The effectiveness of a community outreach intervention to improve follow-up among underserved women at highest risk for cervical cancer
Introduction
Cervical cancer has been entirely preventable since the advent of the Pap smear in 1939, a development that reduced deaths due to this cancer by 85% (Snyder, 2003). Still, 4000 women, predominantly those of color and/or low socioeconomic status, die from cervical cancer yearly in the US (SEER, 2003, Singh et al., 2003, Lawson et al., 2000, Ries et al., 2000, Taylor et al., 1999, Miller and Hailey, 1996, Ramirez et al., 2000). Lack of access to screening is associated with higher rates of cervical cancer and more advanced disease at diagnosis. Equally critical is receipt of timely follow-up of screening abnormalities (Fowler et al., 1984, Marcus et al., 1992, Engelstad et al., 2001). Randomized trials have demonstrated moderate increases in abnormal follow-up through various interventions (brochures, telephone counseling, transportation incentives, letters, and more intensive multi-strategy approaches) (Marcus et al., 1992, Lauver and Rubin, 1990, Manfredi et al., 1990, Paskett et al., 1990, Lerman et al., 1992, Stewart et al., 1994, Del Mar and Wright, 1995, Paskett et al., 1995, Miller et al., 1997, Marcus et al., 1998). However, up to 64% of low-income women still do not receive the recommended follow-up (Frisch, 1996, Melnikow et al., 1999, Kaplan et al., 2000).
In an early study, we found that 30% of women with abnormal Pap tests on emergency department screening, kept no follow-up visits despite nurse-delivered telephone counseling (Hogness et al., 1992). A subsequent randomized controlled trial achieved significant improvement in follow-up through a multi-component intervention (case-management by phone, computerized tracking, and universal colposcopy) compared with usual care, although 35% of women received no follow-up within 6 months of their abnormal Pap smear and 50% never resolved their abnormality (Engelstad et al., 2001). While more intensive than usual care, this intervention focused inside the clinic and was generic in that all women in the intervention arm were offered the same services. We concluded that a more individualized approach, reaching out to high-risk women at home, was needed to achieve the greatest impact on follow-up. Drawing on recent successes in individual tailoring (Skinner et al., 1999, Abrams et al., 1999, Pasick, 2001), the current study sought to identify characteristics associated with incomplete follow-up, and to develop an outreach counseling protocol tailored to each woman's specific characteristics. A randomized, controlled trial was designed to evaluate the effectiveness of this approach.
To inform the intervention, a conceptual framework was developed that elaborates the factors likely to influence follow-up of Pap smear abnormalities in this population (Fig. 1). The major themes that emerged from our formative research were associated with constructs from the Health Belief Model (perceived risk/benefit, perceived barriers, and cues to action) (Strecher and Rosenstock, 1997), and Social Cognitive Theory (particularly behavioral capability-skill building, self-efficacy, and emotional coping responses) (Bandura, 1986). Details of the formative research and the conceptual framework will be presented elsewhere. Our intervention was also based on data from our prior studies to increase rates cancer screening in underserved communities (Hiatt et al., 2001, Hiatt et al., 1996) where we observed a particular responsiveness by women to credible members of their own community (e.g., other women like themselves), and when approached in a very personal manner. The community health outreach worker (in this study, Community Health Advisor—CHA), a common linkage strategy designed to connect individuals in low-income communities with health care systems, has been used successfully worldwide and across numerous health objectives (Bird et al., 1996, Altpeter et al., 1999, Earp et al., 1997, Earp and Flax, 1999, Love et al., 1997). We designed a tailored CHA outreach intervention to locate women with an abnormal Pap test and facilitate follow-up. To our knowledge, this is the first controlled trial to evaluate outreach to increase abnormal Pap smear follow-up.
Section snippets
Setting
The study was conducted at Alameda County Medical Center's (ACMC's) Highland Hospital (HGH), an acute-care county hospital in Oakland, California. HGH provides comprehensive medical services to the ethnically diverse, low-income population of Northern Alameda County. Cervical cancer leads cancer incidence and mortality in this population. Women served in the HGH ambulatory and emergency departments are at increased risk of cervical cancer due to (a) the preponderance of HPV risk factors, (b)
Results
As shown in Fig. 2, 348 eligible women were randomized to intervention (n = 178) or control (n = 170). Women in the two study arms did not differ significantly with respect to race/ethnicity, language, age, obstetric status, insurance status, initial Pap result, or reason for initial Pap, as shown in Table 1.
Women in the intervention group were much more likely to obtain timely follow-up at Highland Hospital than were those in the control group (61% vs. 32%, P = 0.001; Table 2).
Among
Discussion
Our results demonstrate that, for high-risk women screened in a public hospital, a tailored counseling intervention delivered by trained community health outreach workers can effectively increase both the rate and timeliness of follow-up. Women in the intervention group were twice as likely to have a follow-up visit within 6 months of the abnormal result compared with the control group. The cost-effectiveness of this intervention has also been demonstrated (Wagner et al., submitted for
Conclusions
We conclude that computerized tracking and outreach with tailored counseling constitute a highly effective strategy for increasing the proportion of high-risk women with abnormal Pap smears who have timely follow-up in a public hospital clinic. This intervention is equally effective among patients who have had no follow-up within 6 months of their abnormal result. Institutions that provide cervical cancer screening to low-income women should strongly consider the use of community health
Acknowledgments
This research was supported by the National Cancer Institute, Grants #5PO1 CA 55112-05A1 awarded to the Northern California Cancer Center.
The Author's wish to acknowledge the following individuals for their contributions: Mirna Alvarado, Linda Carter, Tasha Thibodeaux, our Community Health Advisors, for their outstanding and tireless efforts to assist women enrolled in this study, Sarah Shema, M.S. for the design and development of the study database and quality assurance of the study data, and
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