Overcoming Challenges to HIV Medical Care-seeking and Treatment Among Data-to-Care Program Clients in Baton Rouge and New Orleans, Louisiana

ABSTRACT

Data to Care (D2C) uses US public health surveillance data to identify persons with diagnosed HIV who are not receiving adequate medical care. These persons are linked to care and ancillary social services through personalized outreach. We conducted semistructured interviews with 36 adults with HIV in Louisiana who were engaged for the first time or reengaged back into HIV care through D2C efforts. Before D2C program staff contact, nearly 40% were not contemplating HIV care. Program clients cited barriers to HIV care, including difficulties with appointment scheduling and transportation, health care service and drug costs, low motivation, and competing non-HIV health needs. Thirty-four of the 36 clients said that D2C staff helped them overcome these barriers. Clients also described psychosocial support from D2C staff. After receiving D2C program assistance, more than 90% of clients reported consistently receiving HIV medical care and taking medications. Our findings suggest that D2C staff successfully identified client needs and provided tailored assistance.

Reducing Homelessness among Persons with HIV: An Ecological Case Study in Delaware

INTRODUCTION

Among persons with HIV (PWH), homelessness is associated with poorer health. From 2009-2014, national HIV prevention goals included a reduction in homelessness among PWH. We sought to examine social ecological factors associated with homelessness among PWH at a sub-national level during that period.

METHODS

National data were used to identify Delaware as the only jurisdiction where homelessness among PWH declined from 2009-2014. We analyzed population-level indicators and conducted telephone interviews with 6 key stakeholders to further examine this trend.

RESULTS

Overall homelessness, household poverty, and median housing price were associated with homelessness among PWH in Delaware. Key stakeholders indicated that centralized intake processes improved screening, referral, and linkages of clients to housing units.

DISCUSSION

In addition to social and economic factors, collaborative program strategies may improve housing outcomes for PWH. Monitoring trends at sub-national levels can help identify successful approaches as well as needed services or policy change.

"Take care of their hierarchy of needs first": strategies used by data-to-care staff to address barriers to HIV care engagement

Data-to-Care (D2C) is a public health strategy designed to engage out-of-care (OOC) persons with HIV (PWH) in HIV care. OOC PWH are identified through review of state and local HIV data and engaged in care through individualized efforts that address barriers to HIV care. Perspectives of D2C program staff can contribute to D2C program development and sustainability. We conducted semi-structured interviews in 2017 with 20 D2C program staff from Louisiana (n = 10) and Virginia (n = 10), states with distinct D2C programs. We used content and thematic analysis to analyze interview transcripts. In both states, common barriers to care for OOC PWH include limited transportation, stigma, substance use, poverty, homelessness, and mental illness. To address these barriers and engage OOC clients in HIV care, staff and programs provided transportation vouchers and housing assistance, integrated substance use and mental health services into care engagement processes, provided empathy and compassion, and assessed and addressed basic unmet needs. Identifying and addressing social and structural barriers to HIV care is a critical and often a necessary first step in engaging OOC clients in HIV care. These findings can be used for D2C program design and implementation, facilitating engagement in HIV care for OOC PWH.

Toward An Enhanced Understanding of HIV Patient Navigation as a Health Care Intervention: An Analysis of Navigation in Practice

Patient navigation is a promising strategy for improving health among persons with multiple barriers to HIV care, yet little is known about navigation's core components. From 24 systematically identified navigation studies, we abstracted navigators' activities, grouped activities into 20 thematic activity categories, and ordered them by frequency. Subsequently, Principal Components Analysis of activity categories was used identify independent clusters. Accompaniment characterized 71% of navigation programs; ≥ half included health education (58%), collaboration/coordination (58%), linkage-to-care (54%), transportation support (54%), service referrals (50%) and instrumental support (50%). Five unique components (comprising 13 activity categories) were identified: (1) services beyond office, (2) health education and relationship building, (3) accompaniment and instrumental support, (4) locating patients and tracking information, and (5) beyond HIV care. Navigators who located patients or tracked information were less likely to provide accompaniment or instrumental support (r = - 0.60, p = 0.002). Findings can enhance precision in developing, describing, evaluating and improving navigation programs.

HIV Patient Navigation in the United States: A Qualitative Meta-Synthesis of Navigators' Experiences

Patient navigation is increasingly used to link and (re)engage persons with human immunodeficiency virus (HIV) to care. A more holistic understanding of patient navigation can be achieved by exploring the experiences of navigators, the persons who comprise half of the navigation process. We conducted a meta-synthesis of navigator experiences with HIV patient navigation using a phenomenological approach. We identified nine relevant studies. Data were analyzed using thematic synthesis. Analysis identified two overarching themes relating to (1) the breadth and depth of bidirectional relationships and functional activities that navigators undertake to connect their clients to care and (2) the inherently personal experience of delivering navigation services. From these thematic findings, we recommend that HIV patient navigators exhibit capacity and expertise in developing and maintaining interpersonal relationships with clients and health care systems/providers and develop self-care practices and emotional boundaries with clients. Our review seeks to advance public health research and practice by articulating key experiences and perspectives of HIV patient navigators, drawing findings and recommendations applicable to the development, implementation, and evaluation of HIV patient navigation.

Client Perspectives and Experiences With HIV Patient Navigation in the United States: A Qualitative Meta-Synthesis

Patient navigation is increasingly utilized to link and (re)engage persons with HIV to care. Understanding client experiences with HIV patient navigation can facilitate intervention design and translation of evidence to practice. We conducted a qualitative meta-synthesis of client experiences with HIV patient navigation. Data were analyzed using thematic synthesis. We identified seven relevant studies; all collected data via in-depth interviews with persons with HIV who participated in HIV patient navigation. Four interrelated themes emerged from analysis that pertain to (1) the complexity of the health and social service environment and the holistic approaches taken by the navigator, (2) the profound significance of the client-navigator relationship, (3) client reluctance to end the navigation program, and (4) client self-efficacy and feelings of hope and psychological change as a result of their navigation experience. The unifying theme across all studies was the value and impact of the client-navigator relationship on client experience and quality of life. Programs should consider hiring navigators who possess strong relational skills and are peers of the clients, and clearly delineating the role of the navigator. Research should examine the impact of the client-navigator relationship on client outcomes and further investigate how participating in patient navigation affects client self-efficacy, client resiliency, and the role of posttraumatic growth to achieve improved HIV outcomes. This review underscores the significance of the relationship within intensive, multilevel interventions for individuals and communities marginalized and isolated from health and social service systems.

Use of Community Health Workers and Patient Navigators to Improve Cancer Outcomes Among Patients Served by Federally Qualified Health Centers: A Systematic Literature Review

Introduction: In the United States, disparities in cancer screening, morbidity, and mortality are well documented, and often are related to race/ethnicity and socioeconomic indicators including income, education, and healthcare access. Public health approaches that address social determinants of health have the greatest potential public health benefit, and can positively impact health disparities. As public health interventions, community health workers (CHWs), and patient navigators (PNs) work to address disparities and improve cancer outcomes through education, connecting patients to and navigating them through the healthcare system, supporting patient adherence to screening and diagnostic services, and providing social support and linkages to financial and community resources. Clinical settings, such as federally qualified health centers (FQHCs) are mandated to provide care to medically underserved communities, and thus are also valuable in the effort to address health disparities. We conducted a systematic literature review to identify studies of cancer-related CHW/PN interventions in FQHCs, and to describe the components and characteristics of those interventions in order to guide future intervention development and evaluation.

Method: We searched five databases for peer-reviewed CHW/PN intervention studies conducted in partnership with FQHCs with a focus on cancer, carried out in the United States, and published in English between January 1990 and December 2013.

Results: We identified 24 articles, all reporting positive outcomes of CHW/PNs interventions in FQHCs. CHW/PN interventions most commonly promoted breast, cervical, or colorectal cancer screening and/or referral for diagnostic resolution. Studies were supported largely through federal funding. Partnerships with academic institutions and community-based organizations provided support and helped develop capacity among FQHC clinic leadership and community members.

Discussion: Both the FQHC system and CHW/PNs were borne from the need to address persistent, complex health disparities among medically underserved communities. Our findings support the effectiveness of CHW/PN programs to improve completion and timeliness of breast, cervical, and colorectal cancer screening in FQHCs, and highlight intervention components useful to design and sustainability.

Changes in Knowledge and Beliefs About Human Papillomavirus and Cervical Cancer Screening Intervals in Low-Income Women After an Educational Intervention

INTRODUCTION

Women have been reluctant to adopt longer than annual intervals for cervical cancer screening, despite guidelines recommending screening every 3 to 5 years. Our study assessed patient knowledge and beliefs about human papillomavirus (HPV) and cervical cancer screening after exposure to an educational intervention, and whether there was a change in time regarding knowledge and beliefs among all study participants in an underserved population.

METHOD

The study was conducted in 15 clinics associated with 6 Federally Qualified Health Centers in Illinois, USA. Cervical cancer screening patients (n = 644) completed a baseline and postintervention follow-up survey. The intervention included an HPV test and an educational pamphlet. Significance testing of changes in knowledge and beliefs was conducted with multilevel, mixed-effects models adjusting for repeated measures of patients and clustering within clinics.

RESULTS

No significant differences in study outcomes were found between the intervention and control groups. Among all women, knowledge of HPV significantly improved over time. At follow-up, fewer women reported that having a co-test is good, wise, will give you peace of mind, will tell you whether you need to worry if Pap is abnormal, is something your doctor thinks you should have, and will give you the best care available. More women said it would be bad, useless, or worrying to wait 3 years for a Pap test at follow-up.

CONCLUSION

HPV knowledge improved over time, but the educational intervention utilized in this study was not successful in improving attitudes and beliefs about co-testing and longer screening intervals, and beliefs about HPV co-testing and 3-year screening intervals were less favorable. Having health care providers discuss the consequences of overscreening and the natural history of HPV and cervical cancer with their patients may help increase adherence to longer screening intervals. Further examination of the essential components for educational intervention in this population is warranted.

Racial and ethnic differences in human papillomavirus positivity and risk factors among low-income women in Federally Qualified Health Centers in the United States

Reasons for racial/ethnic disparities in HPV infection are unclear. This study assessed racial/ethnic differences in and risk factors for HPV positivity among low-income women. Data were collected from 984 low-income women visiting Federally Qualified Health Centers across Illinois (2009-2011). Pearson chi square and Logistic regression analyses were used to examine associations with HPV positivity. Our results showed Mexican-born Hispanics had the lowest HPV positivity (16%), followed by non-Hispanic whites (29%), US-born Hispanics (35%), and non-Hispanic blacks (39%). Mexican-born Hispanics reported fewer risk behaviors for HPV positivity, including first sexual intercourse before age 16 years (9% versus 27%), multiple sexual partners in lifetime (48% versus 90%), and current cigarette smoking status (10% versus 35%) when compared to non-Hispanic whites (p<0.001). In multivariate-adjusted logistic regression, being non-Hispanic black, first sexual intercourse before age 16 years, increasing numbers of recent or lifetime sexual partners and current cigarette smoking status were associated with a higher likelihood of HPV positivity. Our findings highlight racial/ethnic differences in HPV positivity and risk factors in a population of women with similar socioeconomic characteristics. When measuring HPV risk factors within the Hispanic population, foreign-born status and other mediating factors, such as social norms and cultural characteristics, may be relevant to assess the intragroup heterogeneity.

Communication practices about HPV testing among providers in Federally Qualified Health Centers

Objective

Little is known about the information providers share with patients when ordering a co-test, or combined human papillomavirus (HPV) and Papanicolaou (Pap) test, for cervical cancer screening. We assessed provider perceptions of such communication practices with female patients aged 30–60 years.

Methods

We analyzed data from 98 providers in 15 Federally Qualified Health Center clinics across Illinois (2009–2010).

Results

About 70% of the providers reported that when ordering a co-test, they would usually or always communicate information about the HPV test to their patients, explain the test detects a sexually transmitted infection, and discuss how the test results may determine their next screening interval. Most (> 85%) reported that they were comfortable discussing co-test results. Compared with concordant positive results (HPV positive/Pap positive), providers were more likely to perceive that discordant results (HPV positive/Pap negative) would be too complex for patients to understand (25% vs. 15%, p = 0.006), and make patients feel less assured that they were getting the best standard of care (67% vs. 88%, p < 0.001).

Conclusion

As HPV testing plays a more prominent role in cervical cancer screening, more attention should be given to communications between providers and patients about the benefits and harms of different screening options.

Provider beliefs associated with cervical cancer screening interval recommendations: A pilot study in Federally Qualified Health Centers

Background

Among providers who serve low-income and uninsured women, resistance to extending the cervical cancer screening interval following normal Pap and co-test results has been documented. Our objective was to examine provider characteristics and beliefs associated with guideline-consistent screening interval recommendations.

Method

We collected cross-sectional survey data between 2009 and 2010 from 82 primary care providers in six Federally Qualified Health Centers in Illinois, USA. The relationships between characteristics, beliefs, and screening interval recommendations (1 year vs. 3 years) were tested with Pearson chi-square, negative binomial and ordered logistic regression.

Results

Compared to providers who recommended annual intervals after a normal co-test, providers who recommended a guideline-consistent (i.e., 3 years) screening interval were significantly more likely to report the goodness, ease, and benefit of their recommendation and perceived encouragement for a 3-year interval from professional organizations and journals (p < .05). Providers who recommended a 3-year interval were also less likely to report that longer intervals increase patient risk for cervical cancer (p < .05). Interval recommendations were not associated with provider specialty, gender, or years in practice.

Conclusion

Messages that promote the benefits of longer screening intervals after a normal co-test, the natural history of human papillomavirus and cervical cancer, and low risk of developing cancer with a longer interval may be useful to promote evidence-based screening in this population of Federally Qualified Health Center providers. Dissemination of targeted messages through professional journals and specialty organizations should be considered.

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Annual cervical cancer screening is common, but not recommended by guidelines.

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Pilot study assessed provider factors associated with screening recommendations.

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Screening recommendations are associated with positive beliefs about screening tests.

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Perceived risk of the patient developing cancer between screenings is significant.

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Professional journals and organizations can disseminate screening interval messages.

Demographic factors associated with overuse of Pap testing

BACKGROUND

Since 2003, U.S. Preventive Services Task Force guidelines recommend against Pap testing for women without a cervix following a hysterectomy and those aged >65 years. Few population-based studies have investigated factors associated with overuse of Pap testing in the U.S.

PURPOSE

To evaluate patient characteristics associated with overuse of Pap testing.

METHODS

A cross-sectional study was conducted using data from the 2010 National Health Interview Survey (NHIS) for women aged ≥30 years. NHIS is a nationally representative survey that employs a random, stratified, multi-stage cluster sampling design. In 2010, the NHIS administered a Cancer Control Supplement with questions on cervical cancer screening and hysterectomy status. Conducted in 2011-2013, all analyses account for the stratification and clustering of data within the complex NHIS survey design. Multivariate logistic regression models were used in all analyses.

RESULTS

Among women who have undergone a hysterectomy, younger age, Hispanic and black race/ethnicity, exceeding 400% of poverty level, and private health insurance coverage were significantly associated with receipt of a recent Pap test since hysterectomy. Among women aged >65 years, non-Hispanic white ethnicity, higher education level, exceeding 400% of poverty level, and no hysterectomy were significantly associated with receipt of a recent Pap test.

CONCLUSIONS

Targeted efforts to reduce unnecessary testing among older women and women with a hysterectomy in compliance with clinical recommendations for cervical cancer prevention are needed. Specific attention should be paid to privately insured women with incomes above 400% of the federal poverty level.

Alcohol control efforts in comprehensive cancer control plans and alcohol use among adults in the USA

AIMS

To understand how US cancer control plans address alcohol use, an important but frequently overlooked cancer risk factor, and how many US adults are at risk.

METHODS

We reviewed alcohol control efforts in 69 comprehensive cancer control plans in US states, tribes and jurisdictions. Using the 2011 Behavioral Risk Factor Surveillance System, we assessed the prevalence of current alcohol use among US adults and the proportion of these drinkers who exceeded guidelines for moderate drinking.

RESULTS

Most comprehensive cancer control plans acknowledged alcohol use as a cancer risk factor but fewer than half included a goal, objective or strategy to address alcohol use. More than half of US adults reported current alcohol use in 2011, and two of three drinkers exceeded moderate drinking guidelines at least once in the past month. Many states that did not address alcohol use in comprehensive cancer control plans also had a high proportion of adults at risk.

CONCLUSION

Alcohol use is a common cancer risk factor in the USA, but alcohol control strategies are not commonly included in comprehensive cancer control plans. Supporting the implementation of evidence-based strategies to prevent the excessive use of alcohol is one tool the cancer control community can use to reduce the risk of cancer.

Key informant interviews with coordinators of special events conducted to increase cancer screening in the United States

Special events such as health fairs, cultural festivals and charity runs are commonly employed in the community to increase cancer screening; however, little is known about their effectiveness. The purpose of this study is to assess the activities, screening outcomes, barriers and recommendations of special events to increase breast, cervical and colorectal cancer screening. In-depth interviews were conducted nationally with 51 coordinators of events in June to September 2012. Health fairs and screening days were the most common events conducted, primarily for breast cancer education. Goals were to increase awareness of cancer screening and reach special populations. Evidence-based Community Guide strategies to increase cancer screening employed were: small media, reducing structural barriers, one-on-one education or group education. For each event that provided screening on-site or through referral, a mean of 35 breast, 28 cervical and 19 colorectal cancer screenings were reported. Coordinators made recommendations for further evaluation of special events, and most plan to conduct another special event. These data are novel and provide baseline documentation of activities and recommendations for a commonly used community-based cancer screening intervention that lacks evidence of effectiveness. Additional research to better understand the use of special events for increasing cancer screening is warranted.

Current cervical cancer screening knowledge, awareness, and practices among U.S. affiliated pacific island providers: opportunities and challenges

BACKGROUND

Cervical cancer is a leading cause of cancer mortality in nearly all U.S. Affiliated Pacific Island Jurisdictions (USAPIJ); however, most jurisdictions are financially and geographically limited in their capacity to deliver routine screening.

METHODS

We conducted a cross-sectional survey of 72 health care providers from five of the six USAPIJ in 2011 to assess knowledge, beliefs, practices, and perceived barriers regarding routine cervical cancer screening. We compared the responses of providers from jurisdictions that were funded by the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) with those that were not funded.

RESULTS

Most providers reported cervical cancer prevention as a priority in their clinical practices (90.3%) and use the Papanicolaou test for screening (86.1%). Many providers reported knowledge of screening guidelines (76.4%); however, more than half reported that annual screening is most effective (56.9%). Providers in non-NBCCEDP-funded jurisdictions reported greater acceptance of visual inspection with acetic acid (93.9%) and self-sampling for human papillomavirus testing (48.5%) compared with NBCCEDP-funded jurisdictions (15.4% and 30.8% respectively). Providers from non-NBCCEDP-funded jurisdictions reported inadequate technological resources for screening women (42.4%), and approximately 25% of providers in both groups believed that screening was cost-prohibitive.

CONCLUSION

Although cervical cancer screening is a priority in clinical practice, beliefs about annual screening, costs associated with screening, and varying levels of support for alternative screening tests pose barriers to providers throughout the USAPIJ. Further exploration of using evidence-based, lower cost, and sustainable screening technologies is warranted in addition to emphasizing timely follow-up of all positive cases.

A systematic review of special events to promote breast, cervical and colorectal cancer screening in the United States

Background

Special events are common community-based strategies for health promotion. This paper presents findings from a systematic literature review on the impact of special events to promote breast, cervical or colorectal cancer education and screening.

Methods

Articles in English that focused on special events involving breast, cervical, and/or colorectal cancer conducted in the U.S. and published between January 1990 and December 2011 were identified from seven databases: Ovid, Web of Science, CINAHL, PsycINFO, Sociological Abstract, Cochrane Libraries, and EconLit. Study inclusion and data extraction were independently validated by two researchers.

Results

Of the 20 articles selected for screening out of 1,409, ten articles on special events reported outcome data. Five types of special events were found: health fairs, parties, cultural events, special days, and plays. Many focused on breast cancer only, or in combination with other cancers. Reach ranged from 50–1732 participants. All special events used at least one evidence-based strategy suggested by the Community Guide to Preventive Services, such as small media, one-on-one education, and reducing structural barriers. For cancer screening as an outcome of the events, mammography screening rates ranged from 4.8% to 88%, Pap testing was 3.9%, and clinical breast exams ranged from 9.1% to 100%. For colorectal screening, FOBT ranged from 29.4% to 76%, and sigmoidoscopy was 100% at one event. Outcome measures included intentions to get screened, scheduled appointments, uptake of clinical exams, and participation in cancer screening.

Conclusions

Special events found in the review varied and used evidence-based strategies. Screening data suggest that some special events can lead to increases in cancer screening, especially if they provide onsite screening services. However, there is insufficient evidence to demonstrate that special events are effective in increasing cancer screening. The heterogeneity of populations served, event activities, outcome variables assessed, and the reliance on self-report to measure screening limit conclusions. This study highlights the need for further research to determine the effectiveness of special events to increase cancer screening.

Overview of the CDC Cervical Cancer (Cx3) Study: an educational intervention of HPV testing for cervical cancer screening

BACKGROUND

The recommended screening interval when using the Papanicolaou (Pap) and human papillomavirus (HPV) test (co-testing) is 5 years. However because providers are reluctant to extend the screening interval, we launched a study to identify barriers to appropriate use of the co-test and to implement an educational intervention to promote evidence-based screening practices. This article provides an overview of the study including the multi-component intervention and participant demographics.

METHODS

The study was conducted in 15 clinics associated with 6 Federally Qualified Health Centers (FQHCs) in Illinois. Each clinic received HPV tests to administer with routine Pap tests among enrolled patients (n=2,246) and was assigned to a study arm: intervention arm (n=7) received a multi-component educational intervention (small media, academic detailing, and website) for providers and printed educational materials for patients, and control arm (n=8) received printed copies of general guidelines. Clinic coordinators (n=15), providers (n=98), and patients (n=984) completed baseline surveys to assess screening practices.

RESULTS

Providers reported an average age of 41.3 years and were predominately female, non-Hispanic, and white. Patients reported an average age of 45.0 years and nearly two-thirds were Hispanic or black. Of the 2,246 patients, 89% had a normal co-test. Lessons learned from the study included the importance of buy-in at a high level in the organization, a champion provider, and a clinical coordinator devoted to the study.

CONCLUSION

Materials from this study can be adapted to educate providers and patients on appropriate use of the co-test and encourage extended screening intervals as a safe and effective practice.

Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature

IMPORTANCE

Since licensure of the human papillomavirus (HPV) vaccine in 2006, HPV vaccine coverage among US adolescents has increased but remains low compared with other recommended vaccines.

OBJECTIVE

To systematically review the literature on barriers to HPV vaccination among US adolescents to inform future efforts to increase HPV vaccine coverage.

EVIDENCE REVIEW

We searched PubMed and previous review articles to identify original research articles describing barriers to HPV vaccine initiation and completion among US adolescents. Only articles reporting data collected in 2009 or later were included. Findings from 55 relevant articles were summarized by target populations: health care professionals, parents, underserved and disadvantaged populations, and males.

FINDINGS

Health care professionals cited financial concerns and parental attitudes and concerns as barriers to providing the HPV vaccine to patients. Parents often reported needing more information before vaccinating their children. Concerns about the vaccine's effect on sexual behavior, low perceived risk of HPV infection, social influences, irregular preventive care, and vaccine cost were also identified as potential barriers among parents. Some parents of sons reported not vaccinating their sons because of the perceived lack of direct benefit. Parents consistently cited health care professional recommendations as one of the most important factors in their decision to vaccinate their children.

CONCLUSIONS AND RELEVANCE

Continued efforts are needed to ensure that health care professionals and parents understand the importance of vaccinating adolescents before they become sexually active. Health care professionals may benefit from guidance on communicating HPV recommendations to patients and parents. Further efforts are also needed to reduce missed opportunities for HPV vaccination when adolescents interface with the health care system. Efforts to increase uptake should take into account the specific needs of subgroups within the population. Efforts that address system-level barriers to vaccination may help to increase overall HPV vaccine uptake.

Patient knowledge and beliefs as barriers to extending cervical cancer screening intervals in Federally Qualified Health Centers

OBJECTIVE

Despite guidelines recommending cervical cancer screening intervals be extended beyond one year, clinical practice has been slow to change. Patient preferences are a potential barrier. In the Centers for Disease Control's Cervical Cancer (Cx3) Study at Federally Qualified Health Centers (FQHCs) across Illinois, we surveyed patients about screening practices, and assessed beliefs regarding lengthening screening intervals.

METHOD

We analyzed data from 984 low income women in the Cx3 Study (2009-2011). Participants completed a survey assessing health history, knowledge about Pap testing, beliefs and intentions about extending screening intervals, and demographics.

RESULTS

The majority reported annual Pap testing (61%), while only 24% reported a 2-3 year screening interval (recommendation at time of survey). Misunderstandings about the Pap test were prevalent, with over half believing it screened for vaginal, yeast, and sexually transmitted infections (58%-72%). Unfavorable beliefs about extending screening intervals were common. The majority (57%) indicated that they would not wait 3 years to be screened if their physician recommended it, and intentions were associated with knowledge about Pap testing.

CONCLUSION

Most women reported annual cervical cancer screening, and intended to resist longer screening intervals. Patients' lack of knowledge and unfavorable beliefs may serve as barriers to extending screening intervals.

Issues of ovarian cancer survivors in the USA: a literature review

PURPOSE

As the number of ovarian cancer survivors increases, so does the need for appropriate intervention and care. A literature review was conducted to assess the issues affecting ovarian cancer survivors in the USA, including the needs of younger survivors.

METHODS

Articles on six topics (finances/employment, reproductive and sexual health, treatment effects, information needs, genomics, and end-of-life/palliative care) among ovarian cancer survivors were identified through comprehensive database searches. Abstracts for all citations were reviewed to determine relevancy. Data from relevant articles, defined as including a sample size of ≥ 20, published in English, involving human subjects in the USA, and published between 2000 and 2010, were abstracted.

RESULTS

Thirty-four articles were relevant. Common, but often unaddressed, treatment side effects included infertility and issues with sexual health. Survivors reported not receiving adequate information about their disease. Hereditary cancer can lead to concern for family members. End-of-life/palliative care was often not addressed by physicians. Most of the studies used a cross-sectional design and lacked control groups. Participants were primarily recruited from academic medical centers or clinical trials and tended to be White. Few studies specifically addressed young survivors; however, reproductive health issues are common.

CONCLUSIONS

Ovarian cancer has wide-ranging impacts. This review emphasizes the need for more research among ovarian cancer survivors, particularly related to finances, reproductive and sexual health, information, genomics, and end-of-life care. Issues specific to young survivors also deserve more attention. Direction for future research and clinical implications are discussed.

A literature review of the social and psychological needs of ovarian cancer survivors

OBJECTIVE

To identify and comprehensively present the psychosocial needs of ovarian cancer (OvCa) survivors, including young survivors <45 years of age.

METHODS

A literature review was conducted using keywords specific to psychosocial health and OvCa survivorship to identify peer-reviewed, original research articles published in English between January 2000 and December 2010; 28 articles were identified as relevant. Articles were abstracted and results categorized according to six psychosocial domains: quality of life (QoL), social support and relationships, self-image and sexual functioning, psychological distress and functioning, fear of death/recurrence, and personal growth and coping. Findings unique to young survivors are presented when applicable. Psychosocial measurement tools used in relevant studies are also presented.

RESULTS

Physical complications and side effects have significant impact on OvCa survivors' psychosocial health. Access to social support services and relational support is critical, as feelings of isolation are common. Survivors report low levels of sexual activity and satisfaction, potentially causing strain on personal relationships, and survivors experience high levels of distress, depression, and anxiety. However, QoL can improve after diagnosis for some OvCa survivors, many of whom report spiritual growth and strengthened personal relationships. Younger survivors are likely to have greater distress and lower QoL compared with older survivors.

CONCLUSIONS

OvCa is the deadliest of all gynecologic cancers, greatly impacting the psychosocial health of survivors. Increased awareness of psychosocial health among OvCa survivors themselves, their social support system, and their health care providers is necessary to adequately address their unique needs.

Opportunities for public health communication, intervention, and future research on breast cancer in younger women

BACKGROUND

Approximately 6% of breast cancers in the United States occur in women under the age of 40 years. Compared with women ≥40 years of age, younger women are diagnosed at later stages, have higher rates of recurrence and death, and may be predisposed to secondary breast or ovarian cancer. An informal meeting of experts discussed opportunities for research and public health communication related to breast cancer among young (<40 and/or premenopausal) women.

METHODS

In September 2011, the Centers for Disease Control and Prevention hosted 18 experts in oncology, genetics, behavioral science, survivorship and advocacy, public health, communication, ethics, nutrition, physical activity, and environmental health. They (1) reviewed research and programmatic knowledge on risk and preventive factors, early detection, and survivorship; and (2) discussed ideas for research, communication, and programmatic efforts related to young women diagnosed with or at risk for early onset breast cancer.

RESULTS

Levels of evidence and themes for future research regarding risk and preventive factors, including exposures, were discussed. Early detection strategies, including screening, risk assessment, and genetic counseling, as well as survivorship issues, follow-up care, fertility and reproductive health, and psychosocial care were highlighted.

CONCLUSION

Community and academic researchers, providers, advocates, and the federal public health community discussed strategies and opportunities for this unique population. Although the evidence is limited, future research and communication activities may be useful to organize future public health initiatives.

Cervical cancer screening among young adult women in the United States

BACKGROUND

Cervical cancer screening guidelines have evolved significantly in the last decade for young adult women, with current recommendations promoting later initiation and longer intervals.

METHODS

Using self-reported cross-sectional National Health Interview Survey (NHIS) 2000-2010 data, trends in Papanicolaou (Pap) testing among women ages 18-29 years were examined. NHIS 2010 data were used to investigate age at first Pap test (N = 2,198), time since most recent Pap test (n = 1,622), and predictors of Pap testing within the last 12 months (n = 1,622).

RESULTS

The percentage of 18-year-olds who reported ever having a Pap test significantly decreased from 49.9% in 2000 to 37.9% in 2010. Mean age at first Pap test in 2010 was significantly younger for non-Hispanic black women (16.9 years), women < high school education (16.9 years), women who received the HPV vaccine (17.1 years), and women who have ever given birth (17.3 years). The majority reported their last Pap test within the previous 12 months (73.1%). Usual source of healthcare (OR, 2.31) and current birth control use (OR, 1.64) significantly increased chances of having a Pap test within the previous 12 months.

CONCLUSIONS

From 2000 to 2010, there was a gradual decline in Pap test initiation among 18-year-olds; however, in 2010, many women reported ≤12 months since last screening. Evidence-based guidelines should be promoted, as screening young adult women for cervical cancer more frequently than recommended can cause considerable harms.

IMPACT

A baseline of cervical cancer screening among young adult women in the United States to assess adherence to evidence-based screening guidelines.

Association of cutaneous melanoma incidence with area-based socioeconomic indicators-United States, 2004-2006

BACKGROUND

Socioeconomic status (SES) has been associated with melanoma incidence and outcomes. Examination of the relationship between melanoma and SES at the national level in the United States is limited. Expanding knowledge of this association is needed to improve early detection and eliminate disparities.

OBJECTIVE

We sought to provide a detailed description of cutaneous melanoma incidence and stage of disease in relationship to area-based socioeconomic measures including poverty level, education, income, and unemployment in the United States.

METHODS

Invasive cutaneous melanoma data reported by 44 population-based central cancer registries for 2004 to 2006 were merged with county-level SES estimates from the US Census Bureau. Age-adjusted incidence rates were calculated by gender, race/ethnicity, poverty, education, income, unemployment, and metro/urban/rural status using software. Poisson multilevel mixed models were fitted, and incidence density ratios were calculated by stage for area-based SES measures, controlling for age, gender, and state random effects.

RESULTS

Counties with lower poverty, higher education, higher income, and lower unemployment had higher age-adjusted melanoma incidence rates for both early and late stage. In multivariate models, SES effects persisted for early-stage but not late-stage melanoma incidence.

LIMITATIONS

Individual-level measures of SES were unavailable, and estimates were based on county-level SES measures.

CONCLUSION

Our findings show that melanoma incidence in the United States is associated with aggregate county-level measures of high SES. Analyses using finer-level SES measures, such as individual or census tract level, are needed to provide more precise estimates of these associations.

Cancer screening practices among physicians in the national breast and cervical cancer early detection program

BACKGROUND

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides low-income, uninsured women with screening and diagnostic services for breast and cervical cancer. Our study was conducted to describe the demographic and practice characteristics of participating and nonparticipating physicians, as well as their beliefs, adoption of new screening technologies, and recommendations for breast and cervical cancer screening.

METHODS

From a 2006-2007 nationally representative survey, we identified 1,111 practicing primary care physicians who provide breast and cervical cancer screenings and assessed their recommendations using clinical vignettes related to screening initiation, frequency, and cessation. Responses of physicians participating in the NBCCEDP were compared with those from nonparticipating physicians.

RESULTS

Of the physicians surveyed, 15% reported participation in the NBCCEDP, 65% were not participants, and 20% were not sure or did not respond to this question. Program physicians were significantly more likely to practice in multispecialty settings, in a rural location, and in a hospital or clinic setting and had more patients who were female and insured by Medicaid or uninsured compared with nonprogram physicians. Beliefs about the effectiveness of screening tools or procedures in reducing breast or cervical cancer mortality were similar by program participation. Adoption of new technologies, including digital mammography and human papillomavirus (HPV) testing, and making guideline-consistent recommendations for screening initiation, frequency, and cessation did not differ significantly by program participation.

CONCLUSIONS

Although there may be differences in physician characteristics and practice settings, the beliefs and screening practices for both breast and cervical cancer are similar between program and nonprogram providers.

Liquid-based cytology test use by office-based physicians: United States, 2006-2007

BACKGROUND

In the United States, liquid-based cytology (LBC) has become a common screening method for cervical cancer. However, the extent of LBC use, and how it varies by patient and practice characteristics, is unknown.

OBJECTIVE

This report describes the ordering and provision of Papanicolaou (Pap) tests, with a major focus on the extent to which LBC has supplanted conventional cytology. The type of Pap test is examined for visits made to primary care physicians in 2006-2007 by females aged 15-64.

METHODS

Estimates of Pap test cytology use (both LBC and conventional) are based on combined data from the 2006-2007 National Ambulatory Medical Care Survey (NAMCS), an annual nationally representative survey of visits to nonfederal office-based physicians in the United States, as well as on information reported by sample physicians in Cervical Cancer Screening Supplements fielded as part of NAMCS during the same years.

RESULTS

In 2006-2007, LBC was used in approximately 75% of Pap tests for which the type of cytology was known. LBC was less likely to be used for Medicare patients than for privately insured patients, although LBC use did not vary significantly according to the other patient or practice characteristics examined.

CONCLUSION

The high percentage of LBC use by office-based physicians in 2006-2007 confirms the widespread use of this screening method among primary care providers, as has been reported in the literature.

Examining the association between socioeconomic status and potential human papillomavirus-associated cancers

BACKGROUND

This study examined the association between county-level measures of socioeconomic status (SES) and the incidence rate of human papillomavirus(HPV)-associated cancers, including cervical, vulvar, vaginal, anal, penile, and oral cavity and oropharyngeal cancers.

METHODS

The authors collected data from cancer registries for site-specific invasive cancer diagnoses between 1998 and 2003, inclusive, among adults aged >20 years at the time of diagnosis. County-level variables that included education, income, and poverty status were used as factors for socioeconomic status. Measures of rural-urban status, the percentage of the population that currently smoked, and the percentage of women who reported having ever had a Papanicolaou (Pap) test were also studied.

RESULTS

Lower education and higher poverty were found to be associated with increased penile, cervical, and vaginal invasive cancer incidence rates. Higher education was associated with increased incidence of vulvar cancer, male and female anal cancer, and male and female oral cavity and oropharyngeal cancers. Race was an independent predictor of the development of these potentially HPV-associated cancers.

CONCLUSIONS

These findings illustrate the association between SES variables and the development of HPV-associated cancers. The findings also highlight the importance of considering SES factors when developing policies to increase access to medical care and reduce cancer disparities in the United States.