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Wen KY, Dayaratna S, Slamon R, Granda-Cameron C, Tagai EK, Kohler RE, Hudson SV, Miller SM. 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. Transl Behav Med 2024; 14:1-12. [PMID: 38014626 PMCID: PMC10782901 DOI: 10.1093/tbm/ibad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
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.
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Affiliation(s)
- Kuang-Yi Wen
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Sandra Dayaratna
- Department of Obstetrics, Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, 833 Chestnut Street, Philadelphia, PA 19107, USA
| | - Rachel Slamon
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Clara Granda-Cameron
- Department of Graduate Program, College of Nursing, Thomas Jefferson University, 901 Walnut Street, Suite 703, Philadelphia, PA 19107, USA
| | - Erin K Tagai
- Department of Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Racquel E Kohler
- Cancer Health Equity Center, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Suzanne M Miller
- Department of Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
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Atlas SJ, Tosteson ANA, Wright A, Orav EJ, Burdick TE, Zhao W, Hort SJ, Wint AJ, Smith RE, Chang FY, Aman DG, Thillaiyapillai M, Diamond CJ, Zhou L, Haas JS. A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results: A Cluster Randomized Clinical Trial. JAMA 2023; 330:1348-1358. [PMID: 37815566 PMCID: PMC10565610 DOI: 10.1001/jama.2023.18755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/31/2023] [Indexed: 10/11/2023]
Abstract
Importance Realizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results. Objective To test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results. Design, Setting, and Participants Pragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021. Intervention Automated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment. Main Outcomes and Measures The primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk. Results Among 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P < .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result. Conclusions and Relevance A multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer. Trial Registration ClinicalTrials.gov Identifier: NCT03979495.
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Affiliation(s)
- Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Anna N. A. Tosteson
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Dartmouth Cancer Center, Dartmouth Health and Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
- Department of Medicine, Dartmouth Health, Lebanon, New Hampshire
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Timothy E. Burdick
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
- SYNERGY Research Informatics, Dartmouth Health, Lebanon, New Hampshire
- Department of Biomedical Data Science, Dartmouth Health, Lebanon, New Hampshire
| | - Wenyan Zhao
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Shoshana J. Hort
- Department of Medicine, Dartmouth Health, Lebanon, New Hampshire
- SYNERGY Research Informatics, Dartmouth Health, Lebanon, New Hampshire
| | - Amy J. Wint
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Rebecca E. Smith
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
| | - Frank Y. Chang
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David G. Aman
- Research Computing, Dartmouth College, Lebanon, New Hampshire
| | | | - Courtney J. Diamond
- Department of Biomedical Informatics, Irving Medical Center, Columbia University, New York, New York
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jennifer S. Haas
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
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León-Maldonado L, Hernández-Ramírez RU, Torres-Ibarra L, Spiegelman D, Sheth SS, Lazcano E, Cadena-Fiscal JD, Salmerón J. Factors associated with receiving results and attending colposcopy in patients with positive HPV screens in Mexico City. Prev Med Rep 2023; 35:102347. [PMID: 37593354 PMCID: PMC10428024 DOI: 10.1016/j.pmedr.2023.102347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/23/2023] [Accepted: 07/23/2023] [Indexed: 08/19/2023] Open
Abstract
We identified patient and healthcare system factors related to receipt of screening results and attendance to colposcopy among patients with positive screening results in a cervical cancer screening program in Mexico City, Mexico. We analyzed data from 1,351 patients with high-risk human papillomavirus (HPV)-positive results from two screening demonstration studies conducted between 2017 and 2018. Factors associated with receipt of screening results and with adherence to a colposcopy appointment were identified using multivariable logistic regression. Participants had a median age of 40 years (IQR = 32-48), 60% had less than high school education, and 74% had a previous Pap screening in the last 5 years. Fifty-five percent of participants retrieved their screening results at the healthcare facility (HCF) without any reminder. Providing an email address for contact information, attending a HCF with family medicine, and receiving care from experienced nurses were associated with greater adherence to obtaining screening test results. Fifty-seven percent of participants attended their first scheduled colposcopy appointment. Providing a phone number improved adherence to colposcopy, whereas longer travel times between the HCF and the colposcopy clinic was associated with a decrease in colposcopy adherence. Having a Pap test in the last 5 years was positively associated with better compliance with both outcomes. Securing contact information may help to overcome barriers to future follow-up. Additional research is necessary on strategies for obtaining screening test results and scheduling appointments, which may help address barriers to access, such as limited staff availability, distance from the clinic, and travel costs.
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Affiliation(s)
- Leith León-Maldonado
- Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, Mexico
| | - Raúl U. Hernández-Ramírez
- Department of Biostatistics, Center for Methods in Implementation and Prevention Science (CMIPS), Yale School of Public Health (YSPH), New Haven, CT, USA
| | - Leticia Torres-Ibarra
- Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, Mexico
| | - Donna Spiegelman
- Department of Biostatistics, Center for Methods in Implementation and Prevention Science (CMIPS), Yale School of Public Health (YSPH), New Haven, CT, USA
| | - Sangini S. Sheth
- Department of Obstetrics, Gynecology, & Reproductive Sciences, Yale School of Medicine (YSM), New Haven, CT, USA
| | - Eduardo Lazcano
- Dirección General, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, Mexico
| | - José D. Cadena-Fiscal
- Jurisdicción Sanitaria Tlalpan, Servicios de Salud de la Ciudad de México, México City, Mexico
| | - Jorge Salmerón
- Centro de Investigación en Políticas, Población y Salud, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, Mexico
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Kohler RE, Hemler J, Wagner RB, Sullivan B, Macenat M, Tagai EK, Miller SM, Wen KY, Ayers C, Einstein MH, Hudson SV. Confusion and anxiety in between abnormal cervical cancer screening results and colposcopy: "The land of the unknown". PATIENT EDUCATION AND COUNSELING 2023; 114:107810. [PMID: 37244133 PMCID: PMC10527466 DOI: 10.1016/j.pec.2023.107810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
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.
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Affiliation(s)
- Racquel E Kohler
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA.
| | - Jennifer Hemler
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Rachel B Wagner
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Brittany Sullivan
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
| | - Myneka Macenat
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA
| | - Erin K Tagai
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Suzanne M Miller
- Cancer Prevention and Control, Fox Chase Cancer Center/Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, USA
| | - Kuang-Yi Wen
- Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
| | - Charletta Ayers
- Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, 125 Paterson St, New Brunswick, NJ 08901, USA
| | - Mark H Einstein
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers Biomedical and Health Sciences, 185 South Orange Avenue, Newark, NJ 07103, USA
| | - Shawna V Hudson
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, 120 Albany St, New Brunswick, NJ 08901, USA; Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 303 George St, New Brunswick, NJ 08901, USA
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Boitano TK, Ketch P, Maier JG, Nguyen CT, Huh WK, Michael Straughn J, Scarinci IC. Increased disparities associated with black women and abnormal cervical cancer screening follow-up. Gynecol Oncol Rep 2022; 42:101041. [PMID: 35898199 PMCID: PMC9309676 DOI: 10.1016/j.gore.2022.101041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/26/2022] [Accepted: 07/02/2022] [Indexed: 11/25/2022] Open
Abstract
Timely follow-up and treatment after abnormal cervical cancer screening is lacking in over half of all women. Black women have the lowest rate of follow-up after abnormal screening. One-fourth of Black and Hispanic women have delayed follow-up. Insurance status is also associated with timely follow-up with abnormal cervical cancer screening.
Background To determine whether race and ethnicity impacts patient adherence to follow-up for colposcopy after abnormal cervical cancer screening. Methods This retrospective chart review included women that were randomly selected from patients presenting to our colposcopy clinic from 1/2019 to 12/2019. Inclusion criteria were females age ≥21 years-old and appropriate referral for colposcopy. Patients were grouped into three categories: (1) ADHERENT to follow-up if they came to their first scheduled appointment; (2) DELAYED if they presented more than three months from their original referral (usually missing 1–3 appointments); and (3) NOT ADHERENT if they did not show for their appointment after referral. Analysis was performed using SPSS v.26. Results 284 women met inclusion criteria for the study. The majority of women were Black (65.2 %) followed by non-Hispanic Whites (20.0 %) and Latinx (14.8 %). Overall, 39.1 % were ADHERENT, 18.6 % were DELAYED, and 42.3 % were NOT ADHERENT. When compared with non-Hispanic White women, there was a significant difference between race/ethnicity and timing of follow-up (p = 0.03). Blacks were more likely to be NOT ADHERENT (45.9 %; p = 0.03), and Latinx and Blacks were the most likely to be DELAYED (35.7 % and 21.1 %; p = 0.03). Private insurance patients were more likely to be ADHERENT for care compared with un-/underinsured patients (78.9 vs 27.8 %, p = 0.0001). Conclusion There is inadequate follow-up after abnormal cervical cancer screening across all races/ethnicities; however, lack of adherence is higher in Black patients. Moreover, 25% of Hispanic and Black women present in a delayed fashion. Culturally relevant assessments and interventions are needed to understand and address these gaps.
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Chavez A, Khan A. Improving Health Literacy Among Underserved Latinas with PFDs. CURRENT BLADDER DYSFUNCTION REPORTS 2022. [DOI: 10.1007/s11884-022-00650-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Perez L, Tran K, Alvarenga-Bezerra V, Chadha D, Dotson L, Assir F, Cordioli E, Tamura Vieira Gomes M, Podgaec S, Lopes da Silva-Filho A, Ramanujam N, Moretti-Marques R. Cervical Cancer-Related Knowledge, Attitudes, Practices and Self-Screening Acceptance Among Patients, Employees, and Social Media Followers of Major Brazilian Hospital. Cancer Control 2022; 29:10732748221135441. [PMID: 36433760 PMCID: PMC9703545 DOI: 10.1177/10732748221135441] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/16/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Brazil has a high burden of cervical cancer, even though it is preventable, traceable and treatable. Hence, this study evaluated levels of knowledge, attitudes and practices (KAP) related to cervical cancer screening and diagnosis and acceptance of self-screening techniques among women aged 24 and greater. METHODS A cross-sectional KAP survey was administered to n = 4206 women and spanned questions relating to cervical cancer, HPV, speculum, Pap test and colposcopy. Questionnaire was disseminated through a major hospital's social media platforms, intranet and gynecologic-oncology clinics. Logistic regressions evaluated associations between sociodemographic characteristics and knowledge, attitudes, and preventative behaviors against cervical cancer. Participants indicated willingness to try DNA-HPV self-sampling and cervix self-visualization (self-colposcopy). FINDINGS Participants were mostly white individuals (70.5%) with higher education and from social classes A and B. They demonstrated superior levels of KAP than described in the literature, with over 57.8% having answered 80+% of questions correctly. KAP scores were predicted by social class, educational attainment, race, history of premalignant cervical lesions and geographic location. About 80% and 63% would be willing to try DNA-HPV self-sampling and cervix self-visualization, respectively. Interest in self-screening was associated with adequate attitude (OR = 1.85) and inadequate practice (OR = .83). INTERPRETATION Adequate KAP are fundamental for the successful implementation of a self-screening program. Participants were interested in methods that provide them with greater autonomy, control and practicality. Self-screening could address barriers for under-screened women such as shame, discomfort, distance from clinics and competing commitments, enabling Brazil to reach the WHO's cervical cancer elimination goals. It could also decrease excess medical intervention in over-screened populations by promoting shared decision-making.
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The importance of information, motivation, and behavioral skills (IMB): Healthcare provider perspectives on improving adherence to cervical cancer screening among at-risk women. PUBLIC HEALTH IN PRACTICE 2021; 2:100079. [PMID: 36101626 PMCID: PMC9461580 DOI: 10.1016/j.puhip.2021.100079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 12/09/2020] [Accepted: 12/18/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To understand the theoretical framework of how information, motivation, and behavioral skills (IMB) independently and collectively affect cervical cancer screening and testing adherence. Study design Qualitative study. Methods Data collected from three focus groups and seven individual interviews, with 33 healthcare providers, ranging from community health navigators, Ob-Gyn MD’s, nurses, care coordinators, medical assistants, and outpatient managers, representing a grassroots community health agency, a large cancer center, and a public sector health clinic. We recruited providers over a five-month period in the summer to fall of 2019. Provider interviews and focus groups were structured with four to eleven participants per group and were audio-recorded. This study was rooted in grounded theory, analyzing data using the iterative process of Coding, Consensus, Co-occurrence, and Comparison to identify common themes. Results Emerging qualitative findings include the relevance of information, the interaction between information and motivation, the role of behavioral skills, and the symbiotic relationship between information, motivation, and behavioral skills (IMB). Most notable is this interdependency between IMB components, with the core of this relationship being the critical link of coordinating adherence. Conclusion This knowledge will help advance and expand IMB intervention components to improve time to cervical cancer screening and follow-up adherence among at-risk communities. Particularly given COVID-19 barriers, which disproportionately affect at-risk women, this study has practice implications that inform the development of cervical cancer screening practice interventions and strategies to improve adherence, while ensuring safety for both patients and providers.
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Haas JS, Atlas SJ, Wright A, Orav EJ, Aman DG, Breslau ES, Burdick TE, Carpenter E, Chang F, Dang T, Diamond CJ, Feldman S, Harris KA, Hort SJ, Housman ML, Mecker A, Lehman CD, Percac-Lima S, Smith R, Wint AJ, Yang J, Zhou L, Tosteson ANA. Multilevel Follow-up of Cancer Screening (mFOCUS): Protocol for a multilevel intervention to improve the follow-up of abnormal cancer screening test results. Contemp Clin Trials 2021; 109:106533. [PMID: 34375748 PMCID: PMC8900526 DOI: 10.1016/j.cct.2021.106533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/29/2021] [Accepted: 08/04/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION While substantial attention is focused on the delivery of routine preventive cancer screening, less attention has been paid to systematically ensuring that there is timely follow-up of abnormal screening test results. Barriers to completion of timely follow-up occur at the patient, provider, care team and system levels. METHODS In this pragmatic cluster randomized controlled trial, primary care sites in three networks are randomized to one of four arms: (1) standard care, (2) "visit-based" reminders that appear in a patient's electronic health record (EHR) when it is accessed by either patient or providers (3) visit based reminders with population health outreach, and (4) visit based reminders, population health outreach, and patient navigation with systematic screening and referral to address social barriers to care. Eligible patients in participating practices are those overdue for follow-up of an abnormal results on breast, cervical, colorectal and lung cancer screening tests. RESULTS The primary outcome is whether an individual receives follow-up, specific to the organ type and screening abnormality, within 120 days of becoming eligible for the trial. Secondary outcomes assess the effect of intervention components on the patient and provider experience of obtaining follow-up care and the delivery of the intervention components. CONCLUSIONS This trial will provide evidence for the role of a multilevel intervention on improving the follow-up of abnormal cancer screening test results. We will also specifically assess the relative impact of the components of the intervention, compared to standard care. TRIAL REGISTRATION ClinicalTrials.gov NCT03979495.
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Affiliation(s)
- Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - David G Aman
- Information, Technology and Consulting (ITC), Dartmouth College, Lebanon, NH
| | - Erica S Breslau
- Division of Cancer Prevention and Control, National Cancer Institute, Rockville, MD, USA
| | - Timothy E Burdick
- Department of Community and Family Medicine, Dartmouth-Hitchcock Health, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH, USA
| | - Emily Carpenter
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Frank Chang
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Tin Dang
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Courtney J Diamond
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Feldman
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Kimberly A Harris
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shoshana J Hort
- Department of Medicine, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - Molly L Housman
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH, USA
| | - Amrita Mecker
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Constance D Lehman
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanja Percac-Lima
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rebecca Smith
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH, USA
| | - Amy J Wint
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jie Yang
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, NH, USA; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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Viswanathan V, Ganeshkumar P, Selvam JM, Selvavinayagam TS. Referral mechanism and beneficiary adherence in cervical cancer screening program in Tiruchirappalli district, Tamil Nadu state, India, 2012-2015. Indian J Cancer 2021; 59:39-45. [PMID: 34380836 DOI: 10.4103/ijc.ijc_548_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background A screening program for cervical cancer was established in 2011 in Tamil Nadu. Since the inception of the program, coverage, and dropout of screening has not been analyzed. We conducted a study to describe the referral mechanism in the cervical cancer screening program implemented in Tamil Nadu, to estimate the level of adherence to the referral process by the beneficiaries, and to identify strengths and weaknesses related to the referral mechanism in the program. Methods This descriptive study was conducted during 2015-2016 in the Tiruchirappalli administrative district of Tamil Nadu. All women aged 30 years and above, who were screened in public health facilities, were the participants. Using a structured form, we collected the data maintained in the registers at the district health administration. We estimated the screening coverage, follow-up evaluation, and dropout rates at different stages of the referral mechanism. We used SPSS and Epi Info software for analysis. Results Coverage of cervical cancer screening was 4,838(41.6%). We estimated 4,838(41.6%) of screened positives were lost to follow-up for a colposcopy examination. Biopsy samples were obtained from 3425(84%) of those who required a biopsy. Cervical cancer was diagnosed in 159(4.6%) and precancerous lesions in 528(15.4%) women. Conclusion More than half of the target population was screened in public health facilities. The dropout rate was less than half of those screened at the colposcopy evaluation level. Major pitfalls of the program were human resource issues at referral centers and poor maintenance of meaningful data.
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Affiliation(s)
- Vidhya Viswanathan
- Department of Epidemiology, Indian Council of Medical Research - National Institute of Epidemiology, Ayapakkam, Chennai, Tamil Nadu, India
| | - Parasuraman Ganeshkumar
- Department of Epidemiology, Indian Council of Medical Research - National Institute of Epidemiology, Ayapakkam, Chennai, Tamil Nadu, India
| | - Jerard M Selvam
- National Health Mission, Government of Tamil Nadu, Tamil Nadu, India
| | - T S Selvavinayagam
- Department of Public Health and Preventive Medicine, Government of Tamil Nadu, Tamil Nadu, India
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11
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Reece JC, Neal EFG, Nguyen P, McIntosh JG, Emery JD. Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. BMC Cancer 2021; 21:373. [PMID: 33827476 PMCID: PMC8028768 DOI: 10.1186/s12885-021-08100-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/23/2021] [Indexed: 01/07/2023] Open
Abstract
Background Successful breast cancer screening relies on timely follow-up of abnormal mammograms. Delayed or failure to follow-up abnormal mammograms undermines the potential benefits of screening and is associated with poorer outcomes. However, a comprehensive review of inadequate follow-up of abnormal mammograms in primary care has not previously been reported in the literature. This review could identify modifiable factors that influence follow-up, which if addressed, may lead to improved follow-up and patient outcomes. Methods A systematic literature review to determine the extent of inadequate follow-up of abnormal screening mammograms in primary care and identify factors impacting on follow-up was conducted. Relevant studies published between 1 January, 1990 and 29 October, 2020 were identified by searching MEDLINE®, Embase, CINAHL® and Cochrane Library, including reference and citation checking. Joanna Briggs Institute Critical Appraisal Checklists were used to assess the risk of bias of included studies according to study design. Results Eighteen publications reporting on 17 studies met inclusion criteria; 16 quantitative and two qualitative studies. All studies were conducted in the United States, except one study from the Netherlands. Failure to follow-up abnormal screening mammograms within 3 and at 6 months ranged from 7.2–33% and 27.3–71.6%, respectively. Women of ethnic minority and lower education attainment were more likely to have inadequate follow-up. Factors influencing follow-up included physician-patient miscommunication, information overload created by automated alerts, the absence of adequate retrieval systems to access patient’s results and a lack of coordination of patient records. Logistical barriers to follow-up included inconvenient clinic hours and inconsistent primary care providers. Patient navigation and case management with increased patient education and counselling by physicians was demonstrated to improve follow-up. Conclusions Follow-up of abnormal mammograms in primary care is suboptimal. However, interventions addressing amendable factors that negatively impact on follow-up have the potential to improve follow-up, especially for populations of women at risk of inadequate follow-up. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08100-3.
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Affiliation(s)
- Jeanette C Reece
- Colorectal Cancer Unit, Centre for Epidemiology and Biostatistics and Neuroepidemiology Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Level 3 207 Bouverie Street, Parkville, VIC, 3010, Australia. .,Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.
| | - Eleanor F G Neal
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Australia.,Centre for International Child Health, Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Peter Nguyen
- Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Jennifer G McIntosh
- Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Department of Software Systems and Cybersecurity, Faculty of Information Technology, Monash University, VIC, Clayton, Australia
| | - Jon D Emery
- Centre for Cancer Research, Victorian Comprehensive Cancer Centre, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.,Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
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12
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Kuroki L, Massad LS, Martin A, Liu J, Brown D, Leon A, Groesch K, Wilson T, Zeino Y, Diaz-Sylvester P, Delfino K, Hyon K, Kreuter M. Addressing Unmet Basic Needs to Improve Colposcopy Adherence Among Women With Abnormal Cervical Cancer Screening. J Low Genit Tract Dis 2021; 25:106-112. [PMID: 33631781 PMCID: PMC7987876 DOI: 10.1097/lgt.0000000000000593] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of the study were to identify unmet basic needs (BNs) among women referred to colposcopy, to assess patient acceptability/satisfaction with assistance from a navigator to address unmet BNs, and to estimate adherence to colposcopy. METHODS Women were recruited between September 2017 and January 2019 from 2 academic colposcopy centers, one serving a rural and one an urban area. Basic needs were assessed by phone before colposcopy appointments and considered unmet if unlikely to resolve in 1 month. Colposcopy adherence prestudy and poststudy implementation was abstracted over 4-6 months from administrative records. After a lead-in phase of 25 patients at each site, a BN navigator was offered to new participants with 1 or more unmet BNs. Primary outcome was adherence to initial appointment. RESULTS Among 100 women, 59% had 1 or more unmet BNs, with similar prevalence between urban and rural sites. Adherence to initial colposcopy was 83% overall, 72% at the rural clinic, and 94% at the urban clinic (p = .006). These adherence rates were improved from 4 months before study launch (30/59 [51%] rural clinic and 68/137 [50%] urban clinic). Although acceptability of BN navigation was greater than 96% and women felt that it helped them get to their colposcopy visit, having a navigator was not associated with adherence. Women reporting no unmet BNs had the lowest adherence compared with women with 1 or more unmet BNs, regardless of navigator assistance (p = .03). CONCLUSIONS Disadvantaged women who need colposcopy have unmet BNs and value navigator assistance for initial appointments. However, when appointment scheduling includes telephone reminders and inquiring about BNs, a navigator may not add value.
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Affiliation(s)
- Lindsay Kuroki
- Division of Gynecologic Oncology, Washington University School of Medicine, Alvin J. Siteman Cancer Center, St Louis, MO
| | - L Stewart Massad
- Division of Gynecologic Oncology, Washington University School of Medicine, Alvin J. Siteman Cancer Center, St Louis, MO
| | - Anne Martin
- Department of Obstetrics and Gynecology, Southern Illinois University School of Medicine (SIUM), Springfield, IL
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Dominique Brown
- Health Communication Research Laboratory, The Brown School, Washington University in St Louis, St Louis, MO
| | - Andrea Leon
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, MO
| | | | | | - Yahia Zeino
- Department of Obstetrics and Gynecology, Southern Illinois University School of Medicine (SIUM), Springfield, IL
| | | | | | - Katherine Hyon
- Department of Obstetrics and Gynecology, Southern Illinois University School of Medicine (SIUM), Springfield, IL
| | - Matthew Kreuter
- Health Communication Research Laboratory, The Brown School, Washington University in St Louis, St Louis, MO
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13
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Victoria SA, Racquel E K, Lucila S, Melisa P, Viswanath K, Silvina A. Knowledge and perceptions regarding triage among human papillomavirus-tested women: A qualitative study of perspectives of low-income women in Argentina. ACTA ACUST UNITED AC 2020; 16:1745506520976011. [PMID: 33264086 PMCID: PMC7716054 DOI: 10.1177/1745506520976011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
| | - Kohler Racquel E
- Cancer Health Equity, Cancer Institute of New Jersey, Rutgers-The State University of New Jersey, New Brunswick, NJ, USA
| | - Szwarc Lucila
- Centro de Estudios de Estado y Sociedad/Consejo Nacional de Investigaciones Científicas y Técnicas Buenos Aires, Buenos Aires, Argentina
| | - Paolino Melisa
- Centro de Estudios de Estado y Sociedad/Consejo Nacional de Investigaciones Científicas y Técnicas Buenos Aires, Buenos Aires, Argentina
| | - Kasisomayajula Viswanath
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Arrossi Silvina
- Centro de Estudios de Estado y Sociedad/Consejo Nacional de Investigaciones Científicas y Técnicas Buenos Aires, Buenos Aires, Argentina
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14
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Rodday AM, Hackenyos D, Masood R, Savidge N, Lin M, Weidner RA, Parsons SK. Assessment of patients' understanding of and adherence to oral anticancer medication (OAM): Results of a cross-sectional institutional pilot study. J Oncol Pharm Pract 2020; 27:1569-1577. [PMID: 33019872 DOI: 10.1177/1078155220960809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although oral anticancer medications (OAM) provide opportunity for treatment at home, challenges include prescription filling, monitoring side effects, safe handling, and adherence. We assessed understanding of and adherence to OAM in vulnerable patients. METHODS This 2018 pilot study defined vulnerable patients based on Chinese language, older age (≥65 years), and subsidized insurance. All participants had a cancer diagnosis and were taking an OAM filled through the hospital's specialty pharmacy. Participants reported on OAM taking (days per week, times per day, special instructions) and handling (handling, storage, disposal). The specialty pharmacist classified patient-reported responses about OAM taking and handling as adequate or inadequate. OAM regimens were classified by complexity. RESULTS Of 61 eligible patients, 55 participated. Mean age was 68 years (standard deviation [SD] = 12) and 53% were female. Patient subgroups were: 27% Chinese, 64% ≥65 years, and 9% subsidized insurance. Forty-nine percent were on frontline therapy and median time on OAM was 1 year (Quartile 1 = 0.4, Quartile 3 = 1.7). Adequacy of OAM taking (30%) and handling (15%) were low; 15% had adequacy in both. Adequacy of OAM taking and handling did not vary by patient subgroup or regimen complexity. Mean patient-reported adherence was high (5.4, SD = 1, possible range 1-6) and did not vary by adequacy of OAM taking or handling. CONCLUSIONS Understanding of OAM taking and handling in this group of vulnerable patients was low and did not align with patient-reported adherence. Future interventions should ensure that patients understand how to safely take and handle OAM, thereby optimizing their therapeutic potential.
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15
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Alimena S, Manning-Geist B, Pena N, Vitonis AF, Feldman S. Outcomes by Race Among Women Referred to an Academic Colposcopy Clinic with a Patient Navigation Program. J Womens Health (Larchmt) 2020; 30:902-909. [PMID: 32960144 DOI: 10.1089/jwh.2020.8381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Although minority women are at higher risk of cervical cancer in the United States, little is known about differences in rates of colposcopy and loop electrosurgical excision procedure (LEEP) by race once patients present for care. Materials and Methods: A prospective registry of patients presenting to an academic colposcopy clinic was queried from 2008 to 2018. Women with missing race or cytology results, prior hysterectomy, or prior history of cervical, vulvar, or vaginal cancer were excluded. Poisson and logistic regression models were performed to evaluate the associations between race and colposcopy, LEEP, and cancer rates, adjusting for referral Papanicolaou (Pap), human papillomavirus (HPV) result, year of visit, age, insurance, pregnancy, number of sexual partners, and smoking status. Results: A total of 4506 women were included (56.1% white and 43.9% non-white). Referral for high-grade cytology was more likely among white compared to non-white women (22.5% vs. 17.5%, p < 0.001), as well as positive HPV testing (white 7.8% vs. non-white 6.0%, p < 0.001). The colposcopy rate was slightly higher among black (incidence rate ratio [IRR]adjusted 1.11, 95% confidence interval [CI] 1.03-1.19, p = 0.006) and Hispanic women (IRRadjusted 1.13, 95% CI 1.06-1.21, p = 0.0003) compared to white women. Hispanic women were significantly more likely to undergo LEEP (odds ratioadjusted 1.26, 95% CI 1.01-1.58, p = 0.04). However, no significant difference in cancer, adenocarcinoma in situ, or high-grade histology was noted by race. Conclusions: Black and Hispanic women referred for abnormal Pap or HPV results underwent a greater number of colposcopies compared to white women, and Hispanic women underwent a greater number of LEEPs. Although cancer is rare in our cohort, there was no statistical difference in rate of cancer by race.
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Affiliation(s)
- Stephanie Alimena
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Beryl Manning-Geist
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nancy Pena
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Allison F Vitonis
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Sarah Feldman
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Gynecologic Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
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16
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Pouli D, Thieu HT, Genega EM, Baecher-Lind L, House M, Bond B, Roncari DM, Evans ML, Rius-Diaz F, Munger K, Georgakoudi I. Label-free, High-Resolution Optical Metabolic Imaging of Human Cervical Precancers Reveals Potential for Intraepithelial Neoplasia Diagnosis. CELL REPORTS MEDICINE 2020; 1. [PMID: 32577625 PMCID: PMC7311071 DOI: 10.1016/j.xcrm.2020.100017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
While metabolic changes are considered a cancer hallmark, their assessment has not been incorporated in the detection of early or precancers, when treatment is most effective. Here, we demonstrate that metabolic changes are detected in freshly excised human cervical precancerous tissues using label-free, non-destructive imaging of the entire epithelium. The images rely on two-photon excited fluorescence from two metabolic co-enzymes, NAD(P)H and FAD, and have micron-level resolution, enabling sensitive assessments of the redox ratio and mitochondrial fragmentation, which yield metrics of metabolic function and heterogeneity. Simultaneous characterization of morphological features, such as the depth-dependent variation of the nuclear:cytoplasmic ratio, is demonstrated. Multi-parametric analysis combining several metabolic metrics with morphological ones enhances significantly the diagnostic accuracy of identifying high-grade squamous intraepithelial lesions. Our results motivate the translation of such functional metabolic imaging to in vivo studies, which may enable improved identification of cervical lesions, and other precancers, at the bedside.
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Affiliation(s)
- Dimitra Pouli
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, MA 02155, USA.,Present address: Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02115, USA
| | - Hong-Thao Thieu
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Elizabeth M Genega
- Department of Pathology and Laboratory Medicine, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Laura Baecher-Lind
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Michael House
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Brian Bond
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA.,Present address: Department of Obstetrics and Gynecology, University of Massachusetts School of Medicine, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Danielle M Roncari
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Megan L Evans
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Francisca Rius-Diaz
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Málaga, 32 Louis Pasteur Boulevard, 29071 Málaga, Spain
| | - Karl Munger
- Department of Developmental, Molecular, and Chemical Biology, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Irene Georgakoudi
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, MA 02155, USA.,Lead Contact
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17
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Cervical Cancer Screening Behaviors Among Post-Menopausal Women. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2019. [DOI: 10.5812/ijcm.80026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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18
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Manga S, Kiyang E, DeMarco RF. Barriers and facilitators of follow-up among women with precancerous lesions of the cervix in Cameroon: a qualitative pilot study. Int J Womens Health 2019; 11:229-239. [PMID: 31015770 PMCID: PMC6448541 DOI: 10.2147/ijwh.s196112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This pilot study explores the barriers to adherence to follow-up among women with cervical precancer in urban Cameroon. While follow-up of women with a positive screening of cervical precancer is the most important aspect of cervical cancer secondary prevention, women with cervical precancer do not adhere frequently to recommended follow-up schedule in Cameroon. The aim of the study was to explore and describe the barriers and facilitators to follow-up for cervical precancer among women infected and uninfected with HIV in Cameroon. Participants and methods A qualitative research design was used to answer the research questions. Participants included eight HIV-infected and -uninfected women diagnosed with cervical precancer and 19 nurses. Data were collected by in-depth individual patient interviews and focus groups with nurses. An interview guide with open-ended questions, using the social ecological model as a framework, included questions that addressed the complexities of the lives of individuals and professionals within a relational context. The interviews were audio-taped and transcribed verbatim in English language. Thematic analysis of data was completed with no epistemological or theoretical perspective underpinning the analyses. Results Four major themes emerged from the study. They were clinic, personal, and social barriers, and strategies to improve follow-up. Conclusion The use of reminder phone calls and fee reduction, coupled with peer counseling and navigation of women who have been diagnosed with cervical precancer, could be effective ways of improving adherence to follow-up. Further research is needed to explore the same phenomenon among women in rural areas, especially those who were initially attended to in mobile clinics.
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Affiliation(s)
- Simon Manga
- Women's Health Program, Cameroon Baptist Convention Health Services, Bamenda, Cameroon, .,College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA,
| | - Edith Kiyang
- Women's Health Program, Cameroon Baptist Convention Health Services, Bamenda, Cameroon,
| | - Rosanna F DeMarco
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA,
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19
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Pruitt SL, Werner CL, Borton EK, Sanders JM, Balasubramanian BA, Barnes A, Betts AC, Skinner CS, Tiro JA. Cervical Cancer Burden and Opportunities for Prevention in a Safety-Net Healthcare System. Cancer Epidemiol Biomarkers Prev 2018; 27:1398-1406. [PMID: 30185535 DOI: 10.1158/1055-9965.epi-17-0912] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/29/2018] [Accepted: 08/30/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The high prevalence of cervical cancer at safety-net health systems requires careful analysis to best inform prevention and quality improvement efforts. We characterized cervical cancer burden and identified opportunities for prevention in a U.S. safety-net system. METHODS We reviewed tumor registry and electronic health record (EHR) data of women with invasive cervical cancer with ages 18+, diagnosed between 2010 and 2015, in a large, integrated urban safety-net. We developed an algorithm to: (i) classify whether women had been engaged in care (≥1 clinical encounter between 6 months and 5 years before cancer diagnosis); and (ii) identify missed opportunities (no screening, no follow-up, failure of a test to detect cancer, and treatment failure) and associated factors among engaged patients. RESULTS Of 419 women with cervical cancer, more than half (58%) were stage 2B or higher at diagnosis and 40% were uninsured. Most (69%) had no prior healthcare system contact; 47% were diagnosed elsewhere. Among 122 engaged in care prior to diagnosis, failure to screen was most common (63%), followed by lack of follow-up (21%), and failure of test to detect cancer (16%). Tumor stage, patient characteristics, and healthcare utilization differed across groups. CONCLUSIONS Safety-net healthcare systems face a high cervical cancer burden, mainly from women with no prior contact with the system. To prevent or detect cancer early, community-based efforts should encourage uninsured women to use safety-nets for primary care and preventive services. IMPACT Among engaged patients, strategies to increase screening and follow-up of abnormal screening tests could prevent over 80% of cervical cancer cases.
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Affiliation(s)
- Sandi L Pruitt
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas. .,Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
| | - Claudia L Werner
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, Texas.,Parkland Health and Hospital System, Dallas, Texas
| | - Eric K Borton
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Joanne M Sanders
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Bijal A Balasubramanian
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas.,Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas
| | - Arti Barnes
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Andrea C Betts
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas.,Department of Health Promotion and Behavioral Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas
| | - Celette Sugg Skinner
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas.,Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
| | - Jasmin A Tiro
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas.,Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
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20
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Kim K, Lee B, Park Y, Suh DH, No JH, Kim YB. Factors affecting pain during outpatient clinic based surgical procedures in gynecologic oncology. Medicine (Baltimore) 2018; 97:e11721. [PMID: 30075579 PMCID: PMC6081132 DOI: 10.1097/md.0000000000011721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Colposcopy-directed punch biopsy (punch biopsy) and endocervical curettage (ECC) are accompanied by considerable pain. However, many physicians perform these procedures without adequate pain management. Therefore, identification of factors affecting pain experienced during the procedures may encourage physician effort in selective pain management. This study investigated factors affecting the severity of pain experienced during punch biopsy and ECC in an outpatient clinic of gynecologic oncology department.In this retrospective, exploratory study, a total of 101 Korean patients with abnormal cervical cytology underwent punch biopsy and ECC under a paracervical block performed for pain relief. Residents under training performed these procedures and recorded patient-reporting maximum Numeric Rating Scale (NRS) scores experienced during the procedures. Residents were classified into four outpatient clinic training groups (1st-4th); the group designators correspond to the resident's experience in performing these procedures. A linear mixed model adjusted for physician factors such as either residents or outpatient clinic training groups was used to analyze the association between each variable and maximum NRS score.Among the outpatient clinic training groups, maximum NRS scores significantly decreased in the 4th group, compared with those in the 1st group although those were not different among groups when adjusted for residents. Some of cervical cytology findings and discrepancies between the severity of cervical cytology results and those of punch biopsy or ECC showed significant associations with maximum NRS scores. However, when adjusted for either residents or outpatient clinic training groups, maximum NRS scores were not different by age, body mass index, presence of menopause, cervical cytology findings, discrepancies between the severity of cervical cytology results and those of punch biopsy or ECC, and tissue volume.There are no significant factors affecting the severity of pain experienced during punch biopsy and ECC.
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Affiliation(s)
- Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do
| | - Banghyun Lee
- Department of Obstetrics and Gynecology, Hallym University Kangdong Sacred Heart Hospital, Seoul
| | - Youngmi Park
- Division of Statistics, Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do
| | - Dong H. Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do
| | - Jae H. No
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do
| | - Yong B. Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-Do
- Seoul National University, School of Medicine, Seoul, Republic of Korea
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Perlow HK, Ramey SJ, Silver B, Kwon D, Chinea FM, Samuels SE, Samuels MA, Elsayyad N, Yechieli R. Assessment of Oropharyngeal and Laryngeal Cancer Treatment Delay in a Private and Safety Net Hospital System. Otolaryngol Head Neck Surg 2018; 159:484-493. [DOI: 10.1177/0194599818768795] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To examine the impact of treatment setting and demographic factors on oropharyngeal and laryngeal cancer time to treatment initiation (TTI). Study Design Retrospective case series. Setting Safety net hospital and adjacent private academic hospital. Subjects and Methods Demographic, staging, and treatment details were retrospectively collected for 239 patients treated from January 1, 2014, to June 30, 2016. TTI was defined as days between diagnostic biopsy and initiation of curative treatment (defined as first day of radiotherapy [RT], surgery, or chemotherapy). Results On multivariable analysis, safety net hospital treatment (vs private academic hospital treatment), initial diagnosis at outside hospital, and oropharyngeal cancer (vs laryngeal cancer) were all associated with increased TTI. Surgical treatment, severe comorbidity, and both N1 and N2 status were associated with decreased TTI. Conclusion Safety net hospital treatment was associated with increased TTI. No differences in TTI were found when language spoken and socioeconomic status were examined in the overall cohort.
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Affiliation(s)
- Haley K. Perlow
- Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Stephen J. Ramey
- Department of Radiation Oncology, Jackson Memorial Hospital, Miami, Florida, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
| | - Ben Silver
- Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Deukwoo Kwon
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Felix M. Chinea
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
| | - Stuart E. Samuels
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
| | - Michael A. Samuels
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
| | - Nagy Elsayyad
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
| | - Raphael Yechieli
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
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Garcés-Palacio IC, Ramos-Jaraba SM, Rubio-León DC. Health Beliefs Associated with the Follow-Up of Pap Smear Abnormalities Among Low-Income Women in Medellín, Colombia. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2018; 33:417-423. [PMID: 28120138 DOI: 10.1007/s13187-017-1172-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The purpose of the study was to explore variables of the health belief model in relation to the follow-up of abnormal Pap smear among low-income women in Medellín, Colombia. Eight focus groups (62 women) were conducted according to age groups (25-45 and 46-69 years). The data were analyzed using content analysis. The participants perceived themselves as vulnerable, recognized the severity of the disease in terms of both its emotional and physical consequences, perceived the benefits of the follow-up, and mentioned cues to action, such as social support and the support of health entities. Perceived self-efficacy was compromised by health system barriers and by personal barriers, such as placing the needs of their children ahead of their own, fear, neglect, and the pain caused by the diagnostic and therapeutic procedures. Health education activities aimed at increasing the follow-up of abnormal Pap smears should consider psychological factors.
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Affiliation(s)
- Isabel Cristina Garcés-Palacio
- Grupo de Epidemiologia, Facultad Nacional de Salud Pública, Universidad de Antioquia UdeA, Calle 70 No. 52-21, Medellín, Colombia.
| | - Sara Milena Ramos-Jaraba
- Grupo de Epidemiologia, Facultad Nacional de Salud Pública, Universidad de Antioquia UdeA, Calle 70 No. 52-21, Medellín, Colombia
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Inequalities in preventive and restorative dental services in England, Wales and Northern Ireland. Br Dent J 2018; 221:235-9. [PMID: 27608576 DOI: 10.1038/sj.bdj.2016.641] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2016] [Indexed: 11/09/2022]
Abstract
Aims The objective of this study is to assess socioeconomic inequalities in the use of selected dental procedures.Methods Data is from the Adult Dental Health Survey 2009, a nationally representative cross-sectional survey of England, Northern Ireland and Wales. Overall, 6,279 participants were included in the analysis. Occupational classification and education were used to assess variations in the use of preventive, restorative services and tooth extraction using a series of logistic regression models, adjusting for age, sex, ethnicity, DMFT, self-reported oral health, dental visits and country.Results There were clear socioeconomic variations in the utilisation of preventive and restorative services. In the fully adjusted model those with no educational qualification were less likely to report ever having preventive services than those with a degree (OR 0.48, 95%CI: 0.36,0.65). Similarly, individuals in routine/manual occupation were significantly less likely to report ever having preventive services than those in managerial/professional occupation (OR 0.58, 95%CI: 0.46,0.74) in the fully adjusted model.Conclusion The findings imply that despite relatively equitable access and higher use of dental services in UK, the least educated and those at the bottom of social hierarchy are less likely to have preventive and restorative dental services.
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Reuland DS, Brenner AT, Hoffman R, McWilliams A, Rhyne RL, Getrich C, Tapp H, Weaver MA, Callan D, Cubillos L, Urquieta de Hernandez B, Pignone MP. Effect of Combined Patient Decision Aid and Patient Navigation vs Usual Care for Colorectal Cancer Screening in a Vulnerable Patient Population: A Randomized Clinical Trial. JAMA Intern Med 2017; 177:967-974. [PMID: 28505217 PMCID: PMC5710456 DOI: 10.1001/jamainternmed.2017.1294] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Colorectal cancer (CRC) screening is underused, especially among vulnerable populations. Decision aids and patient navigation are potentially complementary interventions for improving CRC screening rates, but their combined effect on screening completion is unknown. OBJECTIVE To determine the combined effect of a CRC screening decision aid and patient navigation compared with usual care on CRC screening completion. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, data were collected from January 2014 to March 2016 at 2 community health center practices, 1 in North Carolina and 1 in New Mexico, serving vulnerable populations. Patients ages 50 to 75 years who had average CRC risk, spoke English or Spanish, were not current with recommended CRC screening, and were attending primary care visits were recruited and randomized 1:1 to intervention or control arms. INTERVENTIONS Intervention participants viewed a CRC screening decision aid in English or Spanish immediately before their clinician encounter. The decision aid promoted screening and presented colonoscopy and fecal occult blood testing as screening options. After the clinician encounter, intervention patients received support for screening completion from a bilingual patient navigator. Control participants viewed a food safety video before the encounter and otherwise received usual care. MAIN OUTCOMES AND MEASURES The primary outcome was CRC screening completion within 6 months of the index study visit assessed by blinded medical record review. RESULTS Characteristics of the 265 participants were as follows: their mean age was 58 years; 173 (65%) were female, 164 (62%) were Latino; 40 (15%) were white non-Latino; 61 (23%) were black or of mixed race; 191 (78%) had a household income of less than $20 000; 101 (38%) had low literacy; 75 (28%) were on Medicaid; and 91 (34%) were uninsured. Intervention participants were more likely to complete CRC screening within 6 months (68% vs 27%); adjusted-difference, 40 percentage points (95% CI, 29-51 percentage points). The intervention was more effective in women than in men (50 vs 21 percentage point increase, interaction P = .02). No effect modification was observed across other subgroups. CONCLUSIONS AND RELEVANCE A patient decision aid plus patient navigation increased the rate of CRC screening completion in compared with usual care invulnerable primary care patients. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02054598.
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Affiliation(s)
- Daniel S Reuland
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill2Division of General Medicine & Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill3Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Alison T Brenner
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill2Division of General Medicine & Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill3Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Richard Hoffman
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City5University of Iowa Holden Comprehensive Cancer Center, University of Iowa, Iowa City6Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque
| | - Andrew McWilliams
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, North Carolina
| | - Robert L Rhyne
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque8University of New Mexico Comprehensive Cancer Center, Albuquerque
| | - Christina Getrich
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque9Department of Anthropology, University of Maryland, College Park
| | - Hazel Tapp
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, North Carolina
| | - Mark A Weaver
- Division of General Medicine & Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill10Department of Biostatistics, University of North Carolina, Chapel Hill
| | - Danelle Callan
- University of New Mexico Comprehensive Cancer Center, Albuquerque
| | - Laura Cubillos
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill
| | | | - Michael P Pignone
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill2Division of General Medicine & Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill3Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill11Department of Internal Medicine, University of Texas Dell Medical School, Austin
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Socioeconomic inequality in the provision of specific preventive dental interventions among children in the UK: Children's Dental Health Survey 2003. Br Dent J 2017; 222:865-869. [DOI: 10.1038/sj.bdj.2017.499] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2017] [Indexed: 11/08/2022]
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Kelly PJ, Hunter J, Daily EB, Ramaswamy M. Challenges to Pap Smear Follow-up among Women in the Criminal Justice System. J Community Health 2017; 42:15-20. [PMID: 27449030 PMCID: PMC5253085 DOI: 10.1007/s10900-016-0225-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Women involved in the United States criminal justice system face a variety of challenges in maintaining their health. Histories of sexual abuse, early initiation of sex, and substance abuse are reflected in more negative reproductive health outcomes, including cervical cancer, than those found among non-incarcerated women. Little is known about how to close this health gap. The present study assessed what incarcerated women perceived to be facilitators and inhibitors of obtaining recommended follow-up for abnormal Pap tests. In-depth individual interviews were conducted with 44 women in an urban county jail about experiences with Pap tests and how they followed-up on abnormal results. We analyzed data using the process of thematic content analysis. Four themes were found, Pap test abnormality as an all-inclusive phrase for women's health problems, unstable lives, the structural challenges of money, and competing demands. Women with criminal justice histories have numerous and complex challenges in following-up abnormal Pap test results, as well as other health problems. Understanding the context around the follow-up for abnormal Pap tests in this population may increase providers' ability to help women effectively obtain cancer prevention care that can be life-saving, as well as to more effectively provide care for other health problems.
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Affiliation(s)
- Patricia J Kelly
- School of Nursing and Health Studies, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO, 64108, USA.
| | - Jennifer Hunter
- School of Nursing and Health Studies, University of Missouri-Kansas City, 2464 Charlotte Street, Kansas City, MO, 64108, USA
| | | | - Megha Ramaswamy
- Department of Preventive Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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Aharon D, Calderon M, Solari V, Alarcon P, Zunt J. Barriers to Follow-Up for Abnormal Papanicolaou Smears among Female Sex Workers in Lima, Peru. PLoS One 2017; 12:e0169327. [PMID: 28060937 PMCID: PMC5217960 DOI: 10.1371/journal.pone.0169327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 12/15/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cervical cancer is the most prevalent cancer among Peruvian women. Female sex workers (FSW) in Peru are at elevated risk for HPV infection, and receive annual Papanicolaou screening. The objective of this study was to identify barriers to follow-up for abnormal Pap smears among FSW in Peru. METHODS 97 FSW attending the Alberto Barton Health Center in Lima were surveyed regarding their STI screening history. 17 women with a history of an abnormal Pap smear were interviewed about their experiences regarding follow-up care. RESULTS Of the 27 HPV-positive women, only 8 (30%) received follow-up treatment. Of the 19 women who did not receive follow-up, 7 (37%) had not been informed of their abnormal result. Qualitative interviews revealed that the major barrier to follow-up was lack of knowledge about HPV and potential health consequences of an abnormal Pap smear. CONCLUSION HPV infection is highly prevalent in Peruvian FSW, yet only 30% of FSW with abnormal Pap smears receive follow-up care. The predominant barriers to follow-up were lack of standardization in recording and communicating results and insufficient FSW knowledge regarding health consequences of HPV infection. Standardization of record-keeping and distribution of educational pamphlets have been implemented to improve follow-up for HPV.
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Affiliation(s)
- Devora Aharon
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
- * E-mail:
| | - Martha Calderon
- Centro de Salud Alberto Barton del Callao, Callao, Lima, Peru
| | - Vicky Solari
- Centro de Salud Alberto Barton del Callao, Callao, Lima, Peru
| | | | - Joseph Zunt
- University of Washington, Seattle, WA, United States
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Vamos CA, Lockhart E, Vázquez-Otero C, Thompson EL, Proctor S, Wells KJ, Daley EM. Abnormal pap tests among women living in a Hispanic migrant farmworker community: A narrative of health literacy. J Health Psychol 2016; 23:1622-1634. [PMID: 27543460 DOI: 10.1177/1359105316664137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study explored narrative responses following abnormal Pap tests among Hispanic migrant farmworkers ( N = 18; ages 22-50 years) via in-depth interviews in Florida. Qualitative analyses utilized health literacy domains (obtain/process/understand/communicate) as a conceptual framework. Participants described how they (1) obtained information about getting a Pap test, (2) processed positive and negative reactions following results, (3) understood results and recommended health-promoting behaviors, and (4) communicated and received social support. Women had disparate reactions and understanding following an abnormal Pap result. Health literacy was a meaningful conceptual framework to understand assets and gaps among women receiving an abnormal Pap test result. Future interventions should incorporate health literacy domains and facilitate patient-provider communications and social support to assist women in decision-making and health-promoting behaviors, ultimately decreasing cancer disparities.
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Affiliation(s)
| | | | | | | | - Sara Proctor
- 2 Catholic Charities Diocese of St. Petersburg, Inc., USA
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Genoff MC, Zaballa A, Gany F, Gonzalez J, Ramirez J, Jewell ST, Diamond LC. Navigating Language Barriers: A Systematic Review of Patient Navigators' Impact on Cancer Screening for Limited English Proficient Patients. J Gen Intern Med 2016; 31:426-34. [PMID: 26786875 PMCID: PMC4803699 DOI: 10.1007/s11606-015-3572-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 06/18/2015] [Accepted: 12/14/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To systematically review the literature on the impact of patient navigators on cancer screening for limited English proficient (LEP) patients. DATA SOURCES Electronic databases (PubMed, PsycINFO via OVID, Web of Science, Cochrane, EMBASE, and Scopus) through 8 May 2015. ELIGIBILITY CRITERIA Articles in this review had: (1) a study population of LEP patients eligible for breast, cervical or colorectal cancer screenings, (2) a patient navigator intervention to provide services prior to or during cancer screening, (3) a comparison of the patient navigator intervention to either a control group or another intervention, and (4) language-specific outcomes related to the patient navigator intervention. STUDY APPRAISAL We assessed the quality of the articles using the Downs and Black Scale. RESULTS Fifteen studies met the inclusion criteria and evaluated the screening rates for breast, colorectal, and cervical cancer in 15 language populations. Fourteen studies resulted in improved screening rates for LEP patients between 7 and 60%. There was great variability in the patient navigation interventions evaluated. Training received by navigators was not reported in nine of the studies and no studies assessed the language skills of the patient navigators in English or the target language. LIMITATIONS This study is limited by the variability in study designs and limited reporting on patient navigator interventions, which reduces the ability to draw conclusions on the full effect of patient navigators. CONCLUSIONS Overall, we found evidence that navigators improved screening rates for breast, cervical and colorectal cancer screening for LEP patients. Future studies should systematically collect data on the training curricula for navigators and assess their English and non-English language skills in order to identify ways to reduce disparities for LEP patients.
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Affiliation(s)
- Margaux C Genoff
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York City, NY, USA
- Department of Psychology, New School for Social Research, New York, NY, USA
| | | | - Francesca Gany
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York City, NY, USA
| | - Javier Gonzalez
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York City, NY, USA
| | - Julia Ramirez
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York City, NY, USA
| | - Sarah T Jewell
- Medical Library, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Lisa C Diamond
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York City, NY, USA.
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Nonzee NJ, Ragas DM, Ha Luu T, Phisuthikul AM, Tom L, Dong X, Simon MA. Delays in Cancer Care Among Low-Income Minorities Despite Access. J Womens Health (Larchmt) 2015; 24:506-14. [PMID: 26070037 DOI: 10.1089/jwh.2014.4998] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Narrowing the racial/ethnic and socioeconomic disparities in breast and cervical cancer requires an in-depth understanding of motivation for adherence to cancer screening and follow-up care. To inform patient-centered interventions, this study aimed to identify reasons why low-income women adhered to or delayed breast or cervical cancer screening, follow-up and treatment despite access to cancer care-related services. METHODS Semistructured qualitative interviews were conducted among women with access to cancer care-related services receiving care at an academic cancer center, federally qualified health centers, or free clinics in the Chicago metropolitan area. Transcripts were coded and analyzed for themes related to rationales for adherence. RESULTS Among 138 participants, most were African American (46%) or Hispanic (36%), English speaking (70%), and between ages 41 and 65 years (64%). Primary drivers of nonadherence included lack of knowledge of resources, denial or fear, competing obligations, and embarrassment. Facilitators included abnormality identification, patient activation, provider-initiated actions, and motivation from family or friends. CONCLUSIONS Interventions targeting increased adherence to care among low-income and ethnic minority women should direct efforts to proactive, culturally and patient-informed education that enables patients to access resources and use the health care system, address misconceptions about cancer, ensure health care providers' communication of screening guidelines, and leverage the patient's social support network.
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Affiliation(s)
- Narissa J Nonzee
- 1 Institute for Public Health and Medicine, Northwestern University , Chicago, Illinois.,2 Robert H. Lurie Comprehensive Cancer Center, Northwestern University , Chicago, Illinois
| | - Daiva M Ragas
- 3 Department of Obstetrics and Gynecology, Northwestern University , Chicago, Illinois
| | - Thanh Ha Luu
- 3 Department of Obstetrics and Gynecology, Northwestern University , Chicago, Illinois
| | - Ava M Phisuthikul
- 3 Department of Obstetrics and Gynecology, Northwestern University , Chicago, Illinois
| | - Laura Tom
- 1 Institute for Public Health and Medicine, Northwestern University , Chicago, Illinois
| | - XinQi Dong
- 4 Rush Institute for Healthy Aging, Rush University Medical Center , Chicago, Illinois
| | - Melissa A Simon
- 1 Institute for Public Health and Medicine, Northwestern University , Chicago, Illinois.,2 Robert H. Lurie Comprehensive Cancer Center, Northwestern University , Chicago, Illinois.,3 Department of Obstetrics and Gynecology, Northwestern University , Chicago, Illinois.,5 Department of Preventive Medicine, Northwestern University , Chicago, Illinois
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Paskett ED, Dudley D, Young GS, Bernardo BM, Wells KJ, Calhoun EA, Fiscella K, Patierno SR, Warren-Mears V, Battaglia TA. Impact of Patient Navigation Interventions on Timely Diagnostic Follow Up for Abnormal Cervical Screening. J Womens Health (Larchmt) 2015; 25:15-21. [PMID: 26625131 DOI: 10.1089/jwh.2014.5094] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Electra D Paskett
- 1 Division of Cancer Prevention and Control, Ohio State University , Columbus, Ohio.,2 Comprehensive Cancer Center, Ohio State University , Columbus, Ohio
| | - Donald Dudley
- 3 Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio , San Antonio, Texas
| | - Gregory S Young
- 4 Center for Biostatistics, Ohio State University , Columbus, Ohio
| | | | - Kristen J Wells
- 5 Department of Psychology, San Diego State University , San Diego, California
| | - Elizabeth A Calhoun
- 6 Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago , Chicago, Illinois
| | - Kevin Fiscella
- 7 Division of Oncology, Department of Family Medicine, Community, and Preventive Medicine, James P. Wilmont Cancer Center, University of Rochester , Rochester, New York
| | - Steven R Patierno
- 8 George Washington University Cancer Institute , Washington, DC.,9 Duke Cancer Institute , Durham, North Carolina
| | - Victoria Warren-Mears
- 10 Northwest Portland Area Indian Health Board, Northwest Tribal Epidemiology Center , Portland, Oregon
| | - Tracy A Battaglia
- 11 Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine , Boston, Massachusetts
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Intrinsic Factors of Non-adherence to Breast and Cervical Cancer Screenings Among Latinas. J Racial Ethn Health Disparities 2015; 3:658-666. [DOI: 10.1007/s40615-015-0184-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 10/17/2015] [Accepted: 10/29/2015] [Indexed: 10/22/2022]
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Driscoll SD. Barriers and facilitators to cervical cancer screening in high incidence populations: A synthesis of qualitative evidence. Women Health 2015; 56:448-67. [DOI: 10.1080/03630242.2015.1101742] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Meyerson BE, Sayegh MA, Davis A, Arno JN, Zimet GD, LeMonte AM, Williams JA, Barclay L, Van Der Pol B. Cervical cancer screening in a sexually transmitted disease clinic: screening adoption experiences from a midwestern clinic. Am J Public Health 2015; 105 Suppl 2:e8-14. [PMID: 25689199 DOI: 10.2105/ajph.2014.302272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined whether a sexually transmitted disease (STD) clinic could reach women who had not received a Papanicolau (Pap) test in the past 3 years. We also explored staff attitudes and implementation of cervical cancer screening. METHODS Women (n = 123) aged 30 to 50 years were offered cervical cancer screening in an Indiana STD clinic. We measured effectiveness by the patients' self-reported last Pap test. We explored adoption of screening through focus groups with 34 staff members by documenting their attitudes about cervical cancer screening and screening strategy adaptation. We also documented recruitment and screening implementation. RESULTS Almost half (47.9%) of participants reported a last Pap test 3 or more years previously; 30% had reported a last Pap more than 5 years ago, and 11.4% had a high-risk test outcome that required referral to colposcopy. Staff supported screening because of mission alignment and perceived patient benefit. Screening adaptations included eligibility, results provision, and follow-up. CONCLUSIONS Cervical cancer screening was possible and potentially beneficial in STD clinics. Future effectiveness-implementation studies should expand to include all female patients, and should examine the degree to which adaptation of selected adoption frameworks is feasible.
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Affiliation(s)
- Beth E Meyerson
- Beth E. Meyerson is with the Indiana University School of Public Health-Bloomington. M. Aaron Sayegh and Alissa Davis are with Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington. Janet N. Arno is with the Marion County Health and Hospital Corporation, Bell Flower Clinic, Indianapolis, IN. Gregory D. Zimet is with the Center for HPV Research, School of Medicine, Indiana University, Indianapolis. Ann M. LeMonte and James A. Williams are with the Infectious Disease Laboratory, Indiana University, Indianapolis. Lynn Barclay is with the American Sexual Health Association, Research Triangle Park, NC. Barbara Van Der Pol is with the University of Alabama, Birmingham
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Farshbaf-Khalili A, Salehi-Pourmehr H, Shahnazi M, Yaghoubi S, Gahremani-Nasab P. Cervical cancer screening in women referred to healthcare centres in Tabriz, Iran. Niger Med J 2015; 56:28-34. [PMID: 25657490 PMCID: PMC4314856 DOI: 10.4103/0300-1652.149167] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Cervical cancer is the second most common cancer among Iranian women and among the few cancers that could be easily diagnosed in the pre-malignant stage. We aimed to assess the status of cervical cancer screening in women referred to health care centres in Tabriz, northwest Iran. MATERIALS AND METHODS This descriptive-analytical study was done on 441 women referred to health care centres of Tabriz, northwest Iran. The centres were selected using the multi-stage cluster sampling method. The participants were selected from the active records of those centres. A questionnaire regarding the socio-demographic characteristics and cervical cancer screening and reasons for referring or not referring for screening was completed by the participants A P < 0.05 was considered as significant. RESULTS Out of the participants 49.4% of women had done the Pap smear test while 50.6% had never done this test. The main reason why women had not performed cervical cancer screening was being unaware of the importance of it (46.1%). Logistic regression analysis with adjustment showed a significant relationship between screening and awareness scores (OR = 1.17, CI = 95%:1.12-1.23), when the effect of other confounding factors [total awareness scores, risk factors (marriage or having sexual intercourse at a young age, history of obvious cervical infection, cautery, cryotherapy or repeated curettage), age and type of family planning] in screening was controlled. CONCLUSION Suitable and continuous educational programmes especially for high risk women should be implemented through the health care services. Preparing educational brochures and pamphlets and providing adequate training on the necessity of early referral and marriage counseling could also be effective in improving woman's awareness and performance.
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Affiliation(s)
- Azizeh Farshbaf-Khalili
- Faculty of Nursing and Midwifery, Research Center of Npmc, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Mahnaz Shahnazi
- Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sina Yaghoubi
- Faculty of Nursing and Midwifery, Tabriz Branch of Islamic Azad University, Tabriz, Iran
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Wieslander CK, Alas A, Dunivan GC, Sevilla C, Cichowski S, Maliski S, Eilber K, Rogers RG, Anger JT. Misconceptions and miscommunication among Spanish-speaking and English-speaking women with pelvic organ prolapse. Int Urogynecol J 2014; 26:597-604. [PMID: 25516231 DOI: 10.1007/s00192-014-2562-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 10/23/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Limited data exist on women's experience with pelvic organ prolapse (POP) symptoms. We aimed to describe factors that prevent disease understanding among Spanish-speaking and English-speaking women. METHODS Women with POP were recruited from female urology and urogynecology clinics in Los Angeles, California, and Albuquerque, New Mexico. Eight focus groups were conducted, four in Spanish and four in English. Topics addressed patients' emotional responses when noticing their prolapse, how they sought support, what verbal and written information was given, and their overall feelings of the process. Additionally, patients were asked about their experience with their treating physician. All interview transcripts were analyzed using grounded theory qualitative methods. RESULTS Qualitative analysis yielded two preliminary themes. First, women had misconceptions about what POP is as well as its causes and treatments. Second, there was a great deal of miscommunication between patient and physician which led to decreased understanding about the diagnosis and treatment options. This included the fact that women were often overwhelmed with information which they did not understand. The concept emerged that there is a strong need for better methods to achieve disease and treatment understanding for women with POP. CONCLUSIONS Our findings emphasize that women with POP have considerable misconceptions about their disease. In addition, there is miscommunication during the patient-physician interaction that leads to further confusion among Spanish-speaking and English-speaking women. Spending more time explaining the diagnosis of POP, rather than focusing solely on treatment options, may reduce miscommunication and increase patient understanding.
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Affiliation(s)
- Cecilia K Wieslander
- Obstetrics and Gynecology, Olive View-UCLA Medical Center, 14445 Olive View Drive, Rm 6D112, Sylmar, CA, 91342, USA,
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Ramachandran A, Freund KM, Bak SM, Heeren TC, Chen CA, Battaglia TA. Multiple barriers delay care among women with abnormal cancer screening despite patient navigation. J Womens Health (Larchmt) 2014; 24:30-6. [PMID: 25513858 DOI: 10.1089/jwh.2014.4869] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND While there is widespread dissemination of patient navigation programs in an effort to reduce delays in cancer care, little is known about the impact of barriers to care on timely outcomes. METHODS We conducted a secondary analysis of the Boston Patient Navigation Research Program (PNRP) to examine the effect that the presence of barriers had on time to diagnostic resolution of abnormal breast or cervical cancer screening tests. We used multivariable Cox proportional hazards regression with time to diagnostic resolution as the outcome to examine the effect of the number of barriers, controlling for demographic covariates and clustered by patients' primary navigator. RESULTS There were 1481 women who received navigation; mean age was 39 years; 32% were White, 27% Black, and 31% Hispanic; 28% had private health insurance; and 38% did not speak English. Overall, half (n=745, 50%) had documentation of one or more barriers to care. Women with barriers were more likely to be older, non-White, non-English language speakers, and on public or no health insurance compared with women without barriers. In multivariable analyses, we found less timely diagnostic resolution as the number of barriers increased (one barrier, adjusted hazard ratio [aHR] 0.81 [95% CI 0.56-1.17], p=0.26; two barriers, aHR 0.55 [95% CI 0.37-0.81], p=0.0025; three or more barriers, aHR 0.31 [95% CI 0.21-0.46], p<0.0001)]. CONCLUSION Within a patient navigation program proven to reduce delays in care, we found that navigated patients with documented barriers to care experience less timely resolution of abnormal cancer screening tests.
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Affiliation(s)
- Ambili Ramachandran
- 1 Women's Health Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine , Boston, Massachusetts
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Reiter PL, Katz ML, Young GS, Paskett ED. Predictors of resolution in navigated patients with abnormal cancer screening tests. THE JOURNAL OF COMMUNITY AND SUPPORTIVE ONCOLOGY 2014; 12:431-8. [PMID: 26288850 PMCID: PMC4545214 DOI: 10.12788/jcso.0094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/14/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patient navigation has been effective in improving cancer care, yet little is known about what predicts timely outcomes in navigated patients. OBJECTIVE To identify predictors of resolution of abnormal cancer screening tests in patients who received navigation. METHODS We examined data on patients with abnormal breast (n = 256) or cervical (n = 150) screening tests or symptoms who received navigation as part of the Ohio Patient Navigator Research Program during 2007-2010. We used multivariable Cox proportional hazards regression models to identify predictors of time to resolution (ie, when a patient's clinical abnormality or abnormal screening test was determined to be a benign condition or a cancer diagnosis). RESULTS The median time to resolution was 183 days for navigated patients with breast abnormalities and 172 days for navigated patients with cervical abnormalities. In patients with breast abnormalities, those who reported at least 1 barrier to care during navigation (HR, 0.66; 95% CI, 0.51-0.86) or higher perceived stress (HR, 0.90; 95% CI, 0.82-0.98) had slower resolution. Among patients with cervical abnormalities, those who reported at least 1 barrier to care during navigation had slower resolution (HR, 0.62; 95% CI, 0.42-0.91). Patients with cervical abnormalities had faster resolution if they had private health insurance, but this effect was present only in younger women (interaction 𝑃 = .003). LIMITATIONS Unknown generalizability of results because patients were female and from clinics in central Ohio. CONCLUSIONS Several variables predicted whether patient navigation led to faster resolution, and predictors differed somewhat by disease site. Results will be useful in improving current patient navigation programs and designing future programs.
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Affiliation(s)
- Paul L Reiter
- Division of Cancer Prevention and Control, College of Medicine; Comprehensive Cancer Center; College of Public Health; The Ohio State University, Columbus, Ohio, USA.
| | - Mira L Katz
- Division of Cancer Prevention and Control, College of Medicine; Comprehensive Cancer Center; College of Public Health; The Ohio State University, Columbus, Ohio, USA
| | - Gregory S Young
- Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Electra D Paskett
- Division of Cancer Prevention and Control, College of Medicine; Comprehensive Cancer Center; College of Public Health; The Ohio State University, Columbus, Ohio, USA
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Pritham UA, Brigdon A, Jones M. Understanding factors related to women's adherence to colposcopy. Nurs Womens Health 2014; 18:402-12. [PMID: 25316540 DOI: 10.1111/1751-486x.12148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Early detection can prevent death from cervical cancer, but success is dependent on women with abnormal cytology attending follow-up procedures, including colposcopy. Factors that influence adherence to colposcopy include age, race, education, socioeconomic status, smoking, chemical dependence, intimate partner violence and anxiety. Comprehension of abnormal Pap smear results and knowledge of current treatment guidelines and follow-up is important in the prevention of cervical cancer. Understanding factors that could inhibit adherence to colposcopy will allow for tailored communication and individualized treatment to prevent colposcopy default. Implementation of colposcopy clinics with designated nurses to track and monitor adherence could help.
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Hernández CM, Wallace D. A profile of Mexican-born women who adhere to national cervical cancer screening recommendations. J Community Health Nurs 2014; 31:157-66. [PMID: 25051321 DOI: 10.1080/07370016.2014.926678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The purpose of this study was to examine Mexican-born women's utilization and adherence to cervical cancer screening guidelines. Ninety-seven women in the southeastern United States participated. Data were collected in Spanish. The majority of women met adherence guidelines for the pap exam. Marital status, educational attainment, marianismo, blood pressure knowledge, fatalism, cultural cancer beliefs, trust in provider, and perceived provider communication abilities were not associated with utilization or adherence to screening guidelines. This study had higher than expected adherence to screening guidelines. Nearly all women received screenings through safety net services indicating the need to advocate for continued public health funding.
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Affiliation(s)
- Christina M Hernández
- a School of Nursing , The University of North Carolina at Greensboro , Greensboro , North Carolina
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Liss DT, Petit-Homme A, Feinglass J, Buchanan DR, Baker DW. Adherence to repeat fecal occult blood testing in an urban community health center network. J Community Health 2014; 38:829-33. [PMID: 23546555 DOI: 10.1007/s10900-013-9685-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Annual fecal occult blood testing (FOBT) has the potential to reduce colorectal cancer mortality, but in practice it is challenging to complete FOBT every year. Repeat FOBT adherence may be especially low in community health center (CHC) settings, where many patients face barriers to annual FOBT completion. We conducted a retrospective cohort analysis to investigate adherence to annual FOBT in an urban CHC network that serves a predominantly Spanish-speaking, uninsured adult patient population. This study used data from the two-year period between January 2010 and December 2011, and included adults aged 50-74 who completed a screening FOBT with a negative result during the first 6 months of 2010. We examined whether each patient completed a second FOBT between 9 and 18 months after the initial negative FOBT, and tested whether repeat FOBT adherence was associated with patient characteristics or the number of clinic visits after the initial negative FOBT. Only 69 of 281 included patients completed repeat FOBT (24.6 % adherence), and none of 62 patients (0 %) with 0 clinic visits completed repeat FOBT. We detected no significant differences in adherence by age, sex, preferred language, insurance status, or number of chronic conditions. In multivariable regression, the adjusted relative risk of repeat FOBT was 1.66 (95 % CI 1.09-2.54; p = 0.02) among patients with 3 or more clinic visits (referent: patients with 1-2 visits). The observed low rate of adherence greatly diminishes the effectiveness of FOBT in reducing CRC mortality. Findings demonstrate the need for systems-based interventions that increase adherence without requiring face-to-face encounters.
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Affiliation(s)
- David T Liss
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611, USA.
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Perceptions of patient-provider communication in breast and cervical cancer-related care: a qualitative study of low-income English- and Spanish-speaking women. J Community Health 2014; 38:707-15. [PMID: 23553683 DOI: 10.1007/s10900-013-9668-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
To explore patient perceptions of patient-provider communication in breast and cervical cancer-related care among low-income English- and Spanish-speaking women, we examined communication barriers and facilitators reported by patients receiving care at safety net clinics. Participants were interviewed in English or Spanish after receiving an abnormal breast or cervical cancer screening test or cancer diagnosis. Following an inductive approach, interviews were coded and analyzed by the language spoken with providers and patient-provider language concordance status. Of 78 participants, 53 % (n = 41) were English-speakers and 47 % (n = 37) were Spanish-speakers. All English-speakers were language-concordant with providers. Of Spanish-speakers, 27 % (n = 10) were Spanish-concordant; 38 % (n = 14) were Spanish-discordant, requiring an interpreter; and 35 % (n = 13) were Spanish mixed-concordant, experiencing both types of communication throughout the care continuum. English-speakers focused on communication barriers, and difficulty understanding jargon arose as a theme. Spanish-speakers emphasized communication facilitators related to Spanish language use. Themes among all Spanish-speaking sub-groups included appreciation for language support resources and preference for Spanish-speaking providers. Mixed-concordant participants accounted for the majority of Spanish-speakers who reported communication barriers. Our data suggest that, although perception of patient-provider communication may depend on the language spoken throughout the care continuum, jargon is lost when health information is communicated in Spanish. Further, the respective consistency of language concordance or interpretation may play a role in patient perception of patient-provider communication.
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Liss DT, Baker DW. Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: the contribution of socioeconomic status and access to care. Am J Prev Med 2014; 46:228-36. [PMID: 24512861 DOI: 10.1016/j.amepre.2013.10.023] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 10/29/2013] [Accepted: 10/31/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prior studies have shown racial/ethnic disparities in colorectal cancer (CRC) screening but have not provided a full national picture of disparities across all major racial/ethnic groups. PURPOSE To provide a more complete, up-to-date picture of racial/ethnic disparities in CRC screening and contributing socioeconomic and access barriers. METHODS Behavioral Risk Factor Surveillance System data from 2010 were analyzed in 2013. Hispanic/Latino participants were stratified by preferred language (Hispanic-English versus Hispanic-Spanish). Non-Hispanics were categorized as White, Black, Asian, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native. Sequential regression models estimated adjusted relative risks (RRs) and the degree to which SES and access to care explained disparities. RESULTS Overall, 59.6% reported being up-to-date on CRC screening. Self-reported CRC screening was highest in the White (62.0%) racial/ethnic group; followed by Black (59.0%); Native Hawaiian/Pacific Islander (54.6%); Hispanic-English (52.5%); American Indian/Alaska Native (49.5%); Asian (47.2%); and Hispanic-Spanish (30.6%) groups. Adjustment for SES and access partially explained disparities between Whites and Hispanic-Spanish (final relative risk [RR]=0.76, 95% CI=0.69, 0.83); Hispanic-English (RR=0.94, 95% CI=0.91, 0.98); and American Indian/Alaska Native (RR=0.91, 95% CI=0.85, 0.97) groups. The RR of screening among Asians was unchanged after adjustment for SES and access (0.78, p<0.001). After full adjustment, screening rates were not significantly different among Whites, Blacks, or Native Hawaiian/Pacific Islanders. CONCLUSIONS Large racial/ethnic disparities in CRC screening persist, including substantial differences between English-speaking versus Spanish-speaking Hispanics. Disparities are only partially explained by SES and access to care. Future studies should explore the low rate of screening among Asians and how it varies by racial/ethnic subgroup and language.
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Affiliation(s)
- David T Liss
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Advancing Equity in Clinical Preventive Services, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - David W Baker
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Advancing Equity in Clinical Preventive Services, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Analysis of patterns of patient compliance after an abnormal Pap smear result: the influence of demographic characteristics on patient compliance. J Low Genit Tract Dis 2014; 17:298-302. [PMID: 23645065 DOI: 10.1097/lgt.0b013e31826b683e] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to determine population characteristics that correlate to suboptimal follow-up after an abnormal cervical cytology result. MATERIALS AND METHODS Nonpregnant women, ages 21 to 65 years, with newly diagnosed abnormal cervical cytology result between January 2009 and January 2012 at an urban clinic were eligible for inclusion in this retrospective chart review. Cervical cytology data and demographic characteristics such as age, ethnicity, employment, marital and smoking status, health insurance and number of pregnancies were abstracted from electronic medical record. A log-linear model was used to determine which factors influenced patient compliance. RESULTS Of the total of 206 women, 78 (37.9%) had optimal follow-up and 128 (62.1%) had suboptimal follow-up. The 3 variables that were statistically significant in influencing patient follow-up after adjusted analyses included severity of cytology result (p = .0013), ethnicity (p = .02), and employment status (p = .0159). The risk ratio for optimal follow-up for those with severe cytology result was 1.81; for the non-whites, 1.77; and for the employed, 1.53. CONCLUSIONS Ethnicity, severity of cervical cytology result, and employment status play an important role in patient follow-up after an abnormal cervical cytology result. Detecting trends in our patient population that influence adherence to follow-up will help health care providers formulate strategies that target this problem.
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Park YS, Park JS. Predictors of Follow-up Screening in Women with Abnormal Pap Smears. ASIAN ONCOLOGY NURSING 2014. [DOI: 10.5388/aon.2014.14.2.84] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Young Suk Park
- Keimyung University Dongsan Medical Center, Daegu, Korea
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DeGroff A, Coa K, Morrissey KG, Rohan E, Slotman B. Key considerations in designing a patient navigation program for colorectal cancer screening. Health Promot Pract 2013; 15:483-95. [PMID: 24357862 DOI: 10.1177/1524839913513587] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Colorectal cancer is the second leading cause of cancer mortality among those cancers affecting both men and women. Screening is known to reduce mortality by detecting cancer early and through colonoscopy, removing precancerous polyps. Only 58.6% of adults are currently up-to-date with colorectal cancer screening by any method. Patient navigation shows promise in increasing adherence to colorectal cancer screening and reducing health disparities; however, it is a complex intervention that is operationalized differently across institutions. This article describes 10 key considerations in designing a patient navigation intervention for colorectal cancer screening based on a literature review and environmental scan. Factors include (1) identifying a theoretical framework and setting program goals, (2) specifying community characteristics, (3) establishing the point(s) of intervention within the cancer continuum, (4) determining the setting in which navigation services are provided, (5) identifying the range of services offered and patient navigator responsibilities, (6) determining the background and qualifications of navigators, (7) selecting the method of communications between patients and navigators, (8) designing the navigator training, (9) defining oversight and supervision for the navigators, and (10) evaluating patient navigation. Public health practitioners can benefit from the practical perspective offered here for designing patient navigation programs.
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Affiliation(s)
- Amy DeGroff
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kisha Coa
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Elizabeth Rohan
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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Dunn S, Rossiter L, Ferne J, Barnes E, Wu W. Improved Adherence to Colposcopy Through Nurse-Led Telephone Counselling and Multifaceted Patient Support. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013; 35:723-729. [DOI: 10.1016/s1701-2163(15)30863-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Communication barriers among Spanish-speaking women with pelvic floor disorders: lost in translation? Female Pelvic Med Reconstr Surg 2013; 19:157-64. [PMID: 23611934 DOI: 10.1097/spv.0b013e318288ac1c] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of our study was to evaluate barriers in communication and disease understanding among office staff and interpreters when communicating with Spanish-speaking women with pelvic floor disorders. METHODS We conducted a qualitative study to evaluate barriers to communication with Spanish-speaking women with pelvic floor disorders among office staff and interpreters. Sixteen office staff and interpreters were interviewed; interview questions focused on experiences with Spanish-speaking patients with pelvic floor disorders in the clinic setting. Interview transcripts were analyzed qualitatively using grounded theory methodology. RESULTS Analysis of the interview transcripts revealed several barriers in communication as identified by office staff and interpreters. Three major classes were predominant: patient, interpreter, and system-related barriers. Patient-related barriers included a lack of understanding of anatomy and medical terminology and inhibited discussions due to embarrassment. Provider-related barriers included poor interpreter knowledge of pelvic floor vocabulary and the use of office staff without interpreting credentials. System-related barriers included poor access to information. From these preliminary themes, an emergent concept was revealed: it is highly likely that Spanish-speaking women with pelvic floor disorders have poor understanding of their condition owing to multiple obstacles in communication. CONCLUSIONS There are many levels of barriers to communications with Latin women treated for pelvic floor disorders, arising from the patient, interpreter, and the system itself. These barriers contribute to a low level of understanding of their diagnosis, treatment options, and administered therapies.
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Gauss JW, Mabiso A, Williams KP. Pap screening goals and perceptions of pain among black, Latina, and Arab women: steps toward breaking down psychological barriers. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2013; 28:367-74. [PMID: 23288606 PMCID: PMC3634871 DOI: 10.1007/s13187-012-0441-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Understanding women's psychological barriers to getting Papanicolaou (Pap) screening has potential to impact cancer disparities. This study examined pain perceptions of Pap testing among black, Latina, and Arab women and goal setting to receive Pap tests. Data on 420 women, in a longitudinal study, were analyzed using Chi-square tests of differences and generalized linear mixed models. At baseline, 30.3 % of black and 35.5 % of Latina women perceived Pap tests to be very painful compared to 24.2 % of Arab women. Perceptions of pain influenced goal settings, such as scheduling a first ever Pap test (odds ratio=0.58, 95 % confidence interval 0.14-0.94). Immediately following the intervention, women's perception that Pap tests are very painful significantly declined (P value <0.001) with Arab and black women registering the greatest improvements (20.3 and 17.3 % reduction, respectively, compared to 8.4 % for Latina). Having the perception that the Pap test is very painful significantly reduces the likelihood of black, Latina, and Arab women setting the goal to schedule their first ever Pap test. Latina women are the least likely to improve their perception that the Pap test is very painful, though national statistics show they have the highest rates of morbidity and mortality from cervical cancer. These findings are instructive for designing tailored interventions to break down psychological barriers to Pap screening among underserved women.
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Affiliation(s)
- Julie W Gauss
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
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Tejeda S, Darnell JS, Cho YI, Stolley MR, Markossian TW, Calhoun EA. Patient barriers to follow-up care for breast and cervical cancer abnormalities. J Womens Health (Larchmt) 2013; 22:507-17. [PMID: 23672296 DOI: 10.1089/jwh.2012.3590] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Silvia Tejeda
- Institute for Health Research and Policy, School of Public Health, University of Illinois at Chicago, Chicago, Illinois 60608, USA.
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