Cervical Cancer Screening Among a Low-Income Multiethnic Population of Women

Increasing cervical cancer screening among underserved women in a large urban county health system: can it be done? What does it take?

BACKGROUND

Further reduction in avoidable cervical cancer morbidity and mortality may require system-wide, integrated approaches implemented in the public health facilities serving the nation's indigent and minority women.

OBJECTIVES

Report on the evaluation of a 5-year demonstration project testing a multicomponent (provider, system, and patient) intervention to increase cervical cancer screening among women who receive their health care through the Los Angeles County Department of Health Services, the second largest County Health Department in the nation.

MATERIALS AND METHODS

A longitudinal nonequivalent control group design was utilized. Data were collected during a baseline (no intervention) year and 2.5 years of intervention. A large hospital, one feeder Comprehensive Health Centers (CHC), and three of the health center's feeder Public Health Centers (PHC) received the intervention. Another hospital, CHC and its three feeder PHCs (matched on size, patient characteristics, and range of services provided) served as comparison sites. Independent random samples of patients 18 years and older were drawn annually at each site (n = 18,642). The outcome measure was a receipt of a Papanicolaou smear during a 9-month period.

RESULTS

At the Hospital and CHC levels a statistically significant intervention effect was observed after controlling for baseline screening rates and case mix. No intervention effect was observed at the PHCs.

CONCLUSION

An intensive multicomponent intervention can increase cervical cancer screening in a large, urban, County health system serving a low-income minority population of under screened women. Retention of program elements in the postresearch phase, and the difficulties and importance of conducting this type of research, is described.

Cervical cancer risk as a predictor of Pap smear use in rural North Carolina

Risk for invasive cervical cancer is reported to be higher in rural areas than urban ones, and cervical cancer-related mortality is higher in rural women due to poorer utilization of preventive services and subsequent presentation at late stages of the disease. This cross-sectional study examined the relationship between prevalence of risk factors for cervical cancer and the degree of compliance with risk-appropriate screening guidelines for cervical cancer. Secondary data were analyzed for 614 women from Robeson County, NC, aged 40 and older, and of mainly rural and low socioeconomic status. High-risk status was determined by the presence of any of the following five risk factors: a history of more than two sexual partners, age at first sexual intercourse under 18 years, history of sexually transmitted disease, history of sexually transmitted disease in sexual partner(s), and smoking. Low-risk status was the absence of all factors. A high-risk participant was considered compliant if she had had at least three Pap smears in the 3 years prior to the interview, while a low-risk participant was considered compliant if she had had at least one Pap smear within the previous 3 years. Overall, 82% of the participants were at high risk for cervical cancer. However, only 41% of all participants were compliant with the risk-appropriate screening guidelines. Low-risk status was significantly associated with compliance with cervical cancer screening guidelines (adjusted OR = 6.7; 95% CI = 3.7 to 11.1, p = .0001). Findings in this study population suggest rural women at high risk for cervical cancer are less likely to be compliant with appropriate Pap smear screening guidelines, indicating the need to target educational programs.

Outcomes of a community-based three-year breast and cervical cancer screening program for medically underserved, low income women

PURPOSE

To evaluate a community level three-year breast and cervical cancer screening program for medically underserved, low income women.

DATA SOURCES

Descriptive data on 128 women gathered from five semiannual screening programs held between 1995 and 1997 were analyzed.

CONCLUSIONS

Poor and medically under served women often face barriers that may discourage or prevent screening activity and measures for early detection of breast and cervical cancer. Besides success in recruiting women to the program, community collaborative partnerships were established that continue to sustain this program.

IMPLICATIONS FOR PRACTICE

The results from this project provide an example of how advance practice nurses (APNs) can demonstrate meaningful and competitive health care services for underserved women and how APNs can actively evaluate programs they offer that affect the health practices of communities in need.

Adolescent behavior and sexually transmitted diseases: the dilemma of human papillomavirus

Adolescence is a period of physical, cognitive, psychosocial, and moral development that often results in risk-taking behavior. As a consequence, adolescents are at high risk for sexually transmitted disease (STD). Two of the most common STDs in the United States, chlamydia and human papillomavirus (HPV), affect millions of adolescent women. HPV, contrasted with chlamydia, poses a unique challenge to health care providers. In addition to causing genital warts, HPV has been shown to be the causative agent in the development of cervical cancer. Interventions that are effective in decreasing the transmission of chlamydia, such as increasing condom use, are less effective in prevention of HPV. Efforts to increase adolescent awareness of HPV, to increase age of first coitus, and to decrease numbers of sexual partners are more effective for HPV prevention. Early screening for HPV, smoking cessation, and health promotion may be effective in decreasing the incidence of cervical cancer in young women. Nurse practitioners and other primary health care providers need a more holistic approach to the prevention of HPV in adolescent women.

The impact of tailored interventions on a community health center population

We conducted a 4-year randomized study in a community health center that serves primarily low income Blacks in Durham, North Carolina. Patients (1318 at baseline) were assigned randomly to one of three study groups: provider prompting intervention alone, provider prompting and tailored print materials or the previous group and tailored telephone counseling. The purpose of the study was to determine whether increasingly intensive, tailored print and telephone interventions also were increasingly effective in promoting adherence to mammograms, Pap tests and overall cancer screening compliance. Thus, the combination of tailored print interventions (print and telephone) should have been more effective than the provider prompting intervention alone, or the print intervention and prompting combination. This is one of the few studies to examine a measure of overall cancer screening compliance and to assess the benefit of combinations of tailored interventions in promoting adherence to cancer screening. Patients gave extremely high ratings to the interventions. At the bivariate level, we found a significant effect of the most intensive group (provider prompting intervention, tailored print communications and tailored telephone counseling) on Pap test compliance (P = 0.05) and borderline significance at the multivariate level (P = 0.06) as well on overall screening compliance (P = 0.06). There was not a significant effect on mammography, probably because a majority of the patients were receiving regular mammograms. We also found some important subgroup differences. For example, a larger proportion of women reported Pap tests in the tailored print and counseling group when they believed the materials were 'meant for me.' These results show that a combination of tailored interventions may have potential for reaching the women who have too often been labeled the 'hard to reach.'

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.

Health beliefs and early detection among Chinese women

Little is known about the knowledge and practices regarding early detection of cancer for Chinese women either living in their homelands or worldwide. The purpose of this exploratory study is to describe how cultural beliefs and understandings may influence participation in early detection programs for the increasing numbers of Chinese women who live in the United States. The Health Belief Model (HBM) emerged as a useful framework for categorizing data obtained in Mandarin from a qualitative study of married, educated Chinese women (n = 23; mean age 30.4 years) who attended a university clinic. Cultural beliefs about modesty, husband's involvement, self-care, relationship between health and body functions, and use of preventive health behaviors in the absence of illness influenced women's participation and supported the HBM. Early detection was not a clear concept for these women: 80% believed performing monthly breast self-examinations and 70% believed receiving annual Papanicolaou smears would prevent cancer.