Inner-city women at risk for cervical cancer: behavioral and utilization factors related to inadequate screening

Understanding the Relationship Between Sexual Assault and Cervical Screening Uptake

Abstract. Background: Cervical screening helps prevent cervical cancer ( NHS, 2019 ). Women who have experienced sexual assault have lower cervical screening attendance, however, no theory-driven research explores reasons for this. The Health Action Process Approach (HAPA) explains intention and ongoing attendance to health-promoting behaviors. Aims: The HAPA was used to identify and explore how sexual assault impacts cervical screening uptake. Method: An online study of 247 women aged 21–63 explored whether HAPA variables (task, maintenance, and recovery self-efficacy, outcome expectancies, risk perception, action, and coping planning), trauma variables (nature and age of abuse, and level of post-traumatic stress disorder symptoms [PTSD]), and other potentially confounding factors related to cervical screening uptake in women who have experienced sexual assault. Regression and mediation analyses were conducted to explore predictive variables of intention and attendance. Results: Self-efficacy beliefs predicted both intention and attendance of cervical screening. Task self-efficacy predicted intention and mediated relationships between HAPA variables and intention. Maintenance self-efficacy predicted attendance and mediated relationships between HAPA variables and attendance. Trauma variables did not predict more variance in intention or attendance over HAPA variables. Limitations: The cross-sectional nature of the study means causality was not established. Conclusion: Self-efficacy develops an understanding of cervical screening in women with experience of sexual assault, over and above the trauma variables of type of assault and PTSD symptoms. Focusing on self-efficacy to improve cervical screening uptake in women who have experienced sexual assault is considered for clinical implications.

The Longitudinal Association between Social Support on HIV Medication Adherence and Healthcare Utilization in the Women's Interagency HIV Study

Social support is associated with HIV-related health outcomes. However, few studies have explored this longitudinally. We assessed psychometric properties of the Medical Outcomes Study's Social Support Survey among women in the Women's Interagency HIV Study, and explored the longitudinal effects of social support on HIV medication adherence (HIV-positive women) and healthcare utilization (HIV-positive and negative women). The 15 questions loaded into two factors, with Cronbach's Alpha > 0.95. Over 3 years, perceived emotional support was associated with optimal medication adherence (OR 1.19, 95% CI 1.10-1.28) and healthcare utilization (OR 1.16, 95% CI 1.05-1.27), and tangible social support with adherence only (OR 1.18, 95% CI 1.08-1.27) when controlling for covariates, including core sociodemographic characteristics and depressive symptoms. Interventions to further understand the drivers of sub-types of social support as well as enhance sustained social support may assist with optimizing care of women with and at risk for HIV.

Attendance to a Screening Program for Cervical Cancer in the City of Florence

The study was aimed to assess: a) the proportion of true refusers among non-attenders resulting from residents and screening database matching, b) the typology of refusers compared to attenders, and c) the reasons for non-attendance as stated by refusers. Three hundred and forty-one non-attenders according to computer-produced lists were interviewed: 29 were not evaluable, 148 had had a Pap test, 18 had not attended for valid reasons, and 146 were true refusers; 94 refusers accepted the interview as far a points b) and c) were concerned. Ninety-four attenders, matched by age and residence, were interviewed for comparison. Attendance at private laboratories or incorrect identification of subjects on the screening record accounted for 45 % or 55 % of misclassified cases, respectively. The adjusted true refusal rate in the last 10 years was 18.1 % compared to a computer-assessed non-attendance rate of 40.7 %. Refusal was significantly associated to socioeconomic status (geographic origin, working activity and educational level of both women and husbands), whereas no significant association was observed for sexual history (deliveries, age at first sexual relation, number of partners) or health-related behavior. Attendance and counseling at the gynecologist's office were strongly associated to attendance, and gynecologists should be stimulated to promote opportunistic screening. The belief that screening is useless in the absence of symptoms, the fear of cancer being detected, postponement or laziness were the reasons for non-attendance stated by 80% of refusers. Improving knowledge about the purpose of the Pap test should be the main goal of any action aimed to improve screening attendance.

Promoting Participation in a Population Screening Program for Breast and Cervical Cancer: A Randomized Trial of Different Invitation Strategies

Aims and background

Attendance level has been identified as a major determinant of cost-effectiveness of organized screening programs. We tested the effectiveness of 4 different invitation systems in the context of an organized population screening program for cervical and breast cancer.

Methods

Women eligible for invitation - 8385 for cervical and 8069 for breast cancer screening - listed in the rosters of 43 and 105 general practitioners (GP), respectively, who had accepted to collaborate in the program, were randomized to 4 invitation groups: Group A - letter signed by the GP, with a prefixed appointment; Group B - open-ended invitation, signed by the GP, prompting women to contact the screening center to arrange an appointment; Group C - letter (same as for group A), signed by the program coordinator, with a prefixed appointment; Group D - extended letter (highlighting the benefits of early cancer detection) signed by the GP, with a prefixed appointment. Assignment to the interventions was based on a randomized block design (block=GP).

Results

Assuming Group A as the reference, the overall compliance with cervical cancer screening was reduced by 39% in Group B (RR=0.61; 95% CI, 0.56-0.68) and by 14% in Group C (RR=0.86; 95% CI, 0.78-0.93); no difference was observed for Group D (RR=1.03; 95% CI, 0.95-1.1). The response pattern was similar for breast screening (Group B: RR=0.71; 95% CI, 0.65-0.76; Group C: RR=0.87; 95% CI, 0.81-0.94; Group D: RR=1.01; 95% CI, 0.94-1.08).

Conclusions

Personal invitation letters signed by the woman's GP, with preallocated appointments, induce a significant increase in compliance with screening. Efficiency can be ensured through the adoption of overbooking, provided that attendance levels are regularly monitored.

Development and Implementation of an Intervention to Increase Cervical Cancer Screening in Inner-City Women

Community interventions are increasingly recognized as an effective method for reaching individuals in need of health behavior change. We present our experience in developing and implementing an intervention to increase Pap test screening in an inner-city community with a high rate of cervical cancer mortality. Results of a baseline needs assessment survey showed that: almost one-half of the population was inadequately screened; 66 percent of inadequately screened women reported belonging to a church; and, a significant proportion of those who tended to rely on the physician for screening did not receive adequate testing. These results formed the basis of our community intervention strategy: lay peer educators, recruited predominantly from churches, were trained to motivate inadequately screened women to actively seek testing. The implementation of the intervention was flexible and responsive to insights gained in the field and process evaluation data. Recommendations for future community-based interventions are offered.

Raising Awareness and Providing Free Screening Improves Cervical Cancer Screening Among Economically Disadvantaged Lebanese/Armenian Women

Women need to practice cervical screening regularly to reduce morbidity and mortality. The purpose of this study was to examine the impact of an intervention program on knowledge, attitude, and practice of cervical screening in the population of Lebanese/Armenian women. The design was a cross-sectional, quasi-experimental posttest survey following a yearlong intervention program. The sample included 176 women, who were members of the Armenian Relief Cross in Lebanon. Interventions consisted of educational classes, media messages, and free screening. The instrument was a self-administered questionnaire. Knowledge of women with intervention was higher (p > .05) and practice rate increased between intervention and comparison groups. No difference in attitude was noted. The study was successful in raising awareness and increasing screening in the sample. It is recommended to continue helping women to overcome barriers for cervical screening.

Cervical cancer screening and psychosocial barriers perceived by patients. A systematic review

Aim of the study

This study aimed at integrating research discussing the role of perceived psychosocial barriers in cervical cancer screening (CCS) uptake. In particular, we analyzed the evidence for the associations between CCS uptake and perceived psychosocial barriers and frequency of psychosocial barriers identified by women.

Material and methods

A systematic search of peer-reviewed papers published until 2011 in 8 databases yielded 48 original studies, analyzing data obtained from 155 954 women. The majority of studies (k = 43) applied correlational design, while 5 had experimental design.

Results

Experimental research indicated a positive effect of 75% of psychosocial interventions targeting barriers. The interventions resulted in a significant increase of CCS uptake. Overall 100% of correlational studies indicated that perceiving lower levels of barriers significantly predicted higher CCS uptake. 53 psychosocial barriers were listed in at least 2 original correlational studies: 9.5% of barriers were related to CCS facilities/environment, 67.9% dealt with personal characteristics of the patient, and 22.6% addressed social factors. As many as 35.9% of perceived barriers referred to negative emotions related to CCS examination procedures and collecting CCS results, whereas 25.7% of barriers referred to prior contacts with health professionals.

Conclusions

Leaflets or discussion on psychosocial barriers between patients and health professionals involved in CCS might increase CCS uptake and thus reduce cervical cancer mortality rates. Communication skills training for health professionals conducting CCS might focus on the most frequently reported barriers, referring to emotions related to CCS examination and collecting CCS results.

The challenge of follow-up in a low-income colposcopy clinic: characteristics associated with noncompliance in high-risk populations

OBJECTIVE

The study aimed to identify sociodemographic and disease-specific factors associated with follow-up in an inner-city multiethnic colposcopy clinic.

MATERIALS AND METHODS

All charts of patients referred to colposcopy clinic for abnormal cervical cytology and/or high-risk human papillomavirus infections to the University of California, Irvine, Colposcopy Clinic in Santa Ana from November 2006 to December 2007 were reviewed. Compliance was defined as at least 1 follow-up evaluation within 3 to 14 months from initial colposcopy appointment. To determine compliance, the following factors were evaluated in a multivariate analysis: race, age, spoken language, insurance status, annual income, marital status, referral cytology, histology, and pregnancy status.

RESULTS

Among the 1,046 scheduled appointments, 50% were attended. Of the patients, 458 with a minimum of 14 months of follow-up were included. The mean (SD) age of these patients was 31.0 (10.7) years. 58% were white and 55% spoke Spanish. A total of 248 patients (54%) had appropriately timed repeat testing, whereas 210 (46%) failed to return within 14 months. In univariate analysis, women who were referred from outside the clinic, single, younger than 40 years, and with self-pay or government-funded insurance were more likely to be noncompliant although this was not statistically significant. In multivariate analysis, referral from outside the clinic, self-pay, or government-funded insurance, Spanish-speaking, and single marital status were all significantly associated with noncompliance. Although cervical intraepithelial neoplasia 2 or 3 was not associated with noncompliance, 45% of women with cervical intraepithelial neoplasia 2 or 3 still did not comply with recommendations.

CONCLUSIONS

This inner-city clinic is perhaps successful at maintaining compliance for women at highest risk for cervical cancer when the triage originates from within the clinic and when the patient is married, English-speaking, and privately insured. However, reasons for those patients at highest risk for noncompliance in this clinic may need to be better characterized.

Faith Moves Mountains: an Appalachian cervical cancer prevention program

OBJECTIVE

To provide a conceptual description of Faith Moves Mountains (FMM), an intervention designed to reduce the disproportionate burden of cervical cancer among Appalachian women.

METHODS

FMM, a community-based participatory research program designed and implemented in collaboration with churches in rural, southeastern Kentucky, aims to increase cervical cancer screening (Pap tests) through a multiphase process of educational programming and lay health counseling.

RESULTS

We provide a conceptual overview to key elements of the intervention, including programmatic development, theoretical basis, intervention approach and implementation, and evaluation procedures.

CONCLUSIONS

After numerous modifications, FMM has recruited and retained over 400 women, 30 churches, and has become a change agent in the community.

Correlates of women's cancer screening and contraceptive knowledge among female emergency department patients

Background

Lack of knowledge regarding preventive health services for women might impede campaigns to expand these services in the emergency department setting. For 18–55-year-old English-speaking women visiting an urban emergency department, we aimed to: (1) Ascertain their knowledge regarding the applicability, purpose, and recommended intervals of three women's cancer screening and three contraceptive methods; and (2) Determine if patient age, race/ethnicity, medical insurance status, and current or recent usage of these methods are associated with greater or lesser knowledge about them.

Methods

Emergency department-based survey on recent or current usage and knowledge about Pap smears, breast self-examinations, mammograms, condoms, birth control, and emergency contraception. Analyses included calculation of summary statistics and creation of multivariable logistic regression models.

Results

Of 1,100 patients eligible for the study, 69.9% agreed to participate. Most of the participants were < age 35, white, single (never married and no partner), Catholic, and had private medical insurance. Participant's recent or current usage of a particular cancer screening or contraceptive method varied by type of method: Pap smear within the past year (69.1%), breast self-exam within the past month (45.5%), mammogram within the past year (65.7% for women age 45–55), condom usage during every episode of sexual intercourse (15.4%), current usage of birth control pills (17.8%), and ever use of emergency contraception (9.3%). The participants correctly answered 87.9% of all survey questions about condoms, 82.5% about birth control pills, 78.5% about breast self-exams, 52.9% about Pap smears, 35.4% about mammograms, and 25.0% about emergency contraception. In multivariable logistic regression models, survey participants who had private medical insurance and those who recently or currently used a given screening or contraceptive method had a greater odds of correctly answering all questions about each cancer screening or contraceptive method.

Conclusion

Although these female ED patients demonstrated strong knowledge on some women's cancer screening and contraceptive methods, there were several areas of knowledge deficit. Women without private medical insurance and those who have not used a particular cancer screening or contraceptive method demonstrated less knowledge. Reduced knowledge about women's cancer screening and contraceptive methods should be considered during clinical encounters and when instituting or evaluating emergency department-based initiatives that assess the need for these methods.

A Qualitative Evaluation of a Faith-Based Breast and Cervical Cancer Screening Intervention for African American Women

This article presents a formative evaluation of a CDC Racial and Ethnic Approaches to Community Health (REACH) 2010 faith-based breast and cervical cancer early detection and prevention intervention for African American women living in urban communities. Focus groups were conducted with a sample of women ( N = 94) recruited from each church participating in the intervention. One focus group was conducted in each of the nine participating churches following completion of the 6-month REACH 2010 intervention. Transcribed data were coded to identify relevant themes. Key findings included (a) the acceptability of receiving cancer education within the context of a faith community, (b) the importance of pastoral input, (c) the effectiveness of personal testimonies and lay health advocates, (d) the saliency of biblical scripture in reinforcing health messages, (e) the effectiveness of multimodal learning aids, and (f) the relationship between cervical cancer and social stigma. Study findings have implications for enhancing faith-based breast and cervical cancer prevention efforts in African American communities.

Factors related to participation in a cervical cancer screening programme in urban Sweden

Fifty-six per cent of invited women aged 25-60 attended the Population-based Cervical Cancer Screening Programme (PCCSP) in Stockholm, Sweden in 1994-1996. The objective of this study was to explore factors related to participation in this PCCSP. Registry data on all women aged 25-60 invited to the PCCSP from 1994 to 1996 (n=307,552) was matched with a national longitudinal population database. Women in the youngest age group (25-29 years old) were found to be less likely to participate in the PCCSP than women in older age groups. Married women or widows attended the programme more often (OR 1.32, 95% confidence interval (95% CI) 1.29-1.34 and OR 1.36, 95% CI 1.27-1.45, respectively) than did single women. Women in the labour force were more likely to participate than those who were not in the labour force (OR 1.82, 95% CI 1.78-1.87). The participation rate was not lower for immigrant women from developing countries than for those born in Sweden. We found that age, marital status and being in the labour force or not are factors associated with participation in the cervical cancer screening programme.

Social and cultural barriers to Papanicolaou test screening in an urban population

OBJECTIVE

To define screening behaviors, attitudes, and beliefs regarding cancer and its treatment among women with cervical cancer.

METHODS

Between August 2000 and July 2002, 148 consecutive women with invasive cervical cancer were queried about barriers to screening. Women presented to outpatient clinics, emergency departments, or inpatient units of 3 urban hospitals. Two groups of women were identified: those who denied having had a Papanicolaou (Pap) test and those who had recalled having Pap test in the past. Responses were compared using t tests, chi(2) tests, and binary logistic regression.

RESULTS

The 146 (99%) respondents were predominantly African Americans (50%) or Hispanic (27%). Thirty-six (25%) women reported no prior screening. Women never screened were significantly more likely to be Hispanic (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.4-6.7), recent immigrants (OR 5.7, 95% CI 2.0-16), less educated (OR 3.6, 95% CI 1.6-8.0), and uninsured (OR 3.9, 95% CI 1.6-9.7). They were more likely to lack family support (adjusted OR 3.5, 95% CI 1.1-11) and lack knowledge about their risk for cervical cancer (adjusted OR 2.6, 95% CI 1.1-6.4). Unscreened women displayed fatalistic attitudes, believing cancer is bad luck (adjusted OR 2.6, 95% CI 1.0-6.9) and not wanting to know they had cancer (adjusted OR 3.0, 95% CI 1.0-9.4)..

CONCLUSION

We have identified factors and beliefs that are barriers to Pap test screening in urban cervical cancer patients. Further studies should evaluate effects of addressing cultural, cognitive, and financial barriers on Pap test compliance.

The safety net: a cost-effective approach to improving breast and cervical cancer screening

PURPOSE

The purposes of the study were (1). to assess the cost-effectiveness of three interventions to deliver breast and cervical cancer screening to women unscreened for >or=3 years and (2). to determine the relation of an invasive cervical cancer diagnosis to the interval since the last true screening test.

METHODS

In a randomized trial, women were randomly assigned to (1). usual care, (2). letter plus follow-up letter, (3). letter plus follow-up phone call, (4). phone call plus follow-up phone call. Screening within 12 weeks was the outcome. A 5-year retrospective review of cervical cancer cases and screening histories was done.

RESULTS

The 8% of women not screened for >or=5 years had 62% of the invasive cervical cancer cases. Mammography outreach led to screening in 10%, 24%, 51%, and 50% of controls, letter/letter, letter/phone, and phone/phone interventions groups, respectively. Cervical cancer screening outreach led to screening in 17%, 22%, 54%, and 50% of the respective groups. Letter reminders alone produced fewer tests at substantially higher costs than did personalized telephone notification.

CONCLUSIONS

For cervical cancer, only 1 person in 12 was not screened in the preceding 5 years, but these accounted for nearly two thirds of invasive cancers. Aggressive outreach to the rarely screened is an important part of screening programs. Letter reminder, followed by a telephone appointment call, was the most cost-effective approach to screening rarely screened women. Lack of accurate information on prior hysterectomy adds substantial unnecessary costs to a screening reminder program.

Interventions for patients, providers, and health care organizations

Clinicians and the organizations within which they practice play a major role in enabling patient participation in cancer screening and ensuring quality services. Guided by an ecologic framework, the authors summarize previous literature reviews and exemplary studies of breast, cervical, and colorectal cancer screening intervention studies conducted in health care settings. Lessons learned regarding interventions to maximize the potential of cancer screening are distilled. Four broad lessons learned emphasize that multiple levels of factors-public policy, organizational systems and practice settings, clinicians, and patients-influence cancer screening; that a diverse set of intervention strategies targeted at each of these levels can improve cancer screening rates; that the synergistic effects of multiple strategies often are most effective; and that targeting all components of the screening continuum is important. Recommendations are made for future research and practice, including priorities for intervention research specific to health care settings, the need to take research phases into consideration, the need for studies of health services delivery trends, and methods and measurement issues.

Pap smear use in a population of older Mexican-American women

BACKGROUND

Hispanic women and older women (age > or = 50 years) in general have been identified as populations of women who often underutilize Papanicolaou (Pap) smears.

OBJECTIVE

To report the rates of cervical cancer screening in a group of older Mexican American women and to identify the correlates of having a Pap smear in the past three years.

DATA SOURCE

The Mammography Use by Older Mexican-American Women Survey, a stratified area probability sample of 452 women ages 50-74 from three southeast Texas counties. Self-report data was collected with in-person interviews from 1997 to 1999.

RESULTS

We found that 93.1% of the women reported at least one Pap smear in their lifetime and that 64.1% reported a Pap smear in the past three years. Odds of reporting a recent Pap smear was lower for older women (OR 0.51, 95% CI 0.32-0.82) and those below the poverty line (OR 0.52, 95% CI 0.33-0.82). The odds were higher for women who had a regular doctor for female care (OR 6.49, 95% CI 2.96-14.23) or a regular clinic or hospital source for female care (OR 5.50, 95% CI 2.55-11.89). Among these older Mexican-American women, cultural factors (language of interview, acculturation, fatalism) did not have a significant effect on screening use.

CONCLUSION

Recent Pap smear use (64.1%) falls well below the year 2010 goal of 90%. Efforts need to be made to overcome barriers to Pap smear utilization for these women, such as providing access to female medical care.

Knowledge of cervical cancer risk factors among Chinese immigrants in Seattle

Chinese American immigrants are a growing part of the United States population. Cervical cancer is a significant cause of morbidity and mortality among Chinese Americans. Pap smear testing is less common in Chinese American immigrants than in the general population. During 1999, we conducted a community-based survey of Chinese American women living in Seattle. We assessed knowledge of cervical cancer risk factors and history of Pap smear testing along with socioeconomic and acculturation characteristics. The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample included 472 women. Most cervical cancer risk factors were recognized by less than half of our participants. Factors independently associated with knowledge of cervical cancer risk factors included marital status, employment, and education. Respondents with the highest knowledge had greater odds of ever receiving a Pap smear, compared to those respondents with the lowest knowledge (OR 2.5; 95% CI: 1.1,5.8). Our findings suggest a need for increased recognition of cervical cancer risk factors among Chinese American immigrants. Culturally and linguistically appropriate educational interventions for cervical cancer risk factors should be developed, implemented and evaluated.

The effect of comorbid illness on receipt of cancer screening by older people

OBJECTIVES

To identify associations between the type and number of diagnoses and receipt of screening for breast, cervical, and colorectal cancer by older people.

DESIGN

Sixth annual follow-up of a community-based survey with 4,162 participants aged 65 and older at baseline in 1986.

SETTING

Piedmont area of North Carolina.

PARTICIPANTS

Two thousand two hundred twenty-five subjects with a mean age of 79 who responded in 1992.

MEASUREMENTS

Self-reported receipt of clinical breast examination, mammography, Papanicolaou (Pap) smear, and fecal occult blood testing (FOBT) within the 2 years before the survey.

RESULTS

Hip fracture was associated with lower rates of mammography (odds ratio (OR) = 0.53, 95% confidence interval (CI) = 0.32-0.87) and cognitive impairment with lower rates of FOBT (OR = 0.71, 95% CI = 0.54-0.94). Hypertension was associated with higher rates of breast examination (OR = 1.56, 95% CI = 1.18-2.07), Pap smear (OR = 1.41, 95% CI = 1.09-1.83), and FOBT (OR = 1.37, 95% CI = 1.12-1.66) and a trend toward increasing rates of mammography (OR = 1.28, 95% CI = 0.98-1.69). The presence of three or more comorbid conditions was associated with an increased rate of mammography (OR = 1.35, 95% CI = 1.06-1.71), breast examination (OR = 1.46, 95% CI = 1.12-1.89), and Pap smear (OR = 1.31, 95% CI = 1.04-1.65).

CONCLUSIONS

With few exceptions, the presence of comorbid conditions is not associated with a decreased rate of receipt of screening. In fact, hypertension and the presence of a higher number of comorbid conditions are associated with a higher rate of receipt of cancer screening. This finding may be due to an increase in the frequency of office visits increasing the opportunity for cancer screening.

Increasing cervical cancer screening among underserved women in a large urban county health system: can it be done? What does it take?

BACKGROUND

Further reduction in avoidable cervical cancer morbidity and mortality may require system-wide, integrated approaches implemented in the public health facilities serving the nation's indigent and minority women.

OBJECTIVES

Report on the evaluation of a 5-year demonstration project testing a multicomponent (provider, system, and patient) intervention to increase cervical cancer screening among women who receive their health care through the Los Angeles County Department of Health Services, the second largest County Health Department in the nation.

MATERIALS AND METHODS

A longitudinal nonequivalent control group design was utilized. Data were collected during a baseline (no intervention) year and 2.5 years of intervention. A large hospital, one feeder Comprehensive Health Centers (CHC), and three of the health center's feeder Public Health Centers (PHC) received the intervention. Another hospital, CHC and its three feeder PHCs (matched on size, patient characteristics, and range of services provided) served as comparison sites. Independent random samples of patients 18 years and older were drawn annually at each site (n = 18,642). The outcome measure was a receipt of a Papanicolaou smear during a 9-month period.

RESULTS

At the Hospital and CHC levels a statistically significant intervention effect was observed after controlling for baseline screening rates and case mix. No intervention effect was observed at the PHCs.

CONCLUSION

An intensive multicomponent intervention can increase cervical cancer screening in a large, urban, County health system serving a low-income minority population of under screened women. Retention of program elements in the postresearch phase, and the difficulties and importance of conducting this type of research, is described.

Cervical cancer risk as a predictor of Pap smear use in rural North Carolina

Risk for invasive cervical cancer is reported to be higher in rural areas than urban ones, and cervical cancer-related mortality is higher in rural women due to poorer utilization of preventive services and subsequent presentation at late stages of the disease. This cross-sectional study examined the relationship between prevalence of risk factors for cervical cancer and the degree of compliance with risk-appropriate screening guidelines for cervical cancer. Secondary data were analyzed for 614 women from Robeson County, NC, aged 40 and older, and of mainly rural and low socioeconomic status. High-risk status was determined by the presence of any of the following five risk factors: a history of more than two sexual partners, age at first sexual intercourse under 18 years, history of sexually transmitted disease, history of sexually transmitted disease in sexual partner(s), and smoking. Low-risk status was the absence of all factors. A high-risk participant was considered compliant if she had had at least three Pap smears in the 3 years prior to the interview, while a low-risk participant was considered compliant if she had had at least one Pap smear within the previous 3 years. Overall, 82% of the participants were at high risk for cervical cancer. However, only 41% of all participants were compliant with the risk-appropriate screening guidelines. Low-risk status was significantly associated with compliance with cervical cancer screening guidelines (adjusted OR = 6.7; 95% CI = 3.7 to 11.1, p = .0001). Findings in this study population suggest rural women at high risk for cervical cancer are less likely to be compliant with appropriate Pap smear screening guidelines, indicating the need to target educational programs.

Barriers to mammography and Pap smear screening among women who recently had neither, one or both types of screening

There is legitimate concern about whether cancer screening programs and other types of prevention and early detection programs are designed to reach those most in need of services. Previous research on barriers to screening has generally addressed screening for specific cancers. The purpose of this study was to evaluate and compare the types and strengths of barriers to both mammography and Pap smear screening experienced by three groups of women. Five hundred and twenty-two women, aged 52-69, who were members of a large health maintenance organization (HMO), completed a survey about cancer screening and associated barriers. Women with no mammogram in the preceding 2 years and with no Pap smear in 3 years were classified into a "safety net" program. We classified women as falling into both (Pap smear and mammography), one (Pap smear or mammography), or neither safety nets. Results consistently revealed that women needing both tests had more numerous and more intense barriers than other women to both types of screening. Factor analyses and descriptive analyses both showed that the types of barriers experienced were very similar for mammography and Pap smear screening. The discussion addresses intervention implications and the additional research needed on women who need both mammogram and Pap smear screening and who have much higher cancer risk than other women.

The relation of household income to mammography utilization in a prepaid health care system

Managed care organizations should be expected to provide equivalent access to preventive and screening services to all members. We studied mammography in 1,667 women members of one HMO who had an overall utilization rate of 84.9%. Significant correlates of mammography utilization included age, estimated household income, and division of the managed care organization in which the member was enrolled. Each $10,000 increment of income increased mammography rates by 2.5 percentage points (95% confidence interval [CI], 1.4% to 3.6%), independent of age and division. Our findings suggest that coverage for mammography services is not sufficient to ensure equivalent use of screening across income groups.

Cancer screening decisions

This review focuses on why people decide to obtain or to avoid screening for cancer. We discuss three topics: (a) physician prompts that may elicit compliant screening behavior, (b) the independent and joint effects of risk perceptions and worry, and (c) the costs and benefits of getting screened. Overall, the data suggest that each of these factors will influence screening. So, for example, people are more likely to seek screening if a physician recommends the behavior, if they feel personally vulnerable and worry a little about cancer, if insurance covers the screening, and if they believe that the test is an effective early detection procedure. Future research needs include studies comparing theories, longitudinal rather than cross-sectional studies, and true experiments. We also need to know more about why physicians are such powerful change agents and the trade-offs of increasing personal risk versus exacerbating worry. Practical recommendations for promoting cancer screening include encouraging physician interventions, explaining risk, and lowering the costs while emphasizing the benefits of screening.

Cervical cancer screening knowledge and practices among Korean-American women

Cervical cancer is one of the most common cancers of American women. The Papanicolaou (Pap) smear test for cervical screening is a widely used and effective means to reduce the morbidity and mortality rate from cervical cancer through early detection. Despite these benefits, many women have never been screened or are not screened at regular intervals. The purpose of this study was to examine cervical cancer screening knowledge and practices of Korean-American women. The sample consisted of 159 Korean-American women, 40 to 69 years of age. The 1987 Cancer Control Supplement questionnaire was translated into Korean and used to collect data. Twenty-six percent of the respondents never heard of the Pap smear test. Only 34% of respondents reported having had a Pap smear test for screening. The most frequently cited reason for not having had a Pap smear test was absence of disease symptoms. Results indicate that education and usual sources of health care were significant factors related to having heard of or having had a Pap smear test. The findings from this study have important implications for health practitioners and policy makers who serve this ethnic population.

Screening for breast and cervical cancers: the importance of knowledge and perceived cancer survivability

INTRODUCTION

This study examines the association between recent screening for breast and cervical cancers, knowledge of cancer risk factors, and perceptions of surviving cancer.

METHODS

Data were from the Cancer Control Supplement to the 1992 National Health Interview Survey (NHIS-CCS). The dependent variable combined breast and cervical cancer screening practices into a single composite index. Two independent variables combined women's knowledge about breast and cervical cancers into single indicators--one representing risk factor knowledge, the other representing perceived likelihood of surviving breast and cervical cancers following early detection.

RESULTS

Multivariate analysis showed that recency of screening for both breast and cervical cancers was associated with knowledge of cancer risk factors and perceptions of surviving cancer. Education, household income, and smoking status also were correlates of comprehensive screening. Significant interactions between income and perceived survivability, and between education and perceived survivability suggested that the effects of income and education on comprehensive screening varied with perceptions about surviving cancer.

CONCLUSION

The study suggests that knowledge and attitudinal questions can be combined for two diseases to enhance understanding of who is most likely to be screened comprehensively for breast and cervical cancers. Although national trends show that large percentages of women over age 50 are having mammograms and Pap tests, this progress is not likely to be sustained unless existing barriers are eliminated. Limited knowledge about breast and cervical cancer risk factors and misperceptions about survival from cancer represent two of these barriers.

A review of cervical cancer screening intervention research: implications for public health programs and future research

In this paper we review the published literature with respect to cervical cancer screening intervention research. Mass media campaigns appear to work best in promoting cervical cancer screening when multiple media are used, when they promote specific screening programs that eliminate or reduce access barriers, or when they are used in combination with other strategies. Many positive examples of using outreach staff to promote cervical cancer screening, as well as using mobile examination rooms in the community, were found. Substantial evidence that letters mailed to patient populations are efficacious was found, especially in promoting interval screening; however, bulk mailings to nonpatient populations have generally not been successful. Both physician and patient prompts have shown promise as well as opportunistic screenings in both the outpatient and the inpatient settings. In addition, several strategies for reducing loss to follow-up among women with abnormal test results were identified, including telephone follow-up, educational mailouts, audiovisual programs, clinic-based educational presentations and workshops, transportation incentives, and economic vouchers. Of special note is the success of other countries in establishing centralized recall systems to promote interval screening for cervical cancer. Ultimately, such systems could replace the need for opportunistic screening in underserved populations and perhaps many community outreach efforts. It is argued that health departments represent a logical starting point for developing a network of recall systems in the United States for underserved women.

Breast and cervical cancer screening among women with physical disabilities

OBJECTIVE

This article reports findings from the National Study of Women with Physical Disabilities about rates of screening for breast and cervical cancer and factors associated with regular screening in a large sample of women with a variety of physical disabilities and a comparison group of women without disabilities.

DESIGN

Case-comparison study using written survey. Data were analyzed using measures of central tendency, chi 2 analysis, logistic regression, and risk using odds ratios.

SETTING

General community.

PARTICIPANTS

A total of 843 women, 450 with disabilities and 393 of their able-bodied friends, aged 18 to 65, who completed the written questionnaire. The most common primary disability type was spinal cord injury (26%), followed by polio (18%), neuromuscular disorders (12%), cerebral palsy (10%), multiple sclerosis (10%), and joint and connective tissue disorders (8%). Twenty-two percent had severe functional limitations, 52% had moderate disabilities, and 26% had mild disabilities.

MAIN OUTCOME MEASURES

Outcomes were measured in terms of frequency of pelvic exams and mammograms.

RESULTS

Women with disabilities tend to be less likely than women without disabilities to receive pelvic exams on a regular basis, and women with more severe functional limitations are significantly less likely to do so. No significant difference was found between women with and without disabilities, regardless of severity of functional limitation, in receiving mammograms within the past 2 years. Perceived control emerged as a significant enhancement factor for mammograms and marginally for pelvic exams. Severity of disability was a significant risk factor for noncompliance with recommended pelvic exams, but not mammograms. Race was a significant risk factor for not receiving pelvic exams, but not mammograms. Household income and age did not reach significance as risk factors in either analysis.

CONCLUSIONS

Women with physical disabilities are at a higher risk for delayed diagnosis of breast and cervical cancer, primarily for reasons of environmental, attitudinal, and information barriers. Future research should focus on the subpopulations that were not surveyed adequately in this study, women with disabilities who have low levels of education or income, or who are of minority status.

Participation in colorectal cancer screening: a review

The purpose of this review is to evaluate the published literature on adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT) and sigmoidoscopy. Specifically, the review addresses the following: 1) prevalence of FOBT and sigmoidoscopy; 2) interventions to increase adherence to FOBT and sigmoidoscopy; 3) correlates or predictors of adherence to FOBT and sigmoidoscopy; and 4) reasons for nonadherence. Other objectives are to put the literature on CRC screening adherence in the context of recently reported findings from experimental interventions to change prevention and early detection behaviors and to suggest directions for future research on CRC screening adherence. CRC screening offers the potential both for primary and for secondary prevention. Data from the 1992 National Health Interview Survey show that 26% of the population more than 49 years of age report FOBT within the past 3 years and 33% report ever having had sigmoidoscopy. The Year 2000 goals set forth in Healthy People 2000 are for 50% of the population more than 49 years of age to report FOBT within the past 2 years and for 40% to report that they ever had sigmoidoscopy. Thus, systematic efforts to increase CRC screening are warranted. To date, attempts to promote CRC screening have used both a public health model that targets entire communities, e.g., mass media campaigns, and a medical model that targets individuals, e.g., general practice patients. Most of these efforts, however, did not include systematic evaluation of strategies to increase adherence. The data on FOBT show that the median adherence rate to programmatic offers of FOBT is between 40% and 50%, depending on the type of population offered the test, e.g., patients or employees. Approximately, 50% of those initially offered testing in unselected populations will respond to minimal prompts or interventions. A salient issue for FOBT, however, is whether or not the behavior can be sustained over time. Fewer studies examined adherence to sigmoidoscopy. Adherence was highest in relatives of CRC cases and in employer-sponsored programs offered to workers at increased risk of CRC. At present, we know very little about the determinants of CRC screening behaviors, particularly as they relate to rescreening.

Interaction of spontaneous and organised screening for cervical cancer in Turin, Italy

In a screening programme for cervical cancer, coverage of the target population is a major determinant of effectiveness and cost-effectiveness and is one of the parameters for programme monitoring recommended by the "European Guidelines for Quality Assurance". An organised screening programme was started in Turin, Italy, in 1992. Spontaneous screening was already largely present, but coverage (proportion of women who had at least a test within 3 years) was low (< 50%) and distribution of smears uneven. No comprehensive registration of spontaneous smears was available. All women were invited for the first round, independently of their previous test history. Coverage was estimated by integrating routine data from the organised programme with data on spontaneous screening obtained by interviews of a random sample of 268 non-compliers to invitation and 167 compliers. Overall (spontaneous + organised) coverage was estimated to be 74% (95% CI, 71-78%). The proportion of the target population covered as an effect of invitation was estimated to be 17% (95% CI, 15-20%). Invitations were successful in increasing coverage in previously poorly screened groups. Although 20-25% of compliers was estimated to have had further tests before the end of the round, we estimated that switching to a 3-year interval saved approximately 0.26 tests per complier. This suggests that invitations to an organised programme even to previously covered women, can be a cost-effective policy. Our method of estimating overall coverage can be useful in many other European areas where a comprehensive registration of smears is not available.

The accuracy of self-reported Pap smear utilisation

This study assessed the accuracy of self-reported Pap smear utilisation over four different time frames, examining the magnitude of errors in self-report and sociodemographic predictors of accuracy. Self-report data on women's cervical screening was collected by interview in a random household survey (Hunter Region, NSW, Australia), with pathology laboratory data collected by a search of records within laboratories. The magnitude of error in self-report was assessed by comparing it against longer intervals in pathology laboratory data. Sociodemographic predictors of accuracy were explored using chi square analyses. Low values for specificity and positive predictive value across all four time frames indicate a considerable degree of inaccuracy in women's reporting of those instances where, in truth, screening has not occurred. Of women reporting a smear within the last three years, only 61.2% were verified within pathology laboratory records. Allowing women some "leeway" in their reporting, comparing self-report to longer intervals of pathology laboratory data, did not greatly improve the accuracy of reporting, confirming that the magnitude of inaccuracy involved is of real clinical significance. Demographic variables were not related to the accuracy of self-report and, while a woman's certainty of her response was predictive, this had little impact on the measures of agreement. Self-report of Pap smear histories consistently results in over-reporting of screening. Other means of assessing the prevalence of screening may be preferable to self-report. Where self-report data is collected, techniques to improve accuracy should be employed, and care should be taken in comparing screening rates obtained by different methods.

Implementation of a breast and cervical cancer screening program in a public hospital emergency department. Cancer Control Center of Harlem

STUDY OBJECTIVE

To assess the feasibility and yields of screening for breast and cervical cancer in an urban public hospital emergency department.

METHODS

Women who presented to the ED of a large, urban public hospital during the study period with nonurgent conditions were eligible for a Papanicolaou test (Pap smear) and a clinical breast examination (CBE) if they were 18 years of age or older and for a mammogram if they were 40 years of age or older, provided they had not had the screening examination within the past year. The Pap smear and CBE were performed by a nurse, and mammography was scheduled for a later date. Women with gynecologic complaints were excluded.

RESULTS

On the basis of screening history, medical status, and age, 1,850 (32%) of the 5,830 women seen in the ER during the 23-month study period were eligible for both mammography and CBE, and 2,361 (41%) were eligible for Pap smears. Of these women, 116 (6%) completed mammography and CBE, and 644 (27%) received Pap smears. Among screened women, 10 (9%) and 20 (3%), respectively, had results that were suspicious or positive for breast or cervical cancer. Follow-up rates were low: 20% for breast screening and 50% for Pap smears. Among those receiving follow-up, 1 woman was found to have breast cancer and 8 were found to have cervical neoplasia.

CONCLUSION

ED cancer screening was feasible and yielded a high rate of cancer detection. Program efficiency was hampered by low volume and high numbers of patients lost to follow-up after abnormal screening results. Greater integration into the acute care setting and more intensive recruitment and follow-up strategies are needed to maximize the potential yield and cost effectiveness of such programs.

Risk factors for invasive cervical cancer in Latino women

Most invasive cervical cancer research in the United States has been conducted on non-Latino-White (NLW) and African-American women. Incidence, mortality, stage at diagnosis and survival indicators for invasive cervical cancer in Latino women in California are compared to NLW and African-American women. A model is presented which depicts structural, behavioral, genetic and biological risk factors for invasive cervical cancer. A literature review of risk factors and their association with invasive cervical cancer was conducted using MEDLINE and PsychINFO databases to determine if ethnic differences in risk factors explain observed differences in morbidity and mortality. Latino women experience a significantly higher incidence and mortality associated with invasive cervical cancer than NLW women. The review of risk factors found that rate differences of cervical cancer screening, early detection and human papilloma virus (HPV) type-specific infection explain much of the disparity in disease burden. Further research must clarify if ethnic differences exist in risk factors associated with ethnic variation in HPV-type prevalence in both cases and their sexual partners, in host immune responses, and multiparity.

Walking the journey of womanhood: Yakama Indian women and Papanicolaou (Pap) test screening

Cervical cancer is the second leading cancer among Alaska Native, American Indian women, who have a high incidence of cervical cancer and low survival rates (Boss, 1991; Michalek & Mahoney, 1990; Page & Asire, 1985). The purpose of this Grounded Theory study was to gain a greater understanding of the meaning of the papanicolaou (Pap) test to the Yakama Indian women of eastern Washington to support the Tribe in the design of effective screening interventions. Data from 15 interviews, focus groups, and participant observation were included in the data analysis. The major theme was: Walking the Journey of Womanhood. Four phases of the journey were identified: (a) Starting the Journey, (b) Blooming, (c) Heading the Household, and (d) Becoming an Elder. In this study we found that interventions to influence Pap test screening among the Yakama women must address structures of care, provider-patient communications, and education for the women. Women heading the households and elders were identified as priority populations for education because they have negative attitudes from previous experiences and have a great influence on the younger women. Messages need to be wellness oriented and traditional methods of education, such as the talking circle, role model, and storytelling, need to be used.

Sociodemographic factors of Pap smear screening in Taiwan

Substantial evidence exists that regular screening is effective in preventing cervical cancer. However, the existing services are underused by many women in Taiwan. To examine the effects of sociodemographic characteristics on the underuse of Papanicolaou (Pap) smear screening, from September to December 1993 we conducted a questionnaire interview on a sample of 4,400 women aged 20 years and older in Taipei city using multistage sampling with probability proportional to size. Our results indicate that 40% of the women sampled have never had a Pap smear and 86% have not had one in the past year. Age is the strongest factor affecting Pap smear use, particularly for women below age 30 and over the age of 65. In addition, women with lower levels of education, women who are not employed, never-married women and women who live outside the city tend to underuse Pap smear screening. These findings help indicate priority groups which should be targeted to increase screening and consequently reduce cervical cancer. Our data also provides a good baseline for comparison of rates of Pap smear screening by various sociodemographic factors in the future.

The quality of cervical cancer screening: a primary care perspective

The bulk of cervical cancer screening is performed by primary care providers; mostly nurses and physicians. The literature regarding the quality of this screening is largely described from three perspectives; clinical, laboratory, and public health. This article describes the primary care perspective regarding issues of quality in cervical cancer screening and suggests areas for improvement. The authors discuss how effectiveness of the test, sampling methods, interpretation by the laboratory, and reporting results impact on the quality of cervical cancer screening. Other factors which influence the quality of screening such as access to care, recall intervals, communication with the patient, costs of testing, and organizational issues are also reviewed.

Women's experiences at cervical screening

Concerns about attendance for cervical screening has focussed on determining the reasons why some women never attend. Less attention has been paid to whether women continue to attend for further smears, although this is essential for further screening. This study investigated women's experiences of cervical screening and their views on subsequent attendance. Three hundred and thirty nine women aged 20-64 were identified from a computerised register of cervical smears as having had a smear test within the previous three years. They were interviewed at home about their most recent experience of screening. Just over half of the women (53%) recalled being anxious before the test, and about one fifth reported embarrassment (19%) or pain (20%) during it. The frequencies of discomfort were higher amongst those who were anxious about the test, although 24% of those who were embarrassed and 28% who had pain reported being unconcerned beforehand. The frequencies of pain and embarrassment were only slightly higher when the smear taker was male. Many women (22%) reported being concerned about the test result although only 10% of those who were concerned were recalled for further assessment. Although a number of women had unpleasant experiences, almost all (95%) who were under 60 years of age said they were likely to attend for a subsequent smear. Taking cervical smears is often an unpleasant experience for women, although some of the distressing events could easily have been avoided. Attention to technique and to the concerns of individual patients, especially ensuring privacy, could reduce the extent of the problem. The uptake of subsequent smears should be monitored to ensure that women are not being discouraged from attendance.

Survey of El Paso physicians' breast and cervical cancer screening attitudes and practices

One hundred and ninety-eight primary care physicians in El Paso, Texas, were surveyed for their practices and attitudes concerning breast and cervical cancer screening. The response rate was 83%. For women 40-49 years old, 77% of respondents stated that they ordered a screening mammogram at least every two years. For women 50-74 years old, 73% said they ordered an annual screening mammogram. For women 75 years and older, 61% stated they ordered an annual screening mammogram. For women 40 years or older, 89% of respondents said they performed annual or more frequent clinical breast examinations. Eighty-four percent of respondents stated they ordered a Pap smear every 1-3 years, both for pre- and post-menopausal women. The most common reasons given for not ordering or doing a breast or cervical screening exam were patient refusal, knowledge that other doctor performs exam, high price, inadequate insurance, patient not under regular care, do not see patient for gynecologic care, and patient being seen for different reason. Seventy percent of respondents do vaginal smears on women who have had a total hysterectomy for a benign condition, and 38% use a cytobrush for endocervical sampling. Respondents were generally more comfortable with their ability to do Pap smears (72% comfortable, 1% uncomfortable) than they were in performing clinical breast examinations (52% comfortable, 4% uncomfortable). Obstetricians and gynecologists were more likely than other physicians to do vaginal smears, use a cytobrush, and feel comfortable with their Pap smear technique.

Age, socio-economic status and survival from cancer of cervix in the West of Scotland 1980-87

The outcome of treatment by age and socio-economic status was examined for 1,588 women with invasive cancer of cervix resident in the West of Scotland and diagnosed between 1980 and 1987. There was no difference in prognosis according to either variable once analysis was controlled for stage at presentation, treatment type and tumour grade. Tumour histology, date of treatment and health board of residence had no significant effect on survival independent of other variables. A strong correlation was found between socio-economic status and the incidence of cervical cancer in the West of Scotland. Women aged 45 and over and living in deprived areas were more likely to present with later stage tumours and to survive less well than younger patients from the more affluent parts of the region. Any additional resources which may be made available for cervical cancer screening should be directed more effectively towards those most at risk.

The socioeconomic correlates of hysterectomies in the United States

The purpose of this study was to examine the relationship between incidence of prior hysterectomy and education, income, and race. Data concerning previous hysterectomy and socioeconomic information were collected from 12,465 women 18 years or older as part of the Behavioral Risk Factor Surveillance System conducted in 16 states in 1988. The results indicate that women with less education and lower incomes were more likely to have had a hysterectomy. Race was not related to hysterectomy rate.

How sources of health information relate to knowledge and use of cancer screening exams

Utilization of many screening procedures to detect cancer in early stages remains low. In order to design more effective strategies to increase utilization of these tests, we assessed the role and relative importance of different information sources on knowledge and use of cancer screening exams. Where individuals get useful information about disease prevention, and the relationship of information sources to cancer screening knowledge and behavior are reported using data from the 1987 National Health Interview Survey. Results indicate that physicians are perceived as important sources of information on how to prevent illness. However, persons who use print media as their most useful source of information are significantly more likely to have heard of cancer screening procedures than those who rely on the doctor as the source. Those who rely on electronic media tend to be less knowledgeable of all screening procedures examined. A strong and consistent association between doctor as the most useful source of information and actually having received the procedure was found. These results suggest that knowledge may not necessarily be a prerequisite to screening and indicate that reliance on the physician to recommend cancer screening may be critical in utilization of these services.

Access to cancer screening services for women

A major effort in preventive care for women has emphasized the obtaining of Pap smears and mammograms. This paper uses survey data from one state to examine issues of access to Pap smears and mammograms. Poor women receiving health care through a managed-care Medicaid program received these services at the same rate as women with other types of health insurance, while the uninsured were less likely to have had either type of service.