Cancer screening in homeless women: attitudes and behaviors

Patient Navigation for Lung Cancer Screening at a Health Care for the Homeless Program: A Randomized Clinical Trial

Importance

People experiencing homelessness die of lung cancer at rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality, but the circumstances of homelessness create barriers to LCS participation.

Objective

To determine whether patient navigation, added to usual care, improved LCS LDCT receipt at a large Health Care for the Homeless (HCH) program.

Design, Setting, and Participants

This parallel group, pragmatic, mixed-methods randomized clinical trial was conducted at Boston Health Care for the Homeless Program (BHCHP), a federally qualified HCH program that provides tailored, multidisciplinary care to nearly 10 000 homeless-experienced patients annually. Eligible individuals had a lifetime history of homelessness, had a BHCHP primary care practitioner (PCP), were proficient in English, and met the pre-2022 Medicare coverage criteria for LCS (aged 55-77 years, ≥30 pack-year history of smoking, and smoking within the past 15 years). The study was conducted between November 20, 2020, and March 29, 2023.

Intervention

Participants were randomized 2:1 to usual BHCHP care either with or without patient navigation. Following a theory-based, patient-centered protocol, the navigator provided lung cancer education, facilitated LCS shared decision-making visits with PCPs, assisted participants in making and attending LCS LDCT appointments, arranged follow-up when needed, and offered tobacco cessation support for current smokers.

Main Outcomes and Measures

The primary outcome was receipt of a 1-time LCS LDCT within 6 months after randomization, with between-group differences assessed by χ2 analysis. Qualitative interviews assessed the perceptions of participants and PCPs about the navigation intervention.

Results

In all, 260 participants (mean [SD] age, 60.5 [4.7] years; 184 males [70.8%]; 96 non-Hispanic Black participants [36.9%] and 96 non-Hispanic White participants [36.9%]) were randomly assigned to usual care with (n = 173) or without (n = 87) patient navigation. At 6 months after randomization, 75 participants in the patient navigation arm (43.4%) and 8 of those in the usual care-only arm (9.2%) had completed LCS LDCT (P < .001), representing a 4.7-fold difference. Interviews with participants in the patient navigation arm and PCPs identified key elements of the intervention: multidimensional social support provision, care coordination activities, and interpersonal skills of the navigator.

Conclusions and Relevance

In this randomized clinical trial, patient navigation support produced a 4.7-fold increase in 1-time LCS LDCT completion among HCH patients in Boston. Future work should focus on longer-term screening participation and outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT04308226.

Cancer risk factors and access to cancer prevention services for people experiencing homelessness

Cancer is one of the most pressing global health issues, and populations with complex needs, such as people experiencing homelessness, have higher cancer incidence and mortality rates compared with the housed population. We mapped the evidence on cancer risk factors as well as barriers and facilitators to cancer prevention services among people experiencing homelessness, which is key to localising research gaps and identifying strategies for tailored interventions adapted to people experiencing homelessness. The results of 40 studies contribute to an understanding of the dynamic, interactive factors at different levels that determine access to cancer prevention services: socioeconomic, psychological, and physical factors (individual level); practical support and relational loops between health-care providers and people experiencing homelessness (interpersonal level); housing and regular medical care (system level); and interventions to facilitate access to cancer prevention (policy level). Furthermore, studies reported higher prevalence of various cancer-associated risk factors among people experiencing homelessness with the most common being tobacco use, ranging from 26% to 73%. The results show the importance of interventions to facilitate cancer prevention services through social support and low-threshold interventions (eg, navigation programmes), and training health-care staff in creating supportive and trusting environments that increase the likelihood of the continuity of care among people experiencing homelessness.

Housing Status Changes Are Associated With Cancer Outcomes Among US Veterans

Cancer is a leading cause of death in older unhoused adults. We assessed whether being unhoused, gaining housing, or losing housing in the year after cancer diagnosis is associated with poorer survival compared with being continuously housed. We examined all-cause survival in more than 100,000 veterans diagnosed with lung, colorectal, and breast cancer during the period 2011-20. Five percent were unhoused at the time of diagnosis, of whom 21 percent gained housing over the next year; 1 percent of veterans housed at the time of diagnosis lost housing. Continuously unhoused veterans and veterans who lost their housing had poorer survival after lung and colorectal cancer diagnosis compared with those who were continuously housed. There was no survival difference between veterans who gained housing after diagnosis and veterans who were continuously housed. These findings support policies to prevent and end homelessness in people after cancer diagnosis, to improve health outcomes.

Housing Status, Cancer Care, and Associated Outcomes Among US Veterans

Importance

Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described.

Objective

To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer.

Design, Setting, and Participants

This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023.

Exposures

Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing.

Main Outcomes and Measures

The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities.

Results

This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively.

Conclusions and Relevance

In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.

Surgical Care of Patients Experiencing Homelessness: A Scoping Review Using a Phases of Care Conceptual Framework

Homelessness is a growing concern across the world, particularly as individuals experiencing homelessness age and face an increasing burden of chronic health conditions. Although substantial research has focused on the medical and psychiatric care of patients experiencing homelessness, literature about the surgical care of these patients is sparse. Our objective was to review the literature to identify areas of concern unique to patients experiencing homelessness with surgical disease. A scoping review was conducted using a comprehensive database for studies from 1990 to September 1, 2020. Studies that included patients who were unhoused and discussed surgical care were included. The inclusion criteria were designed to identify evidence that directly affected surgical care, systems management, and policy making. Findings were organized within a Phases of Surgical Care framework: preoperative care, intraoperative care, postoperative care, and global use. Our search strategy yielded 553 unique studies, of which 23 met inclusion criteria. Most studies were performed at public and/or safety-net hospitals or via administrative datasets, and surgical specialties that were represented included orthopedic, cardiac, plastic surgery trauma, and vascular surgery. Using the Surgical Phases of Care framework, we identified studies that described the impact of housing status in pre- and postoperative phases as well as global use. There was limited identification of barriers to surgical and anesthetic best practices in the intraoperative phase. More than half of studies (52.2%) lacked a clear definition of homelessness. Thus, there is a marked gap in the surgical literature regarding the impact of housing status on optimal surgical care, with the largest area for improvement in the intraoperative phase of surgical and anesthetic decision making. Consistent use of clear definitions of homelessness is lacking. To promote improved care, a standardized approach to recording housing status is needed, and studies must explore vulnerabilities in surgical care unique to this population.

Patient navigation to promote lung cancer screening in a community health center for people experiencing homelessness: Protocol for a pragmatic randomized controlled trial

BACKGROUND

Lung cancer is a major cause of death among people experiencing homelessness, with mortality rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) could reduce lung cancer deaths in this population, although the circumstances of homelessness present multiple barriers to LCS LDCT completion. Patient navigation is a promising strategy for overcoming these barriers.

METHODS

The Investigating Navigation to Help Advance Lung Equity (INHALE) Study is a pragmatic randomized controlled trial of patient navigation for LCS among individuals receiving primary care at Boston Health Care for the Homeless Program (BHCHP). Three hundred BHCHP patients who meet Medicare/Medicaid criteria for LCS will be randomized 2:1 to usual care with (n = 200) or without (n = 100) LCS navigation. Following a structured, theory-based protocol, the patient navigator assists with each step in the LCS process, providing lung cancer education, facilitating shared decision-making visits with primary care providers (PCPs), assisting in making and attending LCS LDCT appointments, arranging follow-up when needed, and offering tobacco cessation support for smokers. The primary outcome is receipt of LCS LDCT at 6 months. Using a sequential explanatory mixed methods approach, qualitative interviews with participants and PCPs will aid in interpreting and contextualizing the trial results.

DISCUSSION

This trial will produce the first experimental evidence on patient navigation for cancer screening in a homeless health care setting. Results could inform cancer health equity efforts at the 299 Health Care for the Homeless programs that serve over 900,000 patients annually in the US.

The Epidemiology of Cancer Among Homeless Adults in Metropolitan Detroit

BACKGROUND

Homeless individuals suffer and die disproportionately from chronic diseases and disorders. We describe the epidemiology of cancer among homeless persons in metropolitan Detroit.

METHODS

A retrospective cohort study was performed using 1973-2014 data from the Metropolitan Detroit Cancer Surveillance System, a population-based cancer registry and member of the National Institutes of Health-National Cancer Institute's Surveillance, Epidemiology, and End Results program. Homeless adults were identified through address at diagnosis listed as a homeless shelter, hospital, or supplemental field indicating homelessness. Age-adjusted, sex-specific proportional incidence ratios (PIR) compared cancer incidence proportions by primary tumor site of homeless patients to the nonhomeless referent population. Kaplan-Meier curves depicted unadjusted survival differences in a propensity score matched sample. Differences in 10-year survival were assessed using the score test with a sandwich estimator accounting for matched cluster effects. Statistical tests were two-sided.

RESULTS

A total of 388 individuals experienced homelessness at first primary invasive cancer diagnosis. Statistically significantly higher proportions of respiratory system (PIR = 1.51; 95% confidence interval = 1.28 to 1.79) and female genital system (PIR = 1.83; 95% confidence interval = 1.31 to 2.55) cancers were observed among homeless men and women, respectively. Homeless persons had poorer overall and cancer-reported survival compared with a propensity score matched referent population (median: overall survival, 20.0 vs 38.0 months, respectively, P < .001; cancer-reported survival, 38.0 vs 64.0 months, respectively, P  < .001).

CONCLUSION

Disparities in disease burden exist between adults who are experiencing homelessness compared with the nonhomeless population at cancer diagnosis. These findings provide clinically relevant information to understand the cancer burden in this medically underserved population and suggest an urgent need to develop cancer prevention and intervention programs to reduce disparities and improve the health of homeless persons.

Cancer screening in the homeless population

Annually, 100 million people experience homelessness worldwide. Most adults that are struggling with homelessness are living to age 50 years or older and need age-appropriate screening for cancer. Cancer-related death in homeless adults is twice as high as the average in the adult population in the USA. However, few studies have examined the rates of and barriers to cancer screening in homeless people. This Review explores cancer-related health disparities between homeless people and the general population by providing a review of data and definitions relating to homelessness, an analysis of barriers to screening in this population, and a discussion of the current and potential interventions and strategies to improve cancer screening in homeless individuals. Recommendations include implementing appropriate data collection methods for this population, supporting cancer screening in places where homeless people usually access care, assessing the effectiveness of approaches to increasing cancer screening in homeless people, and addressing adequate housing as a fundamental social factor.

Reflections of Homeless Women and Women with Mental Health Challenges on Breast and Cervical Cancer Screening Decisions: Power, Trust, and Communication with Care Providers

This study conducted in Toronto, Canada, explored the perceptions of women living in homeless shelters and women with severe mental health challenges about the factors influencing their decision-making processes regarding breast and cervical cancer screening. Twenty-six in-depth qualitative interviews were conducted. The objectives of this research were (i) to provide new insights about women's decision-making processes, (ii) to describe the barriers to and facilitators for breast and cervical cancer screening, and (iii) to offer recommendations for future outreach, education, and screening initiatives developed specifically for under/never-screened marginalized women living in urban centers. This exploratory study utilized thematic analysis to broaden our understanding about women's decision-making processes. A constructed ontology was used in an attempt to understand and describe participants' constructed realities. The epistemological framework was subjective and reflected co-created knowledge. The approach was hegemonic, values-based, and context-specific. The aim of the analysis was to focus on meanings and actions with a broader view to identify the interplay between participants' narratives and social structures, medical praxis, and policy implications. Results from 26 qualitative interviews conducted in 2013-2014 provided insights on both positive and negative prior cancer screening experiences, the role of power and trust in women's decision-making, and areas for improvement in health care provider/patient interactions. Outcomes of this investigation contribute to the future development of appropriately designed intervention programs for marginalized women, as well as for sensitivity training for health care providers. Tailored and effective health promotion strategies leading to life-long cancer screening behaviors among marginalized women may improve clinical outcomes, decrease treatment costs, and save lives.

Cervical cancer screening among homeless women in the Greater Paris Area (France): results of the ENFAMS survey

Little is known about the prevalence of cervical cancer screening (CCS) and its correlates among homeless women in France. The objectives of this study were to determine the prevalence of women who had never been screened for cervical cancer and to identify the associated factors. This cross-sectional study was based on data collected in the ENFAMS survey, which was conducted in 2013 among 764 sheltered homeless mothers in the Greater Paris Area. Robust Poisson regression models were used to estimate the association between no lifetime CCS and certain sociodemographic and health-related factors (selected from the behavioral model of vulnerable populations). Analyses were carried out separately for women with and without a regular gynaecological follow-up (RGF). The proportion of never-screeners was 33% among the women with an RGF versus 64% among those without an RGF (P<0.001). Among the latter, never having been screened for CCS was associated mainly with socioeconomic conditions, the length of time lived in France, a history of delivery in France and the duration of homelessness. In those with an RGF, the factors were mainly poor health service utilization and language difficulties. This first quantitative study of CCS among homeless women in the Greater Paris Area points to the need for it to be proposed and performed more systematically in primary care. Every contact between this hard-to-reach population and health services should be an opportunity to check their screening status and to ensure that those in need actually undergo a Pap test.

Colorectal Cancer Screening Uptake's Association With Psychosocial and Sociodemographic Factors Among Homeless Blacks and Whites

The homeless represent an extremely disadvantaged population that fare worse than minority groups in access to preventive services and health, and minority groups fare worse than Whites. Early detection screening for colorectal cancer (CRC) saves lives, but empirical data about CRC screening practices among homeless Blacks and Whites are limited. Psychosocial risk factors may serve as a barrier to CRC screening completion among homeless Black individuals. A secondary data analysis of a randomized clinical trial for smoking cessation among homeless smokers was conducted to determine whether psychosocial factors and sociodemographic factors were more highly associated with CRC screening uptake among homeless Blacks than among their White counterparts. Study participants ( N = 124) were surveyed on their CRC screening status, sociodemographic variables, and psychosocial correlate measures including anxiety, depression, hopelessness, depression severity, and perceived stress. Associations between these factors were examined with logistic regression. White participants who were currently disabled/unable to work were 6.2 times more likely to ever receive CRC screening than those who were employed. Black participants with public health insurance coverage were 90% less likely to ever obtain CRC screening than participants without health insurance. Black and White participants had similar levels of anxiety symptoms, depression, and hopelessness, yet depression was the only psychosocial variable negatively associated with CRC screening status. Black and White participants with symptoms of depression were 58% less likely to complete screening than those without depression. Mental health risk and sociodemographic factors may serve as barriers to CRC screening among homeless Blacks and Whites.

Using Best-Worst Scaling to Understand Patient Priorities: A Case Example of Papanicolaou Tests for Homeless Women

PURPOSE

Best-worst scaling (BWS) is a survey method for assessing individuals' priorities. It identifies the extremes-best and worst items, most and least important factors, biggest and smallest influences-among sets. In this article, we demonstrate an application of BWS in a primary care setting to illustrate its use in identifying patient priorities for services.

METHODS

We conducted a BWS survey in 2014 in Boston, Massachusetts, to assess the relative importance of 10 previously identified attributes of Papanicolaou (Pap) testing services among women experiencing homelessness. Women were asked to evaluate 11 sets of 5 attributes of Pap services, and identify which attribute among each set would have the biggest and smallest influence on promoting uptake. We show how frequency analysis can be used to analyze results.

RESULTS

In all, 165 women participated, a response rate of 72%. We identified the most and least salient influences on encouraging Pap screening based on their frequency of report among our sample, with possible standardized scores ranging from+1.0 (biggest influence) to -1.0 (smallest influence). Most important was the availability of support for issues beyond health (+0.39), while least important was the availability of accommodations for personal hygiene (-0.27).

CONCLUSIONS

BWS quantifies patient priorities in a manner that is transparent and accessible. It is easily comprehendible by patients and relatively easy to administer. Our application illustrates its use in a vulnerable population, showing that factors beyond those typically provided in health care settings are highly important to women in seeking Pap screening. This approach can be applied to other health care services where prioritization is helpful to guide decisions.

Measuring the Preferences of Homeless Women for Cervical Cancer Screening Interventions: Development of a Best-Worst Scaling Survey

OBJECTIVE

Despite having multiple risk factors, women experiencing homelessness are screened for cervical cancer at a lower rate than women in the general US population. We report on the design of a stated preference study to assess homeless women's preferences for cervical cancer screening interventions, to inform efforts to overcome this disparity.

METHODS

We conducted focus groups with homeless women (n = 8) on cervical cancer screening decisions and analyzed the data using thematic analysis. We applied inclusion criteria to select factors for a stated preference survey: importance to women, relevance to providers, feasibility, and consistency with clinical experience. We conducted pretests (n = 35) to assess survey procedures (functionality, recruitment, administration) and content (understanding, comprehension, wording/language, length).

RESULTS

We chose best-worst scaling (BWS)-also known as object scaling-to identify decision-relevant screening intervention factors. We chose an experimental design with 11 "objects" (i.e., factors relevant to women's screening decision) presented in 11 subsets of five objects each. Of 25 objects initially identified, we selected 11 for the BWS instrument: provider-related factors: attitude, familiarity, and gender; setting-related factors: acceptance and cost; procedure-related factors: explanation during visit and timing/convenience of visit; personal fears and barriers: concerns about hygiene, addiction, and delivery/fear of results; and a general factor of feeling overwhelmed.

CONCLUSION

Good practices for the development of stated preference surveys include considered assessment of the experimental design that is used and the preference factors that are included, and pretesting of the presentation format. We demonstrate the development of a BWS study of homeless women's cervical cancer screening intervention preferences. Subsequent research will identify screening priorities to inform intervention design.

Disparities in Cancer Incidence, Stage, and Mortality at Boston Health Care for the Homeless Program

INTRODUCTION

Homeless people have a high burden of cancer risk factors and suboptimal rates of cancer screening, but the epidemiology of cancer has not been well described in this population. We assessed cancer incidence, stage, and mortality in homeless adults relative to general population standards.

METHODS

We cross-linked a cohort of 28,033 adults seen at Boston Health Care for the Homeless Program in 2003-2008 to Massachusetts cancer registry and vital registry records. We calculated age-standardized cancer incidence and mortality ratios (SIRs and SMRs). We examined tobacco use among incident cases and estimated smoking-attributable fractions. Trend tests were used to compare cancer stage distributions with those in Massachusetts adults. Analyses were conducted in 2012-2015.

RESULTS

During 90,450 person-years of observation, there were 361 incident cancers (SIR=1.13, 95% CI=1.02, 1.25) and 168 cancer deaths (SMR=1.88, 95% CI=1.61, 2.19) among men, and 98 incident cancers (SIR=0.93, 95% CI=0.76, 1.14) and 38 cancer deaths (SMR=1.61, 95% CI=1.14, 2.20) among women. For both sexes, bronchus and lung cancer was the leading type of incident cancer and cancer death, exceeding Massachusetts estimates more than twofold. Oropharyngeal and liver cancer cases and deaths occurred in excess among men, whereas cervical cancer cases and deaths occurred in excess among women. About one third of incident cancers were smoking-attributable. Colorectal, female breast, and oropharyngeal cancers were diagnosed at more-advanced stages than in Massachusetts adults.

CONCLUSIONS

Efforts to reduce cancer disparities in homeless people should include addressing tobacco use and enhancing participation in evidence-based screening.

Eliminating health disparities: innovative methods to improve cervical cancer screening in a medically underserved population

Homeless women have disproportionately lower rates of cervical cancer screening and higher rates of cervical cancer. In 2008, only 19% of the homeless women seen by Boston Health Care for the Homeless Program (BHCHP) were screened for cervical cancer. To improve screening, BHCHP implemented a 6-part intervention that incorporates point-of-care service, multidisciplinary screening, improved health maintenance forms, population management, process improvement, and increased provider and patient education. This resulted in a significant increase in cervical cancer screening, from 19% in 2008 to 50% in 2013. When compared with national and local cervical cancer screening trends, BHCHP surpassed improvement rates seen in other vulnerable populations. Simple and innovative interventions proved to be the most effective and practical methods of improving screening.

Disparities in breast and cervical cancer screening in women with mental illness: a systematic literature review

CONTEXT

Breast and cervical cancer screening rates have improved substantially in the U.S. during the past decade. Cancer screening and other health outcomes in patients with mental illnesses, such as major depression and schizophrenia, remain suboptimal. Understanding the prevalence and root causes of these disparities is an essential first step toward developing effective interventions. This paper presents a systematic literature review of current evidence on breast and cervical cancer screening disparities in women with mental illness.

EVIDENCE ACQUISITION

A systematic PubMed/MEDLINE and PsycINFO search completed in May 2012 retrieved articles pertaining to cancer screening and mentally ill patients using pertinent search terms. Articles that met the inclusion criteria were appraised critically for evidence quality related to screening disparities using defined criteria. Articles that reported cancer screening rates in patients with mental illness were reviewed to determine whether any barriers to screening or factors that promote screening were identified.

EVIDENCE SYNTHESIS

Nineteen studies met the inclusion criteria. Many articles contributed to more than one of the identified areas of interest (i.e., screening utilization, barriers to screening, and factors that encourage screening).

CONCLUSIONS

Substantial evidence in the current literature confirms disparities in breast and cervical cancer screening rates among women with mental illness. However, the mentally ill population is more complex and diverse than many studies imply. Using a global functional indicator that measures the overall impact of mental illness may yield a more useful categorization of influences on cancer screening.

Disparities in cancer screening: acceptance of Pap smears among homeless women

AIMS

Cervical cancer is a preventable disease through screening and early treatment. Rates of cervical cancer are higher in impoverished women, including homeless women. This study assessed the acceptance of free and accessible Pap smears offered to homeless women in a respite care setting.

METHODS

A convenience sample of 205 adult women receiving respite care at a facility for homeless people in Boston, Massachusetts, between 2004 and 2007 were offered screening for cervical cancer during routine encounters with the medical staff during their stay. Rates of acceptance of screening as well as medical and sociodemographic information were collected on the women.

RESULTS

Of 205 women enrolled in the study, 129 (63%) were in need of screening and offered a Pap smear; 80 (62%) accepted and 49 (38%) declined. Of those who agreed to be tested, 56 (70%) had a Pap smear performed, resulting in 10 (18%) atypical results (atypical squamous cells of undetermined significance [ASCUS] or low-grade squamous intraepithelial lesion [LGSIL]) and 15 (27%) benign findings needing follow-up (e.g., vaginitis without evidence of malignancy).

CONCLUSIONS

A large proportion of homeless women receiving respite care decline a free Pap smear despite being in medical need of cervical cancer screening. Access and cost may not be the only barriers to screening among homeless women, and new and innovative approaches to screening in vulnerable populations need to be investigated in order to close the disparity gap.

Cancer screening among jail inmates: frequency, knowledge, and willingness

OBJECTIVES

We determined jail inmates' knowledge of cancer screening tests, their frequency of screening, and their willingness to undergo screening in jail in order to assess preventive health services for jail inmates.

METHODS

We performed a cross-sectional interview survey of random samples of county jail inmates (n=133).

RESULTS

Approximately half (53%) the participants were African American, 17% were White, 11% were Latino, and 9% reported multiple ethnicities. Among women aged 18 years and older, 90% had had a Papanicolaou (Pap) test within 3 years, and 94% were willing to be screened in jail. Having ever had a Pap test while incarcerated was significantly associated with being up to date on cervical cancer screening. For women aged 40 years and older, 41% reported having had a mammogram within 2 years, and 88% were willing to have one. Among men (n=51) and women (n=4) aged 50 years and older, 25% had knowledge of colon cancer screening, 31% were up to date, and 69% were willing to be screened. Increased knowledge about colon cancer screening was significantly associated with being White and having insurance. Jail inmates, particularly African Americans, had significantly lower frequency of sigmoidoscopy and colonoscopy than the general population.

CONCLUSIONS

Jail could be an appropriate venue in which to provide cancer screening for a high-risk population. Inmates were receptive to jail-based screening.

Social inequities along the cervical cancer continuum: a structured review

OBJECTIVE

To reveal areas of research/knowledge related to social inequities and cervical cancer.

METHODS

A Medline search was performed looking for US based research on cervical cancer and social inequities since 1990. The papers found were organized into cells defined by a "cancer disparities grid."

RESULTS

The majority of research published about cervical cancer and social inequities in the US, lies within the social domains of: race/ethnicity and socioeconomic position. Conflicting information exists as to whether race/ethnicity is a good predictor of screening and survival. Some research implied that differentials based on race/ethnicity are likely secondary to differentials in socioeconomic position. Some research about age, insurance status, and immigrant status and cervical cancer was found. Scarce information was found relating to sexuality, language, disability and geography and cervical cancer.

DISCUSSION

The "cancer disparities grid" facilitated a systematic and visual review of existing literature on social inequities and cervical cancer. The grid helped to elucidate uncontested existing social inequities, conflicting social inequities, and areas where social inequity data does not exist. The cancer disparities grid can be used as a research tool to help identify areas for future research, clinical programs, and political action related to cervical cancer and social inequities.

A Community-Based Intervention to Increase Screening Mammography Among Disadvantaged Women at an Inner-City Drop-In Center

PURPOSE

To determine the effectiveness of a community- based intervention to increase the use of screening mammography among disadvantaged women at an inner-city drop-in center.

METHODS

This study involved women 50 to 70 years old who were clients of an inner-city drop-in center in Toronto, Canada, during the years 1995-2002 (N = 158 in 1995-2001 and N = 89 in 2002). In 2002, the drop-in center and a nearby hospital initiated a collaborative breast cancer screening project in which a staff member of the drop-in center accompanied small groups of women for mammography visits at a weekly pre-arranged time. Interrupted time series analysis was used to examine the effect of this intervention on the annual rate of screening mammography, as determined by review of medical records.

RESULTS

More than half of the women 50 to 70 years old who used the drop-in center in 2002 had been diagnosed with a major mental illness, and one-third were either homeless or living in supportive housing. In the 7 years before the introduction of the intervention, annual mammography rates among women using the drop-in center averaged 4.7%. During the intervention year, 26 (29.2%) of 89 women underwent mammography (p = 0.0001 for the change from pre-to post-intervention).

CONCLUSIONS

The introduction of accompanied small-group visits was associated with significantly increased use of mammography in a group of disadvantaged women who were clients of an inner-city drop-in center. This approach may be useful to promote breast cancer screening among women affected by mental illness or homelessness who have contact with community-based agencies.

Missed opportunities in addressing drinking behavior in medical and mental health services

BACKGROUND

Epidemiological and clinical literature point to the importance of screening for alcohol problems in medical and psychiatric settings. However, little is known about which problem drinkers seek help from those services or about the characteristics of those who have their drinking addressed.

METHODS

We interviewed a probability sample of adult dependent and problem drinkers in the general population (n = 672) and consecutive admissions to chemical dependency programs in a northern California county (n = 926). We reinterviewed them 1 year later and measured medical and mental health visits and whether their drinking was addressed during the visit.

RESULTS

Almost two-thirds of problem drinkers had a medical visit, and approximately one-third had a mental health visit, yet drinking was not often discussed, especially during medical visits. Many of those more likely to have a visit were not more likely to have their drinking addressed. Women and individuals older than 40 years had more medical and mental health visits [odds ratio (OR), 1.71; p < 0.001 and OR, 1.55; p < 0.001, respectively, for women; OR, 1.57; p < 0.05 and OR, 1.64; p < 0.05, respectively, for age >/=40 years], but were not more likely to have their drinking addressed in either setting, and women were less likely than men to have their drinking addressed in mental health settings (OR, 0.62; p < 0.05). Those with higher alcohol severity and those who had attended chemical dependency treatment during the previous year were more likely to have their drinking addressed in each setting. Insurance status predicted medical, but not mental health, visits and was not related to having drinking addressed in either setting.

CONCLUSIONS

Drinking behavior was not routinely addressed by medical and mental health practitioners for dependent and problem-drinking men and women who presented in public and private medical and mental health settings.

Type of social support among homeless women: its impact on psychosocial resources, health and health behaviors, and use of health services

BACKGROUND

Information about whether specific types of support are associated with poor psychosocial profiles, health behaviors, and positive use of medical care is critical for identifying homeless women at highest risk for negative outcomes.

OBJECTIVES

This study aimed to examine the impact that various levels of support from substance users and nonusers have on homeless women's psychosocial profiles, health and health behaviors, and use of health services.

METHODS

This cross-sectional survey used a sample of 1,302 sheltered homeless women. Using controls for potential confounders, outcomes were compared across four mutually exclusive subgroups of women reporting support from substance users only (n = 58), substance nonusers only (n = 439), both users and nonusers (n = 136), and no one (n = 669). Structured and psychometrically sound instruments measured social support, substance use, self-esteem, coping, and psychological symptoms. Additional instruments measured sociodemographic characteristics, sexual risk behavior, health status, and use of health services.

RESULTS

As compared with those who have little or no support, women whose support included substance nonusers reported better psychosocial profiles and somewhat greater use of health services. Support from substance nonusers only was associated with better health behaviors and greater use of health services. Support from substance users only was essentially equivalent to not having support.

CONCLUSION

Modifying the social networks of homeless women appears to be associated with improved mental health outcomes, less risky health behaviors, and greater use of health services.

Delivery of primary care to women. Do women's health centers do it better?

OBJECTIVE

Women's health centers have been increasing in number but remain relatively unstudied. We examined patient expectations and quality of care at a hospital-based women's health center compared with those at a general medicine clinic.

DESIGN

Cross-sectional survey.

SETTING

University hospital-affiliated women's health and general internal medicine clinics.

PARTICIPANTS

An age-stratified random sample of 2,000 women over 18 years of age with at least two visits to either clinic in the prior 24 months. We confined the analysis to 706 women respondents who identified themselves as primary care patients of either clinic.

MEASUREMENTS AND MAIN RESULTS

Personal characteristics, health care utilization, preferences and expectations for care, receipt of preventive services, and satisfaction with provider and clinic were assessed for all respondents. Patients obtaining care at the general internal medicine clinic were older and had more chronic diseases and functional limitations than patients receiving care at the women's health center. Women's health center users (n = 357) were more likely than general medicine clinic users ( n = 349) to prefer a female provider ( 57% vs 32%, p =.0001) and to have sought care at the clinic because of its focus on women's health (49% vs 17%, p =. 0001). After adjusting for age and self-assessed health status, women's health center users were significantly more likely to report having had mammography (odds ratio [OR] 4.0, 95% confidence interval [CI] 1.1, 15.2) and cholesterol screening (OR 1.6, 95% CI 1.0, 2.6) but significantly less likely to report having undergone flexible sigmoidoscopy (OR 0.5, 95% CI 0.3, 0.9). There were no significant differences between the clinics on receipt of counseling about hormone replacement therapy or receipt of Pap smear, or in satisfaction.

CONCLUSIONS

These results suggest that, at least in this setting, women's health centers provide care to younger women and those with fewer chronic medical conditions and may meet a market demand. While the quality of gender-specific preventive care may be modestly better in women's health centers, the quality of general preventive care may be better in general medical clinics.