Journal of Community Health Vol. 17, No. 3, June 1992
IMPROVING FUTURE PREVENTIVE CARE T H R O U G H E D U C A T I O N A L EFFORTS AT A WOMEN'S COMMUNITY SCREENING PROGRAM Patricia Carney, RN, MS; Allen J. Dietrich, MD; and Daniel H. Freeman, Jr., PhD
ABSTRACT: Cervical cancer mortality continues to be a significant problem in the United States. Pap Test screening programs have been effective in attracting high risk women, but the impact of these programs on subsequent health care has seldom been explored. This follow up study examined the impact of a cervical cancer screening and education program on preventive health behaviors of New Hampshire women in the 24 months following the screening program. A mailed survey was sent to a random sample of 750 women from program participants to evaluate both their recent preventive health care practices and to identify perceived barriers to obtaining preventive health services. O f these, 71.1 percent responded. Survey responses of the original program participants were linked to each subject's previous answers to the same questions asked 24 months earlier. A comparison group was derived by asking follow up study participants to identify a female acquaintance within five years of her age. Seventy-four percent of the comparison group responded. Survey responses of original program participants were then compared to those of the comparison group. Results indicate that women who participated in the original Project received significantly more preventive health care services in the two years since the Project than in the two years prior to it. Women in the comparison group received more Paps and clinical breast examinations than women in the participant group, perhaps because all participants had received a Pap test two years before. Having a regular health care provider was the most significant characteristic associated with obtaining indicated preventive services. An important contribution of community screening programs may be to encourage women to establish a regular source of care.
Patricia Carney is a predoctoral candidate, School of Nursing University of Washington in Seattle, Washington; Allen Dietrich is an associate professor, department of community and family medicine at Dartmouth Medical School, and Daniel Freeman is a professor, department of community and family medicine at Dartmouth Medical School in Hanover, New Hampshire. This research was supported by Grant # 250-81 of the Hitchcock Foundation, a component of Dartmouth-Hitchcock Medical Center. Requests for reprints should be addressed to: Patricia Carney, RN, MS, Dept. of Community Health Care Systems, University of Washington SM-24, Seattle, WA 98195. © 1992 Human Sciences Press, Inc.
167
168
JOURNAL OF COMMUNITY HEALTH
INTRODUCTION
Many Americans obtain less than the r e c o m m e n d e d level of services for the prevention and early detection of cancer, atherosclerosis and other diseases, x'' Obtaining these services on a regular basis could significantly reduce morbidity and mortality. For example, regular utilization of reliable Pap test screening in all w o m e n over age 18 should eliminate invasive cervical cancer? Community-based cervical cancer early detection programs have met with substantial clinical success, 4-9but the long term impact on patients' subsequent health care seeking behavior in response to the programs has seldom been explored. This follow up study assesses the impact of one such community p r o g r a m on preventive care subsequently obtained by women. Cervical cancer mortality rates in New H a m p s h i r e have been shown to exceed national averages by over 20 percent. ~°'z~ To address this problem, the New H a m p s h i r e Bureau of Health Promotion f u n d e d in 1986 a one year community women's cancer screening and education program. T h e New Hampshire Cervical Cancer Screening and Education Program (NHCCSEP) was designed to provide clinical services to women at high risk, especially those of low income status, who had not had a Pap test in over three years, or who had no regular source of ongoing health care. T h e Program is described in greater detail elsewhere, l' Clinical services were provided by established community health care agencies. Over 1800 women at high risk of cervical cancer were attracted to the p r o g r a m by its recruitment and marketing efforts. Clinical services included: blood pressure measurement, Pap test with pelvic exam, clinical breast exams, and a 15 minute educational session on the importance of obtaining subsequent regular cancer screening services. T h e original p r o g r a m was successful in recruiting participants at high risk for cervical cancer with over 90 percent of participants having one or m o r e target characteristics such as low income, less than a high school education, and multiple sexual partners. One third of the women seen stated they did not have a regular health care provider, and another 25 percent said they had a regular provider but had not seen him or her for over three years. Forty-six percent had not had a Pap test in three years or m o r e and an additional 5 percent of participants over age 21 had never had a Pap test. Twenty-eight w o m e n with abnormal Pap tests (cervical intraepithelial neoplasia grade 1 or higher) were identified in the original program; three of these proved to have gynecological cancers. More than 60 breast abnormalities were r e f e r r e d for further evaluation with the diagnosis of at least one cancer. Twenty-four
P. Carney, A. J. Dietrich, and D. H. Freeman, Jr.
169
w o m e n with blood pressures h i g h e r than 14°//90were identified a n d ref e r r e d for follow up. T h e educational sessions were p e r f o r m e d in small g r o u p s a n d were highly interactive. T h e y were t a u g h t by health educators who provided participants with: specific r e c o m m e n d a t i o n s r e g a r d i n g w h e n to obtain their next a n d f u t u r e Pap tests, breast exams, a n d o t h e r screening services based on NCI working Guidelines, ~ techniques o f breast self-examination, a n d a discussion o f the i m p o r t a n c e o f establishing care with a regular p r o v i d e r for receiving f u t u r e preventive services. A pretest/post-test was used to evaluate k n o w l e d g e retention. T h e post-tests showed that w o m e n knew the r e c o m m e n d a t i o n s a n d rationale for the screening tests, but perceived major barriers to obtaining them, such as cost a n d access to care. T h e long t e r m impact o f the original p r o g r a m on patients' future preventive health care seeking behavior is potentially even m o r e i m p o r t a n t t h a n the identification o f the four cancers. Exploring preventive health behaviors a n d identifying barriers to care w o m e n experie n c e d in the two years following the original p r o g r a m are the focus of this paper. METHODS A mailed survey was employed to evaluate the 24 month impact of the original program on subsequent preventive health care practices as well as the barriers Participant and Comparison groups experienced. The follow up study received Human Subject approval from the institutional review board, and permission to use the original program's data was obtained from the appropriate agencies. The follow up study period began in September of 1989 and ended in August of 1990. Study Sample Seven hundred and fifty women over age 21 who participated in the original program (representing about 50 percent of the original number) were randomly selected, making up the "Participant" group. This selection method yielded an equal distribution of women who had favorable (having had a Pap within the previous three years) and unfavorable health care seeking behavior (having no previous Pap or not having one within the three previous years) prior to their participation in the NHCCSEP. Each participant was then asked to identify the name, address, and telephone number of a female acquaintance within five years of her age. This group of women then served as the Comparison group.
170
JOURNALOF COMMUNITYHEALTH
Instruments Two survey instruments were developed and pilot tested on women in the region with similar characteristics to those in the survey samples. One questionnaire was designed for Participants, the other was designed for Comparison individuals. Both were fully compatible with the original survey (including identical wording of questions asked) so that making comparisons with data from the original program would be possible. The key difference between the two instruments involved obtaining demographic information from women in the Comparison group, which had previously been collected from women in the Participant group. Survey methods included an initial mailing with a personal letter from the Project Director with use of the original program's logo. If no response occurred as a result of the first mailing, a second mailing was performed two weeks later. Those who had moved and whose forwarding address had expired were considered lost to follow up. Telephone follow up was used as necessary to both non-respondents and those who return questionnaires with missing data and/or incomplete information. The follow-up survey evaluated health care practices regarding Pap tests and other preventive services during the 24 months after participants were seen in the original program. Questions in the follow up survey addressed whether the following additional preventive services had also been obtained: mammography, Pap test, and clinical breast exam as well as regular breast selfexam behavior. Barriers experienced by both the Participant and Comparison groups in obtaining these preventive services were also assessed as well as presence of a regular health care provider. Responses were then linked to each participant's post-test response to the same questions 24 months earlier during the original program and were then compared to the Comparison group's responses to the same questions.
Data Analysis The patient was the unit of analysis. The key comparison involved how the health care seeking behavior of participants changed from the two years before to the two years after the earlier project, especially with respect to obtaining Pap tests, breast self-exam and establishment of a relationship with a regular health care provider. Statistical comparisons were made using Fisher's Exact Test (two tailed) for data in two by two factor tables and the Pearson Chisquare was used for multiple group comparisons. All computations were accomplished using SAS STAT Version 6.
RESULTS Response to Follow up Survey O f those in the participant sample, c o m p l e t e data w e r e o b t a i n e d on 71.1 p e r c e n t ( n = 4 7 1 ) . Almost 28 p e r c e n t could not be r e a c h e d , a n d
P. Carney, A. J. Dietrich, a n d D. H. Freeman, Jr.
171
TABLE 1 Demographic Characteristics of Study Sample
Characteristic
Participant
Comparison
Mean Age Education completed high school completed college Marital Status married separated or divorced widowed Race/Cultural Background Caucasian, not Spanish-speaking Household Size* -< 2 Income** > $12,000
50.6 years
48.1 years
37.4% 44.8%
38.2% 47.9%
64.2% 15.2% 10.1%
65.4% 17.7% 11.8%
96.2%
96.2%
54.6%
43%
76.2%
82.4%
*p = .004,**p = .08
1 percent refused to participate in this follow up study. Seventy-one percent of Participants from the original program provided us with names (n = 335) which constituted the Comparison group. Of these, 74 percent responded with complete information (n = 247). Almost 22 percent of the women could not be reached, and 4 percent refused to participate.
Demographics of Study Sample Table 1 outlines the demographic characteristics of the two groups. As indicated here the groups were similar in terms of marital and educational status, ethnic background and income. The Participant Group and the Comparison Group differed significantly only in household size. As previously noted, over 90 percent of the original program participants fit at least one of our target characteristics identifying high risk status. For that reason, we considered all Participants to be appropriate candidates for another Pap test within one or two years. Table 2 illustrates the health behaviors of Participants during the two years before and after the program.
172
JOURNAL
HEALTH
OF COMMUNITY
TABLE 2
Health Behaviors of Participants Before and After the Program*
Behavior
Before
After
Pap Test** Regular Self-Breast Exam** Regular Health Care Provider**
40.2% 52.0% 63.5%
60.3% 61.9% 77.8%
*Note: ALL participants received a Pap test and clinical breast exam as part of the Program 24-28 months prior to the second survey. Before refers to the 24 months prior to the NHCCSP, After refers to the 24 months subsequent to the NHCCSP **p ~ 0.001
TABLE 3
health Behaviors of Participants versus Comparisons Within Last 2 Years t
Behavior Pap Test** Breast Self-Exam Clinical Breast Exam* Mammography age 50 and over (within last year) Regular Health Care Provider**
Participant
Comparison
60.3% 61.9% 71.5%
75.6% 63.5% 84.5%
48.5% 77.8%
54.6% 88.2%
*p < .01, **p -< .001 tAll participants had received a Pap test and a clinical breast examination between twenty-four and twenty-eight months prior to this. T h e services received by Comparisons prior to the past twenty-four months is unknown.
Table 3 outlines the health behaviors exhibited (by self report) during the most recent twenty four months in Participant versus Comparison groups. It is important to remember that all Participants received a Pap test and clinical breast exam at the time of the initial Program. Table 4 compares the barriers experienced in the Participant and Comparison groups. Here financial expense was considered by both groups to be the most important barrier, especially by women in the Participant group.
P. Carney, A . J . Dietrich, a n d D. H. Freeman, Jr.
173
TABLE 4
Comparison of Barriers to Obtaining Preventive Procedures
Participant Financial expense No time Prefer not to go to my regular MD for this Didn't know I n e e d e d one Other*
47.6% 10.4% 7.3% 9.2% 22%
Comparison 24.6% 15.7% 3.5% 12.3% 36.8%
*Responses in the "other" category from both groups included: hysterectomy, physician either moved away or retired, insurance doesn't cover the test, and apathy.
DISCUSSION
This investigation offers insights into whether community programs like the one described can alter participants' long term preventive health care seeking behaviors. Behavior of Participants improved substantially, although they still perceived formidable barriers to care. Results indicate that the rate at which women who attended the original Program obtained subsequent Pap tests increased in the two years since the program when compared to the rate of obtaining Paps prior to their participation. Participants had all been provided with Pap tests and clinical breast examinations through the program. Not surprisingly, the rate at which participants obtained the subsequent Paps was significantly lower than the rate for Comparisons who had not necessarily received a Pap test twenty four months earlier. It is interesting to note that multivariate analysis revealed that more important than participation in the NHCCSEP Program was having a regular health care provider. This was also true for obtaining clinical breast exams. A limitation of this investigation involved the method of obtaining the Comparison group. W o m e n in the Participant group were more likely to provide the name of a woman who had larger households and who were more likely to have a regular health care provider. Members of both the Participant group and the Comparison group found expense to be the greatest barrier to obtaining Pap tests and breast exams. This was especially true for the Participant group. T h e s e procedures are not covered by many insurance plans. Until a mechanism is in place for the provision of these services or they are
174
JOURNAL OF COMMUNITY HEALTH
covered by private insurance and Medicare/Medicaid, this barrier will continue to be a significant stumbling block, particularly for those living in low income households. In summary, this follow up investigation indicated that while participating in a community screening program was associated with obtaining more future preventive care, having a regular health care provider was perhaps the crucial element in altering these women's behavior. In addition to education, assistance in establishing a regular source of health care should be offered at community screening programs. Perhaps once established in a primary care setting, recommended preventive procedures will be obtained.
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Mandelblatt J, Gopaul I, Wistreich M. Gynecological care of elderly women. JAMA 256:376379, 1986. Windsor RA, Kronenfeld JJ, Cain MG, Cutter GR, et. al. Increasing utilization of a rural cervical cancer detection program. Am J Public Health 71:641-643, 1981. Kleinman JC, Kopstein A. Who is being screened for cervical cancer? Am J Public Health 71:73-76, 1981. Boyes DA. The value of a pap smear program and suggestions for its implementation. Cancer 48:613-621, 1981. Stenkvist B, Bergstrom R, Eklund G, Fox CH. Papanicolaou smear screening and cervical cancer; what can you expect?JAMA 252:1423-1426, 1984. Centers for Disease Control: Screening for cervical and breast cancer in Southeastern Kentucky. MMWR 36:845-849, 1988. van der Graaf Y, Vooijs GP, Ziehuis GA. Cervical screening revisited. Acta Cytol 34:366-372, 1990. Michielutte R, Digan MB, Wells HB, Young LD, Jackson DS, Sharp PC. Development of a community cancer education program: the Forsyth County, NC cervical cancer prevention project. Public Health Rep 104:542-51, 1989. Lane DS. Compliance with referrals from a cancer-screening project. J Fam Pratt 17:811-817, 1983. Schwartz E, Dennis DT, Cournoyer JJ, Grady KM. Cancer mortality in New Hampshire 1950-1979. New Hampshire Div. PHS, Nov. 1984. Colby JP, Schwartz E, Dennis DT, Grady KM. Excess cervical cancer mortality, New Hampshire 1974-1983. New Hampshire Div. PHS. Nov. 1985. Dietrich, AJ, Carney-Gersten, P, Holmes, DW, Reed, S, Clauson, B, Zayso, K. Community Screening for Cervical Cancer in New Hampshire J Fam Pract 29:319-323, 1989. National Cancer Institute. Working Guidelines for early detection of cancer: rationale and supporting evidence to decrease mortality. Bethesda, MD, 1987.
IMPROVING FUTURE PREVENTIVE CARE T H R O U G H E D U C A T I O N A L EFFORTS AT A WOMEN'S COMMUNITY SCREENING PROGRAM Patricia Carney, RN, MS; Allen J. Dietrich, MD; and Daniel H. Freeman, Jr., PhD
ABSTRACT: Cervical cancer mortality continues to be a significant problem in the United States. Pap Test screening programs have been effective in attracting high risk women, but the impact of these programs on subsequent health care has seldom been explored. This follow up study examined the impact of a cervical cancer screening and education program on preventive health behaviors of New Hampshire women in the 24 months following the screening program. A mailed survey was sent to a random sample of 750 women from program participants to evaluate both their recent preventive health care practices and to identify perceived barriers to obtaining preventive health services. O f these, 71.1 percent responded. Survey responses of the original program participants were linked to each subject's previous answers to the same questions asked 24 months earlier. A comparison group was derived by asking follow up study participants to identify a female acquaintance within five years of her age. Seventy-four percent of the comparison group responded. Survey responses of original program participants were then compared to those of the comparison group. Results indicate that women who participated in the original Project received significantly more preventive health care services in the two years since the Project than in the two years prior to it. Women in the comparison group received more Paps and clinical breast examinations than women in the participant group, perhaps because all participants had received a Pap test two years before. Having a regular health care provider was the most significant characteristic associated with obtaining indicated preventive services. An important contribution of community screening programs may be to encourage women to establish a regular source of care.
Patricia Carney is a predoctoral candidate, School of Nursing University of Washington in Seattle, Washington; Allen Dietrich is an associate professor, department of community and family medicine at Dartmouth Medical School, and Daniel Freeman is a professor, department of community and family medicine at Dartmouth Medical School in Hanover, New Hampshire. This research was supported by Grant # 250-81 of the Hitchcock Foundation, a component of Dartmouth-Hitchcock Medical Center. Requests for reprints should be addressed to: Patricia Carney, RN, MS, Dept. of Community Health Care Systems, University of Washington SM-24, Seattle, WA 98195. © 1992 Human Sciences Press, Inc.
167
168
JOURNAL OF COMMUNITY HEALTH
INTRODUCTION
Many Americans obtain less than the r e c o m m e n d e d level of services for the prevention and early detection of cancer, atherosclerosis and other diseases, x'' Obtaining these services on a regular basis could significantly reduce morbidity and mortality. For example, regular utilization of reliable Pap test screening in all w o m e n over age 18 should eliminate invasive cervical cancer? Community-based cervical cancer early detection programs have met with substantial clinical success, 4-9but the long term impact on patients' subsequent health care seeking behavior in response to the programs has seldom been explored. This follow up study assesses the impact of one such community p r o g r a m on preventive care subsequently obtained by women. Cervical cancer mortality rates in New H a m p s h i r e have been shown to exceed national averages by over 20 percent. ~°'z~ To address this problem, the New H a m p s h i r e Bureau of Health Promotion f u n d e d in 1986 a one year community women's cancer screening and education program. T h e New Hampshire Cervical Cancer Screening and Education Program (NHCCSEP) was designed to provide clinical services to women at high risk, especially those of low income status, who had not had a Pap test in over three years, or who had no regular source of ongoing health care. T h e Program is described in greater detail elsewhere, l' Clinical services were provided by established community health care agencies. Over 1800 women at high risk of cervical cancer were attracted to the p r o g r a m by its recruitment and marketing efforts. Clinical services included: blood pressure measurement, Pap test with pelvic exam, clinical breast exams, and a 15 minute educational session on the importance of obtaining subsequent regular cancer screening services. T h e original p r o g r a m was successful in recruiting participants at high risk for cervical cancer with over 90 percent of participants having one or m o r e target characteristics such as low income, less than a high school education, and multiple sexual partners. One third of the women seen stated they did not have a regular health care provider, and another 25 percent said they had a regular provider but had not seen him or her for over three years. Forty-six percent had not had a Pap test in three years or m o r e and an additional 5 percent of participants over age 21 had never had a Pap test. Twenty-eight w o m e n with abnormal Pap tests (cervical intraepithelial neoplasia grade 1 or higher) were identified in the original program; three of these proved to have gynecological cancers. More than 60 breast abnormalities were r e f e r r e d for further evaluation with the diagnosis of at least one cancer. Twenty-four
P. Carney, A. J. Dietrich, and D. H. Freeman, Jr.
169
w o m e n with blood pressures h i g h e r than 14°//90were identified a n d ref e r r e d for follow up. T h e educational sessions were p e r f o r m e d in small g r o u p s a n d were highly interactive. T h e y were t a u g h t by health educators who provided participants with: specific r e c o m m e n d a t i o n s r e g a r d i n g w h e n to obtain their next a n d f u t u r e Pap tests, breast exams, a n d o t h e r screening services based on NCI working Guidelines, ~ techniques o f breast self-examination, a n d a discussion o f the i m p o r t a n c e o f establishing care with a regular p r o v i d e r for receiving f u t u r e preventive services. A pretest/post-test was used to evaluate k n o w l e d g e retention. T h e post-tests showed that w o m e n knew the r e c o m m e n d a t i o n s a n d rationale for the screening tests, but perceived major barriers to obtaining them, such as cost a n d access to care. T h e long t e r m impact o f the original p r o g r a m on patients' future preventive health care seeking behavior is potentially even m o r e i m p o r t a n t t h a n the identification o f the four cancers. Exploring preventive health behaviors a n d identifying barriers to care w o m e n experie n c e d in the two years following the original p r o g r a m are the focus of this paper. METHODS A mailed survey was employed to evaluate the 24 month impact of the original program on subsequent preventive health care practices as well as the barriers Participant and Comparison groups experienced. The follow up study received Human Subject approval from the institutional review board, and permission to use the original program's data was obtained from the appropriate agencies. The follow up study period began in September of 1989 and ended in August of 1990. Study Sample Seven hundred and fifty women over age 21 who participated in the original program (representing about 50 percent of the original number) were randomly selected, making up the "Participant" group. This selection method yielded an equal distribution of women who had favorable (having had a Pap within the previous three years) and unfavorable health care seeking behavior (having no previous Pap or not having one within the three previous years) prior to their participation in the NHCCSEP. Each participant was then asked to identify the name, address, and telephone number of a female acquaintance within five years of her age. This group of women then served as the Comparison group.
170
JOURNALOF COMMUNITYHEALTH
Instruments Two survey instruments were developed and pilot tested on women in the region with similar characteristics to those in the survey samples. One questionnaire was designed for Participants, the other was designed for Comparison individuals. Both were fully compatible with the original survey (including identical wording of questions asked) so that making comparisons with data from the original program would be possible. The key difference between the two instruments involved obtaining demographic information from women in the Comparison group, which had previously been collected from women in the Participant group. Survey methods included an initial mailing with a personal letter from the Project Director with use of the original program's logo. If no response occurred as a result of the first mailing, a second mailing was performed two weeks later. Those who had moved and whose forwarding address had expired were considered lost to follow up. Telephone follow up was used as necessary to both non-respondents and those who return questionnaires with missing data and/or incomplete information. The follow-up survey evaluated health care practices regarding Pap tests and other preventive services during the 24 months after participants were seen in the original program. Questions in the follow up survey addressed whether the following additional preventive services had also been obtained: mammography, Pap test, and clinical breast exam as well as regular breast selfexam behavior. Barriers experienced by both the Participant and Comparison groups in obtaining these preventive services were also assessed as well as presence of a regular health care provider. Responses were then linked to each participant's post-test response to the same questions 24 months earlier during the original program and were then compared to the Comparison group's responses to the same questions.
Data Analysis The patient was the unit of analysis. The key comparison involved how the health care seeking behavior of participants changed from the two years before to the two years after the earlier project, especially with respect to obtaining Pap tests, breast self-exam and establishment of a relationship with a regular health care provider. Statistical comparisons were made using Fisher's Exact Test (two tailed) for data in two by two factor tables and the Pearson Chisquare was used for multiple group comparisons. All computations were accomplished using SAS STAT Version 6.
RESULTS Response to Follow up Survey O f those in the participant sample, c o m p l e t e data w e r e o b t a i n e d on 71.1 p e r c e n t ( n = 4 7 1 ) . Almost 28 p e r c e n t could not be r e a c h e d , a n d
P. Carney, A. J. Dietrich, a n d D. H. Freeman, Jr.
171
TABLE 1 Demographic Characteristics of Study Sample
Characteristic
Participant
Comparison
Mean Age Education completed high school completed college Marital Status married separated or divorced widowed Race/Cultural Background Caucasian, not Spanish-speaking Household Size* -< 2 Income** > $12,000
50.6 years
48.1 years
37.4% 44.8%
38.2% 47.9%
64.2% 15.2% 10.1%
65.4% 17.7% 11.8%
96.2%
96.2%
54.6%
43%
76.2%
82.4%
*p = .004,**p = .08
1 percent refused to participate in this follow up study. Seventy-one percent of Participants from the original program provided us with names (n = 335) which constituted the Comparison group. Of these, 74 percent responded with complete information (n = 247). Almost 22 percent of the women could not be reached, and 4 percent refused to participate.
Demographics of Study Sample Table 1 outlines the demographic characteristics of the two groups. As indicated here the groups were similar in terms of marital and educational status, ethnic background and income. The Participant Group and the Comparison Group differed significantly only in household size. As previously noted, over 90 percent of the original program participants fit at least one of our target characteristics identifying high risk status. For that reason, we considered all Participants to be appropriate candidates for another Pap test within one or two years. Table 2 illustrates the health behaviors of Participants during the two years before and after the program.
172
JOURNAL
HEALTH
OF COMMUNITY
TABLE 2
Health Behaviors of Participants Before and After the Program*
Behavior
Before
After
Pap Test** Regular Self-Breast Exam** Regular Health Care Provider**
40.2% 52.0% 63.5%
60.3% 61.9% 77.8%
*Note: ALL participants received a Pap test and clinical breast exam as part of the Program 24-28 months prior to the second survey. Before refers to the 24 months prior to the NHCCSP, After refers to the 24 months subsequent to the NHCCSP **p ~ 0.001
TABLE 3
health Behaviors of Participants versus Comparisons Within Last 2 Years t
Behavior Pap Test** Breast Self-Exam Clinical Breast Exam* Mammography age 50 and over (within last year) Regular Health Care Provider**
Participant
Comparison
60.3% 61.9% 71.5%
75.6% 63.5% 84.5%
48.5% 77.8%
54.6% 88.2%
*p < .01, **p -< .001 tAll participants had received a Pap test and a clinical breast examination between twenty-four and twenty-eight months prior to this. T h e services received by Comparisons prior to the past twenty-four months is unknown.
Table 3 outlines the health behaviors exhibited (by self report) during the most recent twenty four months in Participant versus Comparison groups. It is important to remember that all Participants received a Pap test and clinical breast exam at the time of the initial Program. Table 4 compares the barriers experienced in the Participant and Comparison groups. Here financial expense was considered by both groups to be the most important barrier, especially by women in the Participant group.
P. Carney, A . J . Dietrich, a n d D. H. Freeman, Jr.
173
TABLE 4
Comparison of Barriers to Obtaining Preventive Procedures
Participant Financial expense No time Prefer not to go to my regular MD for this Didn't know I n e e d e d one Other*
47.6% 10.4% 7.3% 9.2% 22%
Comparison 24.6% 15.7% 3.5% 12.3% 36.8%
*Responses in the "other" category from both groups included: hysterectomy, physician either moved away or retired, insurance doesn't cover the test, and apathy.
DISCUSSION
This investigation offers insights into whether community programs like the one described can alter participants' long term preventive health care seeking behaviors. Behavior of Participants improved substantially, although they still perceived formidable barriers to care. Results indicate that the rate at which women who attended the original Program obtained subsequent Pap tests increased in the two years since the program when compared to the rate of obtaining Paps prior to their participation. Participants had all been provided with Pap tests and clinical breast examinations through the program. Not surprisingly, the rate at which participants obtained the subsequent Paps was significantly lower than the rate for Comparisons who had not necessarily received a Pap test twenty four months earlier. It is interesting to note that multivariate analysis revealed that more important than participation in the NHCCSEP Program was having a regular health care provider. This was also true for obtaining clinical breast exams. A limitation of this investigation involved the method of obtaining the Comparison group. W o m e n in the Participant group were more likely to provide the name of a woman who had larger households and who were more likely to have a regular health care provider. Members of both the Participant group and the Comparison group found expense to be the greatest barrier to obtaining Pap tests and breast exams. This was especially true for the Participant group. T h e s e procedures are not covered by many insurance plans. Until a mechanism is in place for the provision of these services or they are
174
JOURNAL OF COMMUNITY HEALTH
covered by private insurance and Medicare/Medicaid, this barrier will continue to be a significant stumbling block, particularly for those living in low income households. In summary, this follow up investigation indicated that while participating in a community screening program was associated with obtaining more future preventive care, having a regular health care provider was perhaps the crucial element in altering these women's behavior. In addition to education, assistance in establishing a regular source of health care should be offered at community screening programs. Perhaps once established in a primary care setting, recommended preventive procedures will be obtained.
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Mandelblatt J, Gopaul I, Wistreich M. Gynecological care of elderly women. JAMA 256:376379, 1986. Windsor RA, Kronenfeld JJ, Cain MG, Cutter GR, et. al. Increasing utilization of a rural cervical cancer detection program. Am J Public Health 71:641-643, 1981. Kleinman JC, Kopstein A. Who is being screened for cervical cancer? Am J Public Health 71:73-76, 1981. Boyes DA. The value of a pap smear program and suggestions for its implementation. Cancer 48:613-621, 1981. Stenkvist B, Bergstrom R, Eklund G, Fox CH. Papanicolaou smear screening and cervical cancer; what can you expect?JAMA 252:1423-1426, 1984. Centers for Disease Control: Screening for cervical and breast cancer in Southeastern Kentucky. MMWR 36:845-849, 1988. van der Graaf Y, Vooijs GP, Ziehuis GA. Cervical screening revisited. Acta Cytol 34:366-372, 1990. Michielutte R, Digan MB, Wells HB, Young LD, Jackson DS, Sharp PC. Development of a community cancer education program: the Forsyth County, NC cervical cancer prevention project. Public Health Rep 104:542-51, 1989. Lane DS. Compliance with referrals from a cancer-screening project. J Fam Pratt 17:811-817, 1983. Schwartz E, Dennis DT, Cournoyer JJ, Grady KM. Cancer mortality in New Hampshire 1950-1979. New Hampshire Div. PHS, Nov. 1984. Colby JP, Schwartz E, Dennis DT, Grady KM. Excess cervical cancer mortality, New Hampshire 1974-1983. New Hampshire Div. PHS. Nov. 1985. Dietrich, AJ, Carney-Gersten, P, Holmes, DW, Reed, S, Clauson, B, Zayso, K. Community Screening for Cervical Cancer in New Hampshire J Fam Pract 29:319-323, 1989. National Cancer Institute. Working Guidelines for early detection of cancer: rationale and supporting evidence to decrease mortality. Bethesda, MD, 1987.
