Impact of a new cervical pap smear screening guideline on member perceptions and comfort levels.

BACKGROUND: An evaluation was conducted to assess patient perceptions and comfort levels with a new triennial Pap smear screening guideline. METHODS: A random sample of women ages 20-69 (N = 673) was selected among members of three provider groups within a large health maintenance organization and mailed a survey. Questions pertained to Pap smear history and perceptions of the new guideline. RESULTS: The overall response rate was 63%. Over one-half of respondents had no recollection of being informed about the change in recommendation. Fourteen percent of subjects responded positively to the change, 16% were neutral, 20% were skeptical, and 50% made negative comments. Women significantly more likely to be negative or skeptical about the new guide line were those who reported more frequent prior Pap smears (P < 0.0001), those reporting a history of abnormal Pap smear (P < 0.01), and more educated women (P < 0.05). No statistical differences were found for those reporting a recent abnormal result, or based on provider group, age, or recollection of being informed. CONCLUSIONS: Regardless of patient knowledge and intellectual understanding of screening intervals, this new guideline raises patient concern about preventive care. More must be done to educate women regarding the change in recommended screening frequency and the reasons for it.     

Visual inspection with acetic acid for cervical cancer screening outside of low-resource settings.

OBJECTIVES: To assess visual inspection with acetic acid (VIA) as a screening tool for use in a well-equipped health center in Peru, to evaluate VIA as an alternative or adjunct to the Papanicolaou (Pap) smear, and to determine if VIA can play a role in settings other than low-resource ones. METHODS: This was a prospective study of 1 921 asymptomatic women living in Lima, Peru, carried out in 1999 and 2000. The study was performed at a cancer center equipped with the latest-generation technology and highly trained oncologists. The women underwent a complete clinical evaluation, including a Pap smear and VIA. Participants with any positive test were referred for colposcopy and biopsy. RESULTS: More women tested positive by VIA than on the Pap smear (6.9% vs. 4.2%; P = 0.0001). There were 35 women with histologic cervical intraepithelial neoplasia grade 1 (CIN 1); of these, 15 were detected by Pap and 20 by VIA (P = 0.4). A diagnosis of CIN 2 or 3 (CIN 2-3) was confirmed in a total of 13 cases; Pap detected 5 of the cases and VIA 11 of the cases (P = 0.06). The positive predictive value for detection of CIN 2+ was 8.3% for VIA and 6.3% for Pap (P = 0.5). Most importantly, while only 2.3% of patients with a positive VIA were lost to follow-up before colposcopy, that was true for 26.3% of the women with a positive Pap smear (P < 0.0001). CONCLUSIONS: VIA is useful for detection of precursor lesions of cervical cancer not only in low-resource settings but also in well-equipped health centers and cancer centers. In these non-low-resource settings, VIA has a positive predictive value comparable to the conventional Pap smear, but it is more likely to achieve earlier diagnosis, follow-up, and treatment than cytology-based screening.     

Recruitment methods and differences in early, late and non-respondents in the first MONICA-Catalonia population survey

The early response rate in the first MONICA-Catalonia population survey was 52.7% and the final response rate was 73.8%. The intensity of recruitment effort in this survey led to a considerable increase in response rate (20%), with the extra cost per late respondent being relatively low ($13.9). Added recruitment effort was most effective in the youngest age group, 25-34 years. It was also more effective among women living in urban areas than among those from rural areas. In men, early respondents had a higher proportion of smokers than late respondents, and in women, early respondents had higher systolic and diastolic blood pressure levels and were more aware of their history of high blood pressure than late respondents. Non-respondents were less educated than respondents in both sexes, and this was more marked in women. No differences were found in the proportion of smokers between respondents and non-respondents. Respondents were more aware of their high blood pressure history than non-respondents. The recruitment costs and distribution of non-response components are given.     

The test-retest reliability of the modified Patient Generated Index

OBJECTIVES: The purpose of this study was to determine the test-retest reliability of the recently modified Patient Generated Index (PGI) when used as a self-completed postal questionnaire by older people with arthritis. METHODS: Two sets of postal questionnaires were used, sent two weeks apart, followed by interviews with a theoretically chosen subsample of respondents to both. Reliability for respondents whose health had not changed in the intervening two weeks was assessed using intraclass correlation coefficients. Data from interviews were used to develop theories to select subgroups for analysis. RESULTS: One thousand one hundred and twenty-nine people over 65 years old with arthritis were surveyed and 53 were selected for interview. The response rates to the two surveys were 78% and 83%, respectively. Complete data for the test-retest analysis were available from 236 (29.2%) respondents. The intraclass correlation coefficient (r(i)) was 0.55 [95% confidence interval (CI) 0.43 to 0.64, P < 0.0001]. The most optimistic range for the limits of agreement was 64.66 around the difference between two total PGI scores. The intraclass correlation coefficient decreased considerably if there had been more than six changes to the areas chosen for inclusion on the second occasion (r(i) = 0.37, 95% CI 0.01 to 0.65, P < 0.05). Interview data showed that some respondents incorrectly interpreted the scoring instructions, often inconsistently. When their data were excluded, the intraclass correlation coefficient increased to 0.67 (95% CI 0.56 to 0.76, P < 0.0001). CONCLUSIONS: The results indicate that the modified PGI may be sufficiently reliable for within-group comparison of elderly people with arthritis, but not for assessing individual patients. However, it also elicits individual patient concerns and priorities about disease that other questionnaire-based instruments may not identify.     

Survey of El Paso physicians' breast and cervical cancer screening attitudes and practices

One hundred and ninety-eight primary care physicians in El Paso, Texas, were surveyed for their practices and attitudes concerning breast and cervical cancer screening. The response rate was 83%. For women 40–49 years old, 77% of respondents stated that they ordered a screening mammogram at least every two years. For women 50–74 years old, 73% said they ordered an annual screening mammogram. For women 75 years and older, 61% stated they ordered an annual screening mammogram. For women 40 years or older, 89% of respondents said they performed annual or more frequent clinical breast examinations. Eighty-four percent of respondents stated they ordered a Pap smear every 1–3 years, both for pre- and post-menopausal women. The most common reasons given for not ordering or doing a breast or cervical screening exam were patient refusal, knowledge that other doctor performs exam, high price, inadequate insurance, patient not under regular care, do not see patient for gynecologic care, and patient being seen for different reason. Seventy percent of respondents do vaginal smears on women who have had a total hysterectomy for a benign condition, and 38% use a cytobrush for endocervical sampling. Respondents were generally more comfortable with their ability to do Pap smears (72% comfortable, 1% uncomfortable) than they were in performing clinical breast examinations (52% comfortable, 4% uncomfortable). Obstetricians and gynecologists were more likely than other physicians to do vaginal smears, use a cytobrush, and feel comfortable with their Pap smear technique.This research was funded through grant 5 RO1 CA52977-03 from the National Cancer Institute. The Luces de Salud office at the El Paso City-County Health Department assisted with data collection.     

Non-response and related factors in a nation-wide health survey

Objective: To analyse selective factors associated with an unexpectedly low response rate. Subjects and methods: The baseline questionnaire survey of a large prospective follow-up study on the psychosocial health of the Finnish working-aged randomly chosen population resulted in 21,101 responses (40.0%) in 1998. The non-respondent analysis used demographic and health-related population characteristics from the official statistics and behavioural, physical and mental health-related outcome differences between early and late respondents to predict possible non-response bias. Reasons for non-response, indicated by missing responses of late respondents, and factors affecting the giving of consent were also analysed. Results: The probability of not responding was greater for men, older age groups, those with less education, divorced and widowed respondents, and respondents on disability pension. The physical health-related differences between the respondents and the general population were small and could be explained by differences in definitions. The late respondents smoked and used more psychopharmaceutical drugs than the early ones, suggesting similar features in non-respondents. The sensitive issues had a small effect on the response rate. The consent to use a medical register-based follow-up was obtained from 94.5% of the early and 90.9% of the late respondents (odds ratio: 1.70; 95% confidence interval: 1.49–1.93). Consent was more likely among respondents reporting current smoking, heavy alcohol use, panic disorder or use of tranquillisers. Conclusions: The main reasons for non-response may be the predisposing sociodemographic and behavioural factors, the length and sensitive nature of the questionnaire to some extent, and a suspicion of written consent and a connection being made between the individual and the registers mentioned on the consent form.     

Pap Testing Among Vietnamese Women: Health Care System and Physician Factors

Cervical cancer occurs more frequently among Vietnamese Americans than women of any other race/ethnicity. In addition, previous studies in California have documented low Papanicolaou (Pap) testing rates in Vietnamese communities. This study focused on health care system factors and physician characteristics associated with recent cervical cancer screening among Vietnamese women. A population-based survey was conducted in Seattle during 2002. In-person interviews were conducted by bilingual, bicultural female survey workers. The survey response rate was 82% and 518 women were included in the analysis. Seventy-four percent of the respondents reported having been screened for cervical cancer on at least one occasion, and 64% reported a Pap smear within the previous 2years. Women with a regular doctor were more likely to have been recently screened than those without a regular doctor (OR=2.33, 95% CI=1.45–3.74). Among those with a regular doctor, having a male physician, receiving care at a private doctor's office (rather than a community, hospital, or multi-specialty clinic), and concern about the cost of health care were independently associated with lower screening rates. Physician ethnicity was not associated with recent Pap smear receipt. The findings support targeted interventions for Vietnamese women without a regular physician and private doctors' offices that serve Vietnamese Americans. The availability of low cost screening services should be publicized in Vietnamese communities.     

Estimating non-response bias in a survey on alcohol consumption: comparison of response waves

AIMS: According to 'the continuum of resistance model' late respondents can be used as a proxy for non-respondents in estimating non-response bias. In the present study, the validity of this model was explored and tested in three surveys on alcohol consumption. METHODS: The three studies collected their data by means of mailed questionnaires on alcohol consumption whereby two studies also performed a non-response follow-up. RESULTS: Comparisons of early respondents, late respondents and non-respondents in one study showed some support for 'the continuum of resistance model', although another study could not confirm this result. Comparison of alcohol consumption between three time response groups showed no significant linear pattern of differences between response waves. CONCLUSIONS: The hypothesis that late respondents are more similar to non-respondents than early respondents, could not be confirmed or rejected. Repeated mailings are effective in obtaining a greater sample size, but seem ineffective in improving the representativeness of alcohol consumption surveys.     

An examination of sociocultural factors associated with cervical cancer screening among low-income Latina immigrants of reproductive age

The purpose of this study was threefold: 1) to examine whether low-income Latina immigrants were less likely to receive a Pap smear than low-income non-Latinas; 2) to examine ethnic differences regarding cervical cancer knowledge; and 3) to examine the sociocultural factors associated with cervical cancer screening among low-income Latina immigrants. Participants included 225 low-income women of reproductive age attending a WIC (Women, Infants, and Children) clinic (50% Latina immigrants and 50% non-Latinas). Latina immigrants were less educated, less likely to have health insurance, and more likely to be married or living with a partner than non-Latinas (ps < 0.05). All non-Latinas had a Pap smear in the past compared to 81.3% of Latina immigrants (p < 0.001). Latina immigrants displayed significantly less knowledge regarding cervical cancer than non-Latinas (ps < 0.01). Latina immigrants tended to display culturally based knowledge and beliefs regarding cervical cancer and screening that may influence getting a Pap smear.     

Predicting risk among non-respondents in prospective studies

Potential non-response bias was investigated in a follow-up study of 2,011 chronically disabled patients. 82.5% and 73.3% of the study subjects responded to self-administered mail questionnaires respectively at 6-month and 1-year follow-up. Information on employment status, the outcome of interest, of approximately 90% of the non-respondents was obtained from indirect sources. Employment rate was lower among the non-respondents than the respondents. Non-response was associated with age, social class, previous employment record, and the type of disability; but none of these characteristics were associated with the outcome. Out of the five known independent risk factors for unemployment, only one (incompletion of rehabilitation course) was associated with non-response. The employment rate among the respondents was also assessed according to the delay in response, that is the number of reminders sent to achieve response. The outcome among- the late respondents was similar to that among the nonrespondents. These data suggest that (a) risk estimates may be biased even when the response rate is greater than 80%, (b) the prevalence of risk factors among non-respondents may not indicate the presence or the degree of non-response bias, but (c) reliable estimates can be obtained from extrapolations of the rates among the respondents according to the delay in response.     

Effect on Trend Estimates of the Difference between Survey Respondents and Non-respondents: Results from 27 Populations in the WHO MONICA Project

Introduction: In the World Health Organization (WHO) MONICA (multinational MONItoring of trends and determinants in CArdiovascular disease) Project considerable effort was made to obtain basic data on non-respondents to community based surveys of cardiovascular risk factors. The first purpose of this paper is to examine differences in socio-economic and health profiles among respondents and non-respondents. The second purpose is to investigate the effect of non-response on estimates of trends. Methods:Socio-economic and health profile between respondents and non-respondents in the WHO MONICA Project final survey were compared. The potential effect of non-response on the trend estimates between the initial survey and final survey approximately ten years later was investigated using both MONICA data and hypothetical data. Results: In most of the populations, non-respondents were more likely to be single, less well educated, and had poorer lifestyles and health profiles than respondents. As an example of the consequences, temporal trends in prevalence of daily smokers are shown to be overestimated in most populations if they were based only on data from respondents. Conclusions: The socio-economic and health profiles of respondents and non-respondents differed fairly consistently across 27 populations. Hence, the estimators of population trends based on respondent data are likely to be biased. Declining response rates therefore pose a threat to the accuracy of estimates of risk factor trends in many countries.     

Cervical Cancer Risk as a Predictor of Pap Smear Use in Rural North Carolina

Risk for invasive cervical cancer is reported to be higher in rural areas than urban ones, and cervical cancer-related mortality is higher in rural women due to poorer utilization of preventive services and subsequent presentation at late stages of the disease. This cross-sectional study examined the relationship between prevalence of risk factors for cervical cancer and the degree of compliance with risk-appropriate screening guidelines for cervical cancer. Secondary data were analyzed for 614 women from Robeson County, NC, aged 40 and older, and of mainly rural and low socioeconomic status. High-risk status was determined by the presence of any of the following five risk factors: a history of more than two sexual partners, age at first sexual intercourse under 18 years, history of sexually transmitted disease, history of sexually transmitted disease in sexual partner(s), and smoking. Low-risk status was the absence of all factors. A high-risk participant was considered compliant if she had had at least three Pap smears in the 3 years prior to the interview, while a low-risk participant was considered compliant if she had had at least one Pap smear within the previous 3 years. Overall, 82% of the participants were at high risk for cervical cancer. However, only 41% of all participants were compliant with the risk-appropriate screening guidelines. Low-risk status was significantly associated with compliance with cervical cancer screening guidelines (adjusted OR = 6.7; 95% CI = 3.7 to 11.1, p = .0001). Findings in this study population suggest rural women at high risk for cervical cancer are less likely to be compliant with appropriate Pap smear screening guidelines, indicating the need to target educational programs.     

Effects and sustainability of a cervical screening program in remote Aboriginal Australia

Abstract: We assessed the effects of an organised cervical screening program, using a population–based cervical cytology register, for Aboriginal women in the Fitzroy Valley, a remote part of the Kimberley region of Western Australia. Comparison of age–specific screening rates in the area during 1987–88, 1990–92 and 1993–94 showed that establishing the program in late 1989 was accompanied by dramatic increases in cervical screening rates, ranging from two– to over fourfold, with the largest increases in women aged 50 years and over. Following the departure of the coordinator in early 1993, screening rates decreased to between 76 per cent and 29 per cent of their 1990–92 levels, with the largest decreases occurring in the 40–49 and 60–69 years age groups. Rates were still above 1987–88 levels for most age groups. Of 545 women screened during 1991–92, 65 per cent had undergone a second Pap smear within the follow–up period of two to four years. Among women recommended for a repeat smear in two years, the probability of having a second smear was negatively associated with age (log–rank statistic = 35.58, 4 df, P < 0.0001). Follow–up of smears recommended for repeat in 12 months or earlier was less adequate in 1993–94 (46 per cent) than in 1991–92 (75 per cent). The program was successful in recruiting a large proportion of eligible women within a relatively short time, but coverage, especially of older women, was not sustained after a decline in the functioning of the recall system owing to staffing and organisational changes.     

Awareness of hypertension and dyslipidemia in a semirural population of young adults: the Bogalusa Heart Study

BACKGROUND: To assess the awareness of hypertension and dyslipidemia in a semirural population of young adults. METHODS: A cohort of 5,707 individuals was surveyed by a questionnaire. The awareness analysis was done on 1,454 subjects screened for cardiovascular risk factors 5 years earlier. RESULTS: Among the respondents (n = 3,699, 65%), the prevalence of hypertension among blacks and whites was 11% and 7.3% (P < 0.0001), respectively; dyslipidemia, 4.7% and 5.8% (P = 0.27). Results from the screening showed a prevalence of 11.4% in blacks versus 6.0% in whites (P < 0.0001) for hypertension; 14.2% versus 17.9% (P = 0.12) for dyslipidemia. Males had a higher prevalence of dyslipidemia than females (24% vs. 12%, P = 0.001). Five years later, among those informed of their hypertension, males were more likely to be aware of their hypertension than females [odds ratio (95% confidence interval) = 5.0 (1.4-17.5)]. Increasing age [1.04 (1.0-1.1)], positive parental history of coronary heart disease [2.6 (1.5-4.3)], and higher education level [2.1 (1.2-33.6)] were associated with the awareness of dyslipidemia. Awareness of the condition increased the proportion of subjects receiving treatment for hypertension, but did not change the proportion receiving treatment for dyslipidemia. CONCLUSIONS: These results underscore the need for cardiovascular health education efforts in this population group.     

Third mailings in epidemiological studies: are they really necessary?

INTRODUCTION: Whether or not third mailings are appropriate or worthwhile in postal epidemiological studies has not been thoroughly investigated and requires examination. METHODS: A self-completion postal questionnaire of 2184 individuals was conducted in 2000. The socio-demographic and health characteristics of four groups of individuals (first mailing respondents, second mailing respondents, third mailing respondents and non-respondents) were compared. RESULTS: Some significant differences between the groups were found, however, the inclusion of respondents to the third mailing did not significantly change the overall characteristics of respondents compared to non-respondents. DISCUSSION: When differences do exist between respondents and non-respondents, our results suggest that a third mailing is unlikely to remove many of these differences. The study supports our previous suggestion that the effort and resources expended in carrying out a third mailing may not be justified.     

Non-response bias in a web-based health behaviour survey of New Zealand tertiary students

ObjectiveThere has been little investigation of non-response bias in web-based health surveys. We hypothesised that non-respondents have a higher prevalence of risk behaviours than respondents.MethodIn 2005, random samples of students aged 17–25 years from 12 New Zealand tertiary institutions (n = 7130) were invited to complete a web-based health behaviour survey, with three e-mail reminders. Early respondents (before 2nd reminder) were compared with late respondents (after 2nd reminder). Late respondents served as a proxy for non-respondents.Results2607 students (37%) responded early, 676 (9%) responded late, and 3847 (54%) did not respond. There were differences between early and late respondents in high school binge drinking (38% vs 47%, p = 0.002) and non-compliance with physical activity guidelines (12% vs 18%, p = 0.004). Differences in overweight/obesity (26% vs 31%, p = 0.058), smoking (18% vs 22%, p = 0.091) and non-compliance with dietary guidelines (76% vs 77%, p = 0.651) were non-significant but point estimates were in the expected direction. Estimated bias in prevalence of risk behaviours was an absolute difference of 1–4% and a relative difference of 0–21%.ConclusionRespondents whose participation was hardest to elicit reported more risk behaviour. Assuming non-respondents' behaviour is similar or more extreme than that of late respondents, prevalence will have been substantially underestimated.     

Characteristics of respondents and non-respondents from a case-control study of breast cancer in younger women

BACKGROUND: This study assessed the nature of potential biases by comparing respondents with non-respondents from a case-control study of breast cancer in younger women. METHODS: The case-control study was conducted in three regions in the US: Atlanta GA, Seattle/Puget Sound WA, and central New Jersey. An abbreviated interview or mailed questionnaire was completed by willing non-respondents, most of whom had refused participation in the main study. RESULTS: Respondents and non-respondents appeared similar with respect to age, race, relative weight, smoking, family history of breast cancer, number of births, age at first birth, and several dietary items. Compared to non-respondents, case and control respondents were of shorter stature, and reported less frequent consumption of doughnuts/pastries. Respondent cases, compared with non-respondent cases, were more highly educated and more likely to have consumed alcohol regularly; similar but not statistically significant tendencies were observed for controls. Respondent cases experienced menarche earlier than non-respondents. Respondent controls were more likely to have used oral contraceptives than non-respondents; a similar but not statistically significant tendency was observed in cases. Comparisons of crude and simulated relative risks using available non-respondents' data generally showed a low impact of non-response on relative risks in this study. CONCLUSIONS: Our results suggest that non-response would not greatly affect relative risk estimates in this study, except possibly regarding height. However, we were limited by the numbers of informative non-respondents and the amount of data collected. Collecting similar information in future studies would be useful, especially since varying methods used to encourage participation may lead to differences in respondents' characteristics.     

Pap smear use in California: are we closing the racial/ethnic gap?

BACKGROUND: Minority women continue to be disproportionately affected by cervical cancer. Minority population groups at high risk for cervical cancer may be failing to fully comply with screening recommendations. The use of Pap smears among women in California was evaluated to identify ethnic groups at higher risk for noncompliance with cervical cancer screening. METHODS: Cross-sectional analysis of 2001 California Health Interview Survey data. Logistic regression was used to assess the independent contribution of race/ethnicity to the use of Pap smears. RESULTS: Hispanic (aPR = 1.03, 95% CI 1.02-1.05) and Black (aPR = 1.03, 95% CI 1.001-1.06) women are more likely to report a Pap smear in the past 3 years as compared to White women. Asians were the least likely to report cervical cancer screening despite a more favorable sociodemographic profile. Screening rates varied among Hispanic or Asian subgroups; Mexicans, Vietnamese, Chinese, and South Asians are particularly underserved. CONCLUSIONS: In contrast to the country as a whole, Hispanic women in California are more likely to report a recent Pap smear as compared to White women. However, racial/ethnic disparities in Pap smear use persist; Asian women are the least likely to report cervical cancer screening as compared to any other group.     

Limited Pap screening associated with reduced risk of cervical cancer in South Africa

BACKGROUND: We investigated the effect of Pap smear screening on the incidence of invasive cancer of the cervix in the Western Cape, South Africa where screening is limited. METHODS: Data were derived from a case-control study of the association of hormonal contraceptives and invasive cervical cancer. Incident cases (n = 524) of invasive cervical cancer who presented at two tertiary hospitals and controls (n = 1540) series matched for age, race, and place of residence were interviewed. Information on a wide range of variables was collected including whether the women had previously had a Pap smear taken and the number and timing of smears. Odds ratios (OR) and 95% CI were calculated using multiple logistic regression. RESULTS: The OR of cervical cancer was reduced among women who had ever had a smear (OR = 0.3, 95% CI: 0.3-0.4). The OR declined with increasing number of smears to 0.2 for >/=>3 smears (trend P = 0.0003). Among women who had a smear <5 years previously the OR was 0.3, but even if the smear was taken >/=15 years previously the women remained at reduced risk (OR = 0.5). CONCLUSION: The data suggest that even limited Pap smear screening reduces the risk of cervical cancer. Should a screening programme be successfully implemented, the incidence of cervical cancer might be reduced by as much as 70%.     

Hispanic acculturation and utilization of cervical cancer screening in the US

BACKGROUND: Hispanic women have an incidence rate of invasive cervical cancer that is twice as high as that of non-Hispanic White women. Previous investigations have reported that Hispanics are less likely to utilize cancer screening services. Using data from the 2000 National Health Interview Survey, this study examined whether acculturation of Hispanic women was associated with cervical cancer screening. METHODS: The subjects included 2307 Hispanic women aged 21-70 who did not have a history of cervical cancer or a hysterectomy. Women were analyzed by acculturation level according to whether or not they ever had a Pap smear and had one in the previous year and previous 3 years. RESULTS: Acculturation levels tended to be inversely correlated with no Pap smear. Compared to lower acculturated women, women who were more acculturated were less likely to never had a Pap smear (OR = 0.86; 95% CI = 0.58-1.27 for moderate acculturated women and OR = 0.51; 95% CI = 0.29-0.89 for higher acculturated women). Similar results were found for having no Pap smear within the past 3 years (OR = 0.83; 95% CI = 0.61-1.13 for moderate acculturated women and OR = 0.73; 95% CI = 0.49-1.08 for higher acculturated women). CONCLUSION: The findings show that lower acculturation was associated with the under use of cervical cancer screening and suggest that these women might have barriers in accessing and utilizing Pap smears.