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

Chatbot-interfaced and cognitive-affective barrier-driven messages to improve colposcopy adherence after abnormal Pap test results in underserved urban women: A feasibility pilot study

Challenges in ensuring adherence to colposcopy and follow-up recommendations, particularly within underserved communities, hinder the delivery of appropriate care. Informed by our established evidence-based program, we sought to assess the feasibility and acceptability of a novel cognitive-affective intervention delivered through a Chatbot interface, aimed to enhance colposcopy adherence within an urban inner-city population. We developed the evidence-based intervention, CervixChat, to address comprehension of colposcopy's purpose, human papillomavirus (HPV) understanding, cancer-related fatalistic beliefs, procedural concerns, and disease progression, offered in both English and Spanish. Females aged 21-65, with colposcopy appointments at an urban OBGYN clinic, were invited to participate. Enrolled patients experienced real-time counseling messages tailored via a Chatbot-driven barriers assessment, dispatched via text one week before their scheduled colposcopy. Cognitive-affective measures were assessed at baseline and through a 1-month follow-up. Participants also engaged in a brief post-intervention satisfaction survey and interview to capture their acceptance and feedback on the intervention. The primary endpoints encompassed study adherence (CervixChat response rate and follow-up survey rate) and self-evaluated intervention acceptability, with predefined feasibility benchmarks of at least 70% adherence and 80% satisfaction. Among 48 eligible women scheduled for colposcopies, 27 (56.3%) agreed, consented, and completed baseline assessments. Participants had an average age of 34 years, with 14 (52%) identifying as non-Hispanic White. Of these, 21 (77.8%) engaged with the CervixChat intervention via mobile phones. Impressively, 26 participants (96.3%) attended their diagnostic colposcopy within the specified timeframe. Moreover, 22 (81.5%) completed the follow-up survey and a brief interview. Barriers assessment revealed notable encodings in the Affect and Values/Goals domains, highlighting concerns and understanding around HPV, as well as its impact on body image and sexual matters. Persistent and relatively high intrusive thoughts and lowered risk perceptions regarding cervical cancer were reported over time, unaffected by the intervention. Post-intervention evaluations documented high satisfaction and perceived usefulness, with recommendations for incorporating additional practical and educational content. Our findings underscore the robust satisfaction and practicality of the CervixChat intervention among a diverse underserved population. Moving forward, our next step involves evaluating the intervention's efficacy through a Sequential Multiple Assignment Randomized Trial (SMART) design. Enhanced by personalized health coaching, we aim to further bolster women's risk perception, address intrusive thoughts, and streamline resources to effectively improve colposcopy screening attendance.

Confusion and anxiety in between abnormal cervical cancer screening results and colposcopy: "The land of the unknown"

OBJECTIVE

Attendance to colposcopy after abnormal cervical cancer screening is essential to cervical cancer prevention. This qualitative study explored patients' understanding of screening results, their experiences of the time leading up to the colposcopy appointment, and colposcopy.

METHODS

We recruited women referred for colposcopy from two urban practices in an academic health system. Individual interviews (N = 15) with participants were conducted after colposcopy appointments about their cervical cancer screening histories, current results, and colposcopy experiences. A team analyzed and summarized interviews and coded transcripts in Atlas.ti.

RESULTS

We found that most women were confused about their screening results, did not know what a colposcopy was before being referred for one, and experienced anxiety in the interval between receiving their results and having their colposcopy. Most women searched for information online, but found "misinformation," "worst-case scenarios" and generic information that did not resolve their confusion.

CONCLUSION

Women had little understanding of their cervical cancer risk and experienced anxiety looking for information and waiting for the colposcopy. Educating patients about cervical precancer and colposcopy, providing tailored information about their abnormal screening test results and potential next steps, and helping women manage distress may alleviate uncertainty while waiting for follow-up appointments.

PRACTICE IMPLICATIONS

Interventions to manage uncertainty and distress in the interval between receiving an abnormal screening test result and attending colposcopy are needed, even among highly adherent patients.

Unlocking infodemics and mysteries in COVID-19 vaccine hesitancy: Nexus of conspiracy beliefs, digital informational support, psychological Well-being, and religious fatalism

Guarding against an anti-science camouflage within infodemics is paramount for sustaining the global vaccination drive. Vaccine hesitancy remains a growing concern and a significant threat to public health, especially in developing countries. Infodemics, conspiracy beliefs and religious fatalism primarily fuel vaccine hesitancy. In addition, anti-vaccine disinformation, lack of understanding, and erroneous religious beliefs also trigger vaccine hesitancy. Global behavioral strategies such as wearing face masks and long-term preventive measures (i.e., COVID-19 vaccination) have effectively limited the virus's spread. Despite the alarming rate of global deaths (i.e., over 99% being unvaccinated), a large proportion of the global population remains reluctant to vaccinate. New evidence validates the usefulness of technology-driven communication strategies (i.e., digital interventions) to address the complex socio-psychological influence of the pandemic. Hence, the present research explored the digital information processing model to assess the interface between informational support (through digital interventions) and antecedents of vaccine hesitancy. This research involved two separate studies: a focus group to operationalize the construct of infodemics, which remained ambiguous in previous literature (Study 1), followed by a cross-sectional survey (Study 2) to examine the conceptual model. Data were collected from 1906 respondents through a standard questionnaire administered online. The focus group's findings revealed a multi-dimensional nature of infodemics that was also validated in Study 2. The cross-sectional survey results substantiated infodemics, religious fatalism and conspiracy beliefs as significant predictors of vaccine hesitancy. Similarly, conspiracy beliefs negatively influence an individual's psychological well-being. Furthermore, information support (through digital intervention) affected infodemics and religious fatalism, whereas it inversely influenced the strength of their relationships with vaccine hesitancy. Information support (through digital intervention) also moderated the relationship between conspiracy beliefs and psychological well-being.

Patient delay and related influencing factors in Chinese women under 35 years diagnosed with cervical cancer: A cross-sectional study

Objective

Patient delay was defined as an interval between the discovery of the initial symptoms and diagnosis, which was longer than 90 days. This study aimed to determine the patient delay rate and related factors in women with cervical cancer in Hunan province, South-Central China.

Methods

A cross-sectional study was conducted among 140 women with cervical cancer aged <35 years from October, 2019 to March, 2021. Assumptions in Andersen Behavioral Model of Health Services Utilization were used to measure the factors influencing patient delay. Logistic regression models were used to identify factors associated with patient delay. A P-value of <5% was considered significant.

Results

A total of 57 (40.71%) young women with cervical cancer had patient delay, with an average delay time of 178.70 (307.90) days. Predisposing factors, such as religion, unemployment, health beliefs related to cancer screening, and a history of cervical cancer screening within 2 years or more (P ​< ​0.05), were associated with patient delay. Enabling factors, such as distance to the nearest medical facility and type of the nearest medical facility, were associated with a reduced likelihood of patient delay. With the need-for-care factor, young women who experienced vaginal pain after or during intercourse had a higher risk (adjusted odds ratio, 33.48; 95% confidence interval, 3.22-348.68, P ​= ​0.003) of patient delay.

Conclusions

These findings reinforce the need for programs to enhance knowledge and awareness about cervical cancer screening and the importance of early diagnosis in women to help eliminate cervical cancer in China by 2050.

Development of a text message-based intervention for follow-up colposcopy among predominately underserved Black and Hispanic/Latinx women

PURPOSE

Underserved Black and Hispanic/Latinx women show low rates of follow-up care after an abnormal Pap test, despite the fact that cervical cancer is one of the few preventable cancers if detected early. However, extant literature falls short on efficacious interventions to increase follow-up for this population. A concurrent mixed methods study was completed to evaluate the acceptability of a text message-based intervention and identify perceived barriers and facilitators to follow-up after an abnormal Pap test among underserved predominantly Black and Hispanic/Latinx women.

METHODS

Patients who completed follow-up for an abnormal Pap test were recruited to complete a cross-sectional survey, qualitative interview assessing barriers and facilitators to follow-up, and text message content evaluation (N = 28). Descriptive statistics were performed to describe background variables and to evaluate the acceptability of text messages. A directed content analysis was completed for the qualitative interviews.

RESULTS

Participants expressed interest in a text message-based intervention to increase abnormal Pap test follow-up. In the qualitative interviews, low knowledge about cervical risk and negative affect toward colposcopy/test results were identified as barriers to follow-up. Facilitators of follow-up included feeling relieved after the colposcopy and adequate social support. Participants rated the text messages as understandable, personally relevant, and culturally appropriate.

CONCLUSION

The findings suggest that underserved Black and Hispanic/Latinx women experience cognitive and emotional barriers that undermine their ability to obtain follow-up care and a text message-based intervention may help women overcome these barriers. Future research should develop and evaluate text message-based interventions to enhance follow-up after an abnormal Pap test.

Knowledge, Attitude, and Practice (KAP) toward Cervical Cancer Screening among Adama Science and Technology University Female Students, Ethiopia

Background

Cervical cancer is a complication of Human Papillomavirus (HPV) infection is the second most common cancer in women worldwide. Eighty percent of the cases occur in low-resource countries. According to the 2009 World Health Organization report, the age-adjusted incidence rate of cervical cancer in Ethiopia was 35.9 per 100,000 patients with 7619 annual number of new cases and 60-81 deaths every year. The study is aimed at assessing the level of knowledge, attitude, and practice concerning cervical cancer among female students at Adama Science and Technology University. Methodology. An institutional based cross-sectional study was conducted among 667Adama Science and Technology University female students. A simple random sampling method was used to select the respondents. Structured self-administered questionnaire was used for data collection.

Results

About 404 (60.6%) of the participants heard about cervical cancer, 478 (71.7%) had positive attitude towards cervical cancer screening, and only 15 (2.2%) participants were screened for cervical cancer. Lack of information about cervical cancer was the most reported reason for not attending to cervical cancer screening. Conclusion and Recommendation. The study showed that there was low knowledge on cervical cancer and screening for premalignant lesion among women. There is a need to promote and encourage women to early cervical cancer screening at precancerous stage by informing their susceptibility to cervical cancer.

The Association Between Fatalism and Mammography Use in Korean American Immigrant Women

Fatalism is reported as a salient cultural belief that influences cancer screening disparities in racial and ethnic minority groups. Previous studies provide a range of measures and descriptions of cancer fatalism, but no studies to our knowledge have analyzed how fatalistic views cluster together within subgroups to form distinct profiles, and how these profiles can be predicted. This study identified subgroups of Korean American immigrants with similar fatalistic beliefs toward cancer and examined the influence of fatalism, health belief variables, and health literacy on mammography use. A cross-sectional survey design was used to obtain a convenience sample of 240 Korean American immigrant women in Los Angeles, California. Latent class analysis was used to identify unobserved subgroups of fatalism. Hierarchical logistic regression models were used to identify predisposing, enabling, and need factors associated with recent mammography use. The latent class analysis model identified three cancer fatalism subgroups: high fatalism (17.8%), moderate fatalism (36.7%), and low fatalism (45.5%). Women in the high fatalism subgroup were more likely to have had a mammogram within the past 2 years than women in the low fatalism subgroup. Regression analysis revealed three facilitators of recent mammogram use: level of fatalism, perceived barriers to mammogram, and family history of cancer. Although cultural beliefs can have a powerful influence on health-seeking behavior, it is important to weigh individual and contextual factors that may weaken or mediate the relationship between fatalism and engaging in preventive care such as having a mammogram.

Psychological factors among Appalachian women with abnormal Pap results

PURPOSE

Women who receive an abnormal Pap result may experience negative psychological factors. The purpose of this study is to assess the baseline occurrence of negative psychological factors and evaluate the relationships between psychological factors and demographic characteristics among Appalachian women who received abnormal Pap results.

METHODS

We conducted a secondary analysis of data collected from Appalachia Kentucky women (N = 521) ages ≥18 enrolled in an intervention. Data included sociodemographics, Beck depression and anxiety inventories, fatalism, and personal control measures. Multiple variable logistic regression was used to investigate the association between demographics and psychological factors.

FINDINGS

Participants were predominantly White (96.2%), with mean age 28.93 ± 11.03 years, and the majority (77%) had yearly income below $20,000. Depression was reported by 34.6% (n = 173); 10% (n = 50) experienced moderate or severe anxiety; 20.6% (n = 107) had fatalistic beliefs; and 55.1% (n = 289) believed they lacked personal control over cancer. Women with lower income had higher occurrence of depression (P = .003). Women with moderate to severe anxiety were significantly older than those with low to moderate depression (34.44 vs 28.34, P < .001). Controlling for other variables, as age increased, the odds of fatalistic beliefs increased, OR (95%) = 1.042 (1.022, 1.062). When education level increased, the odds of fatalistic beliefs decreased, OR (95%) = 0.873 (0.800, 0.952).

CONCLUSIONS

Given the high occurrence of depression, anxiety, and fatalistic beliefs among this population, health care providers should assess for underlying mental health diagnoses and psychological distress during each patient encounter and provide recommendations to address them.

Culturally-adapted behavioral intervention to improve colorectal cancer screening uptake among foreign-born South Asians in New Jersey: the Desi Sehat trial

Objectives: Colorectal cancer (CRC) is the third most common cancer among Americans of South Asian (SA) descent and is a significant public health concern in SA communities. Rates of screening compliance among foreign-born SAs are very low. The goal of this study was to report on the development, acceptability, and preliminary impact of a culturally-targeted 1:1 intervention delivered in English, Hindi, and Urdu, called Desi-Sehat.Design: Ninety-three foreign-born SAs between the ages of 50 and 75 were recruited using community-based organization methods. Participants completed a baseline survey, participated in a 1:1 session with a community health educator, and a follow-up survey was administered four months after the baseline.Results: The acceptance rate was moderate (52.8%). Attendance at the intervention session was high. More than half of the population did not complete the follow-up survey (58.7%). Participant evaluations of the intervention were high. Intent-to-treat analyses indicate a 30% four month follow-up CRC screening uptake. There were significant increases in knowledge and significant reductions in perceived barriers to screening, worry about CRC screening tests, and worry about CRC. Effect sizes for significant changes were in the medium to large range.Conclusions: Desi Sehat was a well-evaluated and participation in the session was high, participant knowledge significantly increased, and screening barriers, worry about CRC, and worry about CRC screening tests declined significantly. Future studies should focus on enhancing recruitment and retention and include a randomized control design.

Knowledge and perceptions regarding triage among human papillomavirus-tested women: A qualitative study of perspectives of low-income women in Argentina

Objectives:

Among cancer prevention studies, little is known about knowledge, attitudes, and beliefs toward triage adherence in the context of the human papillomavirus self-collection test. This formative research aims to identify knowledge, attitudes, and beliefs related to human papillomavirus and cervical cancer prevention specifically about adherence to Pap triage among women residing in a low-income province in Argentina.

Methods:

We conducted six focus groups, stratified by residence and age. All participants were aged 30 or older and had performed human papillomavirus self-collection. Data collection and thematic analysis were carried out using constructs from the Health Belief Model.

Results:

Misinformation regarding human papillomavirus and cervical cancer was common and was a source of distress. Women could not distinguish Pap screening from triage; human papillomavirus risk perception was limited but cervical cancer was perceived as a threatening disease. Women were willing to follow-up after receiving an abnormal screening result. Negative views about clinician-collected screening/triage were common, defined as painful and shameful, and comes with an economic cost (transport/time). Lack of help from family/friends was an obstacle to adhering to triage. Health issues in the family’s records and a physician’s recommendation were a cue to adhere to triage.

Conclusion:

Lack of knowledge or misinformation of the causes of cervical cancer, human papillomavirus, and the multi-step screening and triage process are barriers to follow-up adherence. Interventions to improve communication between women and health providers about screening results and follow-up are needed. Also, health services should be organized to respond to women’s needs and reduce access barriers to follow-up.

The influence of fatalistic beliefs on health beliefs among diabetics in Khartoum, Sudan: a comparison between Coptic Christians and Sunni Muslims

Although there are many studies assessing the influence of religious beliefs on health they do not agree on whether the impact is positive or negative. More so, there is no consensus in the available literature on the definition of fatalism and what it means to individuals. In this phenomenological study we attempt to define what religious fatalism means to people living with diabetes in Khartoum, and how it affects their health beliefs, and how those beliefs affect their sense of coherence and generalized resistance resources, since salutogenesis is the guiding theory in this study. Three Copts and five Sunnis living with diabetes were interviewed, as well as a Coptic clergyman and a Sunni scholar. The semi-structured interviews were recorded and transcribed verbatim for analysis. Thematic network analysis was used to code salient concepts into basic themes, organizing themes and global themes. The empirical findings are thus structured as the three global themes: (1) fatalism and free will; (2) health responsibility; (3) acceptance and coping. Fatalism was defined as events beyond an individual's control where it is then the individual's free will to seek healthy behavior. Thus health responsibility was stressed upon by the participants in this study as well as the clergyman and scholar. There is also the concept of 'God doesn't give one what one cannot handle' that the participants relate to coping and acceptance. This study finds that the meaning of religious fatalism held by participants and religious clergy is not disempowering. The participants believe that they are responsible for their health. The meaning derived from fatalism is related to how they can accept what is beyond their control and cope with their health condition. Religious fatalism contributed to comprehensibility, manageability and meaningfulness in our participants' response to diabetes.

Predictors of adherence to follow-up recommendations after an abnormal Pap smear among underserved inner-city women

OBJECTIVES

This study aimed to identify cognitive-affective predictors of adherence to initial diagnostic colposcopy and 6-month follow-up recommendations among underserved women.

METHODS

A secondary data analysis was completed of a randomized clinical trial assessing tailored telephone counseling for colposcopy adherence after an abnormal screening Pap smear among 210 underserved inner-city women.

RESULTS

Adherence to initial diagnostic colposcopy was significantly associated with greater self-efficacy (OR=1.504, 95% CI 1.021-2.216). Women with lower monitoring attentional style had significantly greater adherence to 6-month follow-up recommendations compared to women with higher monitoring scores (OR=0.785, 95% CI 0.659-0.935).

CONCLUSION

Increasing cervical cancer-related self-efficacy and tailoring cervical cancer risk communication to monitoring attentional style may help improve adherence to follow-up recommendations after an abnormal Pap smear test result.

PRACTICE IMPLICATIONS

Future research is needed to develop and implement psychosocial approaches to improving adherence to diagnostic colposcopy and follow-up recommendations adherence among underserved women.

Breast and Cervical Cancer Screening among US and non US Born African American Muslim Women in New York City

PURPOSE

Health disparities related to breast and cervical cancer among African American and African-born Muslim women in the United States have been identified in previous literature. Our study aimed at exploring the breast and cervical screening rates and factors that influence this population's disposition to adhere to cancer screening exams.

METHODS

Mixed methods were used to collect data with African American and African-born Muslim women in New York City. Data were collected from a total of 140 women; among them, 40 participated in four focus groups.

FINDINGS

Focus groups revealed nine themes: healthcare practices; lack of knowledge/misconceptions; negative perceptions and fear; time; modesty; role of religion; role of men; role of community; stigma and shame. Among 130 women who reported their cancer screening status, 72.3% of those age 21 and over were adherent to cervical cancer screening; 20.0% never had a Pap test. Among women age 40 and over, 80.2% reported adherence to recommended mammogram; 12.8% never had one. Among women under age 40, 52.2% had their last clinical breast exam (CBE) less than three years ago. Among women age 40 and over, 75.0% were adherent to yearly CBE.

CONCLUSIONS

While rates of screenings were above the national average and higher than expected, specific barriers and facilitators related to religious and health beliefs and attitudes that influence the decision to adhere to screening were revealed. These factors should be further explored and addressed to inform future research and strategies for promoting regular breast and cervical cancer screenings.

Impact of Patient Navigation Interventions on Timely Diagnostic Follow Up for Abnormal Cervical Screening

OBJECTIVE

As part of the Patient Navigation Research Program, we examined the effect of patient navigation versus usual care on timely diagnostic follow-up, defined as clinical management for women with cervical abnormalities within accepted time frames.

METHODS

Participants from four Patient Navigation Research Program centers were divided into low- and high-risk abnormality groups and analyzed separately. Low-risk participants (n = 2088) were those who enrolled with an initial Pap test finding of atypical squamous cells of undetermined significance (ASCUS) with a positive high-risk human papillomavirus (HPV) serotype, atypical glandular cells, or low-grade squamous intraepithelial lesion (LGSIL). High-risk participants were those with an initial finding of high-grade squamous intraepithelial lesion (HGSIL) (n = 229). A dichotomous outcome of timely diagnostic follow-up within 180 days was used for the low-risk abnormality group and timely diagnostic follow-up within 60 days for the high-risk group, consistent with treatment guidelines. A logistic mixed-effects regression model was used to evaluate the intervention effect using a random effect for study arm within an institution. A backward selection process was used for multivariable model building, considering the impact of each predictor on the intervention effect.

RESULTS

Low-risk women in the patient navigation arm showed an improvement in the odds of timely diagnostic follow-up across all racial groups, but statistically significant effects were only observed in non-English-speaking Hispanics (OR 5.88, 95% CI 2.81-12.29). No effect was observed among high-risk women.

CONCLUSION

These results suggest that patient navigation can improve timely diagnostic follow-up among women with low-risk cervical abnormalities, particularly in non-English-speaking Hispanic women.

Results of a Health Education Message Intervention on HPV Knowledge and Receipt of Follow-up Care among Latinas Infected with High-risk Human Papillomavirus

A clinic-based intervention study was conducted among high-risk human papillomavirus (HPV)-infected Latinas aged 18-64 years between April 2006 and May 2008 on the Texas-Mexico border. Women were randomly assigned to receive a printed material intervention (n=186) or usual care (n=187) and were followed at three months, six months, and 12 months through telephone surveys and review of medical records. The HPV knowledge of nearly all women had increased greatly, but only two-thirds of women reported they had received follow-up care within one year of diagnosis regardless of additional health education messaging. Our findings suggest that, regardless of type of health education messaging, Latinas living on the Texas-Mexico border are aware that follow-up care is recommended, but they may not receive this care. Individual, familial and medical care barriers to receipt of follow-up care may partially account for the higher rates of cervical cancer mortality in this region.

The causes and circumstances of drinking water incidents impact consumer behaviour: Comparison of a routine versus a natural disaster incident

When public health is endangered, the general public can only protect themselves if timely messages are received and understood. Previous research has shown that the cause of threats to public health can affect risk perception and behaviours. This study compares compliance to public health advice and consumer behaviour during two “Boil Water” notices issued in the UK due to a routine incident versus a natural disaster incident. A postal questionnaire was sent to 1000 randomly selected households issued a routine “Boil Water” notice. Findings were then compared to a previous study that explored drinking water behaviour during a “Boil Water” notice issued after serious floods. Consumers affected by the routine incident showed a significant preference for official water company information, whereas consumers affected by the natural disaster preferred local information sources. Confusion over which notice was in place was found for both incidents. Non-compliance was significantly higher for the natural disaster (48.3%) than the routine incident (35.4%). For the routine incident, compliance with advice on drinking as well as preparing/cooking food and brushing teeth was positively associated with receiving advice from the local radio, while the opposite was true for those receiving advice from the water company/leaflet through the post; we suggest this may largely be due to confusion over needing boiled tap water for brushing teeth. No associations were found for demographic factors. We conclude that information dissemination plans should be tailored to the circumstances under which the advice is issued. Water companies should seek to educate the general public about water notices and which actions are safe and unsafe during which notice, as well as construct and disseminate clearer advice on brushing teeth and preparing/cooking food.

Associations between religion-related factors and cervical cancer screening among Muslims in greater chicago

OBJECTIVE

This study aimed to assess rates of Papanicolaou (Pap) testing and associations between religion-related factors and these rates among a racially and ethnically diverse sample of American Muslim women.

MATERIALS AND METHODS

A community-based participatory research design was used in partnering with the Council of Islamic Organizations of Greater Chicago to recruit Muslim women attending mosque and community events. These participants self-administered surveys incorporating measures of fatalism, religiosity, perceived discrimination, Islamic modesty, and a marker of Pap test use.

RESULTS

A total of 254 survey respondents were collected with nearly equal numbers of Arabs, South Asians, and African American respondents. Of these respondents, 84% had obtained a Pap test in their lifetime, with individuals who interpret disease as a manifestation of God's punishment having a lower odds of having had Pap testing after controlling for sociodemographic factors (odds ratio [OR]=0.87, 95% CI=0.77-1.0). In multivariate models, living in the United States for more than 20 years (OR=4.7, 95% CI=1.4-16) and having a primary care physician (OR=7.7, 95% CI=2.5-23.4) were positive predictors of having had a Pap test. Ethnicity, fatalistic beliefs, perceived discrimination, and modesty levels were not significantly associated with Pap testing rates.

CONCLUSIONS

To our knowledge, this is the first study to assess Pap testing behaviors among a diverse sample of American Muslim women and to observe that negative religious coping (e.g., viewing health problems as a punishment from God) is associated with a lower odds of obtaining a Pap test. The relationship between religious coping and cancer screening behaviors deserves further study so that religious values can be appropriately addressed through cancer screening programs.

Psychosocial barriers to follow-up adherence after an abnormal cervical cytology test result among low-income, inner-city women

OBJECTIVES

Low-income, inner-city women bear a disproportionate burden of cervical cancer in both incidence and mortality rates in the United States, largely because of low adherence to follow-up recommendations after an abnormal cervical cytology result in the primary care setting. The goals of the present study were to delineate the theory-based psychosocial barriers underlying these persistent low follow-up rates and their sociodemographic correlates.

METHODS

Guided by a well-validated psychosocial theory of health behaviors, this cross-sectional, correlational study assessed the barriers to follow-up adherence among underserved women (N = 210) who received an abnormal cervical cytology result. Participants were recruited through an inner-city hospital colposcopy clinic, and were assessed by telephone prior to the colposcopy appointment.

RESULTS

Participants were largely of African American race (82.2%), lower than high school completion education (58.7%), single, never married (67.3%), and without full-time employment (64.1%). Knowledge barriers were most often endorsed (68%, M = 3.22), followed by distress barriers (64%, M = 3.09), and coping barriers (36%, M = 2.36). Forty-six percent reported more than one barrier category. Less education and being unemployed were correlated with higher knowledge barriers (P < .0001 and P < .01, respectively) and more coping barriers (P < .05 and P < .05, respectively). Women who were younger than 30 years displayed greater distress barriers (P < .05).

CONCLUSION

In the primary care setting, assessing and addressing knowledge and distress barriers after feedback of an abnormal cervical cytology result may improve adherence to follow-up recommendations. The use of structured counseling protocols and referral to navigational and other resources may facilitate this process and thereby reduce disparities in cervical cancer.

Evaluation of Socio-demographic Factors for Non-compliance to Treatment in Locally Advanced Cases of Cancer Cervix in a Rural Medical College Hospital in India

Introduction:

Carcinoma cervix is a leading cause of cancer in India. However, majority of the patients face a problem of not being able to complete the treatment.

Aim:

This study was an attempt to find out the important causes of this non-compliance to treatment in a rural Medical College Hospital where majority of the cancer cases are of cervical cancer.

Results:

Out of 144 patients studied over 2 years 88 cases could not complete the treatment. The study revealed that due old age 58.33% cases were defaulters, having many children at home meant a burden to 76.92% cases and 63.89% cases had a problem of not been able to travel a far distance of more than 100 km from home to hospital for treatment.

Conclusion:

These were the important factors of non-compliance and suggested more important than the issues of literacy and poor socio-economic status.

Factors Associated With Adherence to Follow-up Colposcopy

BACKGROUND

Understanding the gaps in knowledge about human papilloma virus (HPV) infection, transmission, and health consequences and factors associated with the knowledge gap is an essential first step for the development of interventions to improve adherence to follow-up among women with abnormal Pap smears.

PURPOSE

To examine the relationship between knowledge about HPV and adherence to scheduled colposcopic evaluation and variables related to lack of knowledge among women with abnormal Pap tests.

METHODS

Telephone surveys were conducted with women who attended their scheduled appointments (adherers) and women who did not attend their appointments (nonadherers).

RESULTS

The multivariable analyses indicate that lower HPV knowledge was independently associated with nonadherence to follow-up, controlling for race and education level. Factors related to lower knowledge scores included non-white race, lower education, and lack of health insurance at the time of the scheduled appointment.

CONCLUSION

Lack of knowledge of HPV was related to nonadherence among women scheduled for colposcopic evaluation.

TRANSLATION TO HEALTH EDUCATION PRACTICE

Health education interventions that deliver complex information about HPV and cervical cancer should be in a format that is accessible and understandable to the women who are most at risk of being nonadherent.

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.

Patient barriers to follow-up care for breast and cervical cancer abnormalities

BACKGROUND

Women with breast or cervical cancer abnormalities can experience barriers to timely follow-up care, resulting in delays in cancer diagnosis. Patient navigation programs that identify and remove barriers to ensure timely receipt of care are proliferating nationally. The study used a systematic framework to describe barriers, including differences between African American and Latina women; to determine recurrence of barriers; and to examine factors associated with barriers to follow-up care.

METHODS

Data originated from 250 women in the intervention arm of the Chicago Patient Navigation Research Program (PNRP). The women had abnormal cancer screening findings and navigator encounters. Women were recruited from a community health center and a publicly owned medical center. After describing proportions of African American and Latina women experiencing particular barriers, logistic regression was used to explore associations between patient characteristics, such as race/ethnicity, and type of barriers.

RESULTS

The most frequent barriers occurred at the intrapersonal level (e.g., insurance issues and fear), while institutional-level barriers such as system problems with scheduling care were the most commonly recurring over time (29%). The majority of barriers (58%) were reported in the first navigator encounter. Latinas (81%) reported barriers more often than African American women (19%). Differences in race/ethnicity and employment status were associated with types of barriers. Compared to African American women, Latinas were more likely to report an intrapersonal level barrier. Unemployed women were more likely to report an institutional level barrier.

CONCLUSION

In a sample of highly vulnerable women, there is no single characteristic (e.g., uninsured) that predicts what kinds of barriers a woman is likely to have. Nevertheless, navigators appear able to easily resolve intrapersonal-level barriers, but ongoing navigation is needed to address system-level barriers. Patient navigation programs can adopt the PNRP barriers framework to assist their efforts in assuring timely follow-up care.

Beyond barriers in studying disparities in women's access to health services in Ontario, Canada: a qualitative metasynthesis

Women live within complex and differing social, economic, and environmental circumstances that influence options to seek health care. In this article we report on a metasynthesis of qualitative research concerning access disparities for women in the Canadian province of Ontario, where there is a publicly funded health care system. We took a metastudy approach to analysis of results from 35 relevant qualitative articles to understand the conditions and conceptualizations of women's inequitable access to health care. The articles' authors attributed access disparities to myriad barriers. We focused our analysis on these barriers to understand the contributing social and political forces. We found that four major, sometimes countervailing, forces shaped access to health care: (a) contextual conditions, (b) constraints, (c) barriers, and (d) deterrents. Complex convergences of these forces acted to push, pull, obstruct, and/or repel women as they sought health care, resulting in different patterns of inequitable access.

"Doctor, what do i have?" Knowledge of cancer diagnosis among immigrant/migrant minorities

This study explores patient knowledge of cancer diagnosis among underserved immigrant/migrant minorities. Patients were recruited at a hospital-based cancer clinic in New York City. Demographic and self-reported diagnosis and treatment information were collected; charts were reviewed to ascertain cancer diagnosis. Four hundred thirty-four patients were included. Eighty-seven percent preferred to speak a language other than English in the health care setting. Sixteen percent had incorrect knowledge of their cancer diagnosis. Multivariate analysis indicated that both preference for a non-English language and diagnosis of a "below the belt" cancer were jointly predictive of incorrect knowledge (LR = 17.01; p = 0.0002). "Below the belt" cancers included bladder, colorectal, gynecological, penile, prostate, and testicular cancers. Among this cohort of immigrant/migrant cancer patients, a considerable proportion was unaware of their correct cancer diagnoses. This may have a significant impact on subsequent cancer education, treatment, and care. Limited-English-proficiency patients may be at particular risk.

Reducing the Excess Burden of Cervical Cancer Among Latinas: Translating Science into Health Promotion Initiatives

PURPOSE

Although deaths from cervical cancer are declining, Latinas are not benefiting equally in this decline. Incidence of invasive cervical cancer among Los Angeles', California Latinas is much higher than among non-Latina Whites (14.7 versus 8.02 per 100,000). This paper examines cervical cancer screening among Latinas.

METHODS

Ninety-seven women of Mexican origin participated in 12 focus groups exploring barriers to screening. Saturation was reached.

RESULTS

All participants knew what a Pap test was and most knew its purpose. More acculturated participants understood the link between HPV and cervical cancer. More recent immigrants did not. There was confusion whether women who were not sexually active need to be screened. Most frequently mentioned barriers were lack of time and concern over missing work. Lower income and less acculturated women were less likely to be aware of free/low-cost clinics. Older and less acculturated participants held more fatalistic beliefs, were more embarrassed about getting a Pap test, were more fearful of being perceived as sexually promiscuous, and were more fearful of receiving disapproval from their husbands.

CONCLUSIONS

Latinas are informed regarding cervical cancer screening; rather they encounter barriers such as a lack of time, money and support. Health promotion interventions can be enhanced via peer-to-peer education, by addressing barriers to cervical cancer screening with in-language, culturally tailored interventions, and working with clinics on systemic changes, such as extended clinic hours.

The relevance of fatalism in the study of Latinas' cancer screening behavior: a systematic review of the literature

BACKGROUND

Fatalism has been identified as a dominant belief among Latinos and is believed to act as a barrier to cancer prevention. However, controversy exists over the utility of the construct in explaining health disparities experienced by disadvantaged populations above the influence of structural barriers such as low socioeconomic status (SES) and limited access to health care.

PURPOSE

This paper reviews the empirical research on fatalism and Latinas' participation in cancer screening in an attempt to determine whether fatalism predicts participation in cancer screening after accounting for structural barriers.

METHOD

Google Scholar, ERIC, CINAHL, Medline, PsychINFO, ProQuest, PubMed, and PsychARTICLES were searched for empirical studies published prior to February 25, 2010.

RESULTS

A total of 43 articles were obtained and 11 met the inclusion criteria. The majority of studies (64%) reported a statistically significant association between fatalism and utilization of cancer screening services after accounting for structural barriers. However, mixed findings and limitations in measurement and design across studies preclude clear conclusions about the nature of the relationship.

CONCLUSION

Preliminary evidence for an inverse association between fatalism and Latinas' utilization of cancer screening services after accounting for structural barriers was identified. However, additional research that addresses methodological limitations is warranted to advance our understanding of the utility of fatalism in explaining inequities in cancer burden experienced by this at-risk group.

Perceptions and influence of a hospital influenza vaccination policy

OBJECTIVE

Seasonal influenza is a significant cause of morbidity and mortality in the United States each year. Healthcare worker (HCW) influenza vaccination is associated with both decreased absenteeism among employees and improved outcomes among patients. However, HCW influenza vaccine uptake remains suboptimal. The objective of this study was to characterize HCWs' understanding of and response to a stringent vaccination policy.

DESIGN, SETTING, AND PARTICIPANTS

A survey of 928 hospital staff at a tertiary academic medical center in Baltimore during the 2008-2009 influenza season.

RESULTS

Of those surveyed, 75% (n = 695) completed the survey; 623 respondents reported regular patient contact, and 91% of those reported vaccination in the current influenza season. However, only 60% reported consistently receiving the vaccine every year. Of those who were vaccinated, 8% (n = 48) reported being vaccinated for the first time during that influenza season. A significant proportion (42%) of respondents were unaware of the major change in hospital policy regarding vaccination. Influences on the decision to be vaccinated varied significantly between those who are regularly vaccinated and those with inconsistent vaccination habits. Attitudes toward hospital policy varied significantly by race and clinical role.

CONCLUSIONS

Although 91% of respondents with regular patient contact reported being vaccinated for influenza in the 2008-2009 season, only 60% reported consistent annual vaccination. Misinformation regarding hospital policies is widespread. Improvements in vaccination rates will likely require multifaceted, targeted efforts focused on specific influences on less adherent groups. The identified variability in influences on the decision to be vaccinated suggests possible targets for future interventions.

Race and ethnic differences in health beliefs about lower urinary tract symptoms

BACKGROUND

Health beliefs are an important mediator between the experience of symptoms and health behaviors, and these beliefs can vary by race or ethnicity.

OBJECTIVES

The aim of this study was to better understand the gap between experiencing symptoms and not seeking medical care by examining health beliefs about lower urinary tract symptoms across race and ethnic groups.

METHOD

Qualitative, semistructured interviews were conducted with 35 Black, Hispanic, and White people who reported at least one urinary symptom but had not spoken with a healthcare provider about the symptom(s). Drawing on Shaw's framework of health behavior and outcomes, a range of beliefs was examined: cause, consequence, continuation, and treatability. Interviews were transcribed, coded, and analyzed for themes according to race or ethnic background.

RESULTS

The belief that lower urinary tract symptoms are a typical part of aging and not amenable to medical treatment was most common among White respondents. Black respondents more commonly attributed their symptoms to personal behaviors over which they had control and therefore did not require medical care. Hispanic respondents appeared more often to live with uncertainty about the cause of their symptoms and an accompanying concern about a future health consequence.

DISCUSSION

The combination of a range of health beliefs to form a cognitive representation made sense of the behavior of not seeking medical care. The finding that sociocultural differences shaped these cognitive representations underscores the need for cultural competency in patient assessment and education. Results have implications for theories of health behavior and indicate further research with larger samples, additional psychosocial influences, and other symptoms.

Predictors of cervical cancer screening for rarely or never screened rural Appalachian women

BACKGROUND AND PURPOSE

Women who have not had a Papanicolaou test in five years or more have increased risk of developing invasive cervical cancer. This study compares Appalachian women whose last screening was more than one year ago but less than five years ago with those not screened for the previous five years or more.

METHODS

Using PRECEDE/PROCEED as a guide, factors related to obtaining Pap tests were examined using cross-sectional data from 345 Appalachian Kentucky women. Bivariate and multivariate analyses were conducted to identify predictors of screening.

RESULTS

Thirty-four percent of participants were rarely- or never-screened. In multiple logistic regression analyses, several factors increased those odds, including belief that cervical cancer has symptoms, and not having a regular source of medical care.

CONCLUSION

The findings from this study may lead to the development of effective intervention and policies that increase cervical cancer screening in this population.

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.

Are breast cancer navigation programs cost-effective? Evidence from the Chicago Cancer Navigation Project

OBJECTIVES

One of the aims of the Chicago Cancer Navigation Project (CCNP) is to reduce the interval of time between abnormal breast cancer screening and definitive diagnosis in patients who are navigated as compared to usual care. In this article, we investigate the extent to which total costs of breast cancer navigation can be offset by survival benefits and savings in lifetime breast cancer-attributable costs.

METHODS

Data sources for the cost-effectiveness analysis include data from published literature, secondary data from the NCI's Surveillance Epidemiology and End Results (SEER) program, and primary data from the CCNP.

RESULTS

If women enrolled in CCNP receive breast cancer diagnosis earlier by 6 months as compared to usual care, then navigation is borderline cost-effective for $95,625 per life-year saved. Results from sensitivity analyses suggest that the cost-effectiveness of navigation is sensitive to: the interval of time between screening and diagnosis, percent increase in number of women who receive cancer diagnosis and treatment, women's age, and the positive predictive value of a mammogram.

CONCLUSIONS

In planning cost-effective navigation programs, special considerations should be made regarding the characteristics of the disease, program participants, and the initial screening test that determines program eligibility.

Understanding, beliefs and perspectives of Aboriginal people in Western Australia about cancer and its impact on access to cancer services

BACKGROUND

Despite a lower overall incidence, Aboriginal Australians experience poorer outcomes from cancer compared with the non-Aboriginal population as manifested by higher mortality and lower 5-year survival rates. Lower participation in screening, later diagnosis of cancer, poor continuity of care, and poorer compliance with treatment are known factors contributing to this poor outcome. Nevertheless, many deficits remain in understanding the underlying reasons, with the recommendation of further exploration of Aboriginal beliefs and perceptions of cancer to help understand their care-seeking behavior. This could assist with planning and delivery of more effective interventions and better services for the Aboriginal population. This research explored Western Australian (WA) Aboriginal peoples' perceptions, beliefs and understanding of cancer.

METHODS

A total of 37 Aboriginal people from various geographical areas within WA with a direct or indirect experience of cancer were interviewed between March 2006 and September 2007. Interviews were audio-recorded, transcribed verbatim and coded independently by two researchers. NVivo7 software was used to assist data management and analysis. A social constructionist framework provided a theoretical basis for analysis. Interpretation occurred within the research team with member checking and the involvement of an Aboriginal Reference Group assisting with ensuring validity and reliability.

RESULTS

Outcomes indicated that misunderstanding, fear of death, fatalism, shame, preference for traditional healing, beliefs such as cancer is contagious and other spiritual issues affected their decisions around accessing services. These findings provide important information for health providers who are involved in cancer-related service delivery.

CONCLUSION

These underlying beliefs must be specifically addressed to develop appropriate educational, screening and treatment approaches including models of care and support that facilitate better engagement of Indigenous people. Models of care and support that are more culturally-friendly, where health professionals take account of both Indigenous and Western beliefs about health and the relationship between these, and which engage and include Indigenous people need to be developed. Cultural security, removing system barriers and technical/scientific excellence are all important to ensure Indigenous people utilise healthcare to realise the benefits of modern cancer treatments.

A national patient navigator training program

Patient Navigation is an intervention aimed at addressing cancer health disparities by eliminating barriers to diagnosis, treatment, and services. Three major patient navigation (PN) programs (The National Cancer Institute, The American Cancer Society &The Center for Medicare and Medicaid Services) are underway to address the needs of medically underserved cancer patients. There has not been national training with a defined curriculum for patient navigators (PNs). Curriculum for training the PNs was created by experts from the three programs. The efficacy of training was evaluated using a pre- and posttest. The data show that overall the posttest scores improved from the pretest. In addition, having a high school education or greater or having more years of work experience were significantly related to improvements on the posttest. The first successful standardized national training program was attended by 116 PNs representing 85 cities with the goal to reduce health disparities for medically underserved.

From 'silent' to 'heard': professional mediation, manipulation and women's experiences of their body after an abnormal Pap smear

While there is a large body of research on cervical cancer screening, fewer studies address the experiences of women receiving abnormal Pap smear results after routine screening. Those studies highlighting such experiences tend to concentrate on resulting psychosocial distress, with an absence in the literature about women's experiences of their bodies during medical follow-up for dysplasia, and no studies were found that explore such experiences over time. In this article, we focus on bodily experiences over time during medical follow-up of an abnormal Pap smear among a group of women in Sweden. This qualitative analysis is based on interview data from a total of 30 women, and with in-depth analysis of the content of 34 transcribed interviews with nine women who were followed longitudinally. We found that medical follow-up involved an experience of both "having" and "being" a body, which changed over time. Women described a process that ranged from having a cervix that was neither felt, 'heard', nor seen, to having a body that became known to them first indirectly through professional mediation and later through direct experience after professional manipulation. The conceptualization of bodily boundaries appeared to change, e.g. through visualization of the previously unfamiliar cervix, pain, vaginal discharge, and bleeding, as well as linkages to the bodies of women in their extended families through the generations. Thus, bodily experiences appear to be an intrinsic part of medical follow-up of an abnormal Pap smear through which health, disease, and risks in the past, present, and future were reconceptualised.

Personal influencing factors associated with pap smear testing and cervical cancer

Pap smear is a screening test that detects abnormal cells before they advance to cancer. Unfortunately, not all women obtain routine screening. The method used was a qualitative study exploring personal influences regarding Pap smears. Face-to-face interviews with 7 low-income African American women who do and do not obtain Pap smears (between 21 and 37 years of age) were conducted at a health department about their social influence, previous health care experience, and cognitive appraisal regarding Pap smears and cervical cancer. Women were found to be socially influenced by their family and their physician. Previous health care experience with the Pap and pelvic was perceived as negative. Cognitively, Pap smears were believed to test for sexually transmitted diseases, including HIV, and the women also felt that if one took good care of oneself it reduced the risk for cervical cancer. It was concluded that exploring beliefs associated with Pap smears and perceptions of vulnerability to cervical cancer and giving correct information and counseling may increase Pap smear screening in women.

Development and Validation of a Religious Health Fatalism Measure for the African-American Faith Community

Health researchers struggle to understand barriers to improving health in the African-American community. The African-American church is one of the most promising venues for health promotion, disease prevention, and disparities reduction. Religious fatalism, the belief that health outcomes are inevitable and/or determined by God, may inhibit healthy behaviors for a subset of religious persons. This study reports the development and validation of the Religious Health Fatalism Questionnaire, a measurement tool for studying faith-related health beliefs in African-Americans. Participants included 276 members of seven predominantly African-American churches. Factor analysis indicated three dimensions: (1) Divine Provision; (2) Destined Plan; and (3) Helpless Inevitability. Evidence is presented for the reliability, convergent and predictive validity of the Religious Health Fatalism Questionnaire.

Factors influencing cancer screening practices of underserved women

PURPOSE

This integrated review was conducted to evaluate the factors that inhibit or promote decisions by African American and Hispanic women to obtain cervical cancer screening.

DATA SOURCES

Research articles were identified using MEDLINE, PubMed, and Cumulative Index to Nursing and Allied Health literature, published between 1999 and 2005.

CONCLUSIONS

Cervical cancer screening practices of African American and Hispanic women were influenced by extrinsic motivators including lack of insurance, no usual source of health care, acculturation, and socioeconomic factors. Intrinsic motivators were related to beliefs and perceptions of vulnerability, such as ignoring cervical cancer screening when no symptoms were present; believing that not knowing if one had cervical cancer was better; and thinking that only women who engage in sexual risk-taking behaviors need to obtain Papanicolaou (Pap) smear testing.

IMPLICATIONS FOR PRACTICE

Nurse practitioners (NPs) have an opportunity to impact the incidence and mortality of cervical cancer by improving screening practices of minority women. They can emphasize the importance of obtaining Pap smears regularly, teach patients the risks for and signs and symptoms of cervical cancer, and provide recommendations for obtaining screening at low cost or no cost to the patient. To improve cancer screening practices, NPs need to address minority women's beliefs about cervical cancer and provide information and services in a culturally sensitive manner at an appropriate level of learning.

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.

Patient navigation and case management following an abnormal mammogram: a randomized clinical trial

BACKGROUND

A high rate of low-income, ethnic minority women delay or fail to keep appointments following abnormal mammograms. This study was designed to test the effectiveness of a structured counseling and patient navigation intervention for improving follow-up rates at a large public sector medical center.

METHODS

This randomized clinical trial, conducted in Los Angeles 2001-2002, included 204 women with abnormal mammograms referred for follow-up who were then assigned to intervention or usual care. The primary outcome was the rate of follow-up through diagnostic resolution within eight months.

RESULTS

The intervention resulted in a significant increase in the rate of adherence to follow-up through diagnostic resolution. The intervention group was much more likely to be adherent through diagnostic resolution than the control group (90% vs. 66%, OR=4.48, p<0.001) and were more likely to experience timely adherence than UC patients (77% vs. 57%, OR=2.5, p=0.01). Intervention effectiveness was not significantly different for women assigned to different levels of service intensity.

CONCLUSIONS

Patient navigation and counseling driven by a structured clinical algorithm are highly effective strategies to improve diagnostic resolution follow-up among low-income, ethnic minority women with abnormal mammograms. The intervention algorithm and available training materials can be adapted for diverse care systems serving high-risk women to decrease loss to follow-up.

Advanced cervical cancer treatment in Harris County: Pilot evaluation of factors that prevent optimal therapy

OBJECTIVE

To document obstacles to completing outpatient treatment faced by indigent patients with cervical cancer and compare treatment costs.

METHODS

A retrospective pilot case series study assessed all indigent Harris County residents referred from Lyndon Baines Johnson Hospital (LBJ) to The University of Texas M. D. Anderson Cancer Center (M. D. Anderson) for advanced cervical cancer treatment between February 2001 and April 2004. Twenty-seven patients required hospital admission during the expected course of outpatient treatment and were identified as the study group. Nine patients, drawn from the same cohort but able to successfully complete the expected course of treatment as outpatients, were selected as the control group.

RESULTS

The median total treatment costs per patient in the study group (n = 27) was 28,892 US dollar more than the median treatment costs for the patients in the control group (n = 9) (P = 0.01). Median number of inpatient days in the study group was 19.6. Social factors identified as significantly different between the study and control groups included transportation difficulties (P = 0.006) and lack of social support (P = 0.08). Additional factors identified in the study group may have social significance such as accessible local housing (11% vs. 0%, P = 0.56) and noncompliance with treatment (37% vs. 11%, P = 0.22).

CONCLUSION

A combination of the lack of adequate methods of transportation and social support may contribute to the high cost of treating indigent patients with cervical cancer in Harris County, Texas.

Assessment of cultural sensitivity of cancer information in ethnic print media

Ethnic minority populations prefer cancer information that is respectful of their customs and beliefs about health and illness. Community newspapers are an important source of cancer information for ethnic groups. Our purpose is to evaluate the cultural sensitivity of cancer information in mass print media targeting ethnic minority readership. We assessed for cultural sensitivity 27 cancer articles published in English-language ethnic newspapers (Jewish, First Nations, Black/Caribbean, East Indian) in 2000 using the Cultural Sensitivity Assessment Tool (CSAT). We found that the overall average CSAT score of 27 cancer articles was 2.71. (Scores<2.50 were classified as culturally insensitive.) Articles in First Nations newspapers were more culturally sensitive according to the CSAT (X=2.86), followed by articles in Black/Caribbean (X=2.79) and Jewish (X=2.78) papers. Cancer articles from East Indian newspapers had a mean CSAT score of 2.30 and were classified as culturally insensitive. Four articles were considered culturally sensitive but did not mention ethnic populations as intended readers or as high-risk groups for cancer. We found that, using the CSAT measure, overall, cancer articles in ethnic newspapers included in this study were culturally sensitive. Given limitations of this instrument, we recommend an additional checklist for evaluating the cultural sensitivity of printed cancer information.

Explaining disparities in treatment seeking: the case of infertility

OBJECTIVE

To present an integrated model of help-seeking, review empirical work in its support, and show its application to the explanation of racial and ethnic disparities in infertility help-seeking.

DESIGN

Review.

SETTING

None.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

None.

CONCLUSION(S)

A help-seeking model provides a plausible explanation of observed disparities in infertility help-seeking. In addition to being related to income, race and ethnicity is related to prior experience with doctors, marital status, parity, knowledge and attitudes toward reproductive technology, and attitudes supporting spiritual rather than technological solutions to health problems.