Using the word 'cancer' in communication about an abnormal Pap test: finding common ground with patient-provider communication

Referring patients with suspected lung cancer: a qualitative study with primary healthcare professionals in Ireland

Lung cancer is the leading cause of cancer death globally. Most cases are diagnosed late. Primary healthcare professionals are often the first point of contact for symptoms of concern. This study explored primary healthcare professionals’ experience of referring individuals with signs and symptoms suggestive of lung cancer along the appropriate healthcare pathway and explored strategies to help primary healthcare professionals detect lung cancer early. Focus groups and individual interviews were conducted with 36 general practitioners, community pharmacists, practice nurses, and public health nurses. Data were analysed thematically. Participants identified typical lung cancer signs and symptoms such as cough and coughing up blood (i.e., haemoptysis) as triggers for referral. Atypical/non-specific signs and symptoms such as back pain, pallor, and abnormal blood tests were perceived as difficult to interpret. Participants often refrained from using the word ‘cancer’ during conversations with patients. Ireland’s Rapid Access Lung Clinics were perceived as underused, with some general practitioners referring patients to these clinics only when clear and definitive lung cancer signs and symptoms are noted. Lack of communication and the resulting disruption in continuity of care for patients with suspected lung cancer were highlighted as healthcare system flaws. Education on early referral can be in the form of communications from professional organizations, webinars, interdisciplinary meetings, education by lung specialists, and patient testimonials. Lung cancer referral checklists and algorithms should be simple, clear, and visually appealing, either developed as standalone tools or embedded into existing primary care software/programmes.

Malnutrition: A Misunderstood Diagnosis by Primary Care Health Care Professionals and Community-Dwelling Older Adults in Ireland

BACKGROUND

Language and communication have an impact on how a clinical condition is treated and experienced, from both the health care professional (HCP) and patient perspective. Malnutrition is prevalent among community-dwelling older adults, yet perceptions of patient understanding of the term malnutrition to date remain underexplored.

OBJECTIVE

This qualitative study explored the use and perceptions of the term malnutrition among HCPs and older adults at risk of malnutrition.

DESIGN

Semi-structured interviews and focus groups were conducted with HCPs and older adults with a prescription for oral nutritional supplements (ONS) in the community, to explore perspectives.

PARTICIPANTS AND SETTING

HCPs with experience of working with older adults were recruited in primary care centers, general practitioner practices, community health organizations, and community pharmacies in County Dublin, Ireland, between 2018 and 2019. Older adults, aged ≥60 years, with a current or previous prescription for ONS were recruited from daycare centers. One-to-one interviews were conducted with general practitioners (n = 16) and patients (n = 13), and focus groups were conducted with other HCPs, including dietitians (n = 22), nurses (n = 22), pharmacists (n = 9), physiotherapists (n = 12), occupational therapists (n = 6), and speech and language therapists (n = 4).

DATA ANALYSIS

Data from interviews and focus groups were transcribed verbatim and analyzed using thematic analysis.

RESULTS

There was mutual agreement between HCPs and patients on the main theme, "malnutrition is a term to be avoided." There were three subthemes with varying input from the different HCP groups and patients: "Malnutrition is a term a patient doesn't want to hear"-malnutrition has negative connotations that imply neglect and stigma; "malnutrition is a clinical term which patients don't understand"-with perceptions that it is better to substitute the term with simpler motivating messages; and "lack of confidence identifying malnutrition"-expressed by non-dietetics HCPs who believed they had insufficient expertise on malnutrition to communicate effectively with patients.

CONCLUSIONS

HCPs and patients perceived negative connotations with the term malnutrition, and HCPs used alternatives in practice. Additional consultation with HCPs and patients is recommended to explore appropriate language for conveying health risks associated with malnutrition. Future research should also address how current communication challenges can be addressed as part of strategic management programs or interventions to prevent and treat malnutrition.

The Cervical Dysplasia Worksheet: A Longitudinal Map of Cervical Dysplasia Cytology and Histology Tests and Procedures

OBJECTIVE

Our objectives were to describe the Cervical Dysplasia Worksheet (CDW), provide evidence of its feasibility to view patient cervical dysplasia results over time, and evaluate patient attitudes toward the tool in the setting of abnormal result follow-up.

MATERIALS AND METHODS

The CDW augments the ASCCP guidelines for managing abnormal cervical cancer screenings by visually depicting cervical cytological and histological history along a color gradient showing severity. We evaluated tool feasibility by graphing a retrospectively reviewed convenience sample of patient data. A cross-sectional evaluation of the tool was then performed to assess patient attitudes in the setting of either dysplasia or colposcopy clinic. Patients had their data graphed on the CDW and explained to them before their clinical encounter. They then gave general comments about the tool and filled out a short evaluation survey.

RESULTS

The large majority of retrospective patient data (N = 167) fit well within the CDW with roughly 20% requiring space for additional comments. Among the 30 patients who participated in our evaluation, almost all agreed (n = 29, 96.7%) that the tool helped them understand their history and results and that they would use the tool in the future.

CONCLUSIONS

The CDW is a novel tool to display a patient's cervical dysplasia history to visualize treatment and future care while enhancing patient-provider communication. Patient evaluation of the tool was largely positive, and suggestions will be taken into consideration for future modification. Further evaluation of the CDW among healthcare providers is needed to analyze its efficacy in the clinical setting.

Health care informational challenges for women diagnosed with cervical intraepithelial neoplasia: a qualitative study

Background

Internationally, women with cervical intraepithelial neoplasia (CIN) lack knowledge about their disease, which limits their ability to take responsibility for self-care and creates negative psychosocial effects, including marital problems. Normally, screening is performed in primary care, and in case of abnormal results, the patient is referred to specialized care for follow-up and treatment. Given the lack of international literature regarding patients’ experiences in primary and specialized healthcare, our study aims to: (a) investigate how women with CIN perceive the communication and management of information by healthcare providers at different moments of their healthcare and (b) identify these women’s informational needs.

Methods

A qualitative exploratory study was carried out in a gynecology unit of a public hospital of the Galician Health Care Service (Spain). Participants were selected through purposive sampling. The sample consisted of 21 women aged 21 to 52 years old with a confirmed diagnosis of CIN. Semistructured interviews were recorded and transcribed. A thematic analysis was carried out, including triangulation of researchers for analysis verification.

Results

Two analytical themes were identified. The first was communication gaps in the diagnosis and management of information in primary and specialized healthcare. These gaps occurred in the following moments of the healthcare process: (a) cervical cancer screening in primary care, (b) waiting time until referral to specialized care, (c) first consultation in specialized care, and (d) after consultation in specialized care. The second theme was participants’ unmatched informational needs. The doubts and informational needs of women during their healthcare process related to the following subthemes: (a) HPV transmission, (b) HPV infection symptoms and consequences, and (c) CIN treatment and follow-up.

Conclusions

This study shows that women who have a diagnosis of CIN experience important healthcare informational challenges when accessing primary and specialized care that have several implications for their wellbeing. The information given is limited, which makes it difficult for women to understand and participate in the decision making regarding the prevention and treatment of CIN. Service coordination among different levels of care and the availability of educational materials at any given time would improve the patients’ healthcare experience.

Direct notification of cervical cytology results to women improves follow-up in cervical cancer screening - A cluster-randomised trial

Up to half of all women do not receive follow-up as recommended after cervical cytology testing and are thus at increased risk of dysplasia progression. Women from lower social positions are at increased risk of not receiving follow-up. Sample takers, often general practitioners, convey results to women, but communication problems constitute a challenge. We aimed to investigate the effect of direct notification of cervical cytology results on follow-up rates. In a 1:1 cluster-randomised controlled trial, we assessed if having the pathology department convey cervical cytology results directly to the investigated women improved timely follow-up, compared with conveying the results via the general practitioner as usual. All women with a cervical cytology performed in a general practice in the Central Denmark Region (2013-2014) and receiving follow-up recommendation were included (n = 11,833). The proportion of women without timely follow-up was lower in the group with direct notifications than in the control group of women receiving usual care, regardless of age, educational status, cohabitation status and ethnicity. Among the women with the most severe cervical cytology diagnoses who are recommended gynaecological follow-up within 3 months, the percentage without timely follow-up was 15.1% in the intervention group and 19.5% in the control group (prevalence difference: -0.04 (95%CI: -0.07; -0.02)). Improved timely follow-up was also observed for women with a recommendation to have follow-up performed at 3 and 12 months. Cervical cytology results conveyed directly by letter to women increased the proportion of women with timely follow-up without raising inequality in follow-up measured by social position. Trial registration: ClinicalTrials.gov (TRN: NCT02002468) 29 November 2013.

Efficacy of Cancer Care Communication Between Clinicians and Latino Patients in a Rural US-Mexico Border Region: a Qualitative Study of Barriers and Facilitators to Better Communication

Quality of clinician-patient cancer communication is vital to cancer care and survivorship. Racial/ethnic minority patients in rural regions may have unique characteristics including cultural beliefs, language barriers, and low health literacy which require effective cross-cultural cancer communication. Despite the growing US population of racial/ethnic minorities and widespread emphasis on culturally appropriate health communication, little is known about challenges and facilitators of cancer communication among underserved rural Latino cancer patients in the US-Mexico border region. This study conducted secondary data analysis of interview data collected from 22 individual cancer patients living on the US side of the US-Mexico border. Thematic analysis was conducted to explore a priori questions regarding patient experiences with cancer care communication with their providers. Emerging themes included lack of language concordance, patient perspectives on clarity and accuracy of information provided, patient perceptions on provider sensitivity in giving cancer diagnosis, and improving the clinical interpersonal relationship. Practice guidelines are suggested and discussed. These findings illuminate the importance of advancing improvement of cancer communication between clinicians and Spanish language-dominant Latinos.

Abnormal pap tests among women living in a Hispanic migrant farmworker community: A narrative of health literacy

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.

Factors associated with receiving Pap tests among married immigrant women of Vietnamese origin in southern Taiwan

The purpose of this study was to explore the factors associated with Pap testing among married immigrant women of Vietnamese origin residing in Taiwan, including demographics, knowledge of cervical cancer, knowledge of Pap tests, fatalism, attitudes toward cervical cancer, and barriers to receiving Pap tests. A cross-sectional correlational design was used. Data were collected from July 2012 to January 2013. Participants were recruited through snowball sampling in two communities in Southern Taiwan. A total of 451 married immigrant women of Vietnamese origin aged 30 years and over were invited to participate in the study and 427 participated. Data analysis included descriptive statistics and multivariate logistic regression. Participants with no children were significantly less likely to have received a Pap test (odds ratio = 0.278, 95% confidence interval [CI] = 0.135-0.569); each additional point of knowledge about Pap tests increased the likelihood of having a Pap test by 19% (odds ratio = 1.190, 95% CI = 1.093-1.297), and each additional point in barriers to receiving Pap tests decreased the chances of having received a Pap test (odds ratio = 0.714, 95% CI = 0.637-0.800). The results can provide governments with a reference for developing policies for cervical cancer prevention among married immigrant Vietnamese women.

A feminist information engagement framework for gynecological cancer patients

Purpose

– The purpose of this paper is to present a three-part framework of information engagement for situated gynecological cancers. These particular cancers intertwine with medicalization of sexuality and gender power dynamics, situating information behaviors and interactions in women’s socio-health perceptions. Using Kavanagh and Broom’s feminist risk framework, the framework establishes functional and temporal parameters for sense-making and information engagement.

Design/methodology/approach

– This paper employs a structured, reiterative literature review with emergent thematic analysis. Nine indices from medicine, information studies, and sociology were searched using combinations of five terms on cervical cancer (CC) and 14 terms on information engagement in the title, abstract, and subject fields. Results were examined on a reiterative basis to identify emergent themes pertaining to knowledge development and information interactions.

Findings

– Environmentally, social stigma and gender roles inhibit information seeking; normalizing CC helps integrate medical, moral, and sexual information. Internally, living with the dichotomy between “having” a body and “being” a body requires high-trust information resources that are presented gradually. Actively, choosing to make or cede medical decision-making requires personally relevant information delivered in the form of concrete facts and explanations.

Research limitations/implications

– The study covers only one country.

Originality/value

– This study’s information framework and suggestions for future research encourage consideration of gender power dynamics, medicalization of sexuality, and autonomy in women’s health information interactions.

The development of a brief jail-based cervical health promotion intervention

The primary objective of this article was to describe the development and pilot implementation of a brief jail-based cervical health promotion intervention. The intervention was guided by a preliminary study of incarcerated women's cervical health knowledge, awareness, and health literacy, as well as a social and feminist approach to intervention development. We developed and conducted a pilot implementation of the Sexual Health Empowerment Project to increase cervical health knowledge, reduce barriers related to beliefs about cervical cancer, and improve self-efficacy and confidence in navigating health systems. This article offers a framework for how empirically and theory-based interventions are developed and tailored for a jail setting. Future work should include the evaluation of the long-term effects of such a disease-specific program on health behaviors and outcomes among high-risk and vulnerable groups of women as they leave jails and enter communities.

What women want: patient recommendations for improving access to breast and cervical cancer screening and follow-up

BACKGROUND

The patient voice remains underrepresented in clinical and public health interventions. To inform interventions that strive to improve access to breast and cervical cancer screening and follow-up among low-income populations, we explored recommendations from low-income women pursuing health care in the safety net.

METHODS

Semi-structured interviews were conducted among women receiving follow-up care for an abnormal breast or cervical cancer screening result or a positive cancer diagnosis in federally qualified health centers, free clinics, or an academic cancer center in the Chicago metropolitan area.

FINDINGS

Of the 138 women interviewed in the parent study, 52 women provided recommendations for improving access to screening and follow-up care. Most were between 41 and 65 years old (62%) and African American (60%) or White (25%). Recommendations included strengthening community-based health education with more urgent messaging, strategic partnerships, and active learning experiences to increase patient engagement, which women regarded as a key driver of access. Women also suggested increasing access by way of changes to health care delivery systems and policy, including more direct patient-provider and patient-clinic communications, addressing delays caused by high patient volume, combining preventive services, expanding insurance coverage, and adjusting screening guidelines.

CONCLUSIONS

This exploratory study demonstrates important insights from the patient lens that may help to increase the acceptability and efficacy of community and clinical interventions aimed at improving access to breast and cervical cancer screening and follow-up. Further research is needed to identify appropriate integration of patient input into interventions, practice, and policy change.

Barriers to cervical cancer screening and follow-up care among Black Women in Massachusetts

OBJECTIVE

To explore factors that might lead to delays in appropriate cervical cancer screening and diagnosis among Black women in Massachusetts.

DESIGN

Qualitative using focus groups.

SETTING

Hospitals, health centers, and community-based organizations in Boston, Massachusetts.

PARTICIPANTS

Sixty-four participants including Black, non-Hispanic women from the general population and cervical cancer survivors, community leaders in women's health, and health care providers.

METHODS

Six focus groups. Data were analyzed using methods based on grounded theory.

RESULTS

Findings from interviews revealed that inadequate information and education of providers and patients create barriers to appropriate screening and treatment practices for Black women. Fear, cultural beliefs, and compounding factors related to poverty, gender roles, and health system barriers create delays to screening and follow-up care. Also, unconscious bias, therapeutic delays, and miscommunication are important factors affecting continuity of care.

CONCLUSION

These results suggest a need for comprehensive, culturally specific cervical cancer prevention education initiatives and interventions for Black women and strategies to improve patient-provider relationships.

Factors Associated With Adherence to Follow-up Colposcopy

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRANSLATION TO HEALTH EDUCATION PRACTICE

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

What do you mean, a spot?: A qualitative analysis of patients' reactions to discussions with their physicians about pulmonary nodules

BACKGROUND

More than 150,000 Americans each year are found to have a pulmonary nodule. Even more will be affected following the publication of the National Lung Screening Trial. Patient-doctor communication about pulmonary nodules can be challenging. Although most nodules are benign, it may take 2 to 3 years to rule out cancer. We sought to characterize patients’ perceptions of communication with their providers about pulmonary nodules.

METHODS

We conducted four focus groups at two sites with 22 adults with an indeterminate pulmonary nodule. Transcripts were analyzed using principles of grounded theory.

RESULTS

Patients described conversations with 53 different providers about the pulmonary nodule. Almost all patients immediately assumed that they had cancer when first told about the nodule. Some whose providers did not discuss the actual cancer risk or explain the evaluation plan experienced confusion and distress that sometimes lasted for months. Patients were frustrated when their providers did not address their concerns about cancer or potential adverse effects of surveillance (eg, prolonged uncertainty, radiation exposure), which in some cases led to poor adherence to evaluation plans. Patients found it helpful when physicians used lay terms, showed the CT image, and quantified cancer risk. By contrast, patients resented medical jargon and dismissive language.

CONCLUSIONS

Patients commonly assume that a pulmonary nodule means cancer. What providers tell (or do not tell) patients about their cancer risk and the evaluation plan can strongly influence patients’ perceptions of the nodule and related distress. We describe simple communication strategies that may help patients to come to terms with an indeterminate pulmonary nodule.