Pap smear screening at an urban Aboriginal health service: report of a practice audit and an evaluation of recruitment strategies

A culturally appropriate women's health service was established at an Aboriginal community-controlled health service in Darwin in 1994. An initial file audit found that 48% of included women had ever been screened with a Pap smear and 37% of women were considered to have been adequately screened. The enhancement of opportunistic screening by file tagging had a modest effect on screening coverage over a 12-month period for women who attended the health service. The proportion of these women who were adequately screened increased from 43% to 48% and of those ever screened increased from 54% to 62%. A randomised trial of recruitment interventions including personal approach, letter and control groups was subsequently performed for women for whom Pap smears were overdue or not recorded. The impact of both interventions on the number of Pap smears performed was low, with 7% of women in the personal approach group, 2% of women in the letter group and no women in the control group having Pap smears during the three-month follow-up period. Low rates of abnormalities were observed for women having Pap smears over a two-year period. The minimal effect of a formal reminder system and letters at this urban Aboriginal health service has resulted in a re-orientation of activities towards strengthening opportunistic screening and the continued promotion of Pap smears in a range of clinic and community settings. It is important to place Pap smear screening in the context of other social, economic and health priorities for Aboriginal women and health workers.     

Evaluation of doctors' reminders in emergency departments to encourage cervical screening

OBJECTIVE: To evaluate opportunistic reminders in emergency departments (EDs) about cervical smears. METHOD: Five EDs in Sydney in 1995-96 participated in a block-randomised control trial, whereby unscreened women at risk for cervical cancer who were seen as nonacute cases were allocated either to brief advice at the end of the ED consultation to return to their GP for a smear (intervention) or usual care (control). Blinded follow-up telephone interviews determined women's compliance four weeks later. RESULTS: 217 women at risk for cervical cancer presented, of whom 53 (23%) were overdue for a Pap smear (22 intervention group; 31 control group). At follow-up, no women in the intervention group had had a smear, although 3 (10%) in the control group had (p = 0.25). CONCLUSIONS: Opportunities in EDs in NSW for opportunistic reminders are infrequent and, even if taken, are unlikely to encourage screening over and above usual care. IMPLICATIONS: General practice remains a more effective location for opportunistic recruitment, although interventions with hospitalised in-patients also show greater promise than reminders in EDs.     

Pap smears in general practice: a secondary analysis of the Australian Morbidity and Treatment Survey 1990 to 1991

Abstract: We investigated the characteristics of Australian general practice that predict performance of Pap smears by secondary analysis of the Australian Morbidity and Treatment Survey 1990 to 1991. Chi–squared analysis identified potential associations between Pap smear rate and patient, doctor and practice variables. Significant associations were examined using logistic regression and generalised estimating equations. Participants were 495 general practitioners who collected information on 113 468 doctor–patient encounters, of which 43 211 encounters involved females aged 18 to 70 years. Pap smear encounters (2449) were identified and classified as patient–requested (62 per cent), diagnostic (5 per cent) or opportunistic (33 per cent). The large difference in the unadjusted Pap smear rates per 100 female encounters for female general practitioners (11.7) and male general practitioners (4.2) required separate analysis by sex of the general practitioner. For male general practitioners, a Pap smear was less likely: as patient age increased; for new patients; for general practitioners with less general practice experience; for general practitioners with no postgraduate qualifications; with metropolitan practice location; and if the practice had more than 25 per cent of patients with English as a second language. For female general practitioners, a Pap smear was less likely: for older known patients; as the age of the general practitioners increased; and for management of fewer problems per 100 encounters. A Pap smear was less likely to be opportunistic: as patient age increased; for general practitioners who were Australian graduates; and for general practitioners with no postgraduate qualifications. Consideration of patient, doctor, and general practice characteristics may facilitate the design of interventions to improve cervical cancer screening.     

Factors associated with Pap smear screening among French women visiting a general practitioner in the Rhône-Alpes region

BackgroundTo help prevent cervical cancer, three yearly opportunistic Pap smear screening is recommended in France for women aged 25–65 years. Pap smear screening coverage varies with age and socioeconomic level. The aim of this cross-sectional study was to identify factors associated with a low uptake of Pap smear screening among women with no limited access to healthcare.MethodsWe analyzed data from women aged 25–65 living in the Rhône-Alpes region who completed a self-administered questionnaire given to them by general practitioners between June and August 2008. The questionnaire covered knowledge about cervical cancer and its prevention as well as the women's history of Pap smear screening and other health-related behaviors. The relationship between low uptake of Pap smear screening – defined as not having had the test within the past 3 years – and a range of possible contributing factors was investigated using logistic regression.ResultsOf 1186 women with an intact uterus who completed the questionnaire, 89.1% said they had had a Pap smear within the past 3 years. On multivariate analysis, the 10.9% who had not were significantly more likely to live alone (1.76 [1.13–2.74]), to have no children (2.17 [1.31–3.62]), to have never used contraception (5.35 [2.98–9.62]), to have less knowledge about Pap smear screening (3.40 [1.55–7.49]), and to be unvaccinated against hepatitis B (0.55 [0.35–0.87]).ConclusionDespite high overall compliance with Pap smear screening recommendations among women who consulted general practitioners, several factors were significantly associated with a low uptake of the service. Considering these factors may help to refine messages aimed at cervical cancer prevention.     

Perceptions of cervical cancer threat, benefits, and barriers of Papanicolaou smear screening programs for women in Iran

OBJECTIVES: The main purpose was to assess associations between HBM variables and participation in cervical cancer screening programs in a sample of Iranian women. METHODS: A total of 333 married women of childbearing age were recruited with cluster sampling. The study was conducted from spring 2002 to spring 2003 and a self-report questionnaire and structured interview were designed to measure the four HBM constructs and Iranian women's knowledge about Pap smear screening. RESULTS: A total of 68.5% reported having undergone at least one Pap test. Women were more likely to participate in Pap smears when they had access to knowledge about cervical cancer and screening programs. Furthermore, the perceived benefit and barrier variables of the Health belief model were two factors related to participation in Pap smear testing. CONCLUSIONS: Health care professionals must provide women with more information about cervical cancer and the benefits of participating in cervical cancer screening programs.     

Factors associated with Pap smear taking in general practice: focusing public health initiatives

Abstract: This study ascertained the relationships of patient, practitioner and consultation factors with: 1. taking a Pap smear or referral to a specialist in the consultation; and 2. an unsuccessful offer to take a Pap smear or making an appointment for a smear. In a cross-sectional study of 3478 women presenting to 230 randomly selected general practitioners in Brisbane and Toowoomba, information about most recent Pap smear, screening in the consultation, and independent variables were collected from patients and doctors. Relationships between three levels of outcome variable (no action, Pap smear taken or referral, appointment or refusal), and independent variables (practitioner variables, consultation variables, patient variables) were modelled using polytomous logistic regression. Presenting for a routine checkup and breast cancer screening were associated with all types of action. Younger age, longer consultations and consultations with a female practitioner were associated with Pap smear taking and referrals, and not appointments or refusals. Being due for a Pap smear, having blood pressure measured, consulting a younger general practitioner and one who ascribed to current guidelines on screening were associated with an appointment or a refusal, when compared with no action. Results identify different profiles of those who get a Pap smear and those who do not, the former indicating a more proactive patient group, while the latter suggest more active general practitioners who attempted opportunistic screening of passive patients, or women who do not specifically seek Pap smears. We have identified factors that have significance for developing public health programs focused on consumers and providers.     

Cancer screening in women: body mass index and adherence to physician recommendations

BACKGROUND: The reasons that obese women are less likely to obtain mammograms and Papanicolaou tests (Pap smears) are poorly understood. This study evaluated associations between body mass index (BMI) and receipt of and adherence to physician recommendations for mammography and Pap smear. METHODS: Data from the 2000 National Health Interview Survey (8289 women aged 40 to 74 years) were analyzed in 2006 using logistic regression. Women with previous hysterectomy were excluded from Pap smear analyses (n=5521). Outcome measures were being up-to-date with screening, receipt of physician recommendations, and women's adherence to physician recommendations for mammography and Pap smear. RESULTS: After adjusting for sociodemographic variables, healthcare access, health behaviors, and comorbidity, severely obese women (BMI > 40 kg/m(2)) were less likely to have had mammography within 2 years (odds ratio [OR]=0.50, 95% confidence interval [CI]=0.37-0.68) and a Pap smear within 3 years (OR=0.43, 95% CI=0.27-0.70). Obese women were as likely as normal-weight women to receive physician recommendations for mammography and Pap smear. Severely obese women were less likely to adhere to physician recommendations for mammography (OR=0.49, 95% CI=0.32-0.76). Women in all obese categories (BMI > 30 kg/m(2)) were less likely to adhere to physician recommendations for Pap smear (ORs ranged from 0.17 to 0.28, p<0.001). CONCLUSIONS: Obese women are less likely to adhere to physician recommendations for breast and cervical cancer screening. Interventions focusing solely on increasing physician recommendations for mammography and Pap smears will probably be insufficient for obese women. Additional strategies are needed to make cancer screening more acceptable for this high-risk group.     

Effectiveness of two direct-mail strategies to encourage women to have cervical (Pap) smears

The aim of this study was to assess the acceptability, utilisazionand differential effectiveness of two direct-mail strategiesfor increasing community Papanicolaou (Pap) smear rates. Thetwo strategies were: a personally addressed letter containingsimple information about Pap smears and a personally addressedletter combined with a series of targeted behavioural promptsdesigned to address a number of aspects of screening which previousresearch had shown to be associated with poor screening rates.The two strategies were assessed in two geo graphically separatedpostal regions in Australia. Each region represented approximately10 women aged 18–70 wars. Outcome data on the change inregional Pap smear rates were obtained from government healthinsurance claims for cervical screening and from pathology servicerecords. Both interventions resulted in statistically significantincreases in attendances for screening over the post-interventionperiod. 42.2% in the region receiving the simple prompt and39.6% in the region receiving the multi-faceted approach Therewas no sigrujicant difference between the two intervention regions.The results indicate that direct-mail strategies can be effectivein prompting attendance for cervical cancer screening. Further,nore, it would appear that a simple informational strategy canbe at least as effective as a more elaborate package. Both interventionsresulted in similar increases in attendances of around 40%.     

Sociodemographic factors of Pap smear screening in Taiwan

Substantial evidence exists that regular screening is effective in preventing cervical cancer. However, the existing services are underused by many women in Taiwan. To examine the effects of sociodemographic characteristics on the underuse of Papanicolaou (Pap) smear screening, from September to December 1993 we conducted a questionnaire interview on a sample of 4,400 women aged 20 years and older in Taipei city using multistage sampling with probability proportional to size. Our results indicate that 40% of the women sampled have never had a Pap smear and 86% have not had one in the past year. Age is the strongest factor affecting Pap smear use, particularly for women below age 30 and over the age of 65. In addition, women with lower levels of education, women who are not employed, never-married women who live outside the city tend to underuse Pap smear screening. These findings help indicate priority groups which should be targeted to increase screening and consequently reduce cervical cancer. Our data also provides a good baseline for comparison of rates of Pap smear screening by various sociodemographic factors in the future.     

Vietnamese women and Pap smears: issues in promotion

OBJECTIVE: Australian data indicate that Vietnamese-born women in Australia have a significantly higher incidence of cervical cancer than other Australian women. This study explored self-reported factors associated with Vietnamese-born women's participation in cervical screening. METHOD: A structured 60-item questionnaire was used to conduct an interview survey with 199 Vietnamese-born women over the age of 18 years and resident in Adelaide. RESULTS: Eighty-seven per cent (87%) of the women had heard of a Pap smear and 75% had had a test at some time. Reported participation increased with age, education level, marriage and length of stay in Australia. The family doctor was the most important source of information about Pap smears and the majority of the women reported they would have a smear if recommended by their doctor. Friends and family were the second information source about cervix screening. CONCLUSIONS AND IMPLICATIONS: These findings have clear implications for practice. Strategies to promote preventive health messages to this group of women should involve general practitioners and peer networks.     

Effectiveness of interventions to improve follow-up after abnormal cervical cancer screening

OBJECTIVE: The purpose of this study was to determine the effectiveness of interventions designed to improve follow-up after an abnormal Pap smear. METHODS: We performed a qualitative meta-analysis of interventions designed to improve follow-up after an abnormal Pap smear and included studies that met the following criteria: randomized or concurrently controlled study design, defined outcomes, and data available for abstraction. Interventions were classified as behavioral, cognitive, sociologic, or combined strategies (e.g., behavioral and cognitive). Abnormal Pap smears were defined as any test result requiring additional follow-up. Effectiveness was measured by the rate of compliance with recommended follow-up. RESULTS: Twenty-two interventions in 10 studies met the inclusion criteria. Cognitive interventions utilizing interactive telephone counseling were the most effective, improving compliance by 24 to 31%. Behavioral interventions, such as patient reminders, were also effective, increasing follow-up by up to 18%. Not all of these results achieved statistical significance. The single sociologic intervention we identified used video-taped peer discussions to provide a message about abnormal Pap smears and appropriate follow-up. This intervention was not associated with increased follow-up after an abnormal test. The effectiveness of interventions using multiple types of strategies to improve follow-up was inconsistent. CONCLUSIONS: Cognitive strategies led to the greatest improvement in compliance with follow-up of abnormal Pap smear screening tests. Extension of similar interventions to follow-up of abnormal breast and colon cancer screening, development of physician- and system-targeted interventions, and evaluation of the cost-effectiveness of these strategies are important priorities for future research.     

Accuracy of Self-Report of Mammography and Pap Smear in a Low-Income Urban Population

Background:Cancer screening history can often be obtained only by self-report, particularly for disadvantaged populations. We examined the accuracy of self-report of mammography and Pap smear for an urban, low-income population.Methods:Women attending non-primary care clinics (mostly surgery and orthopedics) at a large public teaching hospital in Minneapolis between July 1992 and May 1993 were queried about their screening history (n = 477). The women were interviewed by a trained peer-recruiter and asked whether they had ever heard of a Pap smear or mammogram, whether they had ever had one, where it was done, and when the last one was. We verified self-report by checking medical records where the test was performed.Results:The positive and negative predictive value of recall of mammography in the previous year was 72.4% and 90.6%, respectively. The figures for Pap smear recall were somewhat lower, 65.5% and 85.9%, respectively. We found a record of a mammogram in 88% of women able to recall the year. Of these, slightly over two-thirds recalled their mammogram in the same year as their record indicated. Inaccurate recalls were more commonly of the “telescoping” type, i.e., tests were recalled as having occurred more recently than was the case. Recall was substantially better for recent tests. Results for Pap smear recalls were broadly similar.Conclusions:The accuracy of self-report of mammography and Pap smear is relatively poor for medical practice but is acceptable in population surveys with appropriate correction for overreporting.     

Predictors of early rescreening in the National Cervical Screening Program, Australia

OBJECTIVE: To identify variables that predict early rescreening after a negative Pap smear report. METHODS: Cohort study using the records of a statewide Cervical Cytology Registry in Victoria, Australia. The cohort comprised 31,082 women who had a negative Pap smear report during the first half of 1996 and who were rescreened within the subsequent 36 months. Early rescreening was defined as a further Pap smear within 21 months. RESULTS: The strongest predictor of early rescreening was a recommendation at the time of issuing the negative Pap smear report by the laboratory for retesting before two years (adjusted odds ratio = 3.81, 95% confidence interval (CI) 3.58-4.05). Mention of reactive or inflammatory change as part of the negative Pap smear report was also a powerful predictor (adjusted odds ratio = 1.67, 95% CI 1.50-1.85). Significant predictors associated with the women were young age, high socio-economic status and residence in the capital city. Significant predictors associated with the practitioner were if either the index or subsequent smear was collected by an obstetrician/ gynaecologist or a hospital-based clinic, or if the practitioner collecting the index smear was a female. The population-attributable risk per cent associated with the laboratory recommendation was 27%. CONCLUSIONS: This data suggests that a multifaceted strategy targeting pathology laboratories, practitioners and women may be needed to reduce early rescreening. IMPLICATIONS: Early rescreening is wasteful of health resources. New screening programs should be designed to avoid this problem.     

Low knowledge of cervical cancer and cervical pap smears among women in Peru, and their ideas of how this could be improved

Estimates of the percentage of women who have had Pap smears in Peru vary between 7% and 43%. This study explores what women know about cervical cancer and Pap smears, as well as their barriers to obtaining Pap smears. Focus group discussions (FGD) were conducted with a total of 177 women in four Peruvian cities. Discussions reveal that most women did not know what causes cervical cancer. Most women did not know the purpose of Pap smears, although knowledge about Pap smears was higher than knowledge about cervical cancer. Fear, embarrassment, and lack of knowledge were the main barriers identified for not getting Pap smears. Programs and policies aiming to increase Pap smear coverage must start by educating women on cervical cancer and its prevention in order to improve women's perceptions about the screening test and increase Pap smear seeking behaviors in the long term.     

Cervical cancer screening among Chinese immigrants in Seattle, Washington

Introduction: Chinese American women have high rates of invasive cervical cancer, compared to the general population. However, little is known about the Pap testing behavior of ethnic Chinese immigrants.Methods: We conducted a community-based survey of Chinese immigrants living in Seattle, Washington, during 1999. Two indicators of cervical cancer screening participation were examined: at least one previous Pap smear and Pap testing in the last 2 years.Results: The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample for this analysis included 647 women. Nearly one quarter (24%) of the respondents had never had a Pap test, and only 60% had been screened recently. Factors independently associated with cervical cancer screening use included marital status, housing type, and age at immigration.Conclusion: Our findings confirm low levels of cervical cancer screening among Chinese immigrants to North America. Culturally and linguistically appropriate Pap testing intervention programs for less acculturated Chinese women should be developed, implemented, and evaluated.     

Who has Pap smears in New South Wales? Patterns of screening across sociodemographic groups

Abstract: The aim of this study was to determine whether Pap smear screening at adequate intervals is associated with area of residence, frequency of consultations with a general practitioner, socioeconomic status and non-English-speaking background. A representative 10 per cent sample of women from New South Wales and the Australian Capital Territory, aged 25 to 69 years and registered with the Health Insurance Commission (Medicare) (N = 155 281) was used to obtain age, postcode, frequency of Pap smears and frequency of consultations with general practitioners in the three-year period from February 1985 to January 1988. Census data for each postcode area were used as an indicator of other sociodemographic characteristics. Age-specific screening rates did not vary between Sydney, Newcastle/Wollongong, Canberra, and nonmetropolitan areas. In all age groups, having had a smear was most strongly associated with the frequency with which a woman consulted a general practitioner. Women who visited a general practitioner at least four times a year on average were about twice as likely to have had a recent Pap smear as those who averaged less than one visit per year. Screening rates were lowest among women living in areas with the most non-English-speakers and the lowest socioeconomic status. Sociodemographic factors and health service usage patterns influence the proportion of women who are currently being screened. Evaluation of interventions to improve Pap smear screening rates should consider whether the percentage of women screened increases overall, and also whether the imbalances in screening rates between different groups are diminishing.     

Cervical screening in general practice

Abstract: This study examined the effect of three interventions for encouraging women to have a Pap smear in a general practice: tagging the medical record to remind the doctor to offer a Pap smear, sending an invitation to make an appointment for a Pap smear, and sending an invitation with an appointment to attend for a Pap smear at a special screening clinic staffed by women. The study took place in a university general practice at Lockridge, near Perth. A computerised practice age-sex register provided 2139 women in the age range 36 to 69 inclusive. Of these, 757 were eligible for inclusion in the study and were allocated randomly to one of three intervention groups or a control group. In total, 177 women had a Pap smear during the study. Significantly more Pap smears were taken for the appointment-letter and letter-only groups than the control group (odds ratio (OR) 2.13, 95% confidence interval (CI) 1.34 to 3.57, and OR 1.67, CI 1.01 to 2.77 respectively), but there was no significant difference between the tagged-notes and the control groups. Women who attended the screening clinic rated the experience positively. Attendance, however, was inadequate for the clinic's viability in a private practice.     

Cervical Cancer Screening by Immigrant and Minority Women in Canada

Cervical cancer is one of the most preventable forms of cancer and the Pap smear test is one of the most widely accessible forms of cancer screening. An important public health issue is the extent to which Canadian women are engaging in regular screening for cervical cancer, particularly potentially at-risk groups such as recent immigrants and women from minority ethnic backgrounds. We use recent population health surveys to analyze immigrant and native-born women's use of Pap smear testing, with a focus on how screening rates differ by ethnic background and characteristics of immigration. We find that almost all recent immigrant women have markedly lower use of Pap smear testing than comparable Canadian-born women, but these rates slowly increase with years in Canada. However, we find wide variation in rates of screening by ethnic background. Screening rates for White immigrant women from countries where the official language is neither English nor French approach Canadian-born women's utilization rates after 15-20 years in Canada, as do the screening rates of Black and Hispanic women. Screening rates for those from Asian backgrounds remain significantly below native-born Canadian levels even after many years in Canada. As well, immigrant women of Asian background who arrived as children and second-generation Asian Canadians both exhibit significantly lower rates of Pap smear testing than Canadian-born White women.     

Reasons women do not attend screening for cervical cancer: a population-based study in Sweden

BACKGROUND: With an improved compliance with screening a larger reduction of cervical cancer incidence would be within reach. We aimed at investigating why certain women do not attend Pap smear screening and at validating the reliability of self-reported screening. METHODS: In 1998 in the county of Uppsala, Sweden, information was collected through telephone interviews with 430 nonattendees and 514 attendees to Pap smear screening, who were all sampled from a population-based database. The women's recall of attendance was validated against the database. The main outcome measures used were odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Non-attendance was positively associated with nonuse of oral contraceptives (OR = 3.56, 95% CI 2.18-5.83), seeing different gynecologists (OR = 1.90, 95% CI 1.34-2.70), and seeing a physician very often (OR = 3.12, 95% CI 1.45-6.70) or not at all (OR = 1.78, 95% CI 1.09-2.90). Frequent condom use (OR = 1.88, 95% CI 1.02-3.47), living in rural/semirural areas (OR = 1.55, 95% CI 1.07-2.21), and not knowing the recommended screening interval (OR = 2.16, 95% CI 1.20-3.89) were all associated with nonattendance, whereas socioeconomic status was not, when tested in a multivariate model. Among the nonattendees, 57% underestimated the time lapse since last smear. CONCLUSIONS: Seeing a gynecologist on a regular basis and information guiding women to have a Pap smear on their own initiative are important factors for recurrent screening. Therefore, information should be given to all women about the purpose and benefits of Pap smear testing. Self-reports on screening should be treated with caution.     

Beliefs About the Pap Smear Among Mexican Immigrants

Few studies have examined Latinos’ beliefs about the Pap smear or what uses they attribute to the procedure. We conducted qualitative interviews with 28 Mexican immigrant women and 23 Mexican immigrant men recruited through snowball sampling. We found that individuals learned about the Pap smear from a wide variety of sources and often understood the exam to be a screening test for sexually transmitted infections in general. They also related the need for Pap smears and the development of cervical cancer to high risk sexual behaviors. Finally, participants considered men to have a significant role as vectors for disease and as barriers to screening. Our results suggest that interventions to improve cervical cancer prevention among Mexican immigrants may be most effective if they include both men and women and if they recognize and address concerns about STI spread and prevention. Furthermore, interventions must recognize that even when women know how to prevent disease, they may feel disempowered with regard to making behavioral changes that will decrease their risk for STIs or cancer.