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Barriers to Cervical Cancer Screening and Follow-up Care among Black Women in Massachusetts Jacqueline Nolan, Tajan Braithwaite Renderos, Jane Hynson, Xue Dai, Wendy Chow, Anita Christie, and Thomas W. Mangione

Correspondence Tajan Braithwaite Renderos, MPH JSI Research & Training Institute, Inc. 44 Farnsworth Street 7th Floor Boston, MA 02210. [email protected]

ABSTRACT

Keywords African American women cervical cancer prevention health services use treatment delay diagnostic delay

Methods: Six focus groups. Data were analyzed using methods based on grounded theory.

Objective: To explore factors that might lead to delays in appropriate cervical cancer screening and diagnosis among Black women in Massachusetts. Design: Qualitative using focus groups. Setting: Hospitals, health centers, and community-based organizations in Boston, Massachusetts. Participants: Sixty-four participants including Black, non-Hispanic women from the general population and cervical cancer survivors, community leaders in women’s health, and health care providers.

Results: Findings from interviews revealed that inadequate information and education of providers and patients create barriers to appropriate screening and treatment practices for Black women. Fear, cultural beliefs, and compounding factors related to poverty, gender roles, and health system barriers create delays to screening and follow-up care. Also, unconscious bias, therapeutic delays, and miscommunication are important factors affecting continuity of care. Conclusion: These results suggest a need for comprehensive, culturally specific cervical cancer prevention education initiatives and interventions for Black women and strategies to improve patient–provider relationships.

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ity rate among Black women is twice that of White women (2.5 per 100,000 vs. 1.4 per 100,000) (Massachusetts Cancer Registry, 2010). These disparities exist despite near universal access to health insurance and nationally recognized high quality health centers in Massachusetts.

The authors report no conflict of interest or relevant financial relationships.

nnual U.S. cervical cancer incidence and mortality rates have declined by more than 75% over the past half-century due to regular cervical cancer screening using Papanicolaou (Pap) smears (Scarinci et al., 2010). Pap smear screening programs are widely implemented in the United States. Based on self-reported data, 82.5% of White women and 85.4% of Black women have had a Pap smear in the past 3 years in the United States (Kaiser Family Foundation, 2010). Despite the apparent success of cervical cancer screening efforts in the United States and Massachusetts, Black women still bear an excessive burden of cervical cancer as evidenced by racial and ethnic disparities in cervical cancer incidence, stage at diagnosis, and survival rates (National Cancer Institute, 2011). In the United States, the current cervical cancer mortality rate for Black women is almost twice that of White women (4.3 per 100,000 vs. 2.2 per 100,000) (National Cancer Institute, 2011). Similar results are observed in Massachusetts where the cervical cancer mortal-

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 C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

A Jacqueline Nolan, MPH, is a senior consultant, JSI Research & Training Institute, Inc., Boston, MA. Tajan Braithwaite Renderos, MPH, is a consultant, JSI Research & Training Institute, Inc., Boston, MA.

(Continued)

Previous researchers demonstrated that Black women experience inadequate access to preventive services or do not use these services for a variety of reasons, including but not limited to transportation issues, availability of insurance, level of income, level of education, fear, and mistrust of the health care system (Freeman & Wingrove, 2005). Inadequate diagnostic and therapeutic care also contribute to racial differences in late-stage cervical cancer diagnoses (Barry & Breen, 2005). Some authors documented failure to receive appropriate follow-up after a Pap test result among Black women, and in some cases this occurred despite most of these women receiving continuous care in the same place (Peterson, Han, & Freund,

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2003). Women diagnosed with early or local (stage 1) cervical cancer have a 92% chance of survival 5 years after diagnosis whereas survival rates decrease to 17% for women with distant (late) cancer diagnoses (American Cancer Society, 2011). For this reason, a better understanding of barriers to cervical cancer treatment can inform initiatives to address therapeutic delays, which is vitally important to providing optimal care and reducing disparities in racial and ethnic cervical cancer morbidity and mortality. Several authors have investigated barriers to cervical cancer screening or HPV vaccination uptake among Black women. However, the context creating barriers to follow-up care after receipt of an abnormal Pap test result is less understood, and the perspectives of Black female cervical cancer survivors as well as health care providers are not well known. The purpose of this qualitative study was to investigate factors that influence cervical cancer screening and health care delays experienced by Black women in Boston, Massachusetts. The Massachusetts Department of Public Health (MDPH) decided to conduct this study to understand why cervical cancer mortality rates from the Massachusetts Cancer Registry were higher among Black women compared to White women. MDPH contracted with JSI Research & Training Institute, Inc. (JSI) to conduct several focus groups to investigate these factors.

Methods Participants A total of six focus groups comprising 64 participants were conducted in June 2012 among Black, non-Hispanic women (hereafter referred to collectively as “Black”), community leaders and health care providers (see Table 1 for participant characteristics). Because late-stage diagnoses and mortality were greatest for women older than age 35, we only recruited women who identified as Black, non-Hispanic, and were older than age 35. One focus group was convened with Black female cervical cancer survivors; another was held with Black women who had never had cervical cancer. Another focus group was held with community leaders. Individuals eligible for the community leader focus group were involved with coordinating cancer support groups or served as health educators in Boston. The remaining three groups were held with health care providers from two Boston community health centers and a large hospital. The community health centers serve a primarily Black patient population. Most providers were

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The norm of not going to the doctor for preventive care was passed down from generation to generation.

physicians, registered nurses, or nurse practitioners (see Table 2 for provider characteristics).

Recruitment JSI posted flyers in six community health centers and advertisements in three local print newspapers and an online classified advertisement website to recruit Black women for the focus groups. Interested participants were screened over the phone according to predetermined eligibility criteria and their availability for the scheduled focus groups. Community leaders were referred by a key informant from JSI’s community network and were contacted and invited to participate. Key contacts at the three participating institutions assisted with recruitment of providers, this included distributing an invitation to participate in the focus groups, conducting follow-up phone calls to determine which providers would attend, and scheduling the groups. The study was determined to be exempt by the Institutional Review Board (IRB) at JSI.

Procedures Participants in the Black women’s focus groups and the community leader group completed a demographic survey after providing informed consent. The demographic survey included variables such as race, ethnicity, age, health insurance status, highest level of education completed, and total household annual income (see Table 1). Community leaders were only asked about their ethnicity and age. The five community leaders included one European, one Haitian, one Caribbean Islander (Jamaican), and one African American as well as one community leader who did not specify her ethnicity. Three of the community leaders were between ages 45 and 64, one was 18 to 34, and one did not specify her age. Four moderator guides with open-ended questions were developed. The guides for the groups with Black women focused on participants’ understanding of Pap smear tests, facilitators and barriers to getting a Pap test, cultural perspectives of the Pap test, screening experiences, and cervical cancer survivors’ experience with treatment and followup. The community leader guide included the same questions but also asked participants to reflect upon the perspectives and experiences of the women that they serve. The provider guide

Jane Hynson, BSPH, is a project associate, JSI Research & Training Institute, Inc., Boston, MA. Xue Dai, BS, is an intern, JSI Research & Training Institute, Inc., Boston, MA. Wendy Chow, MPH, is a data and evaluation specialist, JSI Research & Training Institute, Inc., Boston, MA. Anita Christie, RN, MHA, CPHQ, is the Director of the Office of Clinical Preventative Services, Women’s Health Network, Massachusetts Department of Public Health, Boston, MA. Thomas W. Mangione, PhD, is a senior research scientist, JSI Research & Training Institute, Inc., Boston, MA.

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Table 1: Sociodemographic Characteristics of Participants General population Black,

Black, non-Hispanic

non-Hispanic women (n = 11)

women with cervical cancer (n = 6)

European

0

0

Haitian

0

0

Caribbean Islander (Jamaican)

0

0

Variable Ethnicity

African American

7

4

Cape Verdean

1

0

Not specified/Not obtained

3

2

18–34

0

0

35–44

3

1

45–64

5

3

Older than 65

1

0

Not specified/not obtained

2

2

Age

Total household annual income Less than $10,000

2

0

$10,000–24,999

3

1

$25,000–49,999

3

1

$50,000–74,999

1

1

Not specified/not obtained

2

3

Less than a high school diploma

1

0

High school graduate, no college

4

2

Some college or associate’s degree

2

1

Bachelor’s degree

0

1

Advanced degree

1

0

Not specified/not obtained

3

2

Yes

8

4

No

0

0

Not specified/not obtained

3

2

Highest degree or level of education completed

Has health insurance (yes/no)

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Data Analysis

focused on provider perceptions of the drivers behind the high rate of late-stage cervical cancer diagnosis among Black women in Boston. The focus groups lasted for approximately 1 1/2 hours. Black women and community leaders received a $50 gift card for their participation in the focus groups.

The focus groups were recorded and transcribed verbatim. The data were analyzed using methods based on grounded theory (Strauss & Corbin, 1990) in which systematic comparisons within and between different groups are used to infer significant themes and describe important differences.

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Table 2: Professions of Provider Participants Type of Provider

n

Doctors (including two Chief

18

Medical Officers) Nurses (Registered Nurse,

17

Nurse Practitioner, Clerical Nurse, Nurse Midwife, Certified Nurse Midwife) Administrative (Human

3

Resource Director, Community Benefits Director) Associate Medical School

2

Professor Senior Health Educator

1

Medical Student

1

Total Providers

42

Transcripts from two of the focus groups (Black women and one of the provider groups) were reviewed by four project members, and a set of codes was developed to represent the themes. Then each of the four project members applied the codes to the transcripts of the remaining four focus groups. Differences in codes applied across the four members were reconciled in a group meeting. Responses within categories were compared within and across other groups. The results from the six groups were then synthesized into major themes.

Results Six major themes emerged from conversations with Black women, community leaders, and providers: (a) inadequate education and information for providers and patients create barriers to appropriate screening and treatment practices; (b) emotional barriers and competing priorities prevent health care seeking; (c) culture influences health seeking and health decision making; (d) inadequate or lack of insurance coverage is a barrier to screening and follow-up; (e) challenges in the patient–provider relationship affect screening, treatment, follow-up, and quality of care; (f) and follow-up diagnostic testing after an abnormal Pap test result is a significant challenge. The specific points described below across the six groups within these six thematic areas were sometimes

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common across participant type but sometimes unique to a specific group. In the presentation of results below, we indicate which groups made the specific points.

Inadequate Education and Information for Providers and Patients Create Barriers to Appropriate Screening and Treatment Practices All groups associated insufficient knowledge and misconceptions about cervical cancer and Pap tests with the high incidence of late-stage cervical cancer among Black women. Many Black women (cervical cancer survivors and women who never had cervical cancer are hereafter referred collectively to as “women”) found information about cervical cancer screening, disease onset, risk factors, symptoms, and treatment to be confusing. Many women explained that they do not know where to access accurate information or the right questions to ask providers. Additionally, all groups explained that because some women believe that cervical cancer is associated with sexual activity, older women may not think that they do not need a Pap test if they are not sexually active. A provider noted a patient saying, “No one’s been there why should you [doctor] see up there?” Community leaders emphasized lack of awareness about the high rate of cervical cancer among Black women, and many women noted that basic sexual and reproductive health education is often not provided within their families. Some women think an abnormal Pap test result is not very serious because they never hear strong messages that cervical cancer kills as is the case with breast cancer. Denial is another reason women do not seek follow-up care, because women cannot feel cervical cancer and may not have any symptoms, they may not see a need for follow-up. Providers explained that younger women often do not return for follow-up because they think the abnormal result will eventually go away, especially if they remain with the same partner. Furthermore, all groups shared that many women do not see the importance of regular preventive care and screenings, so they may not see an OB/GYN until they are pregnant. Providers noted that many women come in for check-ups or exams but are confused about what kind of testing occurs during a vaginal exam. Providers shared that many women believe that a Pap test screens for sexually transmitted infections and vice versa. To help women understand what

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Perceptions of negligent care and treatment prompted some cervical cancer survivors to switch providers to seek appropriate health care.

is occurring during a Pap test, some providers use models in the exam room to demonstrate the screening process. Misinformation Causes Confusion Regarding HPV Vaccination . Women without cervical cancer and providers described patients’ confusion between Depo-Provera birth control shots and the human papillomavirus (HPV) vaccine. Providers said that many Haitian parents do not let their children get the vaccine because they believe it is equivalent to giving their children permission to have sex. Providers suggested that girls should be vaccinated by their pediatrician at an earlier age to remove the association with sexual activity. Providers also questioned the effectiveness of the HPV vaccine, reported diagnosing women with cervical cancer who had been vaccinated, and mentioned that the long-term effects of the vaccine are unknown. Frequent Changing of Treatment and Screening Guidelines Creates Confusion. All groups expressed concerns over frequently changing and complex cervical cancer screening and treatment guidelines. Although providers are expected to educate their patients, they are also often confused by or disagree with the current guidelines. Specifically, providers are confused by or disagree about what age screening should begin and its frequency given sexual activity or lack thereof and therefore may not uniformly broach the topic with their patients. One provider noted:

Multiple Roles of Black Women Conflict with Prioritizing Health Care. All groups noted that because many Black women are primary caregivers and financial providers in their families, family obligations are their first priority. Their health is not a top priority, and attending doctors’ appointments “will just have to wait” while they fulfill other commitments.

Culture Influences Health Seeking and Health Decision Making Both groups noted that accurate information that is culturally and linguistically sensitive is not readily accessible. They also described differences between patients and providers in cultural beliefs and social values and how these affect care. Community leaders noted that male partners may not be supportive of cervical cancer screening. Several women without cervical cancer explained that some religions are against immunizations and Pap tests. Community leaders and women noted that some women take virginity and sexuality very seriously and do not want to undergo a vaginal exam or to discuss sex with their doctors.

Fear. One of the reasons some women may not want to know if they have cervical cancer is they are afraid of finding out if they have cancer and because it is commonly believed in certain cultures and communities that cancer automatically leads to death. One provider noted, “The next steps [for treatment] may be unpleasant [and] are really up-

Culture, immigration, and country of origin also affect screening and follow-up practices. Black women from other countries may have experienced more limited screening and health care service routines before immigrating to the United States, which can influence their health-seeking behaviors when they migrate to the United States. One of the health centers reported commonly seeing Jamaican women who have previously had Pap tests. In contrast, only high socioeconomic status Haitian women commonly received health care services before immigrating to the United States. Providers experienced difficulty in documenting screenings for many women with a latestage diagnosis, particularly if they were screened before immigrating to the United States. This varied depending on the patient’s country of origin as one provider had witnessed the most advanced cancers in women from Africa. Participants explained that women from other countries may not adhere to common practices of Western

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Now that we have changed the guidelines, when you get an abnormal Pap test at 21, it is not the same as when you get it at 17 or 18. Providers will need to take abnormal Pap test results more seriously. They should not undertreat cancer under new guidelines. These are guidelines, not laws.

Emotional Barriers and Competing Priorities Prevent Health Care Seeking

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setting to people.” Some patients fear that if they follow up, they may be unable to have children or to have sex. Furthermore, some women may not disclose abnormal test results to their family or reach out to them for support for fear of isolation, lack of understanding, or disruption to their family. Also, many women who have experienced sexual abuse in the past may be uncomfortable or afraid to get Pap tests.

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medicine and “many women’s health issues [are] dealt with at home,” rather than at a hospital or health center. The norm of not going to the doctor for preventive care was passed down from generation to generation: “If it wasn’t hurting, I’m not going to the hospital. From my upbringing, we were taught not to go to the hospital. We had homemade cough syrup and other home remedies.”

Inadequate or Lack of Insurance Coverage is a Barrier to Screening and Follow-Up Women with or without cervical cancer and community leaders noted that the type of medical insurance that Black, non-Hispanic women have affects the quality of health care they can access and receive. A participant remarked, “Even though in Massachusetts everybody has health care insurance, not all policies cover services equally and sometimes you can get substandard treatment.” Legal loopholes and barriers associated with immigration remain and may lead to inadequate or no insurance coverage or to women accessing care at a later stage. Many of these issues are aggravated by lack of education, illiteracy, and language barriers. Although health centers described having other sources of funding that could cover a visit to an obstetrician-gynecologist or provide many health services to uninsured patients, patients are often unaware of this funding and tend to believe that they will not receive care without health insurance.

Challenges in the Patient–Provider Relationship Affect Screening, Treatment, Follow-Up, and Quality of Care Patients’ mistrust of providers and the health care system reflect significant challenges in the patient–provider relationship. One cervical cancer survivor believed that doctors benefited financially from meeting specific quotas on Pap tests whereas others believed that their cervical cancer developed because of provider negligence and described switching providers due to inadequate care. One woman believed that HPV vaccinations were being promoted to intentionally sterilize Black women. Most survivors felt like they had to educate themselves to advocate for appropriate health care indicating that oftentimes doctors do not clearly explain the nature of their medical condition, appropriate treatment options, and side effects/impact of treatment.

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Health care providers’ unconscious bias and racism was described by both groups of women and community leaders. Two cervical cancer survivors felt that their doctors did not want to touch them and one woman stated, “The way they treated me, they were dehumanizing me because I was a woman of color and an ex-addict.” Community leaders agreed that it is difficult for patients to establish long-term, comfortable relationships with providers. Specifically, because many Boston community health centers are affiliated with teaching hospitals, staff turnover, or student doctor rotations are frequent. Women described young doctors who had poor bedside manner, lacked patience, and sometimes missed important information. One cervical cancer survivor stated: They were telling me things were alright when they weren’t. I went to another hospital to get a second opinion and found out my cancer had been there for 12 long years, that they overlooked and kept saying that these were just abnormal Paps and that there was nothing to worry about. Another cervical cancer survivor noted, “I had an abnormal pap smear and they wanted to freeze my cervix, so I left that provider. They told me that they would watch me but I didn’t trust him, he waited until my warts turned into cancer.” Community leaders added that some providers do not assess their patients’ understanding and are unaware of or insensitive to patients’ cultures or languages. Furthermore, although most administrative staff in the clinics are members of racial or ethnic minority groups, providers, decision makers, and/or persons of authority are often not, posing an additional barrier for patients. Providers recognized that the patient–provider relationship is crucial, as providers are the gateway through which patients access tests, screening, and medical knowledge. Providers also stated that health treatment outcomes differ depending on the location of treatment with better outcomes when patients are treated in cancer centers with numerous specialists available. Other differences reported by providers were the level and quality of screening across the state.

Follow-Up Diagnostic Testing after an Abnormal Pap Test is a Significant Challenge Providers consistently reported significant issues with patient follow-up. Some health centers

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reported having extensive systems in place for follow-up and Pap test management protocol, yet they continue to lose patients to follow-up for a variety of reasons. Commonly reported patientlevel reasons for lack of follow-up were patient confusion about the purpose of the appointment, difficulty keeping track of multiple appointments, communication barriers related to the use of cell phones (e.g., limited minutes, difficulty accessing voicemail, disconnected phones, regularly changing numbers), frequent switching of providers, social and economic factors such as lack of access to transportation, financial barriers, competing priorities such as working multiple jobs, and distrust of the health care system. Common health care system-level reasons included limited patient tracking systems in health centers compared to hospitals; some health centers have to refer women to external academic centers for colposcopies that often results in women missing those appointments and being lost to follow-up. One provider explained, “A lot of women are lost to follow-up in health centers who have had an abnormal Pap 5 to 6 years ago but are not getting the colposcopies they were referred for.” Many women cited doctor appointment wait times from 3 to 6 months as a barrier to seeking needed follow-up care, or difficulty reaching health care providers by phone with questions. On the other hand, a few women described very good systems for reminding and notifying patients of abnormal test results in the hospitals and health centers where they receive care. Some health centers are willing to schedule several appointments on the same day and location to accommodate patients’ schedules. Most women without cervical cancer noted that they do get regular Pap tests and receive their test results.

Second, fear poses a significant psychological barrier to women seeking follow-up care after receiving an abnormal Pap test result. This finding is consistent with other previous studies (Andrasik, Rose, Pereira, & Antoni, 2008; AshingGiwa et al., 2010); specifically, participants described fear of dying from cancer and fear of the side effects of follow-up procedures and treatment.

Several important findings were revealed during the focus groups. First, inadequate information

Third, similar to other studies, women noted that traditional cultural beliefs about virginity and sexuality create barriers to women receiving a Pap test or choosing to have their daughters receive the HPV vaccine (Bartlett & Peterson, 2011; Dorell, Yankey, & Strasser, 2011; Rand et al., 2011). This is further compounded by cultural norms around not seeking formal preventive care. Providers noted that Black women migrating from countries with different screening practices than the United States, especially from Africa and Haiti, were often diagnosed with advanced cancers. As in previous studies, this study underscores the need to research and address barriers to subgroups of populations who self-identify as “Black.” It also supports the need for culturally specific interventions

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Discussion We sought to investigate factors that influence cervical cancer screening and health care delays experienced by Black women in Boston, Massachusetts. The study adds to the literature around potential causes of racial and ethnic disparities in late stage cervical cancer diagnoses among Black women in Boston, Massachusetts, despite seemingly high Pap test screening rates among this population and almost universal health insurance coverage available in Boston (Massachusetts Department of Public Health, 2011).

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and education of providers and patients create barriers to appropriate screening and treatment practices for Black women. Most women experienced difficulty in accessing accurate and readily understandable information about the HPV vaccine, cervical cancer causes, screening, treatment, disease onset, risk factors, and symptoms. Consistent with other studies, providers also expressed that frequently changing and complex cervical cancer screening and treatment guidelines can be confusing to them and noted that they sometimes disagree with the guidelines (Centers for Disease Control and Prevention [CDC], 2002; Sherris et al., 2006). Also consistent with other studies, providers observed that patients were confused about what kind of testing is occurring during any kind of vaginal exam, despite their attempts to communicate this information to patients. Many women believe that the Pap test screens for sexually transmitted infections and vice versa (Ackerson, 2010; Ackerson, Pohl, & Low, 2008). This finding supports recommendations from other studies to use patient navigators or telephone counseling with health educators, or services such as the Cancer Information Service to supplement health communication from a physician, allay fears, and encourage follow-up care when needed (Miller et al., 1997; Simon et al., 2010).

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and translation of health information (Joseph et al., 2012; Kobetz et al., 2011). Fourth, women reported unconscious bias, racism, provider negligence/therapeutic delay, and poor bedside manner of their providers as factors leading to low quality care and exacerbating existing mistrust of providers and the health care system. Fifth, several compounding factors related to poverty and gender roles create significant barriers to seeking follow-up care. Consistent with other studies (Cohn & Clark, 2003), some of these factors include extensive care giving and financial family obligations that conflict with prioritizing health care, inadequate insurance coverage, lack of access to transportation, inconsistent and unreliable cell phone access, and lack of continuity of care with the same provider. Sixth, several health system barriers were noted including limited patient tracking systems in health centers, external referrals for followup care that are often not met, long doctor appointment wait times, and inconvenient scheduling of multiple appointments on different days and/or locations. Our results reinforce the need for providers to receive continuing medical education courses that offer the most up-to-date screening and treatment guidelines for cervical cancer. Given our findings related to patient–provider communication challenges, ongoing medical student and provider training around cultural competency is important. These findings suggest that there is a need to employ public health communication strategies including media awareness campaigns and cervical cancer prevention education initiatives in health care and community settings that are culturally and linguistically appropriate. This study reinforces the need for cervical cancer education initiatives to target not just older Black women but young women also. Hospitals and health centers should be more proactive in letting patients know that funds are available to cover the cost of Pap tests or follow-up testing for patients who have inadequate insurance coverage. These findings have several implications for practice. More studies need to be conducted to explore individual circumstances and screening histories of Black women with late-stage cervical cancer diagnoses; this would require more research with identified cancer patients. Also, researchers should explore experiences with cervical cancer screening and treatment of subgroups of Black women to identify factors that inhibit or facilitate

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There is a need for comprehensive, culturally specific, cervical cancer prevention education initiatives and interventions for Black women and improved education for providers.

follow-up after receipt of an abnormal Pap test result. This study represents one of few in which the authors attempted to understand the causes of failure to follow recommended guidelines for preventive screening and late-stage cervical cancer diagnoses among Black women from the perspectives of cervical cancer survivors, community leaders, and health care providers. It also provides insight into the nature of provider–patient communication issues. A limitation is that cervical cancer survivors with stage IV disease were not included. Also, the total number of Black women participants was smaller than desired and did not include Haitian women or those with undocumented immigration status, both of which are significant subgroups with respect to cervical cancer disparities (Arrossi, Sankaranarayanan, & Parkin, 2003; Miller, 2004; Partners in Health, 2010).

Conclusion Our findings suggest that there is a need for comprehensive culturally specific cervical cancer prevention education initiatives and interventions for Black women as well as improved education for providers. Also, there is a need to improve patient– provider relationships, with a focus on developing a medical provider workforce who can provide empathetic, quality services across the racial, ethnic, and class divide. Further research is needed to provide additional insight into barriers to follow-up after receipt of abnormal Pap test results.

Acknowledgement Supported by the Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number: 5U58DP000821 (contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC) and by the Massachusetts Department of Public Health, Women’s Health Network, Care Coordination Program. The authors thank the Massachusetts Cancer Registry, the Massachusetts Comprehensive Cancer Prevention & Control Program, and Rachel Morse.

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Barriers to cervical cancer screening and follow-up care among Black Women in Massachusetts.

To explore factors that might lead to delays in appropriate cervical cancer screening and diagnosis among Black women in Massachusetts...
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