Network for Understanding Lack of Pap Follow-up

FUNDING SOURCE: Centers for Disease Control and Prevention

TIMELINE: Sept. 30, 2001 - Dec.29, 2004

PRINCIPAL INVESTIGATOR: Kathryn Luchok, PhD (USC HPEB)

CO-PRINCIPAL INVESTIGATOR: Ann Coker, PhD (UT-Houston, SPH)

CO-INVESTIGATORS:
Irene Prabhu Das, MPH (SC DHEC)
Conrad Otterness, MSPH (SC DHEC)
Melody Fortune, BA (MS-DOH)

PROJECT PARTNERS:
SC Dept. of Health and Environmental Control (SC DHEC)
Mississippi Department of Health (MS-DOH)

Although SC cervical cancer mortality rates have decreased over the past several years, South Carolina's age-adjusted mortality rates have remained higher than the national average for all women (2.7 per 100,000). As compared to the state's European-American women, African-American women in South Carolina have a 50% higher incidence rate for cervical cancer and a 26% higher rate of cervical cancer mortality. Pap smear screening is one of the best ways to reduce mortality rates through early detection and subsequent treatment for cervical neoplasia. Pap smear screening can only be successful if women receive diagnostic follow-up and treatment, as needed, in a timely manner.

The purposes of this study are to: 1) investigate why some women with abnormal Pap smears do not obtain follow-up care in a timely manner, and 2) to investigate what differences in follow-up care there may be between African-American and European-American women with abnormal Pap smears enrolled in the SC and MS Breast and Cervical Cancer Early Detection Program (SC-BCCEDP and MS-BCCEDP). The researchers reviewed the relevant literature, conducted in-depth qualitative telephone interviews with health care providers (N=41 clinicians; 56 office managers; 38 follow-up personnel) and BCCEDP staff, in both states (N=12) and in depth in person interviews with women served by the SC-BCCEDP (N=23) in order to identify the demographic, psychosocial, and health status correlates of not receiving timely follow-up care. The researchers then developed a theoretical model to describe factors (client, provider and environmental) which may influence decisions to obtain the recommended follow-up care for abnormal Pap smears. In Year 3, they collected quantitative data through computer assisted in-person interviews with women in both states (N=199-; approximately 59% African-American) who had an abnormal Pap smear and who had and had not received timely follow-up care, in order to identify factors associated with not receiving timely follow-up. They will then test the conceptual model with these empirical data. Findings from this research will be integrated into public and professional education efforts and case-management systems to increase adherence to follow-up and alleviate the burden of cervical cancer among this priority population.

Findings to date include gaps in current literature concerning explanations for why certain factors may be associated with non-adherence. Findings from the qualitative interviews with women indicate a strong dependence on religion for coping, problems with co-morbidities and competing life priorities, the importance of provider concern and a strong belief in taking responsibility for their own health. Clinicians mostly understand women's competing priorities, but did not see their own role in encouraging adherence, nor did they recognize women's co-morbidities and women's motivations to be responsible for their own health. Clinicians focused also on fear and denial among women, which women did not note as barriers to adherence. The CATI explores dimensions of health self-efficacy and religiosity and social support in a larger sample to verify the generalizability of the qualitative findings.

Two doctoral dissertations were completed using data from this study in 2003:

Abbott, Jill M. (2003) Women's Experiences with the Coping Process and its Relationship to Adherence to Abnormal Pap Test Follow-up, HPEB-ASPH, University of South Carolina, Columbia, SC.

Brandt, Heather M. (2003) Understanding Clinician Communication and Recommendations for Women who have Abnormal Pap Tests, , HPEB-ASPH, University of South Carolina, Columbia, SC.

PUBLISHED ABSTRACTS:

Luchok, KJ, Modayil, M., Abbott, JM., Brandt, HM, Prabhu Das, I and Coker, AL. Congruence between clinician and client perspectives on factors affecting follow-up of abnormal Pap test results. Accepted for presentation at the 132nd Public Health Association (APHA) Meeting, Washington, DC November 2004, online at line at www.apha.org.

Abbott, JM, Luchok, KJ, Corwin, SJ, Coker, AL and Prabhu Das, I. Racial differences among women coping with abnormal Pap test results. Accepted for presentation at the 132nd Public Health Association (APHA) Meeting, Washington, DC November 2004, online at line at www.apha.org.

Abbott, JM, Luchok, KJ, Corwin, SJ, Coker, AL and Prabhu Das, I. Competing life priorities for low-income women who have abnormal Pap test results Accepted for presentation at the 132nd Public Health Association (APHA) Meeting, Washington, DC November 2004, online at line at www.apha.org.

Coker, AL. Luchok, KJ, Prabhu Das, I, Abbott, JM and Otterness, C. Understanding lack of Pap follow-up: Qualitative approach. Presented at the 131st APHA Meeting, San Francisco, CA November 2003 in contributed session by the research team entitled Follow-Up of Abnormal Pap Tests, on line at www.apha.org.

Prabhu Das, I, Coker, AL. Luchok, KJ, Abbott, JM and Otterness, C & Bajaj, J. Lack of adherence to follow-up for abnormal Pap results: What do we know? Where do we need to go? Presented at the 131st APHA Meeting, San Francisco, CA November 2003 in contributed session by the research team entitled Follow-Up of Abnormal Pap Tests. online at www.apha.org.

Brandt, HM, Luchok, KJ, Coker, AL, Abbott, JM, Prabhu Das, Clinician communication of abnormal Pap test result to women patients. I. Presented at the 131st APHA Meeting, San Francisco, CA November 2003 in contributed session by the research team entitled Follow-Up of Abnormal Pap Tests. online at www.apha.org.

Luchok, KJ, Brandt, HM, Coker, AL, Abbott, JM, Prabhu Das, I. Clinician perspectives on barriers to timely follow-up of abnormal Pap test results: Presented at the 131st APHA Meeting, San Francisco, CA November 2003 in contributed session by the research team entitled Follow-Up of Abnormal Pap Tests. online at www.apha.org.

Luchok, KJ, Coker, AL, Prabhu Das, I. Understanding lack of Pap follow-up: Women's client perspectives. Abbott, JM, Presented at the 131st APHA Meeting, San Francisco, CA November 2003 in contributed session by the research team entitled Follow-Up of Abnormal Pap Tests, on line at www.apha.org.

MANUSCRIPTS IN PROGRESS:
i. Differences among Women Coping with Abnormal Pap Test Results.
ii. Competing Life Priorities for Low-Income Women who have Abnormal Pap Test Results.
iii. Congruence between clinician and client perspectives on factors affecting follow-up of abnormal Pap test results.
iv. Clinic Characteristics and adherence rates.
v. Systematic literature review.
vi. Clinic procedures for improving follow up - what is being implemented versus professional's perceptions of what promotes follow-up.
vii. Accuracy and Currency of Clinician Communication and Recommendations for Women who have Abnormal Pap Tests and Human Papillomavirus (HPV).