Improving adherence to screening follow-up among women with abnormal Pap smears: results from a large clinic-based trial of three intervention strategies

Factors associated with loss to follow up after abnormal cervical cancer screening in pregnancy

OBJECTIVE

To assess risk factors associated with loss to follow up in patients referred for colposcopy after abnormal cervical cytology during pregnancy in a Southern safety net hospital population.

METHODS

An urban colposcopy center was queried for patients referred for follow up of abnormal cervical cytology during pregnancy and the postpartum period. Patients were identified through a standardized referral code in the electronic medical record. Multivariable logistic regression was used to compare patient characteristics between those who followed up for colposcopy and those lost to follow up. Independent risk factors assessed included age, parity, race, insurance, HIV status, history of mental illness, BMI, gestational age and trimester at screening, cytology at colposcopy referral, interval days until colposcopy, and biopsy histology.

RESULTS

1063 patients were identified, with 40.8% of patients who completed referred colposcopy. Patient characteristics predictive for colposcopy follow up included: maternal age at referral cervical cytology >30 years (1.67; 1.27-2.20; < 0.003), gestational age < 18 weeks at abnormal cervical cytology (1.57; 1.23-2.01; <0.0002), maternal race non-African American (2.20; 1.32-3.65; <0.0024) and with high grade cervical cytology (2.42; 1.81-3.24; <0.0001).

CONCLUSION

In this population, inadequate follow up for abnormal cervical cytology during pregnancy is prominent, especially among those with younger maternal age, African American (AA) race, cervical cytology completed at later gestational ages of pregnancy, and low-grade initial cytology. Higher no-show rate among AA patients supports well-documented health disparities and need for further investigation and protocols to identify those at risk for loss to follow up.

Chatbot-interfaced and cognitive-affective barrier-driven messages to improve colposcopy adherence after abnormal Pap test results in underserved urban women: A feasibility pilot study

Challenges in ensuring adherence to colposcopy and follow-up recommendations, particularly within underserved communities, hinder the delivery of appropriate care. Informed by our established evidence-based program, we sought to assess the feasibility and acceptability of a novel cognitive-affective intervention delivered through a Chatbot interface, aimed to enhance colposcopy adherence within an urban inner-city population. We developed the evidence-based intervention, CervixChat, to address comprehension of colposcopy's purpose, human papillomavirus (HPV) understanding, cancer-related fatalistic beliefs, procedural concerns, and disease progression, offered in both English and Spanish. Females aged 21-65, with colposcopy appointments at an urban OBGYN clinic, were invited to participate. Enrolled patients experienced real-time counseling messages tailored via a Chatbot-driven barriers assessment, dispatched via text one week before their scheduled colposcopy. Cognitive-affective measures were assessed at baseline and through a 1-month follow-up. Participants also engaged in a brief post-intervention satisfaction survey and interview to capture their acceptance and feedback on the intervention. The primary endpoints encompassed study adherence (CervixChat response rate and follow-up survey rate) and self-evaluated intervention acceptability, with predefined feasibility benchmarks of at least 70% adherence and 80% satisfaction. Among 48 eligible women scheduled for colposcopies, 27 (56.3%) agreed, consented, and completed baseline assessments. Participants had an average age of 34 years, with 14 (52%) identifying as non-Hispanic White. Of these, 21 (77.8%) engaged with the CervixChat intervention via mobile phones. Impressively, 26 participants (96.3%) attended their diagnostic colposcopy within the specified timeframe. Moreover, 22 (81.5%) completed the follow-up survey and a brief interview. Barriers assessment revealed notable encodings in the Affect and Values/Goals domains, highlighting concerns and understanding around HPV, as well as its impact on body image and sexual matters. Persistent and relatively high intrusive thoughts and lowered risk perceptions regarding cervical cancer were reported over time, unaffected by the intervention. Post-intervention evaluations documented high satisfaction and perceived usefulness, with recommendations for incorporating additional practical and educational content. Our findings underscore the robust satisfaction and practicality of the CervixChat intervention among a diverse underserved population. Moving forward, our next step involves evaluating the intervention's efficacy through a Sequential Multiple Assignment Randomized Trial (SMART) design. Enhanced by personalized health coaching, we aim to further bolster women's risk perception, address intrusive thoughts, and streamline resources to effectively improve colposcopy screening attendance.

Factors associated with receiving results and attending colposcopy in patients with positive HPV screens in Mexico City

We identified patient and healthcare system factors related to receipt of screening results and attendance to colposcopy among patients with positive screening results in a cervical cancer screening program in Mexico City, Mexico. We analyzed data from 1,351 patients with high-risk human papillomavirus (HPV)-positive results from two screening demonstration studies conducted between 2017 and 2018. Factors associated with receipt of screening results and with adherence to a colposcopy appointment were identified using multivariable logistic regression. Participants had a median age of 40 years (IQR = 32-48), 60% had less than high school education, and 74% had a previous Pap screening in the last 5 years. Fifty-five percent of participants retrieved their screening results at the healthcare facility (HCF) without any reminder. Providing an email address for contact information, attending a HCF with family medicine, and receiving care from experienced nurses were associated with greater adherence to obtaining screening test results. Fifty-seven percent of participants attended their first scheduled colposcopy appointment. Providing a phone number improved adherence to colposcopy, whereas longer travel times between the HCF and the colposcopy clinic was associated with a decrease in colposcopy adherence. Having a Pap test in the last 5 years was positively associated with better compliance with both outcomes. Securing contact information may help to overcome barriers to future follow-up. Additional research is necessary on strategies for obtaining screening test results and scheduling appointments, which may help address barriers to access, such as limited staff availability, distance from the clinic, and travel costs.

Association between vehicle ownership and disparities in mortality after myocardial infarction

Background

Access to reliable transportation is fundamental in the management of chronic disease. The purpose of this study was to investigate the association between vehicle ownership at the neighborhood-level and long-term mortality after myocardial infarction (MI).

Methods

This is a retrospective observational study evaluating adult patients admitted for MI between January 1st, 2006, and December 31st, 2016. Neighborhoods were defined by census tract and household vehicle ownership data was obtained from the American Community Survey courtesy of the University of California, Los Angeles Center for Neighborhood Knowledge. Patients were divided into 2 groups: those living in neighborhoods with higher vehicle ownership, and those living in neighborhoods with lower vehicle ownership. The cutoff of 4.34% of households reporting not owning a vehicle was used to define a neighborhood as one with "higher" vs "lower" vehicle ownership as this was the median value for the cohort. The association between vehicle ownership and all-cause mortality after MI was assessed using Cox proportional hazards regression models.

Results

A total of 30,126 patients were included (age 68.1 +/- 13.5 years, 63.2% male). After adjusting for age, sex, race/ethnicity, and medical comorbidities, lower vehicle ownership was associated with increased all-cause mortality after MI (hazard ratio [HR] 1.10; 95% confidence interval [CI] 1.06-1.14; p<0.001). This finding remained significant after adjusting for median household income (HR 1.06; 95% CI 1.02-1.10; p = 0.007). Upon comparison of White and Black patients living in neighborhoods with lower vehicle ownership; Black patients were found to have an increased all-cause mortality after MI (HR 1.21, 95% CI 1.13-1.30, p<0.001), a difference which remained significant after adjusting for income (HR 1.20; 95% CI 1.12-1.29; p<0.001). There was no significant difference in mortality between White and Black patients living in neighborhoods with higher vehicle ownership.

Conclusion

Lower vehicle ownership was associated with increased mortality after MI. Black patients living in neighborhoods with lower vehicle ownership had a higher mortality after MI than White patients living in similar neighborhoods but Black patients living in neighborhoods with higher vehicle ownership had no worse mortality than their White counterparts. This study highlights the importance of transportation in determining health status after MI.

Distance to radiation therapy facility influences surgery type among older women with early‐stage breast cancer

BACKGROUND

Breast-conserving surgery plus radiation (BCT) yields equivalent or better survival than mastectomy for early-stage breast cancer (ESBC) women. However, nationwide mastectomy trends increased in recent decades, attracting studies on underlying causes. Prior research identified that long distance to the radiation treatment facility (RTF) was associated with mastectomy. Still, it is unclear whether such association applies to young and old ESBC women comparably. We sought to delineate such impacts by age.

METHODS

Women diagnosed with stages 0-II breast cancer in 2013-2017 receiving either BCT or mastectomy were identified from the Louisiana Tumor Registry. We assessed the association of surgery (mastectomy vs. BCT) with the distance to the nearest or nearest accessible RTFs using multivariable logistic regression adjusting the socio-demographic and tumor characteristics. The nearest accessible RTF was determined based on patients' health insurance. For Medicaid, uninsured, and unknown insurance patients, the nearest accessible RTF is the nearest RTF owned by the government. The interaction effect of age and distance was evaluated as well.

RESULTS

Of 11,604 patients, 46.7% received mastectomy. Compared with distance ≤5 miles to the nearest RTF, those with distance ≥40 miles or 15-40 miles had higher odds of mastectomy (adjusted (adj) OR = 1.39, 95% CI = 1.07-1.82; adj OR = 1.17, 95% CI = 1.02-1.34). To the nearest accessible RTF, the adj ORs were 1.25 (95% CI = 1.03-1.51) and 1.19 (95% CI = 1.04-1.35), respectively. Age-stratified analysis showed the significant association (p < 0.05) only presented among women aged ≥65, but not those aged <65 years.

CONCLUSION

Distance to the nearest or nearest accessible RTF influences the surgery choice, especially among women in Louisiana ≥65 years with ESBC. Further understanding of factors leading to the decision for mastectomy in this age group is needed.

The Road Less Traveled: Transportation Barriers to Cancer Care Delivery in the Rural Patient Population

Patients with cancer residing in geographically rural areas experience lower rates of preventative screening, more advanced disease at presentation, and higher mortality rates compared with urban populations. Although multiple factors contribute, access to transportation has been proposed as a critical barrier affecting timeliness and quality of health care delivery in rural populations. Patients from geographically rural regions may face a variety of transportation barriers, including lack of public transportation, limited access to private vehicles, and increased travel distance to specialized oncologic care. A search using PubMed was conducted to identify articles pertaining to transportation barriers to cancer care and tested interventions in rural patient populations. Studies demonstrate that transportation barriers are associated with delayed follow-up after abnormal screening test results, decreased access to specialized oncology care, and lower rates of receipt of guideline-concordant treatment. Low clinical trial enrollment and variability in survivorship care are also linked to transportation barriers in rural patient populations. Given the demonstrated impact of transportation access on equitable cancer care delivery, several interventions have been tested. Telehealth visits and outreach clinics appear to reduce patient travel burden and increase access to specialized care, and patient navigation programs are effective in connecting patients with local resources, such as free or subsidized nonemergency medical transportation. To ensure equal access to high-quality cancer care and reduce geographic disparities, the design and implementation of tailored, multilevel interventions to address transportation barriers affecting rural communities is critical.

Effect of interventions for non-emergent medical transportation: a systematic review and meta-analysis

INTRODUCTION

Transportation is an important social determinant of health. We conducted a systematic review of the associations on health and health care utilization of interventions aimed at reducing barriers to non-emergency transportation and non-medical transportation.

METHODS

We searched three databases and the gray literature through mid-January 2022. Included studies needed to assess an intervention targeted at non-emergency or non-medical transportation barriers, report missed (or kept) visits, health care utilization, costs, or health outcomes. Data extraction was performed in duplicate and included information about study design, results, and risk of bias. Primary outcomes were frequency of missed appointments, health care utilization, costs, and health outcomes. Synthesis was both narrative and meta-analytic using a random effects model.

RESULTS

Twelve studies met inclusion criteria, three randomized trials, one controlled trial, and eight observational studies. All included studies had some element of risk of bias. Populations studied usually had chronic or serious health conditions or were poor. Interventions included van rides, bus or taxi vouchers, ride-sharing services, and others. Meta-analysis of seven studies (three trials, four observational studies) yielded a pooled estimate of missed appointments = 0.63 (95% confidence interval [CI] 0.48, 0.83) favoring interventions. Evidence on cost, utilization, and health outcomes were too sparse to support conclusions. Evidence on the effect of non-medical transportation is limited to a single study.

CONCLUSIONS AND RELEVANCE

Interventions aimed at non-emergency transportation barriers to access health care are associated with fewer missed appointments; the association with costs, utilization or health outcomes is insufficiently studied to reach conclusions. This review was registered in PROSPERO as ID CRD42020201875.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology.

MAIN RESULTS

Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

Understanding the role of oncogenic human papillomavirus (HPV) status on adherence behaviors among women with abnormal cervical cytology

BACKGROUND

With the introduction of oncogenic Human Papillomavirus (HPV) testing into cervical screening there is a renewed focus on primary prevention among high-risk groups. To date, little is known about the effectiveness of this program, and the extent to which individual-level factors, such as psychosocial health and agency, may play a role. In particular, it is unclear if knowledge of one's oncogenic HPV status impacts on adherence behaviors amongst women with screening abnormalities. The purpose of this study was to identify if clinical, demographic or psychosocial factors predict non-adherence with recommended colposcopy follow-up.

METHODS

This prospective pilot study included 145 women referred to a large Toronto colposcopy clinic between December, 2013 and September, 2014. Demographic, clinical and psychosocial characteristics were collected at three points in time: (1) at initial colposcopy consultation; (2) 4-6 weeks following initial consultation, and; (3) at time of follow-up appointment (within 12 months of initial consultation).

RESULTS

Overall, 13% (n = 145) of the women were classified as non-adherent. Older women (OR = 0.73, p < 0.01) and those with higher-grade lesions (OR = 0.10, p < 0.01) were less likely to be non-adherent, whereas current smokers (OR = 22.46, p < 0.01) were more likely to be non-adherent. While not statistically significant, variation in rates of non-adherence amongst the various HPV status groups (untested; 15.3%, HPV positive; 5.3%, HPV negative; 6.7%) warrants further study.

CONCLUSION

Findings of this study indicate that younger women, those with higher-grade lesions and current smokers were more likely to be non-adherent to recommended colposcopy follow-up. While HPV status did not reach statistical significance, the direction of this finding suggests that testing for HPV may have a positive reinforcing role on adherence to follow-up. The direction of this finding warrants further study, and potentially a practical clinical goal as HPV testing for women becomes standard of care.

Demographic factors associated with missed follow-up among solid tumor patients treated at a large multi-site academic institution

Aim: To identify demographic predictors of patients who miss oncology follow-up, considering that missed follow-up has not been well studies in cancer patients. Methods: Patients with solid tumors diagnosed from 2007 to 2016 were analyzed (n = 16,080). Univariate and multivariable logistic regression models were constructed to examine predictors of missed follow-up. Results: Our study revealed that 21.2% of patients missed ≥1 follow-up appointment. African-American race (odds ratio [OR] 1.33; 95% CI: 1.17-1.51), Medicaid insurance (OR 1.59; 1.36-1.87), no insurance (OR 1.66; 1.32-2.10) and rural residence (OR 1.78; 1.49-2.13) were associated with missed follow-up. Conclusion: Many cancer patients miss follow-up, and inadequate follow-up may influence cancer outcomes. Further research is needed on how to address disparities in follow-up care in high-risk patients.

Outcomes by Race Among Women Referred to an Academic Colposcopy Clinic with a Patient Navigation Program

Background: Although minority women are at higher risk of cervical cancer in the United States, little is known about differences in rates of colposcopy and loop electrosurgical excision procedure (LEEP) by race once patients present for care. Materials and Methods: A prospective registry of patients presenting to an academic colposcopy clinic was queried from 2008 to 2018. Women with missing race or cytology results, prior hysterectomy, or prior history of cervical, vulvar, or vaginal cancer were excluded. Poisson and logistic regression models were performed to evaluate the associations between race and colposcopy, LEEP, and cancer rates, adjusting for referral Papanicolaou (Pap), human papillomavirus (HPV) result, year of visit, age, insurance, pregnancy, number of sexual partners, and smoking status. Results: A total of 4506 women were included (56.1% white and 43.9% non-white). Referral for high-grade cytology was more likely among white compared to non-white women (22.5% vs. 17.5%, p < 0.001), as well as positive HPV testing (white 7.8% vs. non-white 6.0%, p < 0.001). The colposcopy rate was slightly higher among black (incidence rate ratio [IRR]_adjusted 1.11, 95% confidence interval [CI] 1.03-1.19, p = 0.006) and Hispanic women (IRR_adjusted 1.13, 95% CI 1.06-1.21, p = 0.0003) compared to white women. Hispanic women were significantly more likely to undergo LEEP (odds ratio_adjusted 1.26, 95% CI 1.01-1.58, p = 0.04). However, no significant difference in cancer, adenocarcinoma in situ, or high-grade histology was noted by race. Conclusions: Black and Hispanic women referred for abnormal Pap or HPV results underwent a greater number of colposcopies compared to white women, and Hispanic women underwent a greater number of LEEPs. Although cancer is rare in our cohort, there was no statistical difference in rate of cancer by race.

Impact of Transportation Interventions on Health Care Outcomes: A Systematic Review

INTRODUCTION

Lack of reliable transportation can be a barrier to keeping appointments or accessing other health care services. Increasingly, insurers and health care delivery systems subsidize transportation services for patients. This systematic review synthesizes existing research on nonemergency medical transportation interventions.

METHODS

We searched 3 databases (Embase, PubMed, Google) for studies of health care sector-sponsored programs that provided patients assistance with nonemergency transportation and directly assessed the impact of transportation assistance on health and health care utilization outcomes. Studies meeting inclusion criteria were graded for quality using standard grading criteria.

FINDINGS

Eight studies met all inclusion criteria. Most were rated as low quality. All studies included examined process or health care utilization outcomes, such as uptake of transportation services, return for follow-up, or missed appointment rates; only 1 included health outcomes, such as illness severity and blood pressure. Results were mixed. More rigorous studies showed low patient uptake of transportation services and inconsistent impacts on health and utilization outcomes.

CONCLUSIONS

Despite considerable interest in subsidizing transportation services to improve health for patients facing transportation barriers, little rigorously conducted research has demonstrated the impact of transportation services on health or health care utilization. Some extant literature suggests that transportation assistance is more likely to be effective when offered with other interventions to reduce social and economic barriers to health.

A Systematic Review of Interventions to Minimize Transportation Barriers Among People with Chronic Diseases

Transportation is an important social determinant of health. Transportation barriers disproportionately affect the most vulnerable groups of society who carry the highest burden of chronic diseases; therefore, it is critical to identify interventions that improve access to transportation. We synthesized evidence concerning the types and impact of interventions that address transportation to chronic care management. A systematic literature search of peer-reviewed studies that include an intervention with a transportation component was performed using three electronic databases-PubMed, EMBASE, and CINAHL-along with a hand-search. We screened 478 unique titles and abstracts. Two reviewers independently evaluated 41 full-text articles and 10 studies met eligibility criteria for inclusion. The transportation interventions included one or more of the following: providing bus passes (n = 5), taxi/transport vouchers or reimbursement (n = 3), arranging or connecting participants to transportation (n = 2), and a free shuttle service (n = 1). Transportation support was offered within multi-component interventions including counseling, care coordination, education, financial incentives, motivational interviewing, and navigation assistance. Community health/outreach workers (n = 3), nurses (n = 3), and research or clinic staff (n = 3) were the most common interventionists. Studies reported improvements in cancer screening rates, chronic disease management, hospital utilization, linkage and follow up to care, and maternal empathy. Overall, transportation is a well-documented barrier to engaging in chronic care among vulnerable populations. We found evidence suggesting transportation services offered in combination with other tailored services improves patient health outcomes; however, future research is warranted to examine the separate impact of transportation interventions that are tested within multi-component studies.

Reimbursement Incentives to Improve Adherence to Follow-Up of Cervical Cancer Cytology Screening Results in Peru

OBJECTIVE

The purpose of this study was to determine Peruvian women's attitudes toward novel reimbursement incentives used to improve adherence to obtaining cervical cytology test results.

MATERIALS AND METHODS

Women presenting for cervical cancer screening in Peru completed a 34-item Investigational Review Board-approved questionnaire. The questionnaire determined their attitudes toward various reimbursement incentives to improve adherence to obtaining cervical cytology results. Descriptive statistics, generalized linear models, and Kruskal-Wallis tests were used in the analyses.

RESULTS

Completed questionnaires were available for 997 women. Most women (51%) would be more likely to return for their Pap result if an incentive was provided, 79% (759/956) agreed that they would pay for the Pap test, and 51% (402/859) would be willing to pay 10 Soles or less. Quechua-speaking women considered follow-up more difficult (p < .0001) but were less likely to return for their Pap results (p < .0001), pay for the Pap test (p < .0001), and afford paying more than 5 Soles (p < .0001) than women who spoke Spanish or both languages. More women who earn 1000 Soles/year or less would likely return if incentivized (p < .0001), felt the incentive would help them remember to return (p = .0047), and would be willing to pay whether there was a rebate (p = .010) as compared with women earning more money.

CONCLUSIONS

A reimbursement incentive program designed to improve follow-up of cervical cytology test results was acceptable to most Peruvian women. Such a behavioral-modifying program may improve patient follow-up after cervical cytology testing. Implementation may reduce the morbidity and mortality of cervical cancer in remote regions of the country.

Health Service Accessibility and Risk in Cervical Cancer Prevention: Comparing Rural Versus Nonrural Residence in New Mexico

PURPOSE

Multiple intrapersonal and structural barriers, including geography, may prevent women from engaging in cervical cancer preventive care such as screening, diagnostic colposcopy, and excisional precancer treatment procedures. Geographic accessibility, stratified by rural and nonrural areas, to necessary services across the cervical cancer continuum of preventive care is largely unknown.

METHODS

Health care facility data for New Mexico (2010-2012) was provided by the New Mexico Human Papillomavirus Pap Registry (NMHPVPR), the first population-based statewide cervical cancer screening registry in the United States. Travel distance and time between the population-weighted census tract centroid to the nearest facility providing screening, diagnostic, and excisional treatment services were examined using proximity analysis by rural and nonrural census tracts. Mann-Whitney test (P < .05) was used to determine if differences were significant and Cohen's r to measure effect.

FINDINGS

Across all cervical cancer preventive health care services and years, women who resided in rural areas had a significantly greater geographic accessibility burden when compared to nonrural areas (4.4 km vs 2.5 km and 4.9 minutes vs 3.0 minutes for screening; 9.9 km vs 4.2 km and 10.4 minutes vs 4.9 minutes for colposcopy; and 14.8 km vs 6.6 km and 14.4 minutes vs 7.4 minutes for precancer treatment services, all P < .001).

CONCLUSION

Improvements in cervical cancer prevention should address the potential benefits of providing the full spectrum of screening, diagnostic and precancer treatment services within individual facilities. Accessibility, assessments distinguishing rural and nonrural areas are essential when monitoring and recommending changes to service infrastructures (eg, mobile versus brick and mortar).

Pathways to Early Detection of Cervical Cancer for a Multiethnic, Indigent, Emergency Department Population

When access to primary care is limited, low-income women of all races and ethnicities seek care in public hospital emergency departments (EDs) in which preventive services are often unavailable. This project implemented and evaluated a cervical screening program in an inner-city ED. Clinicians were asked to offer Pap smears to women undergoing diagnostic pelvic examinations. Women with abnormal results were randomized to follow-up in one of two settings. Women with normal results received an intervention promoting annual rescreening. In 12 months, 1,523 Pap smears were performed on 1,442 women; 58% were African American; 21%, Hispanic; and 7%, Asian. Among these women, more than 22 languages were spoken, and 26% did not recall having a prior Pap smear. Preliminary findings suggest that cervical cancer screening can be incorporated into routine ED care, creating an important alternative pathway to early detection for a high-risk population.

Results of a Health Education Message Intervention on HPV Knowledge and Receipt of Follow-up Care among Latinas Infected with High-risk Human Papillomavirus

A clinic-based intervention study was conducted among high-risk human papillomavirus (HPV)-infected Latinas aged 18-64 years between April 2006 and May 2008 on the Texas-Mexico border. Women were randomly assigned to receive a printed material intervention (n=186) or usual care (n=187) and were followed at three months, six months, and 12 months through telephone surveys and review of medical records. The HPV knowledge of nearly all women had increased greatly, but only two-thirds of women reported they had received follow-up care within one year of diagnosis regardless of additional health education messaging. Our findings suggest that, regardless of type of health education messaging, Latinas living on the Texas-Mexico border are aware that follow-up care is recommended, but they may not receive this care. Individual, familial and medical care barriers to receipt of follow-up care may partially account for the higher rates of cervical cancer mortality in this region.

Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge

BACKGROUND

Achieving safe transitions of care at hospital discharge requires accurate and timely communication. Both the presence of and follow-up plan for diagnostic studies that are pending at hospital discharge are expected to be accurately conveyed during these transitions, but this remains a challenge.

OBJECTIVE

To determine the prevalence, characteristics, and communication of studies pending at hospital discharge before and after the implementation of an electronic medical record (EMR) tool that automatically generates a list of pending studies.

DESIGN

Pre-post analysis.

PATIENTS

260 consecutive patients discharged from inpatient general medicine services from July to August 2013.

INTERVENTION

Development of an EMR-based tool that automatically generates a list of studies pending at discharge.

MAIN MEASURES

The main outcomes were prevalence and characteristics of pending studies and communication of studies pending at hospital discharge. We also surveyed internal medicine house staff on their attitudes about communication of pending studies.

KEY RESULTS

Pre-intervention, 70% of patients had at least one pending study at discharge, but only 18% of these were communicated in the discharge summary. Most studies were microbiology cultures (68%), laboratory studies (16%), or microbiology serologies (10%). The majority of study results were ultimately normal (83%), but 9% were newly abnormal. Post-intervention, communication of studies pending increased to 43% (p < 0.001).

CONCLUSIONS

Most patients are discharged from the hospital with pending studies, but in usual practice, the presence of these studies has rarely been communicated to outpatient providers in the discharge summary. Communication significantly increased with the implementation of an EMR-based tool that automatically generated a list of pending studies from the EMR and allowed users to import this list into the discharge summary. This is the first study to our knowledge to introduce an automated EMR-based tool to communicate pending studies.

Psychosocial barriers to follow-up adherence after an abnormal cervical cytology test result among low-income, inner-city women

OBJECTIVES

Low-income, inner-city women bear a disproportionate burden of cervical cancer in both incidence and mortality rates in the United States, largely because of low adherence to follow-up recommendations after an abnormal cervical cytology result in the primary care setting. The goals of the present study were to delineate the theory-based psychosocial barriers underlying these persistent low follow-up rates and their sociodemographic correlates.

METHODS

Guided by a well-validated psychosocial theory of health behaviors, this cross-sectional, correlational study assessed the barriers to follow-up adherence among underserved women (N = 210) who received an abnormal cervical cytology result. Participants were recruited through an inner-city hospital colposcopy clinic, and were assessed by telephone prior to the colposcopy appointment.

RESULTS

Participants were largely of African American race (82.2%), lower than high school completion education (58.7%), single, never married (67.3%), and without full-time employment (64.1%). Knowledge barriers were most often endorsed (68%, M = 3.22), followed by distress barriers (64%, M = 3.09), and coping barriers (36%, M = 2.36). Forty-six percent reported more than one barrier category. Less education and being unemployed were correlated with higher knowledge barriers (P < .0001 and P < .01, respectively) and more coping barriers (P < .05 and P < .05, respectively). Women who were younger than 30 years displayed greater distress barriers (P < .05).

CONCLUSION

In the primary care setting, assessing and addressing knowledge and distress barriers after feedback of an abnormal cervical cytology result may improve adherence to follow-up recommendations. The use of structured counseling protocols and referral to navigational and other resources may facilitate this process and thereby reduce disparities in cervical cancer.

Challenges and Recommendations to Recruiting Women Who Do Not Adhere to Follow-Up Gynecological Care

PURPOSE

Non-adherence to recommended follow-up visits after an abnormal cytological finding is associated with poorer outcomes and higher health care costs. The purpose of this paper is to describe the challenges when examining reasons for non-adherence to cervical cancer screening follow-up and to discuss the recommendations to overcome those challenges.

METHODS

We conducted a telephone survey with two subgroups of women: 1) those which adhered to recommended follow-up care after an abnormal Pap test, and 2) those which did not adhere.

RESULTS

The follow-up accrual among non-adherent women lagged behind that of adherers. We were able to contact and conduct a survey with 51% of the adherers and 26% of the non-adherers. The challenges in studying non-adherent women were related to several distinct factors: 1) the definition of non-adherence, 2) the availability of alternate contact information, 3) the amount and type of financial incentives, and 4) the availability of staffing. We describe strategies employed to increase the accrual of non-adherent women.

DISCUSSION

This paper describes four recommendations that may play a role in understanding and reducing non-adherence to follow-up gynecological care.

The development and evaluation of a community based model for cervical cancer screening based on self-sampling

OBJECTIVE

To develop and implement a community based model for cervical cancer prevention that allows the communities to manage the screening and the healthcare system to focus resources on evaluation and management of the positives.

METHODS

Using self-sampling and the concepts founded in Community Based Participatory Research (CBPR), we progressively developed a model to efficiently reach the women, especially rural communities; and collect the volume of samples needed to support high throughput centralized low cost per case processing.

RESULTS

8382 eligible women, ages 35 to 59, in 130 rural communities participated. The screening was organized by the local government administration and conducted by the community leaders (CLs). The model used was progressively designed through detailed assessment of key elements at 6 decision points in 26 workshops that were used to train the CLs and the local promoters. The communities were able to accurately conduct the screening; in the final model a local medical worker conducted a 50-minute workshop featuring instructional posters and structured role-play. A manual and a workshop DVD were created for distribution to and implementation by local governments. The average callback rate was 84.3%, without involvement of the local doctors in the management of the positives.

CONCLUSION

An efficient community based model capable of massive screening events was developed. We believe that the callback rate will be further improved when local doctors are trained in the management of the positives. Many elements impact coverage and further research is needed to define the influence of the identified key variables.

Tailored telephone counseling to improve adherence to follow-up regimens after an abnormal pap smear among minority, underserved women

OBJECTIVE

The present study explored the impact of a tailored telephone counseling intervention on increasing follow-up adherence after an abnormal Pap smear result among low-income, minority women, which may reduce cervical cancer disparity.

METHODS

Participants (N=211) were randomly assigned to receive: (1) a telephone reminder that included an assessment of barriers to adherence, as well as counseling tailored to the barriers elicited; (2) telephone reminder and barriers assessment, followed by a mailed home tailored barriers print brochure; or (3) enhanced standard care comprising telephone reminder and barriers assessment. Assessments were obtained at initial contact and 1-week later, as well as at 6- and 12-months after the initial colposcopy.

RESULTS

The telephone counseling group showed greater adherence to follow-up recommendations than did the combined other two groups (p<0.05). For the initial colposcopy, tailored telephone barriers counseling was more effective among women with a high school education or less.

CONCLUSION

Tailored telephone barriers counseling improves adherence to initial colposcopy, as well as to longer-term medical follow-up, among low-income, inner-city women.

PRACTICE IMPLICATIONS

Dissemination of barriers counseling into ongoing telephone reminder calls and contacts may decrease disparities in cancer outcomes, especially among women with less than post-secondary education.

Adherence barriers and facilitators for cervical screening amongst currently disadvantaged women in the greater Cape Town region of South Africa

Background

In South Africa cervical cancer is the second most commonly occurring cancer amongst women, and black African women have the highest risk of developing this disease. Unfortunately, the majority of South African women do not adhere to recommended regular cervical screening.

Objectives

The purpose of this research was to explore the perceptions, experiences and knowledge regarding cervical screening of disadvantaged women in two informal settlements in South African urban areas.

Method

The Health Belief Model (HBM) provided a theoretical framework for this study. Four focus groups (n = 21) were conducted, using questions derived from the HBM, and thematic analysis was used to analyse the data. The ages of the women who participated ranged from 21 to 53 years.

Results

The analysis revealed lack of knowledge about screening as a key structural barrier to treatment. Other structural barriers were: time, age at which free screening is available, and health education. The psychosocial barriers that were identified included: fear of the screening procedure and of the stigmatisation in attending screening. The presence of physical symptoms, the perception that screening provides symptom relief, HIV status, and the desire to know one's physical health status were identified as facilitators of cervical screening adherence.

Conclusion

This knowledge has the potential to inform healthcare policy and services in South Africa. As globalisation persists and individuals continue to immigrate or seek refugee status in foreign countries, increased understanding and knowledge is required for successful acculturation and integration. Developed countries may therefore also benefit from research findings in developing countries.

Intervention to improve follow-up for abnormal Papanicolaou tests: a randomized clinical trial

OBJECTIVE

To evaluate the effect of a theory-based, culturally targeted intervention on adherence to follow-up among low-income and minority women who experience an abnormal Pap test.

METHOD

5,049 women were enrolled and underwent Pap testing. Of these, 378 had an abnormal result and 341 (90%) were randomized to one of three groups to receive their results: Intervention (I): culturally targeted behavioral and normative beliefs + knowledge/skills + salience + environmental constraints/barriers counseling; Active Control (AC): nontargeted behavioral and normative beliefs + knowledge/skills + salience + environmental constraints/barriers counseling; or Standard Care Only (SCO). The primary outcome was attendance at the initial follow-up appointment. Secondary outcomes included delay in care, completion of care at 18 months, state anxiety (STAI Y-6), depressive symptoms (CES-D), and distress (CDDQ). Anxiety was assessed at enrollment, notification of results, and 7-14 days later with the CDDQ and CES-D.

RESULTS

299 women were included in intent-to-treat analyses. Adherence rates were 60% (I), 54% (AC), and 58% (SCO), p = .73. Completion rates were 39% (I) and 35% in the AC and SCO groups, p = .77. Delay in care (in days) was (M ± SD): 58 ± 75 (I), 69 ± 72 (AC), and 54 ± 75 (SCO), p = .75. Adherence was associated with higher anxiety at notification, p < .01 and delay < 90 days (vs. 90+) was associated with greater perceived personal responsibility, p < .05. Women not completing their care (vs. those who did) had higher CES-D scores at enrollment, p < .05.

CONCLUSIONS

A theory-based, culturally targeted message was not more effective than a nontargeted message or standard care in improving behavior.

Patient barriers to follow-up care for breast and cervical cancer abnormalities

BACKGROUND

Women with breast or cervical cancer abnormalities can experience barriers to timely follow-up care, resulting in delays in cancer diagnosis. Patient navigation programs that identify and remove barriers to ensure timely receipt of care are proliferating nationally. The study used a systematic framework to describe barriers, including differences between African American and Latina women; to determine recurrence of barriers; and to examine factors associated with barriers to follow-up care.

METHODS

Data originated from 250 women in the intervention arm of the Chicago Patient Navigation Research Program (PNRP). The women had abnormal cancer screening findings and navigator encounters. Women were recruited from a community health center and a publicly owned medical center. After describing proportions of African American and Latina women experiencing particular barriers, logistic regression was used to explore associations between patient characteristics, such as race/ethnicity, and type of barriers.

RESULTS

The most frequent barriers occurred at the intrapersonal level (e.g., insurance issues and fear), while institutional-level barriers such as system problems with scheduling care were the most commonly recurring over time (29%). The majority of barriers (58%) were reported in the first navigator encounter. Latinas (81%) reported barriers more often than African American women (19%). Differences in race/ethnicity and employment status were associated with types of barriers. Compared to African American women, Latinas were more likely to report an intrapersonal level barrier. Unemployed women were more likely to report an institutional level barrier.

CONCLUSION

In a sample of highly vulnerable women, there is no single characteristic (e.g., uninsured) that predicts what kinds of barriers a woman is likely to have. Nevertheless, navigators appear able to easily resolve intrapersonal-level barriers, but ongoing navigation is needed to address system-level barriers. Patient navigation programs can adopt the PNRP barriers framework to assist their efforts in assuring timely follow-up care.

High-risk populations for vision loss and eye care underutilization: a review of the literature and ideas on moving forward

Much work has been done to highlight and understand the significant disparities in the use of eye care services, but they continue to exist. We review the existing literature on utilization in high-risk populations to provide a context for understanding what "high-risk" means, to understand the utilization patterns among high-risk populations, and to highlight barriers to appropriate eye care utilization. We also discuss potential approaches to reduce these disparities.

The impact of a culturally tailored patient navigator program on cervical cancer prevention in Latina women

BACKGROUND

Cervical cancer disproportionately affects Latina women in the United States. This study evaluated the impact of patient navigation on cervical cancer prevention in Latinas.

METHODS

Between January 2004 and April 2011, 533 Latina women with an abnormal Pap smear requiring colposcopy received patient navigation from their healthcare center in Chelsea, Massachusetts, to the Massachusetts General Hospital (MGH). The comparison group comprised 253 non-navigated Latinas from other primary care practices at MGH referred to the same MGH colposcopy clinic. Primary outcomes were the percentage of missed colposcopy appointments, time to colposcopy, and changes in the severity of cervical pathology at colposcopy over two time periods, 2004-2007 and 2008-2011.

RESULTS

The mean age in both groups was 35 years (range 22-86). Navigated women had fewer missed colposcopy appointments over time, with the average falling from 19.8% to 15.7% (p=0.024), compared with an insignificant increase in the no-show rates from 18.6% to 20.6% (p=0.454) in the comparison group. The difference in the no-show rate trend over time between the groups was significant (p<0.001). The time to colposcopy did not change in either group, though trends over time demonstrated a shorter follow-up for navigated women (p=0.010). The grade of cervical abnormality among navigated women decreased from a numerical score of 2.03 to 1.83 (p=0.035) over the two time intervals, while the severity of pathological score in the non-navigated group did not change significantly from 1.83 to 1.92 (p=0.573) in the same interval. Comparison of trends in pathological score over time showed a decrease in the severity of cervical abnormality for navigated participants compared to the non-navigated group (p<0.001).

CONCLUSION

Patient navigation can prevent cervical cancer in Latina women by increasing colposcopy clinic attendance, shortening time to colposcopy, and decreasing severity of cervical abnormalities over time.

Cervical cancer screening, diagnosis and treatment interventions for racial and ethnic minorities: a systematic review

OBJECTIVES

To systematically review the literature to determine which interventions improve the screening, diagnosis or treatment of cervical cancer for racial and/or ethnic minorities.

DATA SOURCES

Medline on OVID, Cochrane Register of Controlled Trials, CINAHL, PsycINFO and Cochrane Systematic Reviews.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

We searched the above databases for original articles published in English with at least one intervention designed to improve cervical cancer prevention, screening, diagnosis or treatment that linked participants to the healthcare system; that focused on US racial and/or ethnic minority populations; and that measured health outcomes. Articles were reviewed to determine the population, intervention(s), and outcomes. Articles published through August 2010 were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

One author rated the methodological quality of each of the included articles. The strength of evidence was assessed using the criteria developed by the GRADE Working Group.

RESULTS

Thirty-one studies were included. The strength of evidence is moderate that telephone support with navigation increases the rate of screening for cervical cancer in Spanish- and English-speaking populations; low that education delivered by lay health educators with navigation increases the rate of screening for cervical cancer for Latinas, Chinese Americans and Vietnamese Americans; low that a single visit for screening for cervical cancer and follow up of an abnormal result improves the diagnosis and treatment of premalignant disease of the cervix for Latinas; and low that telephone counseling increases the diagnosis and treatment of premalignant lesions of the cervix for African Americans.

LIMITATIONS

Studies that did not focus on racial and/or ethnic minority populations may have been excluded. In addition, this review excluded interventions that did not link racial and ethnic minorities to the health care system. While inclusion of these studies may have altered our findings, they were outside the scope of our review.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Patient navigation with telephone support or education may be effective at improving screening, diagnosis, and treatment among racial and ethnic minorities. Research is needed to determine the applicability of the findings beyond the populations studied.

Contribution of health care coverage in cervical cancer screening follow-up: findings from a cross-sectional study in Colombia

OBJECTIVE

To determine the role of health care coverage (HCC) in follow-up of cervical cancer screening (seeking Papanicolaou test results and follow-up when abnormal results were found) among Colombian women.

METHODS

A population-based cross-sectional study of 24,717 women, using the 2005 Colombian Demographic and Health Survey, was conducted.

RESULTS

Nearly 4% of women screened did not seek their results. For approximately 17% of the women, there was no follow-up when abnormal results were found. Women in the contributory regime (private insurance) and those in the subsidized regime (public insurance) were more likely to seek Papanicolaou test results than women without HCC, even after adjusting for sociodemographic factors (adjusted odds ratio [ORa], 1.96; 95% confidence interval [CI], 1.60-2.41 and ORa, 1.34; 95% CI, 1.14-1.58, respectively). For follow-up when abnormal results were found, there was no difference between the subsidized regime and no HCC, but women in the contributory regime were more likely to follow-up than women without HCC (ORa, 1.40; 95% CI, 1.05-1.86).

CONCLUSIONS

Seeking Papanicolaou test results is relatively high among Colombian women; however, there are differences according to HCC. Follow-up when abnormal Papanicolaou test results were found was positively associated only with private insurance; follow-up is the same for women without insurance and with public insurance. Exploring strategies to promote follow-up among women and to improve cervical cancer follow-up services for those enrolled in the subsidized regime may increase follow-up rates among Colombian women.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

World-wide, cervical cancer is the second most common cancer in women. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical cancer screening.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2009. MEDLINE, EMBASE and LILACS databases up to March 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible the data were synthesised in a meta-analysis.

MAIN RESULTS

Thirty-eight trials met our inclusion criteria. These trials assessed the effectiveness of invitational and educational interventions, counselling, risk factor assessment and procedural interventions. Heterogeneity between trials limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. Secondary outcomes including cost data were incompletely documented so evidence was limited. Most trials were at moderate risk of bias. Informed uptake of cervical screening was not reported in any trials.

AUTHORS' CONCLUSIONS

There is evidence to support the use of invitation letters to increase the uptake of cervical screening. There is limited evidence to support educational interventions but it is unclear what format is most effective. The majority of the studies are from developed countries and so the relevance to developing countries is unclear.

Barriers to follow-up of an abnormal Pap smear in Latina women referred for colposcopy

BACKGROUND

Lower rates of follow-up after an abnormal Pap smear in racial and ethnic minorities may contribute to the higher incidence and mortality rates of cervical cancer seen in these groups.

OBJECTIVE

To identify patient-perceived barriers to follow-up after an abnormal Pap smear result among Latina women. DESIGN, PARTICIPANTS AND APPROACH: Qualitative, semi-structured, one-on-one interviews were conducted with patients from an academic hospital-affiliated urban community health center. Three groups of women were interviewed: new colposcopy clinic patients, patients who had previous colposcopies and patients enrolled in the health center's patient navigator program. Open-ended questions explored their knowledge, beliefs and experiences with colposcopy. Content analysis of transcripts was performed using established qualitative techinques.

RESULTS

Of 40 Latina women recruited, 75% spoke only Spanish. The average age was 31.5 (range 18-55). Personal and system barriers identified were categorized into four themes: (1) anxiety/fear of procedure and diagnosis; (2) scheduling/availability of appointments interfering with work and/or child care; (3) inadequate communication about appointments, including lack of explanation regarding diagnosis, procedure and results; and (4) pain. New patients more commonly reported problems with scheduling and communication. Follow-up patients were more concerned about pain, and navigated women most often reported fear of results but had fewer concerns about inadequate communication.

CONCLUSION

Anxiety/fear was the most common personal barrier, while difficulty scheduling appointments and inadequate communication were the major systems barriers identified in these Latina women. Interventions to lower these barriers to colposcopy among Latina women may increase adherence to follow-up of abnormal Pap smears.

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

OBJECTIVE

To investigate provider and patient views about communication regarding cervical cancer screening follow-up.

METHODS

Using qualitative analysis, we interviewed 20 providers and 10 patients from two urban clinics that serve low-income African American and Hispanic women. Semi-structured interviews and focus groups assessed familiarity with National Cancer Institute's Cancer Information Service (CIS) and reactions to a letter asking women with abnormal Pap test to telephone CIS. The letter suggested questions to ask prior to receiving follow-up.

RESULTS

No patient or provider was familiar with CIS. Providers but not patients expressed discomfort with use of the word 'cancer' in the letter and in CIS's name. Providers feared that reference to cancer would provoke fatalism and impede timely follow-up, whereas patients felt information about cancer risk was needed to prompt timely follow-up. Information providers found necessary to convey in order to accurately explain abnormal Pap tests surpassed patients' literacy levels.

CONCLUSION

Qualitative data suggest important gaps in perspective between providers and patients. There is a need to bridge the gap and overcome communication challenges to promote timely medical follow-up and have better health outcomes.

PRACTICE IMPLICATIONS

Implications and strategies for improving patient-provider education and communication about abnormal Pap test are discussed.

Incentives, health promotion and equality

The use of incentives to encourage individuals to adopt ‘healthier’ behaviours is an increasingly popular instrument in health policy. Much of the literature has been critical of ‘negative’ incentives, often due to concerns about equality; ‘positive’ incentives, however, have largely been welcomed as an instrument for the improvement of population health and possibly the reduction of health inequalities. The aim of this paper is to provide a more systematic assessment of the use of incentives from the perspective of equality. The paper begins with an overview of existing and proposed incentive schemes. I then suggest that the distinction between ‘positive’ and ‘negative’ incentives – or ‘carrots’ and ‘sticks’ – is of limited use in distinguishing those incentive schemes that raise concerns of equality from those that do not. The paper assesses incentive schemes with respect to two important considerations of equality: equality of access and equality of outcomes. While our assessment of incentive schemes will, ultimately, depend on various empirical facts, the paper aims to advance the debate by identifying some of the empirical questions we need to ask. The paper concludes by considering a number of trade-offs and caveats relevant to the assessment of incentive schemes.

How protective is cervical cancer screening against cervical cancer mortality in developing countries? The Colombian case

Background

Cervical cancer is one of the top causes of cancer morbidity and mortality in Colombia despite the existence of a national preventive program. Screening coverage with cervical cytology does not explain the lack of success of the program in reducing incidence and mortality rates by cervical cancer. To address this problem an ecological analysis, at department level, was carried out in Colombia to assess the relationship between cervical screening characteristics and cervical cancer mortality rates.

Methods

Mortality rates by cervical cancer were estimated at the department level for the period 2000-2005. Levels of mortality rates were compared to cervical screening coverage and other characteristics of the program. A Poisson regression was used to estimate the effect of different dimensions of program performance on mortality by cervical cancer.

Results

Screening coverage ranged from 28.7% to 65.6% by department but increases on this variable were not related to decreases in mortality rates. A significant reduction in mortality was found in departments where a higher proportion of women looked for medical advice when abnormal findings were reported in Pap smears. Geographic areas where a higher proportion of women lack health insurance had higher rates of mortality by cervical cancer.

Conclusions

These results suggest that coverage is not adequate to prevent mortality due to cervical cancer if women with abnormal results are not provided with adequate follow up and treatment. The role of different dimensions of health care such as insurance coverage, quality of care, and barriers for accessing health care needs to be evaluated and addressed in future studies.

Effect of incentives on insecticide-treated bed net use in sub-Saharan Africa: a cluster randomized trial in Madagascar

Background

Insecticide-treated bed nets (ITNs) have been shown to reduce morbidity and mortality due to malaria in sub-Saharan Africa. Strategies using incentives to increase ITN use could be more efficient than traditional distribution campaigns. To date, behavioural incentives have been studied mostly in developed countries. No study has yet looked at the effect of incentives on the use of ITNs. Reported here are the results of a cluster randomized controlled trial testing household-level incentives for ITN use following a free ITN distribution campaign in Madagascar.

Methods

The study took place from July 2007 until February 2008. Twenty-one villages were randomized to either intervention or control clusters. Households in both clusters received a coupon redeemable for one ITN. After one month, intervention households received a bonus for ITN use, determined by visual confirmation of a mounted ITN. Data were collected at baseline, one month and six months. Both unadjusted and adjusted results, using cluster specific methods, are presented.

Results

At baseline, 8.5% of households owned an ITN and 6% were observed to have a net mounted over a bed in the household. At one month, there were no differences in ownership between the intervention and control groups (99.5% vs. 99.4%), but net use was substantially higher in the intervention group (99% vs. 78%), with an adjusted risk ratio of 1.24 (95% CI: 1.10 to 1.40; p < 0.001). After six months, net ownership had decreased in the intervention compared to the control group (96.7% vs. 99.7%), with an adjusted risk ratio of 0.97 (p < 0.01). There was no difference between the groups in terms of ITN use at six months; however, intervention households were more likely to use a net that they owned (96% vs. 90%; p < 0.001).

Conclusions

Household-level incentives have the potential to significantly increase the use of ITNs in target households in the immediate-term, but, over time, the use of ITNs is similar to households that did not receive incentives. Providing incentives for behaviour change is a promising tool that can complement traditional ITN distribution programmes and improve the effectiveness of ITN programmes in protecting vulnerable populations, especially in the short-term.

Tracking abnormal cervical cancer screening: evaluation of an EMR-based intervention

INTRODUCTION

System level barriers have been associated with inadequate follow-up of abnormal cervical cytology.

OBJECTIVE

The aim of this study was to develop and evaluate an electronic tracking system to improve follow-up of abnormal Pap tests.

PROGRAM DESCRIPTION

We implemented an electronic medical record (EMR)-based Pap test tracking system at two clinical practices at an inner-city academic health center. The system generated a provider-specific monthly report of all abnormal Pap results, and provided a patient-specific Pap tracking table embedded in the EMR for each subject.

EVALUATION

We compared abnormal Pap test follow-up rates for the 24 months pre-intervention with rates 12 months following its implementation (post-intervention). The evaluation followed all subjects for 12 months from the date of their abnormal Pap test, looking for diagnostic resolution.

RESULTS

Subjects were young women (mean age = 30.5) of primarily white (42%) and African American (37%) descent, who spoke English (88%). Forty-eight percent were insured through publicly subsidized insurance. Controlling for type of abnormality and practice location, the adjusted mean time to resolution decreased significantly from 108 days (confidence interval, CI 105-112 days) in the pre-intervention period to 86 days (CI 81-91 days).

CONCLUSION

Our study cannot demonstrate that with follow up, we directly avoided cases of invasive cervical cancer. However, we show that in an at-risk urban population, an automated, EMR-based tracking system reduced the time to resolution, and increased the number of women who achieved diagnostic resolution.

Tailored information about cancer risk and screening: a systematic review

OBJECTIVE

To study interventions that provide people with information about cancer risk and about screening that is tailored to their personal characteristics. We assess the tailoring characteristics, theory base and effects on risk perception, knowledge and screening behavior of these interventions.

METHODS

A systematic literature review in this field was performed. PubMed, EMBASE, PsychINFO, CINAHL and Cochrane databases were searched. Forty studies fulfilled all inclusion criteria. Methodological quality was assessed and a best evidence synthesis conducted for the 28 randomized controlled trials without co-intervention or with similar co-intervention in intervention and control group.

RESULTS

Most included studies evaluated an intervention aiming to promote cancer screening. The majority of articles (30) evaluated information that was tailored based on variables related to behavior change, sometimes combined with cancer risk factors. Ten other articles described an intervention that tailored information based on risk factors only.

CONCLUSION

Information that was tailored based on behavior change variables increased realistic perception of cancer risks and knowledge of cancer compared to generic information. Also, information tailored to individuals' risk factors increased realistic risk perception compared to generic information.

PRACTICE IMPLICATIONS

To improve cancer risk perception and knowledge health providers could better give patients information about cancer risk and screening that is tailored to their personal characteristics than generic information.

A theory-based approach to understanding follow-up of abnormal Pap tests

We applied a general theoretical framework to understand intentions to attend recommended follow-up for abnormal Pap results. Participants were 338 women attending university-affiliated clinics. Intention was associated with favorable attitudes toward follow-up (OR = 5.3); perceiving attending follow-up as consistent with one's self-concept (OR = 3.0); self-efficacy (OR = 1.8); and believing one would be told exactly what is wrong (OR = 1.3). Intention was negatively associated with believing the problem could be avoided by not returning for follow-up (OR = 0.75). Beliefs, affect and attitudes differed by race and ethnicity (all p < .05). Attendance at follow-up was related to attitude and self-concept (both p < .05). Results have implications for theory development and patient education.

Variations in practice guideline adherence for abnormal cervical cytology in a county healthcare system

BACKGROUND

Reduction in cervical cancer incidence and mortality is not only dependant on promoting cervical cancer screening but also on providing appropriate follow-up and treatment of abnormal cervical cytology.

OBJECTIVES

The objective of this study was to determine variations in guideline adherence for women requiring abnormal cervical cytology follow-up.

SUBJECTS

Subjects of the study are women 18 years or older with an abnormal Pap test in 2000 within a large county healthcare system (n = 8,571).

MEASUREMENTS

Guideline adherence was determined by the presence or absence of the appropriate follow-up procedure within an acceptable time interval for each degree of cytological abnormality. Patients with no follow-up studies were deemed to be lost to follow-up.

RESULTS

Of study subjects, 18.5% were lost to follow-up care. Of the remaining 6,987 women, 60.3% received optimal care, 9.4% received suboptimal care, and 30.3% received poor care. Follow-up rates were higher for patients with higher degree of cytological abnormality (OR, 1.29, 95% CI, 1.17-1.42), older patients (OR, 1.03, 95% CI, 1.02-1.030) and those receiving the index Pap test at a larger healthcare facility (OR, 1.13; 95% CI, 1.01-1.27). Receiving optimal care was positively correlated with higher degree of cytological abnormality (p < .0001) and larger facility size (p = .002). Regional variations in care demonstrated the largest cluster having the lowest lost to follow-up rate and the most optimal care.

CONCLUSIONS

A significant number of women with abnormal cervical cytology are receiving less than optimal care. Further studies are required to determine the specific healthcare delivery practices that need to be targeted to improve guideline adherence for follow-up of abnormal cytology.

Human papillomavirus triage of women with persistent borderline or mildly dyskaryotic smears: Comparison of costs and side effects of three alternative strategies

The conventional direct referral to colposcopy of persistent borderline or mildly dyskaryotic (BMD) smears in cervical cancer screening leads to considerable unnecessary referrals and associated anxiety and costs. This may be improved by including testing for oncogenic human papillomavirus (HPV) in the triage. We assessed costs and side effects (referrals, treatments and time in follow-up) for 3 possible HPV triage strategies (immediate HPV testing, a 6-month delay in HPV testing, a 2-stage combination of both) and compared them with the conventional strategy. The assessments are based on recent Dutch data from various national databases and trials. We estimated that the referral rate could be reduced by 49, 58 and 58% with immediate, delayed and 2-stage HPV testing, respectively. As a consequence, the average length of follow-up, as well as average costs, also decrease. Therefore, we advocate including HPV testing before referring to colposcopy. Among the 3 HPV strategies, analysis of additional aspects favors implementation of immediate HPV testing.

Adherence to recommendations for follow-up to abnormal Pap tests

OBJECTIVE

To evaluate whether timely adherence rates differ by race among women with abnormal Pap tests participating in a cost-free or reduced-cost program.

METHODS

Eligible subjects included women aged 47-64 years who received a referral for follow-up care after an abnormal Pap test from 1999 to 2002 in South Carolina (n=330). Adherence was measured as days to receipt of follow-up care after an abnormal Pap test. Cox proportional hazards modeling was used to estimate risk factors associated with time to adherence within 60 and 365 days by race.

RESULTS

African-American and non-Hispanic white women had similar adherence to follow-up. Among white women, those with high-grade lesions were less likely to adhere in a timely manner relative to those with low-grade lesions (hazard ratio 0.6, 95% confidence interval [CI] 0.4-1.0). For African-American women, rural residence (hazard ratio: 0.5, 95% CI 0.2-0.9) and history of abnormal Pap tests (hazard ratio 0.6, 95% CI 0.3-1.0) were associated with decreased adherence, whereas less education (hazard ratio 2.3, 95% CI 1.3-3.9) was associated with increased adherence.

CONCLUSION

Adherence rates do not differ by race. However, risk factors for adherence within race are variable. Interventions tailored to the differential needs of racial and ethnic groups may prove effective toward increasing timely adherence rates.

LEVEL OF EVIDENCE

II.

Assessing equity in clinical practice guidelines

Recognition of the need for systematically developed clinical practice guidelines (CPGs) has increased dramatically over the past 20 years. CPGs have focused primarily on the effectiveness of interventions, explicitly or implicitly addressing the following question: Will adherence to a recommendation do more good than harm? At times they have also focused on the cost-effectiveness of interventions: Are the net benefits worth the costs? They rarely have focused on equity: Are the recommendations fair? The Knowledge Plus Project of the International Clinical Epidemiology Network attempts to improve the process of CPG development by formulating strategies to consider not just technical issues (effectiveness, and efficiency) but sociopolitical dimensions as well (equity and local appropriateness). This article discusses a proposed lens for users to evaluate how well CPGs address issues of equity.

Controversy in colposcopic management: a Canadian survey

OBJECTIVE

The substantial reduction in cervical cancer mortality over the last 40 years is attributed to the use of Papanicolaou cervical smear screening with subsequent colposcopic assessment and treatment. Although there is consensus regarding colposcopic management of high-grade intraepithelial cervical lesions, optimal management of patients with low-grade (LG) lesions is less clear. Our goal was to document the colposcopic management of the latter group in Canada.

METHODS

A survey was mailed to 252 colposcopists in seven Canadian provinces who recommended management for colposcopy scenarios. Responses were reported in aggregate form.

RESULTS

A total of 120/252 (48%) completed questionnaires. Most respondents were 41 to 50 years old, and 68% were male. For women found on colposcopy to have no evidence of a low-grade cervical LG lesion, 43% recommended discharge from colposcopy, and 53% recommended repeat colposcopy. For referrals with a biopsy-confirmed LG lesion, 13% recommended discharge to cytological follow-up, 65% recommended repeat colposcopy, and 16% recommended treatment. Following excisional treatment of LG lesions with negative margins, 13% recommended discharge to cytological follow-up, and 69% recommended further colposcopy.

CONCLUSION

These results demonstrate wide variation in management of low-grade cervical lesions among Canadian colposcopists and highlight the need to establish evidence-based management protocols.

Understanding Barriers for Adherence to Follow-Up Care for Abnormal Pap Tests

OBJECTIVE

Approximately 4000 women annually will die from preventable and treatable cervical cancer. Failure to adhere to follow-up recommendations after an abnormal Pap test can lead to development of cervical cancer. This paper summarizes the body of literature on adherence to follow-up after an abnormal Pap test in order to facilitate development of interventions to decrease morbidity and mortality due to cervical cancer.

METHODS

We conducted a comprehensive search of published literature addressing risk factors for adherence or interventions to improve adherence following an abnormal Pap test as the outcome. We included peer-reviewed original research conducted in the United States from 1990 to 2005.

RESULTS

Fourteen analytical and twelve experimental studies that met our criteria were reviewed. Lesion severity and health beliefs were consistently associated with adherence rates. Communication interventions, including telephone reminders, counseling, and educational sessions, increased follow-up compliance across intervention studies. Inconsistent evidence for associations among race, income, and age were found.

CONCLUSIONS

Further research is needed to reinforce current studies addressing health beliefs and social support. Interventions that focus on the interplay among psychological, educational, and communication barriers are necessary. These interventions should be adapted and applied across various racial/ethnic and socioeconomic groups to reach all women with a high-risk profile for invasive cervical cancer.

Use of loop electrosurgical excision procedure specimens to provide tissue fractions for immunologic analyses

OBJECTIVE

To determine if dividing loop electrosurgical excision procedure (LEEP) specimens to provide tissue for research increases rates of LEEP specimen misdiagnosis and recurrent cervical intraepithelial neoplasia.

MATERIALS AND METHODS

In this chart review, 42 women with biopsy-confirmed cervical intraepithelial neoplasia (CIN) 2,3 had up to 20% of their LEEP specimens sectioned and used for immunologic analysis. The remainder of each specimen was assessed routinely. Follow-up cytologic analyses and cervical biopsies also were assessed. This cohort was compared with a control cohort of 80 patients with biopsy confirmed CIN 2,3 whose LEEP specimens were not divided. Statistical significance was defined as a p value of < .05.

RESULTS

There were no statistically significant differences between the groups with regard to histologic assessment of LEEP specimens or follow-up outcomes.

CONCLUSIONS

Use of up to 20% of LEEP specimens for research purposes neither adversely affects histologic evaluation of LEEP specimens nor leads to poorer follow-up outcomes.

Demographic, risk factor, and knowledge differences between Latinas and non-Latinas referred to colposcopy

OBJECTIVE

Disparities occur in the incidence and mortality of cervical cancer among minority women in the US. Screening lowers cervical cancer incidence. Screening rates are lower for minority women than for White women in the US. This study sought to identify demographic, risk factor, and perception of the role of Pap smears between Latinas and non-Latinas.

METHODS

A written survey was administered to 150 Latinas and 150 non-Latinas attending a colposcopy unit. Data on demographics, risk factors, screening rates, knowledge about cervical cancer screening, and perceived barriers to participation in screening programs were collected.

RESULTS

A total of 140 Latinas and 146 non-Latinas completed the survey. Marital status and health insurance status were similar in the two groups. 30% of Latinas and 73.3% of non-Latinas reported completing college (p<0.0001). Only 55.7% of Latinas were employed, compared to 82.2% of non-Latinas (p<0.0001). 21% of Latinas and 53.4% of non-Latinas reported an annual income greater than 35,000 dollars (p<0.0001). Among Latinas, women with 1-5 lifetime Pap smears were less likely to have completed college than those with more than 5 lifetime Pap smears (OR=2.11; 95% CI 1.05-4.22) and to have an annual income of less than 35,000 dollars (OR=3.81; 95% CI 1.64-8.87). Latinas were less likely to have > or =6 lifetime sexual partners, use tobacco, and have a history of sexually transmitted infections. Latinas more commonly reported fear of test results (OR, 0.04; 95% CI 0.02-0.09) and inability to communicate with their provider in Spanish (p<0.0001) as barriers to screening than the non-Latina respondents.

CONCLUSIONS

Several of the barriers limiting access to cervical cancer screening programs are also present among screened Latinas undergoing further evaluation for abnormal Pap smears.