Understanding Lack of Pap Follow-up: Women Clients’ Perspectives

Understanding Lack of Pap Follow-up:Women Clients’ Perspectives Jill M. Abbott, DrPH1, Kathryn J. Luchok, PhD2, Ann L. Coker, PhD3, and Irene Prabhu Das, MSPH4 1 Ohio State University, Comprehensive Cancer Center 2 University of South Carolina, Department of Health Promotion, Education, and Behavior 3 University of Texas at Houston Health Science Center, School of Public Health 4 South Carolina Department of Health and Environmental Control

Study Objective • To better understand women’s perspectives concerning adherence to abnormal Pap test follow-up • Identify facilitating and hindering factors • Describe primary coping strategies • Explain how these factors affect women’s adherence to follow-up recommendations

Background • Pap test screening has increased dramatically in recent decades • Understanding multiple factors that affect adherence can increase program effectiveness

Working Conceptual Model Nature of Provider – Client Communication Practice support Provider Abnormal Pap Detected Intention to Adhere to Follow-Up Adherence to Follow-Up Client Self-Efficacy Knowledge Expectations Competing priorities Fear of cancer System/Environment

Cervical Cancer in South Carolina *8th in USA in cervical cancer mortality *10.25 per 100,000 cervical cancer incidence

Study Population • SC Breast and Cervical Cancer Early Detection Program clients • Had an abnormal Pap test between 1999 and 2000 • African American and Caucasian women • Acknowledge receipt of abnormal Pap test results • Both adherent and non-adherent women

Methods • Semi-structured Interview Guide • 40 items • Expert reviewed, pilot-tested and revised • Content: • Facilitating and hindering factors • Coping strategies • Sociodemographic variables

Methods • Data Collection • 19 in-depth, in-person interviews • Approximately 60 minutes each • Audiotaped with consent • $20 incentive • Data Management • Interviews transcribed verbatim • Reviewed for quality control

Methods • Data Analysis • Constant comparison method • “Paper and pen” note-based analysis • Qualitative data managed using NVivo 2.0 (QSR Inc.) • Descriptive statistics analyzed in Excel

Participant Characteristics • N=19 Women • Mean age = 59.47 years • 53% African American (n=10) • 68% had GED, high school diploma or higher (n=13) • 37% married (n=7) • 53% adherent (n=10)

Results • Barriers to obtaining complete and timely follow-up care • Client/personal factors • Living on restricted income • Meeting the competing needs of significant others • Living with co-morbid conditions • Environmental factors • Transportation

“Well, I desire to have medical insurance, but I can’t afford it…and I want the care. I want to take care of myself.” • “Well, my husband, he had to go to the doctor on Monday and wanted me to go with him…So, that made me cancel mine and go with him…” • “My father was really sick in Oklahoma, and he passed away during that time, and I put this off until I could get that took care of.” • “Oh, transportation because, where I had to go, it’s about 60/65 miles one way. Sometimes I had to borrow the money to get there, you know, for gas.”

Results • Factors facilitating adherence to follow-up recommendations • Provider factors • Clinicians’ sensitivity and concern • Clinic staff’s friendliness • Assistance with scheduling follow-up appointments • Reminders about needed follow-up or previously scheduled follow-up appointments

“Just to know that somebody is concerned about my health is good…and they made me feel comfortable.” • “He was really great about that. He saw that I did not want to have the surgery, so he came up with these other things.” • “Other than be nice and friendly…They shouldn’t just scoot you in there and scoot you out, you know, like you don’t have it.”

Results • Most women (n=17) identified concern for their own health as a facilitating factor • “Just knowing that I was going to get the results…get help for myself and just thinking about the good that it is going to be for me.”

Results • Predominant coping strategies • Problem management • Emotional regulation “At first, I asked, ‘Why?’ Secondly, I got at home by myself , cried, and I got upset, and you have to relieve this built in tension. And then I prayed and asked God to help me and guide and give me strength to go through this. That was it.”

Results • Few differences between adherent and non-adherent women • More non-adherent women identified transportation as a barrier • Only non-adherent women used planning • More adherent women used prayer and active coping

Discussion • Low-income women in SC face numerous challenges in their daily lives • Support of family and friends may not be an important consideration • Interactions with clinicians and clinic staff play a major role in women’s experiences

Recommendations • Develop clinical and community interventions to increase adherence that are tailored for higher-risk populations • Incorporate components that acknowledge and mediate their daily struggles • Develop clinical and community interventions to include aspects of the coping process • Use of adaptive coping responses may improve adherence rates

Acknowledgments Thanks to the women who gave freely of their time to recount their experiences. This project was supported by a grant from the Centers for Disease Control and Prevention (CDC). Grant Number U48/CCU409664-09. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of CDC.

Understanding Lack of Pap Follow-up: Women Clients’ Perspectives