Improving Adherence to Colposcopy Recommendations: Insights from Interviews

1. Improving adherence to colposcopy recommendations:Recommendations from interviews with individuals advised to receive colposcopySafe Healthy Strong Conference – March 22, 2018 Melissa DeNomie, MS and Leslie Ruffalo, PhD– Medical College of Wisconsin Maria Barker – Planned Parenthood Wisconsin

2. Overview • Cervical cancer • Used to be deadly • Now is very survivable • 12,000 women die each year – often people of color • Colposcopy – key component of very effective cervical cancer screening process • However many women fail to get recommended colposcopies

3. Our project • Question: Why do so few women get recommended colposcopies • Insurance? • Transportation? • Fear of procedure? • Grant to fund this project • Interviews to better understand these reasons • Patients at Waukesha Family Practice Center and Planned Parenthood Wisconsin

4. The questions • Talk about the process of being told you needed a colposcopy. • Talk about your reaction to the news that you needed a colposcopy. Did you feel afraid or anxious? • If someone you knew needed a colposcopy, what would you tell her about the experience you had? Would you recommended they get a colposcopy? • (For non-adherers) Did your fears prevent you from having a colposcopy? What were you afraid of? What else prevented you from getting a colposcopy?

5. Socioecological model • Academic model (Bronfenbrenner, 1979) describing behavior • Different levels of factors that influence decisions: • Individual • Your own thoughts, feelings, actions • Interpersonal • Interactions/conversations with other people • Family and friends • Organizational • Clinic • Community • What we hear from the media, television, radio • Policy/systems • Laws – state and federal • Access to health care

6. Individual Level “I was scared because my aunt died of cervical cancer. She…died at 53.” • Lack of understanding • Big words • Complicated screening process • Feeling motivated to get a colposcopy • For others • Because of severity of cancer • Thoughts about HPV • Stigma, incorrect ideas about HPV • Don’t understand how common HPV is • Thoughts about pregnancy • Perhaps afraid that if they have colposcopy they won’t be able to get pregnant • Afraid that if they don’t have the colposcopy they will get cancer and won’t be able to get pregnant

7. Interpersonal Level • Doctor’s explanation (good or bad) • Support (or lack of support) from family • Motivated to stay healthy for children • Sickness/death of a loved one/parent impacting the patient’s insurance status and/or ability to get a colposcopy “My anxiety was so high waiting for it to come back. And when it came back – I celebrate with my kids every time that it comes back a good outcome because it’s like I can still be with you.”

8. Organizational Level “Because it was the doctor and her resident, there was a lot of silent time…silence makes me nervous.” • Discomfort with additional people in room • E.g., residents, students • Procedural factors • How things are communicated to patient • Things during the procedure that make someone more comfortable • Finding the balance • Want patients to take the recommendation seriously, but don’t want to scare them off

9. Community Level “It was made better by the fact that my sister had gotten an abnormal pap and had told me about it, two of my roommates, and one of my best friends had talk to me about it. It didn’t’ seem as scary because I knew other women who had been through the process.” • HPV • People who understand how common HPV is express less fear about colposcopy • HPV is an “STD” so it can create negative feelings, • If we can “normalize” HPV (let people know it is very very common!) people might have fewer negative feelings about HPV, cervical cancer, • Trust for clinics • Patients expressed trust for Planned Parenthood • How do we use this trust to improve likelihood that people adhere to colposcopy recommendations? • Transportation • Lack of public transportation can be a barrier

10. Policy and Systems Level “I love [Planned Parenthood] , I wish people were understanding of what it does for women in general… It makes it so accessible to be taken care of and most people who haven’t been here don’t understand what it’s all about.” • Access to health care • Planned Parenthood – important resource for un- and underinsured

11. Cultural Implications A few ideas that might impact women’s decisions about colposcopy: • Familialism – the family is more important than the individuals • Fatalism – “I leave my health in the hand’s of God” • Gender roles – men might not fully support women’s health issues • Modesty – culture might not fully support gynecological procedures • Trust for medicine – history of exploitation of certain cultures by medicine/research

12. Discussion • Attendees’ experiences with patients • How do we improve colposcopy adherence? • What role does culture/ethnicity play in colposcopy adherence?

13. Thank you! Melissa DeNomie Maria Barker Program Manager I Multicultural Programs Manager Medical College of Wisconsin Planned Parenthood of Wisconsin 414-955-8867, mdenomie@mcw.edu414-289-3788, maria.barker@ppwi.org