The accuracy of self-reported Pap smear utilisation

Social inequalities in participation in cancer screening: does the mode of data collection matter? The CONSTANCES cohort

BACKGROUND

Self-reported data are prone to item non-response and misreporting. We investigated to what extent the use of self-reported data for participation in breast (BCS) and cervical cancer screening (CCS) impacted socioeconomic inequalities in cancer screening participation.

METHODS

We used data from a large population-based survey including information on cancer screening from self-reported questionnaire and administrative records (n = 14 122 for BCS, n = 27 120 CCS). For educational level, occupation class and household income per capita, we assessed the accuracy of self-reporting using sensitivity, specificity and both positive and negative predictive value. In addition, we estimated to what extent the use of self-reported data modified the magnitude of socioeconomic differences in BCS and CCS participation with age-adjusted non-screening rate difference, odds ratios and relative indices of inequality.

RESULTS

Although women with a high socioeconomic position were more prone to report a date for BCS and CCS in questionnaires, they were also more prone to over-declare their participation in CCS if they had not undergone a screening test within the recommended time frame. The use of self-reported cancer screening data, when compared with administrative records, did not impact the magnitude of social differences in BCS participation but led to an overestimation of the social differences in CCS participation. This was due to misreporting rather than to item non-response.

CONCLUSIONS

Women's socioeconomic position is associated with missingness and the accuracy of self-reported BCS and CCS participation. Social inequalities in cancer screening participation based on self-reports are likely to be overestimated for CCS.

“Taking responsibility for my health”: Health system barriers and women’s attitudes toward cervical cancer screening in Romania and Bulgaria

The study used mixed-methods to illustrate the complexity of the interplay between the contexts in Bulgaria and Romania and women’s attitudes and behaviors related to screening. A secondary analysis of quantitative data from Romanian (n = 1053) and Bulgarian (n = 1099) women and qualitative interviews ( n = 30 Romanian, n = 35 Bulgarian) was performed. Low rates of screening attendance were found in both countries. Regression analysis illustrates that attitudes and social norms significantly predicted intentions and screening behavior in both countries. Thematic analysis revealed that systemic barriers and cultural meanings were relevant to women’s decisions to attend screening or avoid contact with the health-care system.

Human Papillomavirus Vaccination and Pap Smear Uptake Among Young Women in the United States: Role of Provider and Patient

BACKGROUND

It has been reported that Pap smear use is higher among U.S. women who received the human papillomavirus (HPV) vaccine than unvaccinated women. This study assessed the role of provider and patient in the difference of Pap smear use by vaccination status.

METHODS

We conducted a cross-sectional study of 5416 young women (21-30 years of age) with detailed information on Pap smear use and HPV vaccination status from the National Health Interview Survey (NHIS) 2013-2015. Vaccinated women received at least one dose of HPV vaccine. Main outcomes included Pap smear in the past year, provider's recommendation for Pap smear, and patient-initiated Pap smear.

RESULTS

The prevalence of Pap smear in the past year was much higher among vaccinated women than unvaccinated women (67.5% vs. 52.8%, p < 0.001). Compared with unvaccinated women, vaccinated women were more likely to receive a provider's recommendation for Pap testing (60.8% vs. 50.8%, p < 0.001), to obtain Pap testing after receiving a provider's recommendation (75.1% vs. 67.9%, p = 0.004), and to initiate Pap testing themselves (57.7% vs. 38.2%, p < 0.001). However, among women who visited an obstetrician/gynecologist (OB/GYN) in the past year, the positive association between HPV vaccination and Pap smear recommendation and uptake vanished.

CONCLUSIONS

Unvaccinated women who have not visited an OB/GYN in the past year are less likely to receive a recommendation for Pap testing from their providers or to initiate Pap testing themselves without a provider's recommendation. They should be encouraged to visit an OB/GYN provider for cervical cancer screening.

Understanding Transgender Men's Experiences with and Preferences for Cervical Cancer Screening: A Rapid Assessment Survey

PURPOSE

Transgender men are less likely than cisgender women to receive cervical cancer screening. The purpose of the current study was to understand experiences with and preferences for cervical cancer screening among transgender men.

METHODS

Ninety-one transgender men ages 21-63 completed the survey. The survey evaluated experiences with and preferences for screening, including opinions regarding human papillomavirus (HPV) self-sampling as a primary cervical cancer screening.

RESULTS

Half (50.5%) of participants did not have Pap smear screening within the past 3 years. The majority (57.1%) of participants preferred HPV self-sampling over provider-collected Pap smear screening. Participants who reported discrimination were more likely to prefer HPV self-sampling (odds ratio = 3.29, 95% confidence interval 1.38-7.84, P = 0.007).

CONCLUSION

Primary HPV testing via HPV self-sampling may improve cervical cancer screening uptake among transgender men. Future work should pilot this innovative cervical cancer screening method within this population.

Cervical cancer screening among women ≥70 years of age in the United States-A referral problem or patient choice

OBJECTIVE

Clinical guidelines recommend that women with a history of adequate screening and not otherwise at high risk may discontinue cervical cancer screening after 65 years of age. However, screening remains common among US women over 65 years old. This study was conducted to examine whether overutilization was attributable to provider's recommendation or patient choice.

METHOD

This cross-sectional study used data from 1752 female participants (70+ years) from the 2013 National Health Interview Survey (NHIS). We quantitatively assessed the proportions of provider-recommended and patient self-initiated Pap smears.

RESULTS

Among female respondents, 40.8% had a Pap smear within the past 3 years, 19.4% had a Pap smear in the last year, and 39.7% reported receiving a recommendation for a Pap smear from their provider in the past year. Among women who received a recommendation to obtain a Pap smear, 39.8% did so within the past 12 months compared to 5.9% of women who did not receive a recommendation (adjusted odds ratio 10.5, 95% confidence interval 7.39-15.0). About 70% of women who visited an obstetrician/gynecologist and reported receiving a recommendation to have a Pap smear did so in the past year, while 32.3% of women who visited an obstetrician/gynecologist but did not receive a recommendation obtained one.

CONCLUSION

Pap smears were common among women ≥70 years of age. Health care providers may need additional education on current guidelines regarding indications for Pap smears in this age group to help reduce screening of patients who may not benefit.

Effects of Cardiovascular Disease on Compliance with Cervical and Breast Cancer Screening Recommendations Among Adult Women

BACKGROUND

Cardiovascular disease (CVD) is common among women and is a leading cause of death in the United States. This study assessed the impact of CVD on compliance with the US Preventive Services Task Force guidelines for cervical and breast cancer screening among U.S. adult women.

METHODS

A cross-sectional study was conducted on 17,408 women using data from the National Health Interview Survey 2013. A total of 11,788 respondents (21-65 years old) with complete information on Pap smear and 11,409 women (40+ years old) with complete information on mammography compliance were included. Multivariate logistic regression models were used to assess the impact of CVD on cervical and breast cancer screening practices.

RESULTS

Women with CVD were marginally more likely to have had a mammogram in accordance with guidelines (odds ratio 1.17; 95% confidence interval 1.04-1.31) than those without CVD. However, compliance with Pap tests was similar (80.6% vs 82.3%, p>0.05) between the two groups. Myocardial infarction was associated with reduced odds of Pap smear compliance (odds ratio: 0.30; 95% confidence interval 0.18-0.51).

CONCLUSIONS

Women with prior myocardial infarction should be encouraged to continue receiving regular Pap smears. More research is needed to assess whether observed differences in Pap testing between patients with and without a history of myocardial infarction result from lack of provider recommendation or from patient noncompliance with their recommendations.

Attendance at cervical cancer screening and use of diagnostic and therapeutic procedures on the uterine cervix assessed from individual health insurance data (Belgium, 2002-2006)

Objective

To assess the coverage for cervical cancer screening as well as the use of cervical cytology, colposcopy and other diagnostic and therapeutic interventions on the uterine cervix in Belgium, using individual health insurance data.

Methods

The Intermutualistic Agency compiled a database containing 14 million records from reimbursement claims for Pap smears, colposcopies, cervical biopsies and surgery, performed between 2002 and 2006. Cervical cancer screening coverage was defined as the proportion of women aged 25–64 that had a Pap smear within the last 3 years.

Results

Cervical cancer screening coverage was 61% at national level, for the target population of women between 25 and 64 years old, in the period 2004–2006. Differences between the 3 regions were small, but varied more substantially between provinces. Coverage was 70% for 25–34 year old women, 67% for those aged 35–39 years, and decreased to 44% in the age group of 60–64 years. The median screening interval was 13 months. The screening coverage varied substantially by social category: 40% and 64%, in women categorised as beneficiary or not-beneficiary of increased reimbursement from social insurance, respectively. In the 3-year period 2004–2006, 3.2 million screen tests were done in the target group consisting of 2.8 million women. However, only 1.7 million women got one or more smears and 1.1 million women had no smears, corresponding to an average of 1.88 smears per woman in three years of time. Colposcopy was excessively used (number of Pap smears over colposcopies = 3.2). The proportion of women with a history of conisation or hysterectomy, before the age of 65, was 7% and 19%, respectively.

Conclusion

The screening coverage increased slightly from 59% in 2000 to 61% in 2006. The screening intensity remained at a high level, and the number of cytological examinations was theoretically sufficient to cover more than the whole target population.

Factors associated with cervical cancer screening uptake among Inuit women in Nunavik, Quebec, Canada

BACKGROUND

The Canadian circumpolar Inuit population has a higher incidence rate of cervical cancer than the general population and the majority of cases occur among underscreened women. The objectives of this study were to determine Pap smear utilization rates and to determine factors associated with time-inappropriate use of cervical cancer screening among a cohort of Inuit women from Nunavik, Quebec, Canada.

METHODS

This study utilizes baseline information collected from a cohort formed between January 2002 and December 2007 to study the natural history of HPV among Inuit women aged 21-69 years in Nunavik, Quebec. Cervical cancer screening history and other variables were obtained from a baseline questionnaire and medical chart review. Unconditional logistic regression was used to estimate the odds ratios and 95% confidence intervals for potential predictors of not having a Pap smear within the previous 3 years prior to cohort entry.

RESULTS

A total of 403 Inuit women who had a baseline questionnaire and chart review were included. The mean age of the study population was 34.2 years. In the three years prior to study entry, 25% of women did not have a Pap smear. Older age and never giving birth were significant predictors of time-inappropriate Pap smear use.

CONCLUSIONS

Our results suggest that older women and women who are not accessing reproductive care have a lower compliance with time-appropriate cervical cancer screening and future research should address potential strategies to increase screening coverage among this group.

Women with safety concerns report fewer gender-specific preventive healthcare services

BACKGROUND

Violence and safety exposures, primarily in the form of intimate partner violence (IPV) exposures, have been associated with increased healthcare utilization in women and variable associations with preventive services. It remains unknown, however, if broader measures of violence and safety exposures are associated with preventive healthcare utilization.

METHODS

Data from the 2004 The Philadelphia Health Management Corporation survey were used to compare self-reported utilization of preventive healthcare services for participants who did and did not report exposures to violence or have safety concerns during the past year, using novel but nonvalidated measures of violence and safety concerns. The sample included women aged 18-96 years who reported having a usual source of care. Measures of preventive healthcare utilization included timing of last mammogram, cervical cytology, breast examination, blood cholesterol testing, blood pressure measurement, and screening for colon cancer.

RESULTS

The survey had an American Association for Public Opinion Research response rate of 30.4%. Of the 6285 women surveyed who reported having a usual source of care, 456 (7.3%) reported either an exposure to violence or safety concerns, and 5821 did not. Using logistic regression models, women aged 18-65 years who reported safety concerns were less likely to report having cervical cancer testing in the past 12 months (OR 0.68, 95% CI 0.49-0.94). Women > or =40 years who reported safety concerns in the last year were less likely to report having clinical breast examinations (OR 0.63, 95% CI 0.43-0.93) or mammography (OR 0.57, 95% CI 0.39-0.83). Physical violence exposure was not significantly associated with preventive healthcare utilization.

CONCLUSIONS

In this large population-based sample, women with recent self-reported safety concerns report receiving fewer recommended gender-specific preventive services.

Inequalities in cervical cancer screening for women with or without a regular consulting in primary care for gynaecological health, in Paris, France

OBJECTIVES

To describe the individual characteristics associated with the absence of cervical smear (CCST); to investigate the role of residential neighbourhood, particularly practitioner density; and to explore changes in individual and contextual determinants after taking regular consulting in primary care for gynaecological health (RCGH) into account.

DATA

1843 adult women from the SIRS survey conducted in 2005 in the Paris metropolitan area. Multilevel logistic regressions analysed factors associated with never-screening.

RESULTS

10% of the women had never undergone CCST. Being single, less educated, of foreign origin, with no children, and without health insurance, having never worked, having never undergone a serious health problem and/or having nobody in their circle with cancer were associated with no CCST. Once adjusted on individual characteristics, living in a middle- (OR=1.95; IC=1.05-3.62) or in a lower-class neighbourhood (OR=2.31; IC=1.26-4.25) was associated with increased risks of never-screening, but neighbourhood physician density was not. Interactions were found between socioeconomic status and RCGH. Individual- and neighbourhood-level associations with CCST were different for women with or without an RCGH.

CONCLUSION

This study analysed individual and contextual inequalities in CCST practice in the Paris metropolitan area. To benefit from an RCGH did not seem to reduce all the social inequalities in CCST practice.

Personal factors influence use of cervical cancer screening services: epidemiological survey and linked administrative data address the limitations of previous research

BACKGROUND

National screening programs have reduced cervical cancer mortality; however participation in these programs varies according to women's personal and social characteristics. Research into these inequalities has been limited by reliance on self-reported service use data that is potentially biased, or administrative data that lacks personal detail. We address these limitations and extend existing research by examining rates and correlates of cervical screening in a large epidemiological survey with linked administrative data.

METHODS

The cross-sectional sample included 1685 women aged 44-48 and 64-68 years from the Australian Capital Territory and Queanbeyan, Australia. Relative risk was assessed by logistic regression models and summary Population Attributable Risk (PAR) was used to quantify the effect of inequalities on rates of cervical cancer screening.

RESULTS

Overall, 60.5% of women participated in screening over the two-year period recommended by Australian guidelines. Screening participation was associated with having children, moderate or high use of health services, employment, reported lifetime history of drug use, and better physical functioning. Conversely, rates of cervical screening were lower amongst women who were older, reliant on welfare, obese, current smokers, reported childhood sexual abuse, and those with anxiety symptoms. A summary PAR showed that effective targeting of women with readily observable risk-factors (no children, no partner, receiving income support payments, not working, obese, current smoker, anxiety, poor physical health, and low overall health service use) could potentially reduce overall non-participation in screening by 74%.

CONCLUSIONS

This study illustrates a valuable method for investigating the personal determinants of health service use by combining representative survey data with linked administrative records. Reliable knowledge about the characteristics that predict uptake of cervical cancer screening services will inform targeted health promotion efforts.

Factors associated with non-attendance, opportunistic attendance and reminded attendance to cervical screening in an organized screening program: a cross-sectional study of 12,058 Norwegian women

BACKGROUND

Cervical cancer incidence and mortality may be reduced by organized screening. Participant compliance with the attendance recommendations of the screening program is necessary to achieve this. Knowledge about the predictors of compliance is needed in order to enhance screening attendance.

METHODS

The Norwegian Co-ordinated Cervical Cancer Screening Program (NCCSP) registers all cervix cytology diagnoses in Norway and individually reminds women who have no registered smear for the past three years to make an appointment for screening. In the present study, a questionnaire on lifestyle and health was administered to a random sample of Norwegian women. The response rate was 68%. To address the predictors of screening attendance for the 12,058 women aged 25-45 who were eligible for this study, individual questionnaire data was linked to the cytology registry of the NCCSP. We distinguished between non-attendees, opportunistic attendees and reminded attendees to screening for a period of four years. Predictors of non-attendance versus attendance and reminded versus opportunistic attendance were established by multivariate logistic regression.

RESULTS

Women who attended screening were more likely than non-attendees to report that they were aware of the recommended screening interval, a history of sexually transmitted infections and a history of hormonal contraceptive and condom use. Attendance was also positively associated with being married/cohabiting, being a non-smoker and giving birth. Women who attended after being reminded were more likely than opportunistic attendees to be aware of cervical cancer and the recommended screening interval, but less likely to report a history of sexually transmitted infections and hormonal contraceptive use. Moreover, the likelihood of reminded attendance increased with age. Educational level did not significantly affect the women's attendance status in the fully adjusted models.

CONCLUSIONS

The likelihood of attendance in an organized screening program was higher among women who were aware of cervical screening, which suggests a potential for a higher attendance rate through improving the public knowledge of screening. Further, the lower awareness among opportunistic than reminded attendees suggests that physicians may inform their patients better when smears are taken at the physician's initiative.

Low rates of cervical cancer screening among urban immigrants: a population-based study in Ontario, Canada

OBJECTIVE

Women who are immigrants or socioeconomically disadvantaged have been found to have significantly lower cervical cancer screening rates than their peers in Toronto, Ontario, Canada. The objective of this study was to examine rates of appropriate cervical cancer screening among women living in Ontario, Canada, using recent registration with Ontario's universal health insurance plan as an indicator of immigrant status.

METHODS

This retrospective cohort study included 2,273,995 screening-eligible women aged 25 to 69 years, who resided in Ontario's metropolitan areas during the calendar years 2003, 2004, and 2005. A validated algorithm was applied to the Ontario-wide physicians' claims database to determine which women had undergone cervical cancer screening with a Pap test during the 3-year period.

RESULTS

Appropriate cervical cancer screening occurred for 61.1% of women. Despite adjustment for physician contact and pregnancy rates, cervical cancer screening rates were especially low among: women aged 50 to 69 years; women living in low-income areas; and women who had registered with Ontario's universal health insurance plan within the preceding 10 years, a group consisting largely of recent immigrants. Women with all 3 of these characteristics had a screening rate of 31.0% compared with 70.5% among women with none of these characteristics.

CONCLUSION

Within a system of universal health insurance, appropriate cervical cancer screening is significantly lower among women who are older, living in low-income areas, or recent immigrants. Efforts to reduce disparities in cervical cancer screening should focus on women with these characteristics.

Adherence to cervical cancer screening guidelines for U.S. women aged 25-64: data from the 2005 Health Information National Trends Survey (HINTS)

BACKGROUND

Although it is widely accepted that Papanicolaou (Pap) screening can reduce cervical cancer mortality, many women still do not maintain regular cervical cancer screenings.

OBJECTIVE

To describe the prevalence of cervical cancer screening and the demographic, behavioral, psychological, and cancer-related knowledge factors associated with adherence to U.S. Preventive Services Task Force (USPSTF) cervical cancer screening guidelines among women in the United States.

METHODS

Data for women aged 25-64 were obtained from the National Cancer Institute's (NCI) 2005 Health Information National Trends Survey (HINTS). Women were considered adherent to screening guidelines if they had two consecutive, on-schedule screenings and planned to have another within the next 3 years. The sample comprised 2070 women.

RESULTS

Ninety-eight percent of women reported ever having a Pap smear, 90% reported having had a recent Pap smear (within 3 years), and 84% were adherent to USPSTF screening guidelines. Maintaining regular cervical cancer screening was significantly associated with having health insurance, normal body mass index (BMI), smoking status (nonsmoker), mood (absence of a mood disturbance), and being knowledgeable about cervical cancer screening and human papillomavirus (HPV) infection.

CONCLUSIONS

Based on the observation that women who were current smokers, obese, or experiencing a substantial degree of psychological distress were significantly less likely to adhere to recommended screening guidelines, we suggest that healthcare providers pay particular attention to the screening needs of these more vulnerable women.

Barriers to cervical cancer screening attendance in England: a population-based survey

Objectives

To explore barriers to cervical screening attendance in a population-based sample, and to compare barriers endorsed by women who were up-to-date with screening versus those who were overdue. We also tested the hypothesis that women who were overdue for screening would be more generally disillusioned with public services, as indexed by reported voting behaviour in elections.

Setting

A population-based survey of women in England.

Methods

Face-to-face interviews were carried out with 580 women aged 26–64 years, and recruited using stratified random probability sampling as part of an omnibus survey. Questions assessed self-reported cervical screening attendance, barriers to screening, voting behaviour and demographic characteristics.

Results

Eighty-five per cent of women were up-to-date with screening and 15% were overdue, including 2.6% who had never had a smear test. The most commonly endorsed barriers were embarrassment (29%), intending to go but not getting round to it (21%), fear of pain (14%) and worry about what the test might find (12%). Only four barriers showed significant independent associations with screening status: difficulty making an appointment, not getting round to going, not being sexually active and not trusting the test. We found support for our hypothesis that women who do not attend for screening are less likely to vote in elections, even when controlling for barrier endorsement and demographic factors.

Conclusions

Practical barriers were more predictive of screening uptake than emotional factors such as embarrassment. This has clear implications for service provision and future interventions to increase uptake. The association between voting behaviour and screening uptake lends support to the hypothesis that falling screening coverage may be indicative of a broader phenomenon of disillusionment, and further research in this area is warranted.

Registry data for cross-country comparisons of migrants' healthcare utilization in the EU: a survey study of availability and content

BACKGROUND

Cross-national comparable data on migrants' use of healthcare services are important to address problems in access to healthcare; to identify high risk groups for prevention efforts; and to evaluate healthcare systems comparatively. Some of the main obstacles limiting analyses of health care utilization are lack of sufficient coverage and availability of reliable and valid healthcare data which includes information allowing for identification of migrants. The objective of this paper was to reveal which registry data on healthcare utilization were available in the EU countries in which migrants can be identified; and to determine to what extent data were comparable between the EU countries.

METHODS

A questionnaire survey on availability of healthcare utilization registries in which migrants can be identified was carried out among all national statistic agencies and other relevant national health authorities in the 27 EU countries in 2008-9 as part of the Migrant and Ethnic Minority Health Observatory-project (MEHO). The information received was compared with information from a general survey on availability of survey and registry data on migrants conducted by Agency of Public Health, Lazio Region, Italy within the MEHO-project; thus, the information on registries was double-checked to assure accuracy and verification.

RESULTS

Available registry data on healthcare utilization which allow for identification on migrants on a national/regional basis were only reported in 11 EU countries: Austria, Belgium, Denmark, Finland, Greece, Italy, Luxembourg, the Netherlands, Poland, Slovenia, and Sweden. Data on hospital care, including surgical procedures, were most frequently available whereas only few countries had data on care outside the hospital. Regarding identification of migrants, five countries reported having information on both citizenship and country of birth, one reported availability of information on country of birth, and five countries reported availability of information on citizenship.

CONCLUSION

Lack of registry data in 16 EU countries, shortage of data on healthcare utilization, and the diversity in the definition of migrant status hampers cross-national comparisons and calls for an urgent establishment of registries, expansion of the existing registry information, and adoption of a common, generally acceptable definition and identification method of migrants across the EU.

How accurate are self-reports? Analysis of self-reported health care utilization and absence when compared with administrative data

OBJECTIVE

To determine the accuracy of self-reported health care utilization and absence reported on health risk assessments against administrative claims and human resource records.

METHODS

Self-reported values of health care utilization and absenteeism were analyzed for concordance to administrative claims values. Percent agreement, Pearson's correlations, and multivariate logistic regression models examined the level of agreement and characteristics of participants with concordance.

RESULTS

Self-report and administrative data showed greater concordance for monthly compared with yearly health care utilization metrics. Percent agreement ranged from 30% to 99% with annual doctor visits having the lowest percent agreement. Younger people, males, those with higher education, and healthier individuals more accurately reported their health care utilization and absenteeism.

CONCLUSIONS

Self-reported health care utilization and absenteeism may be used as a proxy when medical claims and administrative data are unavailable, particularly for shorter recall periods.

Inequalities in reported use of breast and cervical screening in Great Britain: analysis of cross sectional survey data

OBJECTIVE

To investigate the relation between women's reported use of breast and cervical screening and sociodemographic characteristics.

DESIGN

Cross sectional multipurpose survey.

SETTING

Private households, Great Britain. Population 3185 women aged 40-74 interviewed in the National Statistics Omnibus Survey 2005-7.

MAIN OUTCOME MEASURES

Ever had a mammogram, ever had a cervical smear, and, for each, timing of most recent screen.

RESULTS

91% (95% confidence interval 90% to 92%) of women aged 40-74 years reported ever having had a cervical smear, and 93% (92% to 94%) of those aged 53-74 years reported ever having had a mammogram; 3% (2% to 4%) of women aged 53-74 years had never had either breast or cervical screening. Women were significantly more likely to have had a mammogram if they lived in households with cars (compared with no car: one car, odds ratio 1.67, 95% confidence interval 1.06 to 2.62; two or more cars, odds ratio 2.65, 1.34 to 5.26), and in owner occupied housing (compared with rented housing: own with mortgage, odds ratio 2.12, 1.12 to 4.00; own outright, odds ratio 2.19, 1.39 to 3.43), but no significant differences by ethnicity, education, occupation, or region were found. For cervical screening, ethnicity was the most important predictor; white British women were significantly more likely to have had a cervical smear than were women of other ethnicity (odds ratio 2.20, 1.41 to 3.42). Uptake of cervical screening was greater among more educated women but was not significantly associated with cars, housing tenure, or region.

CONCLUSIONS

Most (84%) eligible women report having had both breast and cervical screening, but 3% report never having had either. Some inequalities exist in the reported use of screening, which differ by screening type; indicators of wealth were important for breast screening and ethnicity for cervical screening. The routine collection within general practice of additional sociodemographic information would aid monitoring of inequalities in screening coverage and inform policies to correct them.

Self-report versus medical records for assessing cancer-preventive services delivery

Accurate measurement of cancer-preventive behaviors is important for quality improvement, research studies, and public health surveillance. Findings differ, however, depending on whether patient self-report or medical records are used as the data source. We evaluated concordance between patient self-report and medical records on risk factors, cancer screening, and behavioral counseling among primary care patients. Data from patient surveys and medical records were compared from 742 patients in 25 New Jersey primary care practices participating at baseline in SCOPE (supporting colorectal cancer outcomes through participatory enhancements), an intervention trial to improve colorectal cancer screening in primary care offices. Sensitivity, specificity, and rates of agreement describe concordance between self-report and medical records for risk factors (personal or family history of cancer, smoking), cancer screening (breast, cervical, colorectal, prostate), and counseling (cancer screening recommendations, diet or weight loss, exercise, smoking cessation). Rates of agreement ranged from 41% (smoking cessation counseling) to 96% (personal history of cancer). Cancer screening agreement ranged from 61% (Pap and prostate-specific antigen) to 83% (colorectal endoscopy) with self-report rates greater than medical record rates. Counseling was also reported more frequently by self-report (83% by patient self-report versus 34% by medical record for smoking cessation counseling). Deciding which data source to use will depend on the outcome of interest, whether the data is used for clinical decision making, performance tracking, or population surveillance; the availability of resources; and whether a false positive or a false negative is of more concern.

Inadequate cervical cancer screening among mid-aged Australian women who have experienced partner violence

OBJECTIVES

Partner violence is linked to cervical cancer and other gynaecological conditions. However, results of current research into associations between partner violence and cervical cancer screening have been inconclusive. Therefore, the current research investigates the association between partner violence and inadequate cervical cancer screening.

METHODS

Participants were 7312 women aged 45-50 years who responded to the Australian Longitudinal Study on Women's Health population-based surveys in 1996 and 2004. The women self-reported frequency of Pap smears via mailed questionnaire.

RESULTS

Women who had experienced partner violence at least eight years earlier, compared with those who had not, were more likely to report current inadequate screening (OR: 1.42, 95%CI: 1.21; 1.66). After adjusting for known barriers to preventive screening (education, income management, marital status, general practitioner visits, chronic conditions) and depression, partner violence was independently associated with inadequate Pap tests (OR: 1.20, 95%CI: 1.01; 1.42). This association was no longer significant once access to a GP of choice was added to the model (OR: 1.18, 95%CI: 0.99; 1.40).

CONCLUSIONS

The significance of this study lies not just in confirming a negative relationship between cervical cancer screening and partner violence, but in suggesting that good access to a physician of choice appears to significantly decrease this negative relationship.

Optimal recall length in survey design

Self-reported data collected via surveys are a key input into a wide range of research conducted by economists. It is well known that such data are subject to measurement error that arises when respondents are asked to recall past utilisation. Survey designers must determine the length of the recall period and face a trade-off as increasing the recall period provides more information, but increases the likelihood of recall error. A statistical framework is used to explore this trade-off. Finally we illustrate how optimal recall periods can be estimated using hospital use data from Sweden's Survey of Living Conditions.

Preventive services use among women seen by gynecologists, general medical physicians, or both

OBJECTIVE

To estimate how preventive services and counseling differ for women seen by general medical physicians and gynecologists, and whether seeing both types of physicians had a greater impact on delivery of gender-specific and gender-neutral preventive care than by either type of physician alone.

METHODS

Using data from the 2000 National Health Interview Survey, we studied the association of provider type with Pap tests, tobacco use screening, and exercise and diet counseling among women 18-64 years (n=7,317), and these services along with clinical breast examinations, mammograms, and colon cancer screening among women aged 50-64 years (n=1,551). We modeled care using multivariable logistic regression and used propensity score techniques to limit selection bias from choice of provider.

RESULTS

In the study sample, 15% were seen by general medical physicians, 62% by gynecologists, and 23% by both. Overall rates of gender-specific services (Pap test, clinical breast examination, mammography) were high (88-95%), whereas gender-neutral services were low (23-53%). Patients of gynecologists only were more likely to have Pap tests (adjusted relative risk [RR] 1.26, 95% confidence interval [CI] 1.24-1.27), tobacco use screening (adjusted RR 1.08, 95% CI 1.02-1.14), mammography (adjusted RR 1.25, 95% CI 1.20-1.28), and clinical breast examination (adjusted RR 1.25, 95% CI 1.19-1.29). In general, combined gynecologist and general care did not increase the likelihood of preventive care. Propensity score analyses confirmed these results.

CONCLUSION

Patients of gynecologists receive more preventive services compared with patients of general medical physicians, although rates of gender-neutral services were low regardless of provider type. These findings validate gynecologists' roles as providers of basic preventive care services but demonstrate that considerable room exists to improve delivery of preventive care to women.

Accuracy of self-reported cancer-screening histories: a meta-analysis

BACKGROUND

Survey data used to study trends in cancer screening may overestimate screening utilization while potentially underestimating existing disparities in use.

METHODS

We did a literature review and meta-analysis of validation studies examining the accuracy of self-reported cancer-screening histories. We calculated summary random-effects estimates for sensitivity and specificity, separately for mammography, clinical breast exam (CBE), Pap smear, prostate-specific antigen testing (PSA), digital rectal exam, fecal occult blood testing, and colorectal endoscopy.

RESULTS

Sensitivity was highest for mammogram, CBE, and Pap smear (0.95, 0.94, and 0.93, respectively) and lowest for PSA and digital rectal exam histories (0.71 and 0.75). Specificity was highest for endoscopy, fecal occult blood testing, and PSA (0.90, 0.78, and 0.73, respectively) and lowest for CBE, Pap smear, and mammogram histories (0.26, 0.48, and 0.61, respectively). Sensitivity and specificity summary estimates tended to be lower in predominantly Black and Hispanic samples compared with predominantly White samples. When estimates of self-report accuracy from this meta-analysis were applied to cancer-screening prevalence estimates from the National Health Interview Survey, results suggested that prevalence estimates are artificially increased and disparities in prevalence are artificially decreased by inaccurate self-reports.

CONCLUSIONS

National survey data are overestimating cancer-screening utilization for several common procedures and may be masking disparities in screening due to racial/ethnic differences in reporting accuracy.

Why don't some women return for cervical smears? A hermeneutic phenomenological investigation

To enhance understanding of how having a cervical smear can lead some women not to keep up-to-date with this test, a hermeneutic (interpretative) phenomenological study was undertaken. Participants were six purposively selected New Zealand women -- predominantly Māori -- at least 6 months overdue for a follow-up cervical screen in the previous 6 years. Each woman gave an in-depth interview. Transcribed and analyzed via a general inductive approach, the interviews suggested that the smears can violate women's positive aloneness with their bodies, and magnify aloneness as a negative state. Overdueness for the test avoids these effects. To minimize such effects, primary health care needs to acknowledge and address these issues, for example by providing an opportunity to connect the aloneness to trusted others.

Randomised trial of intensive academic detailing to promote opportunistic recruitment of women to cervical screening by general practitioners

OBJECTIVE

To evaluate a multifaceted intervention involving intensive academic detailing for general practitioners (GPs) to improve recruitment of women for cervical screening.

METHODS

We conducted a cluster randomisation trial involving 39 general practices in inner-metropolitan Sydney. GPs' knowledge, propensity to an opportunistic approach, competence and confidence were assessed by self-report before and after the intervention. To measure GP behaviour, recall of an opportunistic discussion about cervical screening was determined in cross-sectional samples of female patients at baseline (n = 1,090) and post-test (n = 1,062).

RESULTS

Knowledge improved marginally in both groups but there were no changes in other GP self-reported measures. At post-test, women attending GPs in the intervention group were no more likely than those in the control group to recall an opportunistic inquiry about their cervical screening status (OR 0.65, 95% CI 0.40-1.08). Women in the intervention group who were overdue for cervical screening were no more likely than their control group counterparts at post-test to recall advice about cervical screening (OR 2.16, 95% CI 0.75-6.14) or written information (OR 0.34, 95% CI 0.04-26.5).

CONCLUSIONS

Intensive academic detailing does not improve an opportunistic approach to cervical screening in general practice.

IMPLICATIONS FOR PUBLIC HEALTH PRACTICE

In an evidence-based climate, implementation of academic detailing as a strategy to improve cervical screening rates in general practice would be premature.

Do cervical cancer screening rates increase in association with an intervention designed to increase mammography usage?

OBJECTIVES

To assess cervical cancer screening behaviors among underserved women participating in an intervention designed to increase mammography use.

METHODS

This was a randomized trial of 897 women from three racial groups (white, African American, Native American) living in a rural county in North Carolina. Baseline and followup surveys were completed by 815 women; 775 women provided data to be included in these analyses. The intervention group received an educational program focused on mammography delivered by a lay health advisor, and the control group received a physician letter/brochure focusing on Pap tests.

RESULTS

Women in both the intervention (OR 1.70; 1.31, 2.21, p < 0.001) and control groups (OR 1.38; 1.04, 1.82, p = 0.025) significantly increased cervical cancer screening rates within risk appropriate guidelines. No differences by racial group were documented. Women categorized in the high-risk group for developing cervical cancer (>2 sexual partners, age <18 years at first sexual intercourse, smoker; treated for sexually transmitted disease [STD] or partner with treated STD) significantly (OR 1.88; 1.54, 2.28, p < 0.001) increased Pap test completion. However, a nonsignificant increase (OR 1.25; 0.87, 1.79, p = 0.221) in Pap test completion was demonstrated in women categorized as low risk for cervical cancer.

CONCLUSIONS

This study suggests that women in an intensive behavioral intervention designed to increase mammography use may also increase Pap test completion, similar to a minimal intervention focused only on increasing Pap test completion. These results have implications for the design and evaluation of behavioral intervention studies.

Frequency of Gynecologic Follow-Up and Cervical Cancer Screening in the Swiss HIV Cohort Study

BACKGROUND

According to current recommendations, HIV-infected women should have at least 1 gynecologic examination per year.

OBJECTIVES

To analyze factors associated with frequency of gynecologic follow-up and cervical cancer screening among HIV-infected women followed in the Swiss HIV Cohort Study (SHCS).

METHODS

Half-yearly questionnaires between April 2001 and December 2004. At every follow-up visit, the women were asked if they had had a gynecologic examination and a cervical smear since their last visit. Longitudinal models were fitted with these variables as outcomes.

RESULTS

A total of 2186 women were included in the analysis. Of the 1146 women with complete follow-up in the SHCS, 35.3% had a gynecologic examination in each time period, whereas 7.4% had never gone to a gynecologist. Factors associated with a poor gynecologic follow-up were older age, nonwhite ethnicity, less education, underweight, obesity, being sexually inactive, intravenous drug use, smoking, having a private infectious disease specialist as a care provider, HIV viral load <400 copies/mL, and no previous cervical dysplasia. No association was seen for living alone, CD4 cell count, and positive serology for syphilis.

CONCLUSIONS

Gynecologic care among well-followed HIV-positive women is poor and needs to be improved.

Effectiveness of cervical cancer screening over cervical cancer mortality among Japanese women

BACKGROUND

Various studies have revealed that cervical cancer (CC) screening significantly reduces both CC incidence and mortality in developed countries. Although Japan introduced a nationwide government funded annual CC screening for the women aged 30+ in 1982, the effectiveness of CC screening on CC mortality has not yet been evaluated by any prospective cohort study. Therefore, the present study evaluated the association of CC mortality with self-reported CC screening and some other factors by a nationwide cohort study.

METHODS

Baseline survey of the Japan Collaborative Cohort Study for the enrollment of subjects was completed during 1988-90 and followed until 2003. This study only analyzed 63,541 women, aged 30-79 years, who were free from any cancer history at enrollment.

RESULTS

During the follow-up period, 38 CC deaths were identified. The mean age at mortality was 67.0 years, with a mortality rate of 4.2 per 100,000 person-years. Participation rate in CC screening was 46.9%. Age-adjusted Cox model indicated significantly lower CC mortality [hazard ratio (HR) = 0.30, 95% confidence interval (CI) = 0.12-0.74] due to CC screening. Protectiveness remained almost the same (HR = 0.30, 95% CI = 0.12-0.76) when adjusted for age, body mass index and number of deliveries. The results also revealed that CC screening could reduce at least 50% of CC deaths even after excluding the effect of possible self-selection bias.

CONCLUSIONS

CC screening in Japan may reduce CC mortality significantly for women aged 30-79 years. However, further studies with more CC deaths and increased statistical power are needed to validate the findings.

Estimation of Pap-test coverage in an area with an organised screening program: challenges for survey methods

Background

The cytological screening programme of Viterbo has completed the second round of invitations to the entire target population (age 25–64). From a public health perspective, it is important to know the Pap-test coverage rate and the use of opportunistic screening. The most commonly used study design is the survey, but the validity of self-reports and the assumptions made about non respondents are often questioned.

Methods

From the target population, 940 women were sampled, and responded to a telephone interview about Pap-test utilisation. The answers were compared with the screening program registry; comparing the dates of Pap-tests reported by both sources. Sensitivity analyses were performed for coverage over a 36-month period, according to various assumptions regarding non respondents.

Results

The response rate was 68%. The coverage over 36 months was 86.4% if we assume that non respondents had the same coverage as respondents, 66% if we assume they were not covered at all, and 74.6% if we adjust for screening compliance in the non respondents. The sensitivity and specificity of the question, "have you ever had a Pap test with the screening programme" were 84.5% and 82.2% respectively. The test dates reported in the interview tended to be more recent than those reported in the registry, but 68% were within 12 months of each other.

Conclusion

Surveys are useful tools to understand the effectiveness of a screening programme and women's self-report was sufficiently reliable in our setting, but the coverage estimates were strongly influenced by the assumptions we made regarding non respondents.

Exame citopatológico de colo uterino em mulheres com idade entre 20 e 59 anos em Pelotas, RS: prevalência, foco e fatores associados à sua não realização

OBJETIVO: Determinar a prevalência e o foco de realização do exame citopatológico do colo uterino e também fatores associados à sua não realização em mulheres com idade entre 20 e 59 anos residentes na cidade de Pelotas, RS. MÉTODOS: Entre outubro e dezembro de 2003 foi realizado um estudo transversal de base populacional. Através de amostragem por conglomerados foram sorteados 144 setores censitários em múltiplos estágios. Foram investigadas variáveis sociodemográficas e a realização de exame citopatológico do colo uterino. RESULTADOS: Dentre as 1404 mulheres que constituem a população-alvo dos programas de prevenção do câncer do colo uterino, 83,0% realizaram o exame citopatológico do colo uterino nos três anos antecedentes a este estudo. Mostraram-se significativamente associadas (P<0,05) à não realização deste tipo de exame nos últimos três anos as seguintes variáveis: faixas etárias de 20 a 29 anos e 50 a 59 anos em relação às mulheres de 40 a 49 anos de idade, menor escolaridade, menor quintil de pontos obtidos para construção do nível socioeconômico segundo a Associação Nacional de Empresas de Pesquisa (ANEP), cor da pele mulata ou preta e não consultar um ginecologista nos últimos 12 meses. CONCLUSÕES: Apesar de este estudo mostrar alta cobertura na realização de citopatológico do colo uterino nos três anos antecedentes a entrevista, as mulheres com maior número de fatores de risco do câncer de colo uterino apresentaram menor índice de realização deste exame.

Patient Recall of the Mechanics of Cervical Spine Manipulation

OBJECTIVE

To determine how accurately patients with neck pain and/or headache can recall the mechanics of their cervical spine manipulative therapy immediately after its administration.

METHODS

A survey analysis of immediate patient recall after cervical spine manipulative therapy was performed in a private clinic. The group consisted of 94 sequentially presenting neck pain and/or headache patients with 54 (57%) females and 40 (43%) males. The mean age of the patients was 41.9 years (SD = 13.8; range, 17-96 years). Patients received diversified cervical spine manipulative therapy using a standardized set-up of lateral flexion coupled with flexion. Immediately after the cervical spine manipulative therapy, each patient completed a one-page questionnaire regarding the mechanics of the procedure. Patient responses were analyzed to determine the accuracy of their recall of head positioning.

RESULTS

Among the patients, 78.7% reported that they experienced a component of rotation and/or extension, although the technique used involved a premanipulative set-up of lateral bending coupled with flexion.

CONCLUSION

Patients with primary complaints of neck pain and/or headache, when asked to recall the mechanics of their recently applied cervical spine manipulative therapy, displayed a low rate of accuracy. Rotation and/or extension of the cervical spine were the most frequently given incorrect responses.

Use of cervical cancer screening among insured women: the extent of missed opportunities

The objective of the study is to identify opportunities to improve cervical cancer screening among privately insured women. From MedStat's Marketscan database, we identified 735,181 women aged 21-64 years who remained in the same insurance plan during the entire period of 2000-2002. We obtained the percentages of women who had a Papanicolaou (Pap)-test reimbursement claim and any health-related claim during the 3-year period. For women without a Pap-test claim, we obtained information about the frequency of insurance claims, type of health-care provider, and type of insurance plan in which the women were enrolled. The multivariate logistic regression model was used to identify factors independently associated with not having a Pap test. Of the total sample, in the 3-year period, 96% had at least one health insurance reimbursement claim and 69% had at least one claim for a Pap test. Approximately, 87% of the women who had no Pap-test claim had a health claim; 44% of such claims were from primary care providers. In the multiple logistic regression model, factors that were independently associated with having no Pap test were old age, being dependents of employees, and enrollment in comprehensive insurance plans. Efforts to increase the use of cervical cancer screening service should consider additional risk factors besides lack of insurance coverage. Concerted efforts by insurance and health-care providers are needed to improve adherence to the recommended cervical cancer screening guidelines, both by consumers and service providers.

Comparison of papanicolaou (Pap) test rates across Ontario and factors associated with cervical screening

BACKGROUND

Cervical cancer remains a significant yet preventable disease despite the widespread availability of Pap test screening, which detects cervical cancer and its precursor lesions. The aims of this study were to: i) estimate and compare age- and hysterectomy-adjusted Pap test rates across the 37 Ontario public health units (PHUs), and ii) explore the association between several factors and Pap test rates (at the ecological level).

METHODS

Cytobase, an Ontario Pap test registry, captures more than 80% of all Pap tests in Ontario. Cytobase was used to determine Pap test rates adjusted for age, hysterectomy and Cytobase coverage for the year 2001. Multiple linear regression analyses were used to evaluate the relationship between Pap test rates and various factors at an ecological level,

RESULTS

Age-, hysterectomy- and Cytobase-adjusted one-year Pap rates ranged from 11.6% to 73.9% among PHUs. The overall rate for Ontario was 40.7%. Multivariate analyses indicated that the presence of a teaching hospital was associated with higher Pap test rates.

CONCLUSION

One-year Pap test rates varied greatly across the 37 public health units in Ontario. Pap test rates determined using Cytobase were lower than self-reported rates obtained from the Canadian Community Health Survey, possibly due to "over-reporting". In general, women were not screened as frequently as recommended by the Ontario Cervical Screening Program. A positive association was observed between Pap test rates and the presence of a teaching hospital. Data quality issues limit the ability to monitor cervical screening. A provincial registry would address these issues.

Effect of a yearlong, moderate-intensity exercise intervention on the occurrence and severity of menopause symptoms in postmenopausal women

OBJECTIVE

To evaluate the effect of moderate-intensity exercise on the occurrence and severity of menopause symptoms.

DESIGN

A yearlong, randomized, clinical trial, conducted in Seattle, WA, with 173 overweight, postmenopausal women not taking hormone therapy in the previous 6 months. The intervention was a moderate-intensity exercise intervention (n = 87) versus stretching control group (n = 86). Using logistic regression, odds ratios comparing exercise with controls were calculated at 3, 6, 9, and 12 months for menopause symptoms and their severity.

RESULTS

There was a significant increase in hot flash severity and decreased risk of memory problems in exercisers versus controls over 12 months, although the numbers affected were small. No other significant changes in symptoms were observed.

CONCLUSIONS

Exercise does not seem to decrease the risk of having menopause symptoms in overweight, postmenopausal women not taking hormone therapy and may increase the severity of some symptoms in a small number of women.

Cervical cancer screening among U.S. women: analyses of the 2000 National Health Interview Survey

BACKGROUND

Cervical cancer screening is not fully utilized among all groups of women in the United States, especially women without access to health care and older women.

METHODS

Papanicolaou (Pap) test use among U.S. women age 18 and older is examined using data from the 2000 National Health Interview Survey (NHIS).

RESULTS

Among women who had not had a hysterectomy (n = 13,745), 83% reported having had a Pap test within the past 3 years. Logistic regression analyses showed that women with no contact with a primary care provider in the past year were very unlikely to have reported a recent Pap test. Other characteristics associated with lower rates of Pap test use included lacking a usual source of care, low family income, low educational attainment, and being unmarried. Having no health insurance coverage was associated with lower Pap test use among women under 65. Despite higher insurance coverage, being age 65 and older was associated with low use. Rates of recent Pap test were higher among African-American women.

CONCLUSIONS

Policies to generalize insurance coverage and a usual source of health care would likely increase use of Pap testing. Also needed are health system changes such as automated reminders to assist health care providers implement appropriate screening. Renewed efforts by physicians and targeted public health messages are needed to improve screening among older women without a prior Pap test.

Estimating racial/ethnic disparity in mammography rates: it all depends on how you ask the question

BACKGROUND

Estimates of racial disparity in mammography appear to differ depending on the data source. This study examined the impact of different survey methodology on estimates of racial disparity in mammography.

METHODS

Responses from 3,090 women > or =40 years to two different questions from the 1996 Medical Expenditure Panel Survey (MEPS) were compared when a mammogram was last obtained versus what medical services, including mammography, were obtained over a 4-month interval, aggregated across 1 year.

RESULTS

There was no significant racial disparity in 1-year mammography prevalence based on the first question (white-black difference, 3.3%; 95% confidence interval [CI], -2.5, 9.2). In contrast, a significant disparity in 1-year mammography prevalence was found based on the medical services question (difference, 13.1%; 95% CI 8.6, 17.6). Disparity estimates by Hispanic ethnicity were similar for the two questions: white-Hispanic difference, 1.6%; 95% CI -4.3, 7.5, and white-Hispanic difference 5% (-0.2, 10.1). Adjustment for age, income, and insurance did not alter these findings.

CONCLUSIONS

Estimates of racial, but not ethnic, disparities in mammography seem to depend on how the question is asked. These results caution against exclusive reliance on annual self-reports for monitoring disparities in preventive care.

Effectiveness and Efficiency of Opportunistic Cervical Cancer Screening

BACKGROUND

Several countries have adopted nationally organized cervical screening programs, but many continue with opportunistic screening. Comparison of the effectiveness and efficiency of the 2 systems is important for informing policy.

OBJECTIVES

The objectives of this study were to assess the effectiveness and efficiency of an opportunistic cervical screening system, and to compare this with what could be achieved through an organized program.

RESEARCH DESIGN

We propose a model for estimating the effectiveness and efficiency of opportunistic screening systems and demonstrate it using data from a cross-sectional study of 1826 women in Hong Kong. We estimated the coverage and frequency of screening and used this to estimate effectiveness (number of cases of invasive cervical cancer potentially prevented) and efficiency (tests per case prevented) of the current system. Similar estimates were made for various organized programs with different screening intervals and coverage.

RESULTS

Ever screening coverage in this opportunistic system was 44%, resulting in 26% to 31% reduction in potential new cases (n = 144-183). Compared with this, a 3-yearly or 5-yearly screening policy aiming for 80% coverage would prevent an additional 46% (equivalent to 254 new cases out of a population of 2.3 million women per year) and 41% (222 per year), respectively. This could be achieved with more efficient use of resources, reducing the number of tests per case prevented from 2018 to 1545 and 1007, respectively.

CONCLUSIONS

At best, the effectiveness of this opportunistic system is equivalent to an organized program with 10-yearly screening and 50% coverage but at much greater cost. Poor coverage and over screening of a minority of women contributes to its inefficiency.

The frequency of Pap smear screening in the United States

BACKGROUND

U.S. professional medical societies and the national health systems of all other industrialized nations recommend that most women need not undergo Papanicolaou (Pap) smear screening annually. There are no data, however, regarding the frequency at which women actually undergo screening.

OBJECTIVE

To describe the frequency of cervical cancer screening in the United States.

DESIGN

National Health Interview Survey, a cross-sectional population-based telephone survey conducted by the National Center for Health Statistics.

PARTICIPANTS

Representative sample of U.S. women age 21 and older who denied a history of cancer (N = 16,467).

MEASUREMENTS

Pap smear screening frequency, categorized as no regular screening or screening at 1 of 3 discrete screening intervals (every year, every 2 years, or every 3 years) based on each woman's reported number of Pap smears in the previous 6 years.

RESULTS

The vast majority (93%) of American women report having had at least one Pap smear in their lifetime. Among women with no history of abnormal smears, 55% undergo Pap smear screening annually, 17% report a 2-year screening interval, 16% report being screened every 3 years, and 11% are not being screened regularly. Even the very elderly report frequent screening-38% of women age 75 to 84 and 20% of women age 85 and older reported annual Pap smears. Overall, 20% of women reported having had at least one abnormal Pap smear. Among these women, rates of frequent Pap smear screening are considerably higher-80% undergo annual screening, with only a modest decline in screening frequency with increasing age.

CONCLUSIONS

The majority of American women report being screened for cervical cancer more frequently than recommended. Lengthening the screening interval would not only reduce the volume of specimens that cytotechnologists are required to read, but would also reduce the follow-up testing after abnormal smears.

Some methodologic lessons learned from cancer screening research

Credible and useful methodologic evaluations are essential for increasing the uptake of effective cancer screening tests. In the current article, the authors discuss selected issues that are related to conducting behavior change interventions in cancer screening research and that may assist researchers in better designing future evaluations to increase the credibility and usefulness of such interventions. Selection and measurement of the primary outcome variable (i.e., cancer screening behavior) are discussed in detail. The report also addresses other aspects of study design and execution, including alternatives to the randomized controlled trial, indicators of study quality, and external validity. The authors conclude that the uptake of screening should be the main outcome when evaluating cancer screening strategies; that researchers should agree on definitions and measures of cancer screening behaviors and assess the reliability and validity of these definitions and measures in different populations and settings; and that the development of methods for increasing the external validity of randomized designs and reducing bias in nonrandomized studies is needed.

Screening mammography and Pap tests among older American women 1996-2000: results from the Health and Retirement Study (HRS) and Asset and Health Dynamics Among the Oldest Old (AHEAD)

BACKGROUND

We wanted to determine the frequency of self-reported receipt of screening mammography and Papanicolaou (Pap) tests in older women and investigate important predictors of utilization, based on 2 national longitudinal surveys.

METHODS

This cohort study includes participants from 4 waves (1994-2000) of the Health and Retirement Study (HRS)--5,942 women aged 50 to 61 years, and 4 waves (1993-2000) of the Asset and Health Dynamics Among the Oldest Old (AHEAD) survey--4,543 women aged 70 years and older. The self-reported receipt of screening mammograms and Pap smears in the most recent 2 years were reported in 1996 and 2000 for HRS, with predictors of receipt measured in 1994 and 1998. In AHEAD, the self-reported receipt of screening mammograms and Pap smears in the most recent 2 years were reported in 1995 and 2000, with predictors of receipt measured in 1993 and 1998.

RESULTS

Receipt of mammography is stable at 70% to 80% among women aged 50 to 64 years, then declines to around 40% among those aged 85 to 90 years. For Pap tests there is a decline from 75% among women aged 50 to 54 years to 25% in those aged 85 to 90 years. For both mammography and Pap tests, the rates increased in all groups from 1995/1996 to 2000. Higher education, being married, higher income, not smoking, and vigorous exercise were consistently associated with higher rates of receipt.

CONCLUSIONS

Although the use of mammography and Pap tests for screening declines into old age, use has been increasing recently. The large and increasing number of tests performed might not be justified given the lack of evidence of effect in older age-groups.

The use of preventive healthcare by Canadian women who drink alcohol

BACKGROUND

Despite established links among heavy alcohol consumption, other poor health behaviors, and poor health status, no Canadian study has specifically addressed the relationship between drinking and the use of preventive healthcare services. This study examines the relationship between drinking and female-specific preventive health service use through a secondary analysis of the 1996-1997 NPHS.

METHODS

Recent use of Pap smears and mammograms was examined in relation to current alcohol consumption, using multivariate logistic regression (weighted n = 25,095).

RESULTS

In general, there was a trend toward greater odds of recent service use among light and moderate drinkers than among heavy drinkers and lifetime abstainers. However, only moderate drinkers were significantly (P < 0.01) more likely than abstainers to have recently had a Pap smear.

CONCLUSIONS

The trend toward lower use of preventive services by heavy drinkers is concerning considering the established harmful effects of prolonged alcohol consumption on health and the tendency for multiple risk behaviors to cluster together in the same individuals. Early detection of departures from good health may alleviate the elevated use of healthcare services among those diagnosed with alcohol use disorders.

Factors related to the practice of breast self examination (BSE) and Pap smear screening among Malaysian women workers in selected electronics factories

BACKGROUND: The Malaysian Ministry of Health promotes breast self-examination (BSE) for all women, and Pap smear screening every three years for all sexually active women ages 20 years and above. The objectives of this paper were to examine the practice of these two screening tests among women production workers in electronics factories, and to identify factors related to practice. METHODS: This was a cross-sectional survey of women production workers from ten electronics factories. Data was collected by a self-administered questionnaire from a total of 1,720 women. The chi-square test, odds ratio and binomial logistic regression were used in bivariate and multivariate analysis. RESULTS: Prevalence rates were 24.4% for BSE once a month, and 18.4% for Pap smear examination within the last three years. Women who were significantly more likely to perform BSE every month were 30 years and older, Malays, with upper secondary education and above, answered the BSE question correctly, and had a Pap smear within the last three years. The proportion of women who had a Pap smear within the last three years were significantly higher among those who were older, married, with young children, on the contraceptive pill or intra-uterine device, had a medical examination within the last five years, answered the Pap smear question correctly, and performed BSE monthly. CONCLUSION: Screening practice rates in this study were low when compared to national rates. Socio-demographic and health care factors significantly associated with screening practice are indicative of barriers which should be further understood so that more effective educational and promotional strategies could be developed.

Cobertura e motivos para a realização ou não do teste de Papanicolaou no Município de São Paulo

Investigou-se a prevalência da realização do teste de Papanicolaou alguma vez na vida e nos últimos três anos entre mulheres de 15 a 49 anos, o recebimento do resultado do último teste realizado e os motivos relatados para a realização ou não do exame. Um inquérito domiciliar foi realizado no Município de São Paulo em 2000, com uma amostra representativa de 1.172 mulheres selecionadas aleatoriamente em seus domicílios. Das mulheres que já tinham iniciado a vida sexual (n = 1.050), 86,1% (932) realizaram o teste alguma vez na vida e 77,3 % (839) nos últimos três anos. Das que já realizaram o teste, 806 (87,0%) receberam o resultado do último exame. Os principais motivos para a realização do último teste foram: demanda espontânea (55,5%), recomendação médica (25%) e presença de queixas ginecológicas (18,2%). As principais razões para a não realização do exame foram: ausência de problemas ginecológicos, vergonha ou medo e dificuldades de acesso. A despeito do relativo aumento na cobertura do teste de Papanicolaou e de mais da metade das mulheres demandarem espontaneamente pelo exame, sua realização foi menor entre aquelas com as piores condições sócio-econômicas e, portanto, de maior risco para o câncer cervical.

Nurse practitioners and preventive screening in the hospital

The purpose of this study was to investigate a reminder to discuss cervical cancer screening with hospitalized females. A quasi-experimental design was used to compare the association of a reminder intervention for nurse practitioners with two outcomes: prevalence of cervical cancer screening as documented in patients' charts and patients' self-report of cervical cancer screening 4 months after discharge. Data were collected by chart review and phone survey. The sample consisted of nurse practitioners caring for eligible female patients at a university teaching hospital. Chi-square was used to test all research questions. The rate of documentation of cervical cancer screening increased from 2% to 69% after implementation of the reminder intervention. The reminder intervention did not impact patients actually receiving Pap smears after discharge. The significant increase in documentation of screening associated with the use of the single reminder in the patients' charts support the use of this low-cost intervention.

Sociodemographic predictors of pap test receipt, currency and knowledge among Australian women

BACKGROUND

Knowledge of sociodemographic variations in cervical cancer screening can help identify population groups at risk of underutilization of cervical cancer procedures and practices. The aim of this research was to examine sociodemographic predictors of receipt, currency (being up-to-date for), and knowledge of Pap test.

METHODS

We used data from the 1995 National Health Survey. A subsample of women was given self-administered questionnaires that included questions about the Pap test. The sample size was 7,572. Using multiple logistic regression, we examined the association of age, marital status, region of residence, country of birth, Index of Relative Socioeconomic Disadvantage (IRSD), and education with Pap test receipt, currency, and knowledge.

RESULTS

Women under 30 and over 49 years of age, those not presently married, those with lower levels of education, and those born in the Middle East or Asia (compared with the Australian/New Zealand-born women) were at a greater risk of not receiving and having no knowledge of Pap test.

CONCLUSIONS

The results of this study suggest that, as part of a comprehensive cancer screening strategy, women who are unlikely to obtain a Pap smear might benefit from targeted interventions to improve adherence to cervical cancer screening programs.

Learning about pap smears: an educational skit for Hispanic adolescents

PURPOSE

To assess the efficacy of an educational skit on improving knowledge and decision making/behavior toward obtaining a Pap smear.

METHODS

Ninety-two Hispanic high school female volunteers participated in an intervention, single-sample, preintervention/postintervention survey. Data were collected prior to (T(0)), immediately after (T(1)), and seven weeks after (T(2)) the intervention. The intervention was a live, 15-minute, English-language skit.

RESULTS

Fifty percent reported sexual intercourse. Viewing the skit was associated with 29% of those who needed a Pap smear done, actually scheduling or having a Pap smear done between T(0) and T(2). However, a causal relationship was not proven (P = 0.09). Knowledge was greater at T(1) and T(2) compared to T(0) (P < 0.00001). However, there was a decrease in knowledge at T(2) compared to T(1). More subjects agreed that females their age were at risk for cancer at T(2) compared to T(0) (P = 0.0001).

CONCLUSIONS

There was an improvement in and retention of knowledge about Pap smears after viewing this educational skit. This study sets the stage for evaluating this educational skit on a larger sample with a comparison group.