Cervical cancer screening barriers and facilitators from the perspectives of women with a history of criminal-legal system involvement and substance use

BACKGROUND

The wide availability of routine screening with Papanicolaou (Pap) tests and vaccinations against human papillomavirus has resulted in a decline in rates of cervical cancer. As with other diseases, however, disparities in incidence and mortality persist. Cervical cancer, is found more often, at later stages, and has worse outcomes in people who live in rural areas, identify as Black or Hispanic, and in people who are incarcerated. Studies report 4-5 times higher rates of cervical cancer incidence in people detained in jails and prisons than in community-based samples. Studies to explain cervical cancer differences have been inconclusive, though there is broad consensus that issues of access play a role. In this study, we sought to learn more from people who have a history of criminal-legal system involvement and substance use about what barriers and facilitators they perceive in accessing cervical cancer preventive health and other support services in the community.

RESULTS

We conducted semi-structured interviews with open-ended questions by telephone with 20 self-identified women, ages 22-58, in Birmingham, Alabama. Interviews were audio recorded and transcribed and the transcripts analyzed using immersion-crystallization techniques. Our team identified two main themes, making connections: the importance of interpersonal communication, which stressed barriers and facilitators related to what makes for effective and humanistic interactions in cervical health prevention and other services, and getting it done: the logistics of access and availability, which highlighted elements of cost and payment; scheduling; transportation; and clinic policies.

CONCLUSIONS

People with a history of criminal-legal system involvement and substance abuse meet with a variety of enabling and impeding factors at personal and interpersonal as well as systemic levels in obtaining cervical health services. To better ensure that women in this high-risk group have equitable access to cervical cancer prevention and treatment-and thus better cancer outcomes-will require multilevel efforts that include an emphasis on improving the human connection in health care encounters and improving the nuts-and-bolts logistics related to accessing that care.

Getting started in jail, prison, and legal system research

Extensive health inequities exist for persons with criminal-legal involvement in the USA. Researchers, both novice and experienced, are critical in documenting these inequities and implementing programs that address the many health and social problems of this population. However, working with currently or formerly incarcerated persons brings new challenges to researchers that may have not been previously considered as necessary. Because incarcerated persons were systemically exploited by biomedical researchers until reform following the Civil Rights Movement, resulting in their designation as a vulnerable population in the Code of Federal Regulations, enhanced protections are necessary in implementing contemporary research involving incarcerated persons. These enhanced protections can delay or prolong the regulatory approval process, particularly to the novice carceral system researcher, which may discourage some from engaging with this important population. Drawing on the many years of experience working with incarcerated persons accumulated by the Sexual Health Empowerment (S)HE Team at the University of Kansas Medical Center (KUMC), this article offers some concrete steps toward getting started in this work.