Understanding Lack of Pap Followup: Women Clients Perspectives

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Understanding Lack of Pap Follow-upWomen
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
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Study Objective

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

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Background

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

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

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Methods

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

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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

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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

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Participant Characteristics

• N19 Women
• Mean age 59.47 years
• 53 African American (n10)
• 68 had GED, high school diploma or higher (n13)
• 37 married (n7)
• 53 adherent (n10)

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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

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Well, I desire to have medical insurance, but I
cant afford itand 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 himSo, 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, its about 60/65 miles one way. Sometimes I
had to borrow the money to get there, you know,
for gas.
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Results

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

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Just to know that somebody is concerned about my
health is goodand 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 friendlyThey shouldnt just
scoot you in there and scoot you out, you know,
like you dont have it.
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Results

• Most women (n17) identified concern for their
  own health as a facilitating factor

Just knowing that I was going to get the
resultsget help for myself and just thinking
about the good that it is going to be for me.
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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.
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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

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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 womens experiences

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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

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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.