Elizabeth Gabzdyl Janet L. Engstrom Barbara L. McFarlin
Health Care Workers’ BELIEFS and PRACTICES Around PAP SCREENING FOR ADOLESCENTS Seeking Contraception
Th e United States continues to have one of the highest ad olescent pregnancy rates, with an adolescent birth rate in 2009 of 34.2 births per 1,000 women compared to other developed countries such as Canada and the Netherlands with rates of 14.1 and 5.3 per 1,000 women, respectively (UNdata, 2013). Many adolescents, defined as 10 to 19 years of age (World Health Organization [WHO], n.d.) in the United States do not use contraception at sexual debut. Between 23 percent and 52 percent of adolescents report not using contraception at sexual debut, and the younger the adolescents the less likely they are to use contraception (Coles, Makino, & Stanwood, 2011; Finer & Philbin, 2013; Gibbs, 2013; Martinez, Copen, & Abma, 2011). Annually, approximately 252,000 pregnancies occur in adolescents ages 15 to 17 who didn’t use contraception at their first intercourse (Finer & Philbin, 2013). Many adolescents don’t seek contraception for weeks or even months after becoming sexually active (Finer & Philbin, 2013). Abstract: Adolescents often avoid seeing a health care provider to obtain contraception because they do not want to undergo a pelvic exam and Pap screening for fear of stress, pain or embarrassment. Th e purpose of this quality improvement project was to study health care workers’ attitudes and beliefs about Pap screening and to educate them on the latest evidence-based guidelines, with the hope of ultimately decreasing unnecessary screening. Results showed a modest reduction in the frequency of Pap screening; however, many adolescents continued to undergo unnecessary Pap screening. Th e reluctance of health care workers to change their practice demonstrates the need for better methods of translating evidence-based guidelines into practice. DOI: 10.1111/1751-486X.12203 Keywords: adolescents | birth control | contraception | Pap screening | quality improvement project | unintended pregnancy
Quality Improvement Project Th e purpose of this quality improvement project was to deter mine whether health care workers caring for adolescents follow current evidence-based recommendations for Pap screening before providing contraception, and whether they change their practice after participating in an educational program explaining current guidelines. Attitudes and beliefs about Pap screening before and after the educational program were also studied.
Sample and Setting Twenty-eight health care workers at three federally qualified health care clinics in a large metropolitan health care system in the Midwestern United States participated voluntarily in an educational program explaining current guidelines for Pap screening in adolescents. Participants were physicians, nursemidwives, physician assistants, registered nurses, medical assistants and reception staff. All health care workers were included in the educational intervention because research demonstrates that a multidisciplinary team approach, including not only clinical staff but also offi ce staff and administrative personnel, is more effective than targeting a single type of health care worker (Cabana, Rushton, & Rush, 2002). Including the entire health care team in the intervention helps to assure that all staff members are “on the same page” and provide information that is congruent with current practice guidelines.
Multifaceted Intervention A multifaceted intervention consisting of a 20-minute educational program and the provision of printed materials, including copies of the current guidelines and consensus opinions as well as copies of the PowerPoint slides from the educational presentation, was provided to health care workers in the three clinic settings. A multifaceted intervention was used because multifaceted approaches are more effective in motivating change in clinical practice (Prochaska & Diclemente, 1982; Prochaska, Redding, & Evers, 2008). Th e information presented in the educational intervention had four key points focusing on adolescents: (1) improving access to contraception and decreasing the unintended pregnancies; (2) decreasing unnecessary Pap screening; (3) a brief discussion
BOX 1
BENEFITS OF ELIMINATING PAP SCREENING FOR ADOLESCENTS INITIATING OR CONTINUING CONTRACEPTION Decreasing rate of unintended pregnancy Increase access to contraception Fewer unnecessary Pap screens
Elizabeth Gabzdyl, CNM, DNP, APN, is a clinical assistant professor at the University of Illinois at Chicago in Chicago, IL; Janet L. Engstrom, PhD, APN, CNM, WHNP-BC, is a professor and acting department chair, Department of Women, Children and Family Nursing at Rush University in Chicago, IL; Barbara L. McFarlin, PhD, CNM, RDMS, FACNM, is an associate professor and head of the Department of Women, Children and Family Health Science at the University of Illinois at Chicago in Chicago, IL. Th e authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
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Fewer abnormal Pap screens and resulting interventions, colposcopies and preterm births Decreased health care costs Sources: Gabzdyl (2010), McCracken and Loveless (2014), Moscicki and Cox (2010), Tepper et al. (2010).
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Th ere are many benefits of eliminating Pap screening for adolescents initiating or continuing contraception (see Box 1). Research has demonstrated that removing barriers to obtaining contraception reduces unintended pregnancies by providing easier access to birth control initiation and by leading to increased continuation rates (Gabzdyl, 2010; McCracken & Loveless, 2014; Tepper, Curtis, Steenland, & Marchbanks, 2013). One modifiable barrier to seeking contraception is the requirement for pelvic examination and Pap screening to initiate contraception. Adolescents often avoid seeing a health care provider to obtain contraception because they do not want to undergo a pelvic examination and Pap screening, or because they have heard stories from friends or family that the examination is stressful, painful and embarrassing (Oscarsson, 2011). Occasionally a pelvic exam is necessary in the event of a vaginal problem that needs to be evaluated or prior to insertion of an intrauterine device; therefore, not every pelvic examination can be safely eliminated. Since the early 1990s, many health organizations, such as the WHO, International Planned Parenthood Federation (IPPF), Planned Parenthood Federation of America (PPFA), American College of Obstetricians and Gynecologists (ACOG), Society of Obstetricians and Gynaecologists of Canada (SOGC) and Royal College of Obstetricians and Gynaecologists (RCOG), have recommended eliminating Pap screening as a requirement to initiate or continue contraception for adolescents (Stewart et al., 2001). Since 2009, ACOG, the United States Preventive Services Task Force, American Cancer Society and many other health organizations have recommended that Pap screening not begin until age 21 regardless of whether the adolescent is sexually active, the age she became sexually active or is initiating or continuing contraception (ACOG, 2012; Moyer, 2012; Smith, Brooks, Cokkinides, Saslow, & Brawley, 2013).
Photo © Cristi Nistor / thinkstockphotos.com
about the high rate of HPV clearance or regression in adolescents and (4) basing practice on current guidelines and consensus opinions about Pap screening (ACOG, 2012; Moyer, 2012; Smith et al., 2013). Lunch was provided for all attendees. Copies of all materials were left with the clinic managers for staff who were unable to attend. Pap screening guidelines and a contraceptive decision algorithm were to be posted in examination rooms for staff reference; however, the agency did not permit their display. A computerized list of patients who met the inclusion criteria was generated by the agency’s director of research and was sent electronically as an encrypted file to the principal investigator. During the 2-month period prior to the educational intervention, the health records of nonpregnant, adolescent females ages 15 to 21 who were scheduled for contraceptive appointments (ICD-9 diagnostic codes V25.01, V25.02, V25.03, V25.09, V72.31 and V72.40) were reviewed to obtain the following information: race/ethnicity, age, number of previous Pap screens, reason for first Pap screening, previous Pap screening results, reason for the current visit and whether Pap screening was performed at the current visit. Th ese same data were collected again 6 weeks after the completion of the educational intervention. Records were excluded if women were pregnant, if a visit wasn’t contraception-related or if a woman didn’t meet the inclusion criteria. Th ere were 97 cases that met the criteria for inclusion in this project before the educational intervention and 99 cases after the intervention. Th e attitudes and beliefs of health care workers at the three clinics were measured using a short, investigator-developed survey. One survey was administered immediately before the educational session. Participants were asked to check boxes to indicate their responses and place the surveys in an opaque box
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to preserve anonymity. Th ese were later tallied after all were completed. Th e items on the preintervention survey asked the health care workers to identify their role in the clinic, specify the age when they thought women should have their first
to seeking contraception is the requirement for pelvic examination and Pap screening to initiate contraception Pap screening, indicate whether they believed that adolescents should be required to have Pap screening before initiating contraception, indicate whether they knew if there was a policy in the clinic about whether Pap screening was required before initiating contraception and indicate whether they thought that the current clinic policy was appropriate. A second survey was administered approximately 6 weeks after the educational intervention. Th e items on the postinter vention survey asked the health care workers to identify their role in the clinic; whether the educational intervention changed their practice and if it didn’t, why not; whether they thought that providing contraception to adolescents without requiring a Pap screening and a pelvic examination is a good option and if they weren’t following the current guidelines, whether there was anything that would make them change their practice.
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Health care workers whose practice didn’t change after the educational intervention cited various reasons, including time, cost, concern of increased
Data Analysis Data were analyzed using SPSS version 19.0 (Chicago, IL). Chisquare tests were calculated for categorical data. Fisher’s exact test was computed when there were fewer than five cases per cell. Mann-Whitney U tests were performed for ordinal level data, and t-tests were calculated for continuous, normally distributed data. Th e level of significance was set at .05 for all tests of statistical significance.
Ethical Considerations Th is project was approved by the institutional review boards of the University of Illinois at Chicago and the health care system where the project was implemented. All health care workers who completed the attitude and belief surveys consented to participate in the project. No personal identifying information was collected from either the health records of the adolescents who received care in the clinic or from the health care workers.
Limitations Th is quality improvement project has several limitations. A relatively small number of records were reviewed. Replicating this project with a larger number of records reviewed, while targeting varied settings and payor mixes, populations and regions, would reveal further important trends. Updated Pap screening recommendations were released by ACOG in 2009 and again in 2012. With frequent updates it may be more difficult for health care workers to be aware of current guidelines. Furthermore, Pap screening practices may have improved over time, so further change may have occurred since the project was initiated.
Results Complete data were collected from 196 adolescent health records—97 before the educational intervention and 99 after the intervention. Th e adolescents seen at these clinics and whose records were reviewed were nearly exclusively African American and Latina as summarized in Table 1 (see “Supporting
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Information). Before the educational intervention, 36.1 percent of adolescents were required to have Pap screening for contraceptive visits, compared with 22.2 percent of the adolescents after the educational intervention. Th e decrease in frequency of Pap screening was statistically significant (X2(df = 1) = 4.56, p = .041). Th e health care workers’ attitudes and beliefs about requir ing Pap screening before initiating or continuing contraception for adolescents is summarized in Table 2 (see “Supporting Information”). Before the educational intervention, when health care workers were asked to identify recommended time or age for initial Pap screening, their responses varied widely ranging from at the time of initiation of intercourse to age 21. When the health care workers were surveyed before the educational intervention and asked if they believed it important for adolescents to have Pap screening to initiate contraception, 68.4 percent of the offi ce staff responded yes and 22.2 percent of healthcare providers responded yes. Health care workers whose practice didn’t change after the educational intervention cited various reasons, including time, cost, concern of increased liability, not wanting to do things differently, not agreeing with the guidelines, not believing it would be possible to follow the guidelines and not believing that changing practice would make any difference. When asked what, if anything, would make them change their practice, their answers revealed two types of response: either that nothing would make them change or that they would change if they were given guidelines and told to follow them. Th e earliest age of first Pap screening was young in both the pre- and postimplementation groups (14 and 13, respectively), although surprisingly, the mean at first Pap was 17.7 years preimplementation and 16.8 years postimplementation. Most adolescents had already received at least one Pap screening (see Table 1 in “Supporting Information”) and many had received multiple Pap screenings (as many as five). Of those who had received Pap screenings, a substantial number had abnormal results (32.3 percent preimplementation and 31 percent post-implementation).
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Discussion Th ere is widespread agreement by multiple health organiza tions about when Pap screening should be initiated (ACOG, 2012; Moyer, 2012; Smith et al., 2013). Th e recommended age for initiation of Pap screening has been 21 years since 2009 when ACOG changed its recommendation to age 21 regardless of onset of sexual activity or contraceptive use (ACOG, 2012). As Pap screening technology has been advancing quickly in recent years, so have the guidelines and recommendations for classifying, interpreting and managing the findings, and these will likely continue to evolve (ACOG, 2012). Th is project demonstrated that a multifaceted educational intervention reviewing current Pap screening guidelines with health care workers significantly reduced the number of adolescents who were required to undergo Pap screening to initiate or continue contraception. However, the educational program had only a modest impact, reducing the frequency of Pap screening from 36.1 percent before the intervention to 22.2 percent after the intervention. Th us, a substantial number of adolescents continued to undergo unnecessary Pap screening. Unnecessary Pap screening is a barrier to adolescents seeking contraception and increases the cost of health care (Moscicki & Cox, 2010). Unnecessary screening also increases the risk that an adolescent will have an abnormal Pap that
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requires more extensive evaluation, thereby further increasing the cost of health care and exposure to interventions that may increase the long-term risk of preterm birth in subsequent pregnancies (Moscicki & Cox, 2010). In this project, many of the adolescents had already undergone Pap screening as early as age 13 years, and many had experienced multiple Pap screenings. Several of the adolescents had experienced abnormal Pap screens and received follow-up such as repeat Pap screening and colposcopy. ACOG and the American Society for Colposcopy and Cervical Pathology (ASCCP) recommend following a treatment algorithm for a young woman under the age of 21 who has a diagnosis of cervical intraepithelial neoplasia grade 2,3 (CIN 2,3; ACOG, 2013; Massad et al., 2013). Th ere was a notable reluctance of some health care workers to change their practice or beliefs about Pap screening despite being involved in a multifaceted educational program and being presented with scientific evidence and the current consensus guidelines from multiple health organizations. Moscicki and Cox (2010) identified two important factors may play a role in health care workers use of Pap screening. Th e first is fear of poten tial litigation, which has increasingly driven practice, especially in the United States. Th e second factor is the “fee for service” health care system, which provides a financial incentive to perform reimbursable procedures contrary to the recommendations of current guidelines (Moscicki & Cox, 2010). Additional factors included potential income loss from fewer Pap screens and colposcopies, as well as fear of change (Moscicki & Cox, 2010; see Box 2). Th e reluctance of health care workers to change Pap screen ing practices demonstrates the need for better methods of translating evidence-based Pap screening guidelines to practice, with the goal of all women receiving consistent health care based on the most current evidence, not on other factors such as provider opinion or preference. One final consideration involves the ethical concerns of continuing to require testing and examinations that multiple organizations over a decade ago had stated as unnecessary for initiation of hormonal contraception (Stewart et al., 2001).
Conclusion Th e findings of this project demonstrate that there is much work to be done to optimize access to contraception for adolescents. Achieving compliance with current Pap screening guidelines is an important step in making contraception more
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BOX 2
The reluctance of health care workers to change Pap screening practices demonstrates the need translating evidenceguidelines to practice
BARRIERS TO PRACTICE CHANGE
References
Not aware of new guideline
American College of Obstetricians and Gynecologists (ACOG). (2012). ACOG practice bulletin number 131: Screening for cervical cancer. Obstetrics and Gynecology, 120(5), 1222–1238. doi:10.1097/AOG.0b013e318277c92a
Not familiar with guideline details Disagreement with new guideline Uncertain of ability to follow new guideline Belief that change will not make a difference Diffi culty creating new routine Organizational constraints, such as time, reimbursement Source: Cabana et al. (2002).
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American College of Obstetricians and Gynecologists. (2013). Practice bulletin no. 140: Management of abnormal cervical cancer screening test results and cervical cancer precursors. Obstetrics and Gynecology, 122(6), 1338–1367. Retrieved from doi. org/10.1097/01.AOG.0000438960.31355.9e Cabana, M. D., Rushton, J. L., & Rush, A. J. (2002). Implementing practice guidelines for depression: Applying a new framework to an old problem. General Hospital Psychiatry, 24(1), 35–42. Coles, M. S., Makino, K. K., & Stanwood, N. L. (2011). Contraceptive experiences among adolescents who experience unintended birth. Contraception, 84(6), 578–584. Retrieved from doi. org/10.1016/j.contraception.2011.03.008
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readily available. However, the resistance of health care workers to following evidence-based guidelines may require more draconian measures, such as creating nonnegotiable clinic policies that require adherence to such guidelines (see Box 3). It may also be necessary to change reimbursement structures so that clinicians and health care facilities aren’t reimbursed for unnecessary procedures. Finally, education of adolescents and all women about recommended guidelines is also important so that they know that they have the right to decline screening and still receive contraception. NWH
BOX 3
STEPS TO ACHIEVING COMPLIANCE WITH ADOLESCENT PAP SCREENING GUIDELINES Create nonnegotiable clinic policies that require adherence to guidelines
Supporting Information Additional Supporting Information may be found online at: http://onlinelibrary.wiley.com/doi/10.1111/ 1751-486X.12203/suppinfo
Change reimbursement structures so that unnecessary Pap screens are not reimbursed Educate adolescents that Pap screening is not necessary for contraception
Finer, L. B., & Philbin, J. M. (2013). Sexual initiation, contraceptive use, and pregnancy among young adolescents. Pediatrics, 131(5), 886–891. Retrieved from doi.org/10.1542/peds.2012-3495 Gabzdyl, E. M. (2010). Contraceptive care of adolescents: Overview, tips, strategies, and implications for school nurses. Journal of School Nursing: The Official Publication of the National Association of School Nurses, 26(4), 267–277. Retrieved from doi. org/10.1177/1059840510374459 Gibbs, L. (2013). Gender, relationship type and contraceptive use at first intercourse. Contraception, 87(6), 806–812. Retrieved from doi.org/10.1016/j.contraception.2012.09.030 Martinez, G., Copen, C. E., & Abma, J. C. (2011). Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2006-2010 National Survey of Family Growth. Vital and Health Statistics, Series 23, Data from the National Survey of Family Growth, 31, 1–35.
Prochaska, J. O., Redding, C. A., & Evers, K. (2008). The transtheoretical model & stages of change. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.). Health behavior and health education: Th eory, research, and practice (4th ed.). San Francisco, CA: Jossey-Bass.
Massad, L. S., Einstein, M. H., Huh, W. K., Katki, H. A., Kinney, W. K., Schiffman, M., … Lawson, H. W. (2013). 2012 Updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstetrics & Gynecology, 121(4), 829–846. Retrieved from doi.org/10.1097/ AOG.0b013e3182883a34
Smith, R. A., Brooks, D., Cokkinides, V., Saslow, D., & Brawley, O. W. (2013). Cancer screening in the United States, 2013: A review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening. CA: A Cancer Journal for Clinicians, 63(2), 88–105. Retrieved from doi.org/10.3322/caac.21174
McCracken, K. A., & Loveless, M. (2014). Teen pregnancy: An update. Current Opinion in Obstetrics & Gynecology, 26(5), 355– 359. Retrieved from doi.org/10.1097/GCO.0000000000000102
Stewart, F., Harper, C., Ellertson, C., Grimes, D., Sawaya, G., & Trussell, J. (2001). Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. Journal of the American Medical Association, 285(17), 2232.
Moscicki, A.-B., & Cox, J. T. (2010). Practice improvement in cervical screening and management (PICSM): Symposium on management of cervical abnormalities in adolescents and young women. Journal of Lower Genital Tract Disease, 14(1), 73–80. Moyer, V. A. (2012). Screening for cervical cancer: U.S. preventive services task force recommendation statement. Annals of Internal Medicine, 156(12), 880–891. Retrieved from doi. org/10.7326/0003-4819-156-12-201206190-00424 Oscarsson, M. G. (2011). Psychological adjustment of women in cervical cancer screening. Current Women’s Health Reviews, 7(4), 353–357. Prochaska, J. O., & Diclemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Th eory, Research & Practice , 19(3), 276–288. doi:10.1037/ h0088437
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Tepper, N. K., Curtis, K. M., Steenland, M. W., & Marchbanks, P. A. (2013). Physical examination prior to initiating hormonal contraception: A systematic review. Contraception, 87(5), 650–654. Retrieved from doi.org/10.1016/j.contraception.2012.08.010 UNdata. (2013). Adolescent birth rate, per 1,000 women. Retrieved from data.un.org/Data.aspx?d=MDG&f=seriesRowID%3A761 World Health Organization (WHO). (n.d.). Core competencies in adolescent health and development for primary care providers. Retrieved from www.who.int/maternal_child_adolescent/ documents/core_competencies/en/
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Health Care Workers’ BELIEFS and PRACTICES Around PAP SCREENING FOR ADOLESCENTS Seeking Contraception
Th e United States continues to have one of the highest ad olescent pregnancy rates, with an adolescent birth rate in 2009 of 34.2 births per 1,000 women compared to other developed countries such as Canada and the Netherlands with rates of 14.1 and 5.3 per 1,000 women, respectively (UNdata, 2013). Many adolescents, defined as 10 to 19 years of age (World Health Organization [WHO], n.d.) in the United States do not use contraception at sexual debut. Between 23 percent and 52 percent of adolescents report not using contraception at sexual debut, and the younger the adolescents the less likely they are to use contraception (Coles, Makino, & Stanwood, 2011; Finer & Philbin, 2013; Gibbs, 2013; Martinez, Copen, & Abma, 2011). Annually, approximately 252,000 pregnancies occur in adolescents ages 15 to 17 who didn’t use contraception at their first intercourse (Finer & Philbin, 2013). Many adolescents don’t seek contraception for weeks or even months after becoming sexually active (Finer & Philbin, 2013). Abstract: Adolescents often avoid seeing a health care provider to obtain contraception because they do not want to undergo a pelvic exam and Pap screening for fear of stress, pain or embarrassment. Th e purpose of this quality improvement project was to study health care workers’ attitudes and beliefs about Pap screening and to educate them on the latest evidence-based guidelines, with the hope of ultimately decreasing unnecessary screening. Results showed a modest reduction in the frequency of Pap screening; however, many adolescents continued to undergo unnecessary Pap screening. Th e reluctance of health care workers to change their practice demonstrates the need for better methods of translating evidence-based guidelines into practice. DOI: 10.1111/1751-486X.12203 Keywords: adolescents | birth control | contraception | Pap screening | quality improvement project | unintended pregnancy
Quality Improvement Project Th e purpose of this quality improvement project was to deter mine whether health care workers caring for adolescents follow current evidence-based recommendations for Pap screening before providing contraception, and whether they change their practice after participating in an educational program explaining current guidelines. Attitudes and beliefs about Pap screening before and after the educational program were also studied.
Sample and Setting Twenty-eight health care workers at three federally qualified health care clinics in a large metropolitan health care system in the Midwestern United States participated voluntarily in an educational program explaining current guidelines for Pap screening in adolescents. Participants were physicians, nursemidwives, physician assistants, registered nurses, medical assistants and reception staff. All health care workers were included in the educational intervention because research demonstrates that a multidisciplinary team approach, including not only clinical staff but also offi ce staff and administrative personnel, is more effective than targeting a single type of health care worker (Cabana, Rushton, & Rush, 2002). Including the entire health care team in the intervention helps to assure that all staff members are “on the same page” and provide information that is congruent with current practice guidelines.
Multifaceted Intervention A multifaceted intervention consisting of a 20-minute educational program and the provision of printed materials, including copies of the current guidelines and consensus opinions as well as copies of the PowerPoint slides from the educational presentation, was provided to health care workers in the three clinic settings. A multifaceted intervention was used because multifaceted approaches are more effective in motivating change in clinical practice (Prochaska & Diclemente, 1982; Prochaska, Redding, & Evers, 2008). Th e information presented in the educational intervention had four key points focusing on adolescents: (1) improving access to contraception and decreasing the unintended pregnancies; (2) decreasing unnecessary Pap screening; (3) a brief discussion
BOX 1
BENEFITS OF ELIMINATING PAP SCREENING FOR ADOLESCENTS INITIATING OR CONTINUING CONTRACEPTION Decreasing rate of unintended pregnancy Increase access to contraception Fewer unnecessary Pap screens
Elizabeth Gabzdyl, CNM, DNP, APN, is a clinical assistant professor at the University of Illinois at Chicago in Chicago, IL; Janet L. Engstrom, PhD, APN, CNM, WHNP-BC, is a professor and acting department chair, Department of Women, Children and Family Nursing at Rush University in Chicago, IL; Barbara L. McFarlin, PhD, CNM, RDMS, FACNM, is an associate professor and head of the Department of Women, Children and Family Health Science at the University of Illinois at Chicago in Chicago, IL. Th e authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
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Fewer abnormal Pap screens and resulting interventions, colposcopies and preterm births Decreased health care costs Sources: Gabzdyl (2010), McCracken and Loveless (2014), Moscicki and Cox (2010), Tepper et al. (2010).
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Opening photo © Stacey Newman / thinkstockphotos.com
Th ere are many benefits of eliminating Pap screening for adolescents initiating or continuing contraception (see Box 1). Research has demonstrated that removing barriers to obtaining contraception reduces unintended pregnancies by providing easier access to birth control initiation and by leading to increased continuation rates (Gabzdyl, 2010; McCracken & Loveless, 2014; Tepper, Curtis, Steenland, & Marchbanks, 2013). One modifiable barrier to seeking contraception is the requirement for pelvic examination and Pap screening to initiate contraception. Adolescents often avoid seeing a health care provider to obtain contraception because they do not want to undergo a pelvic examination and Pap screening, or because they have heard stories from friends or family that the examination is stressful, painful and embarrassing (Oscarsson, 2011). Occasionally a pelvic exam is necessary in the event of a vaginal problem that needs to be evaluated or prior to insertion of an intrauterine device; therefore, not every pelvic examination can be safely eliminated. Since the early 1990s, many health organizations, such as the WHO, International Planned Parenthood Federation (IPPF), Planned Parenthood Federation of America (PPFA), American College of Obstetricians and Gynecologists (ACOG), Society of Obstetricians and Gynaecologists of Canada (SOGC) and Royal College of Obstetricians and Gynaecologists (RCOG), have recommended eliminating Pap screening as a requirement to initiate or continue contraception for adolescents (Stewart et al., 2001). Since 2009, ACOG, the United States Preventive Services Task Force, American Cancer Society and many other health organizations have recommended that Pap screening not begin until age 21 regardless of whether the adolescent is sexually active, the age she became sexually active or is initiating or continuing contraception (ACOG, 2012; Moyer, 2012; Smith, Brooks, Cokkinides, Saslow, & Brawley, 2013).
Photo © Cristi Nistor / thinkstockphotos.com
about the high rate of HPV clearance or regression in adolescents and (4) basing practice on current guidelines and consensus opinions about Pap screening (ACOG, 2012; Moyer, 2012; Smith et al., 2013). Lunch was provided for all attendees. Copies of all materials were left with the clinic managers for staff who were unable to attend. Pap screening guidelines and a contraceptive decision algorithm were to be posted in examination rooms for staff reference; however, the agency did not permit their display. A computerized list of patients who met the inclusion criteria was generated by the agency’s director of research and was sent electronically as an encrypted file to the principal investigator. During the 2-month period prior to the educational intervention, the health records of nonpregnant, adolescent females ages 15 to 21 who were scheduled for contraceptive appointments (ICD-9 diagnostic codes V25.01, V25.02, V25.03, V25.09, V72.31 and V72.40) were reviewed to obtain the following information: race/ethnicity, age, number of previous Pap screens, reason for first Pap screening, previous Pap screening results, reason for the current visit and whether Pap screening was performed at the current visit. Th ese same data were collected again 6 weeks after the completion of the educational intervention. Records were excluded if women were pregnant, if a visit wasn’t contraception-related or if a woman didn’t meet the inclusion criteria. Th ere were 97 cases that met the criteria for inclusion in this project before the educational intervention and 99 cases after the intervention. Th e attitudes and beliefs of health care workers at the three clinics were measured using a short, investigator-developed survey. One survey was administered immediately before the educational session. Participants were asked to check boxes to indicate their responses and place the surveys in an opaque box
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July 2015
to preserve anonymity. Th ese were later tallied after all were completed. Th e items on the preintervention survey asked the health care workers to identify their role in the clinic, specify the age when they thought women should have their first
to seeking contraception is the requirement for pelvic examination and Pap screening to initiate contraception Pap screening, indicate whether they believed that adolescents should be required to have Pap screening before initiating contraception, indicate whether they knew if there was a policy in the clinic about whether Pap screening was required before initiating contraception and indicate whether they thought that the current clinic policy was appropriate. A second survey was administered approximately 6 weeks after the educational intervention. Th e items on the postinter vention survey asked the health care workers to identify their role in the clinic; whether the educational intervention changed their practice and if it didn’t, why not; whether they thought that providing contraception to adolescents without requiring a Pap screening and a pelvic examination is a good option and if they weren’t following the current guidelines, whether there was anything that would make them change their practice.
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Health care workers whose practice didn’t change after the educational intervention cited various reasons, including time, cost, concern of increased
Data Analysis Data were analyzed using SPSS version 19.0 (Chicago, IL). Chisquare tests were calculated for categorical data. Fisher’s exact test was computed when there were fewer than five cases per cell. Mann-Whitney U tests were performed for ordinal level data, and t-tests were calculated for continuous, normally distributed data. Th e level of significance was set at .05 for all tests of statistical significance.
Ethical Considerations Th is project was approved by the institutional review boards of the University of Illinois at Chicago and the health care system where the project was implemented. All health care workers who completed the attitude and belief surveys consented to participate in the project. No personal identifying information was collected from either the health records of the adolescents who received care in the clinic or from the health care workers.
Limitations Th is quality improvement project has several limitations. A relatively small number of records were reviewed. Replicating this project with a larger number of records reviewed, while targeting varied settings and payor mixes, populations and regions, would reveal further important trends. Updated Pap screening recommendations were released by ACOG in 2009 and again in 2012. With frequent updates it may be more difficult for health care workers to be aware of current guidelines. Furthermore, Pap screening practices may have improved over time, so further change may have occurred since the project was initiated.
Results Complete data were collected from 196 adolescent health records—97 before the educational intervention and 99 after the intervention. Th e adolescents seen at these clinics and whose records were reviewed were nearly exclusively African American and Latina as summarized in Table 1 (see “Supporting
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Information). Before the educational intervention, 36.1 percent of adolescents were required to have Pap screening for contraceptive visits, compared with 22.2 percent of the adolescents after the educational intervention. Th e decrease in frequency of Pap screening was statistically significant (X2(df = 1) = 4.56, p = .041). Th e health care workers’ attitudes and beliefs about requir ing Pap screening before initiating or continuing contraception for adolescents is summarized in Table 2 (see “Supporting Information”). Before the educational intervention, when health care workers were asked to identify recommended time or age for initial Pap screening, their responses varied widely ranging from at the time of initiation of intercourse to age 21. When the health care workers were surveyed before the educational intervention and asked if they believed it important for adolescents to have Pap screening to initiate contraception, 68.4 percent of the offi ce staff responded yes and 22.2 percent of healthcare providers responded yes. Health care workers whose practice didn’t change after the educational intervention cited various reasons, including time, cost, concern of increased liability, not wanting to do things differently, not agreeing with the guidelines, not believing it would be possible to follow the guidelines and not believing that changing practice would make any difference. When asked what, if anything, would make them change their practice, their answers revealed two types of response: either that nothing would make them change or that they would change if they were given guidelines and told to follow them. Th e earliest age of first Pap screening was young in both the pre- and postimplementation groups (14 and 13, respectively), although surprisingly, the mean at first Pap was 17.7 years preimplementation and 16.8 years postimplementation. Most adolescents had already received at least one Pap screening (see Table 1 in “Supporting Information”) and many had received multiple Pap screenings (as many as five). Of those who had received Pap screenings, a substantial number had abnormal results (32.3 percent preimplementation and 31 percent post-implementation).
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Discussion Th ere is widespread agreement by multiple health organiza tions about when Pap screening should be initiated (ACOG, 2012; Moyer, 2012; Smith et al., 2013). Th e recommended age for initiation of Pap screening has been 21 years since 2009 when ACOG changed its recommendation to age 21 regardless of onset of sexual activity or contraceptive use (ACOG, 2012). As Pap screening technology has been advancing quickly in recent years, so have the guidelines and recommendations for classifying, interpreting and managing the findings, and these will likely continue to evolve (ACOG, 2012). Th is project demonstrated that a multifaceted educational intervention reviewing current Pap screening guidelines with health care workers significantly reduced the number of adolescents who were required to undergo Pap screening to initiate or continue contraception. However, the educational program had only a modest impact, reducing the frequency of Pap screening from 36.1 percent before the intervention to 22.2 percent after the intervention. Th us, a substantial number of adolescents continued to undergo unnecessary Pap screening. Unnecessary Pap screening is a barrier to adolescents seeking contraception and increases the cost of health care (Moscicki & Cox, 2010). Unnecessary screening also increases the risk that an adolescent will have an abnormal Pap that
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requires more extensive evaluation, thereby further increasing the cost of health care and exposure to interventions that may increase the long-term risk of preterm birth in subsequent pregnancies (Moscicki & Cox, 2010). In this project, many of the adolescents had already undergone Pap screening as early as age 13 years, and many had experienced multiple Pap screenings. Several of the adolescents had experienced abnormal Pap screens and received follow-up such as repeat Pap screening and colposcopy. ACOG and the American Society for Colposcopy and Cervical Pathology (ASCCP) recommend following a treatment algorithm for a young woman under the age of 21 who has a diagnosis of cervical intraepithelial neoplasia grade 2,3 (CIN 2,3; ACOG, 2013; Massad et al., 2013). Th ere was a notable reluctance of some health care workers to change their practice or beliefs about Pap screening despite being involved in a multifaceted educational program and being presented with scientific evidence and the current consensus guidelines from multiple health organizations. Moscicki and Cox (2010) identified two important factors may play a role in health care workers use of Pap screening. Th e first is fear of poten tial litigation, which has increasingly driven practice, especially in the United States. Th e second factor is the “fee for service” health care system, which provides a financial incentive to perform reimbursable procedures contrary to the recommendations of current guidelines (Moscicki & Cox, 2010). Additional factors included potential income loss from fewer Pap screens and colposcopies, as well as fear of change (Moscicki & Cox, 2010; see Box 2). Th e reluctance of health care workers to change Pap screen ing practices demonstrates the need for better methods of translating evidence-based Pap screening guidelines to practice, with the goal of all women receiving consistent health care based on the most current evidence, not on other factors such as provider opinion or preference. One final consideration involves the ethical concerns of continuing to require testing and examinations that multiple organizations over a decade ago had stated as unnecessary for initiation of hormonal contraception (Stewart et al., 2001).
Conclusion Th e findings of this project demonstrate that there is much work to be done to optimize access to contraception for adolescents. Achieving compliance with current Pap screening guidelines is an important step in making contraception more
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BOX 2
The reluctance of health care workers to change Pap screening practices demonstrates the need translating evidenceguidelines to practice
BARRIERS TO PRACTICE CHANGE
References
Not aware of new guideline
American College of Obstetricians and Gynecologists (ACOG). (2012). ACOG practice bulletin number 131: Screening for cervical cancer. Obstetrics and Gynecology, 120(5), 1222–1238. doi:10.1097/AOG.0b013e318277c92a
Not familiar with guideline details Disagreement with new guideline Uncertain of ability to follow new guideline Belief that change will not make a difference Diffi culty creating new routine Organizational constraints, such as time, reimbursement Source: Cabana et al. (2002).
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American College of Obstetricians and Gynecologists. (2013). Practice bulletin no. 140: Management of abnormal cervical cancer screening test results and cervical cancer precursors. Obstetrics and Gynecology, 122(6), 1338–1367. Retrieved from doi. org/10.1097/01.AOG.0000438960.31355.9e Cabana, M. D., Rushton, J. L., & Rush, A. J. (2002). Implementing practice guidelines for depression: Applying a new framework to an old problem. General Hospital Psychiatry, 24(1), 35–42. Coles, M. S., Makino, K. K., & Stanwood, N. L. (2011). Contraceptive experiences among adolescents who experience unintended birth. Contraception, 84(6), 578–584. Retrieved from doi. org/10.1016/j.contraception.2011.03.008
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readily available. However, the resistance of health care workers to following evidence-based guidelines may require more draconian measures, such as creating nonnegotiable clinic policies that require adherence to such guidelines (see Box 3). It may also be necessary to change reimbursement structures so that clinicians and health care facilities aren’t reimbursed for unnecessary procedures. Finally, education of adolescents and all women about recommended guidelines is also important so that they know that they have the right to decline screening and still receive contraception. NWH
BOX 3
STEPS TO ACHIEVING COMPLIANCE WITH ADOLESCENT PAP SCREENING GUIDELINES Create nonnegotiable clinic policies that require adherence to guidelines
Supporting Information Additional Supporting Information may be found online at: http://onlinelibrary.wiley.com/doi/10.1111/ 1751-486X.12203/suppinfo
Change reimbursement structures so that unnecessary Pap screens are not reimbursed Educate adolescents that Pap screening is not necessary for contraception
Finer, L. B., & Philbin, J. M. (2013). Sexual initiation, contraceptive use, and pregnancy among young adolescents. Pediatrics, 131(5), 886–891. Retrieved from doi.org/10.1542/peds.2012-3495 Gabzdyl, E. M. (2010). Contraceptive care of adolescents: Overview, tips, strategies, and implications for school nurses. Journal of School Nursing: The Official Publication of the National Association of School Nurses, 26(4), 267–277. Retrieved from doi. org/10.1177/1059840510374459 Gibbs, L. (2013). Gender, relationship type and contraceptive use at first intercourse. Contraception, 87(6), 806–812. Retrieved from doi.org/10.1016/j.contraception.2012.09.030 Martinez, G., Copen, C. E., & Abma, J. C. (2011). Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2006-2010 National Survey of Family Growth. Vital and Health Statistics, Series 23, Data from the National Survey of Family Growth, 31, 1–35.
Prochaska, J. O., Redding, C. A., & Evers, K. (2008). The transtheoretical model & stages of change. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.). Health behavior and health education: Th eory, research, and practice (4th ed.). San Francisco, CA: Jossey-Bass.
Massad, L. S., Einstein, M. H., Huh, W. K., Katki, H. A., Kinney, W. K., Schiffman, M., … Lawson, H. W. (2013). 2012 Updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstetrics & Gynecology, 121(4), 829–846. Retrieved from doi.org/10.1097/ AOG.0b013e3182883a34
Smith, R. A., Brooks, D., Cokkinides, V., Saslow, D., & Brawley, O. W. (2013). Cancer screening in the United States, 2013: A review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening. CA: A Cancer Journal for Clinicians, 63(2), 88–105. Retrieved from doi.org/10.3322/caac.21174
McCracken, K. A., & Loveless, M. (2014). Teen pregnancy: An update. Current Opinion in Obstetrics & Gynecology, 26(5), 355– 359. Retrieved from doi.org/10.1097/GCO.0000000000000102
Stewart, F., Harper, C., Ellertson, C., Grimes, D., Sawaya, G., & Trussell, J. (2001). Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. Journal of the American Medical Association, 285(17), 2232.
Moscicki, A.-B., & Cox, J. T. (2010). Practice improvement in cervical screening and management (PICSM): Symposium on management of cervical abnormalities in adolescents and young women. Journal of Lower Genital Tract Disease, 14(1), 73–80. Moyer, V. A. (2012). Screening for cervical cancer: U.S. preventive services task force recommendation statement. Annals of Internal Medicine, 156(12), 880–891. Retrieved from doi. org/10.7326/0003-4819-156-12-201206190-00424 Oscarsson, M. G. (2011). Psychological adjustment of women in cervical cancer screening. Current Women’s Health Reviews, 7(4), 353–357. Prochaska, J. O., & Diclemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Th eory, Research & Practice , 19(3), 276–288. doi:10.1037/ h0088437
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Tepper, N. K., Curtis, K. M., Steenland, M. W., & Marchbanks, P. A. (2013). Physical examination prior to initiating hormonal contraception: A systematic review. Contraception, 87(5), 650–654. Retrieved from doi.org/10.1016/j.contraception.2012.08.010 UNdata. (2013). Adolescent birth rate, per 1,000 women. Retrieved from data.un.org/Data.aspx?d=MDG&f=seriesRowID%3A761 World Health Organization (WHO). (n.d.). Core competencies in adolescent health and development for primary care providers. Retrieved from www.who.int/maternal_child_adolescent/ documents/core_competencies/en/
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