigated in two semirural communities. We randomly selected 512 people, 212 from general practitioners' surgeries, who received the materials from their general practitioners at the end of a routine consultation, and 300 from the electoral register, who received it through the mail in a personally addressed envelope. Of all those who received the materials, 55 (10.7 per cent) were not contactable and 386 (84.5 per cent) of those contacted consented to the survey. Structured interviews were conducted with consenting individuals two weeks after distribution to assess recall of receipt, retention, utilisation and perceived acceptability. Of those receiving the material by mail, 77.4 per cent recalled receiving it, 75.4 per cent reported keeping the booklet and 66.7 per cent reported reading it. Of those receiving it from a general practitioner, 90.9 per cent recalled receiving it, 93.3 per cent reported keeping the booklet and 56 per cent reported reading it. Perceived acceptability of the material was high, with over 80 per cent of respondents finding it very or fairly eye-catching, believable, interesting and easy to read. Although general practitioner distribution led to higher rates of receipt and retention, mail-out distribution led to higher utilisation rates and allowed access to a larger proportion of the population, resulting in more people being exposed to the education message.