Barriers to Follow-Up of an Abnormal Pap Smear in Latina Women Referred for Colposcopy

Abstract

BACKGROUND: Lower rates of follow-up after an abnormal Pap smear in racial and ethnic minorities may contribute to the higher incidence and mortality rates of cervical cancer seen in these groups. OBJECTIVE: To identify patient-perceived barriers to follow-up after an abnormal Pap smear result among Latina women. DESIGN, PARTICIPANTS AND APPROACH: Qualitative, semi-structured, one-on-one interviews were conducted with patients from an academic hospitalaffiliated urban community health center. Three groups of women were interviewed: new colposcopy clinic patients, patients who had previous colposcopies and patients enrolled in the health center's patient navigator program. Open-ended questions explored their knowledge, beliefs and experiences with colposcopy. Content analysis of transcripts was performed using established qualitative techinques. RESULTS: Of 40 Latina women recruited, 75% spoke only Spanish. The average age was 31.5 (range 18-55). Personal and system barriers identified were categorized into four themes: (1) anxiety/fear of procedure and diagnosis; (2) scheduling/availability of appointments interfering with work and/or child care; (3) inadequate communication about appointments, including lack of explanation regarding diagnosis, procedure and results; and (4) pain. New patients more commonly reported problems with scheduling and communication. Followup patients were more concerned about pain, and navigated women most often reported fear of results but had fewer concerns about inadequate communication. CONCLUSION: Anxiety/fear was the most common personal barrier, while difficulty scheduling appointments and inadequate communication were the major systems barriers identified in these Latina women. Interventions to lower these barriers to colposcopy among Latina women may increase adherence to follow-up of abnormal Pap smears.

Patient Barriers to Follow-Up Care for Breast and Cervical Cancer Abnormalities

“…Other studies also report that women experience system issues with regard to follow-up care including inconvenient scheduling times, long clinic waits, and variations in healthcare services/procedures from clinic to clinic. 27,29,31,33,46,54 We did not find that women's characteristics were associated with interpersonal-level barriers, but it is important to note that the types interpersonal barriers slightly differed by ethnicity. African American women most commonly reported communication barriers related to not understanding information given to them by medical personnel.…”

“…13 Studies have also found delay-related psychosocial barriers, including fear of pain associated with follow-up exams or with fear of cancer. 16,[27][28][29] Interpersonal factors associated with delays include inadequate communication or dissatisfaction with providers on test results or procedures. 27,28,30 System factors associated with delays include inconvenient appointment hours and long clinic waits; 29,31 having to seek care at larger hospitals; 32 first diagnostic appointment with radiology rather than a surgical consultancy; 32 and variations in healthcare services/procedures from clinic to clinic.…”

Delays in Cancer Care Among Low-Income Minorities Despite Access

“…Reasons for adherence included abnormality identification, patient activation, provider-initiated actions, and motivation from family or friends. Unlike some qualitative studies, 13,15,21,31 ours purposefully identified only reasons women directly attributed to adherence, thereby highlighting factors most proximal along the pathway to care decisions.…”

“…At the individual level, obstacles to care identified have included low education level, 10 poor health literacy, 11 concerns about test efficacy, 12 and language and cultural beliefs related to cancer, distrust, and fear. [13][14][15] Compounded with these concerns, systems barriers such as difficulty accessing highquality diagnostic services, 16 variability in site of care, 17 poor access to primary care physicians or specialists, 18 and lack of insurance, 19,20 can impact adherence to cancer-related care. Health care reform provisions target financial barriers to access to cancer care but will unlikely attenuate the full range of obstacles to care.…”

“…A small body of qualitative literature has examined breast or cervical cancer care among low-income women of color. Most focus on a single ethnicity, 13,[21][22][23] age group, 24 and time point along the care continuum, such as screening, 21,23 follow-up, 13,25 or survivorship, 15,22,26 and factors directly linked to adherence are overall not consistently delineated.…”