Telephone Counseling Improves Adherence to Colposcopy Among Lower-Income Minority Women By C. Lerman, P. Hanjani, C. Caputo, S. Miller, E. Delmoor, S. Nolte, and P. Engstrom Purpose: A randomized trial was conducted to evaluate the impact of a telephone counseling intervention to improve patient adherence to colposcopic examination for suspected cervical intraepithelial neoplasia (CIN). Methods: Subjectswere lower-income, minoritywomen who missed a scheduled initial appointment for colposcopy at an urban medical clinic. Patients were randomly assigned to either a control condition (n = 42) or a telephone counseling condition (n = 48). The 15-minute, structured telephone counseling intervention protocol addressed educational, psychosocial, and practical barriers to colposcopy adherence. Results: The most common patient-reported barriers to colposcopy adherence included a lack of understanding of the purpose of colposcopy (50%), worry about or fear of cancer (25%), and forgetting (23%). Telephone counseling was found to be highly effective in addressing
IN
1991, ABOUT 13,000 women will develop cervical cancer, and 4,500 women will die of this disease.' There is strong evidence that invasive cervical cancer
these barriers and improving adherence to diagnostic follow-up and treatment. Of patients in the control condition, 43% complied with a rescheduled colposcopy appointment, compared with 67% in the telephone counseling condition. Logistic regression analysis indicated that the effect of telephone counseling was independent of sociodemographic confoundervariables (odds ratio = 2.6; P < .003). Additionally, 74% of patients who received the initial telephone counseling adhered to recommended treatment, compared with 53% of patients in the control condition. Conclusion: Brief, structured telephone contact may be a cost-effective mechanism for improving adherence to diagnostic follow-up and treatment for a variety of cancer screening tests. J Clin Oncol 10:330-333. © 1992 by American Society of Clinical Oncology. Patient adherence to diagnostic follow-up and treat-
ment of suspected CIN is critical to reduce morbidity and mortality from cervical cancer.6 However, as many
can be prevented through early detection and treatment of dysplasia and carcinoma in situ (cervical intraepithelial neoplasia [CIN]). 2 Such precursor lesions are being
as 40% of patients with positive Papanicolaou (Pap) test
identified in increasing numbers of adolescents and
microinvasive cervical cancer had delayed seeking fol-
young women 3 and are most prevalent among women of
low-up for more than 8 weeks.8 Moreover, as many as 20% of patients with biopsy-confirmed CIN do not keep
4
lower socioeconomic status.
If left untreated, about
results fail to adhere to recommendations for colpos-
copy and/or biopsy.' In one study, 37% of patients with
50% of mild dysplasias (CIN I) will progress to more
their appointments for treatment. 9
severe lesions (CIN III), and 70% of women with CIN III will develop invasive cervical cancer.5
to colposcopy after a positive Pap test result. Nonadher-
Several factors have been associated with adherence ers tend to be younger, unmarried, and less well edu-
cated."0 Additionally, psychologic distress has been obFrom the Division of PopulationScience, Fox Chase CancerCenter, Philadelphia;Section of Pelvic Oncology, Department of Obstetrics and Gynecology, and Section of General Internal Medicine, Department of Medicine, Temple University School of Medicine, Philadelphia;and Departmentof Psychology, Temple University, Philadelphia, PA. Submitted June 12, 1991; acceptedAugust 21, 1991. Supported by institutional grants awarded to Fox Chase Cancer Center (NationalInstitutesof Health grantno. RR05895), an appropriationfrom the Commonwealth of Pennsylvania, and grants awarded to Temple University (NationalInstitutes of Health R01 CA46591). Presented in part in the Proceedings of the American Society of Clinical Oncology and in a poster session at the May 1991 Annual Meeting. Address reprint requests to Caryn Lerman, PhD, Fox Chase Cancer Center, 510 Township Line Rd, Cheltenham, PA 19012. © 1992 by American Society of Clinical Oncology. 0732-183X192/1002-0011$3.00/0
330
served in a substantial proportion of women after
receipt of positive Pap test results.11,12 These psychologic consequences of screening cannot be ignored because of the possible negative impact on patient adherence to diagnosis follow-up and treatment.11,13-15 Previous research suggests that proper education and counseling of women with positive Pap test results can
enhance adherence to diagnostic follow-up. In a recent randomized trial, written educational materials emphasizing the importance of early detection led to significant
improvements in subsequent adherence to repeat screening among women with positive Pap test results.' 6 However, for more recalcitrant and noncompliant women, more intensive outreach efforts may be necessary.
Journalof Clinical Oncology, Vol 10, No 2 (February), 1992: pp 330-333
Downloaded from ascopubs.org by University of Newcastle Upon Tyne on August 26, 2019 from 128.240.208.034 Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
331
TELEPHONE COUNSELING AND COLPOSCOPY ADHERENCE
Here we report on a randomized trial to evaluate a brief telephone counseling intervention to improve adherence to diagnostic follow-up and treatment among women who were noncompliant with their initial colposcopy appointment. This intervention was tested in a predominantly lower-income, African-American study population, as these women tend to be at greatest risk for 10nonadherence to cervical screening and followup. ,14
METHODS Subjects Subjects were females aged 14 years and older who missed their initial scheduled appointment for colposcopy to evaluate positive class III-V results of a Pap test. Eligible patients for this study were those who had a telephone and did not have any prior history of cervical cancer. All subjects had been referred for colposcopy to the Pelvic Oncology Section of the Department of Obstetrics and Gynecology of Temple University Hospital. This clinic serves the predominantly lower-income community of North Philadelphia. Historical data from this clinic indicate that the base rate of colposcopy adherence after a missed appointment is about 38%. In accordance with the guidelines for human subjects experimentation, all respondents had provided verbal consent to participate in this study. The overall response rate to the telephone contact was 70%; 24% of patients could not be reached after 10 attempts, 3% of women were ineligible due to a language barrier, and 3% refused to be surveyed. The resulting sample of respondents included 90 women. Demographic characteristics of subjects are listed in Table 1.
Procedures Within 1 week of the initial missed appointment, all subjects were contacted by telephone by a health educator from Fox Chase Cancer Center. They were asked to participate in a study to understand reasons why women do not attend the Colposcopy Clinic for recommended follow-up for positive Pap test results. Eligible subjects were randomized to one of two conditions Table 1. Sociodemographic Characteristics of Respondents (n = 90) Variable Age (years) 14-19 20-24 25-29 30+ Race Black Hispanic White Marital status Married Unmarried Education < High school High school graduate > High school
No.
%
29 25 21 15
32.2 27.8 23.3 16.7
76 8 6
84.4 8.9 6.7
7 83
7.8 92.2
involving a brief telephone contact: the control condition (n = 42) or the telephone counseling condition (n = 48). The control condition reflected usual care, which involves a telephone call to reschedule the missed appointment plus assessment of barriers to adherence. The telephone counseling condition included components of the control condition plus the barriers counseling intervention. Barriers to adherence to the initial colposcopy appointment were assessed by asking patients, in an open-ended fashion, the reason(s) why they did not attend this appointment. Predetermined categories, based on barriers elicited in our pilot research, were used to code these data. These categories included: educational barriers (ie, lack of understanding regarding the purpose of the colposcopy, believing colposcopy is unnecessary if subject is asymptomatic, and lack of confidence in Pap test results); psychologic barriers (ie, anxiety about the procedure and fear of cancer and/or treatment); and practical barriers (ie, forgetting, cost, transportation/child care problems, and lack of time). During the same telephone contact, patients randomized to the telephone counseling condition received a barriers counseling intervention designed to reduce educational, psychosocial, and practical barriers to adherence. This 15- to 20-minute standardized protocol was based on the decisional counseling approach of Janis and Mann.'7 During barriers counseling, scripted health education messages were delivered for each barrier to adherence that was elicited from the patient. These messages ranged from 30 to 60 seconds in duration. For example, if a patient reported that she did not understand the purpose of the colposcopy, the counselor explained that "the purpose is to find abnormal changes in cells on your cervix at an early stage ... " and that, "if untreated, these abnormal cells in the cervix can develop into cancer .... " Patients who reported fear of cancer as a barrier were told "a positive Pap test usually does not mean cancer. Most show abnormal cells in the cervix ... if found and treated early, cancer of the cervix can be prevented . . ." For patients reporting practical barriers to adherence, such as transportation and child care, concrete action plans for attending the clinic were offered. The colposcopy appointment was rescheduled for all patients at the conclusion of the phone contact. Adherence to the rescheduled colposcopy appointment was determined for all patients from medical records. Nonadherence was validated by patient self-report during a subsequent telephone contact. Six patients indicated that they had obtained a colposcopy at an alternate hospital and were coded as adherers. Adherence to recommended treatment was assessed similarly for those subjects who received the colposcopy examination and had been advised to receive treatment for CIN. The x2 test of association was used to compare adherers and nonadherers in terms of group assignment (ie, control v telephone counseling) and sociodemographic characteristics. Logistic regression analysis was used to test the impact of the intervention, controlling for the effects of potential sociodemographic confounder variables. RESULTS Sociodemographic Characteristics
43 31 16
47.8 34.5 17.7
Over one half of respondents were aged 24 years or
younger (Table 1). Twenty-three percent were aged 25 to 29 years, and only 17% were aged 2 30 years. The majority of respondents were black (85%) and unmarried (92%). Almost one half of respondents had less
Downloaded from ascopubs.org by University of Newcastle Upon Tyne on August 26, 2019 from 128.240.208.034 Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
332
LERMAN ET AL
than a high school education. There were no significant differences in demographic variables between patients in the control and telephone counseling conditions. Barriersto Colposcopy Adherence Patient-reported barriers to adherence to the initial colposcopy appointment are listed in Table 2. Eighteen percent of patients reported a single barrier to adherence, 54% reported two barriers, and 31% reported three or more. When individual barriers were collapsed into barrier categories, the results showed that 54% of patients reported an educational barrier, 31% reported a psychologic barrier, and 61% reported a practical barrier to colposcopy adherence. In addition, about 20% of patients reported an educational barrier together with a psychosocial or practical barrier. The single most commonly reported barrier to adherence was a lack of understanding of the purpose of colposcopy: one half of patients reported that they did not adhere to the colposcopy appointment for this reason. Fear of cancer and possible treatment (24%) and forgetting (23%) also were reported by a substantial proportion of patients. Other important barriers to adherence included cost (14%), transportation/child care difficulties (14%), and lack of time (13%). Overall, 40% of patients attributed their nonadherence to at least one of these three barriers. Anxiety about the procedure (11%), believing it is unnecessary (2%), and lack of confidence in Pap test results (2%) were relatively less important. Impact of Telephone Counseling on Adherence Proportions of women who adhered to the rescheduled colposcopy appointment are listed in Table 3 by group. Forty-three percent of patients in the control group adhered to colposcopy, compared with 67% in the Table 2. Barriers to Colposcopy Adherence (n = 90) Barrier Reported*
Educational barriers Purpose unclear Not necessary; no symptoms Do not trust results Psychologic barriers Fear of cancer and/or treatment Anxiety about procedure Practical barriers Forgot Cost Transportation/child care No time *Barriers not mutually exclusive.
%of Respondents
50.0 2.2 2.2 24.4 11.1
Table 3. Colposcopy Adherence By Group Complier
Noncomplier
Group*
No.
%
No.
%
Control (n = 42) Telephone counseling (n = 28)
18 32
42.9 66.7
24 16
57.1 33.3
2 *x test of association = 4.2; P < .05.
telephone counseling group. A X2 test of association indicated that this difference in proportions is statistically significant (x 2 = 4.2; P < .05). Logistic regression analysis was conducted to examine the effect of study group (control v telephone counseling) on adherence to colposcopy, while controlling for the effects of potential sociodemographic confounder variables (ie, age, race, education, and marital status). None of the sociodemographic variables were found to predict adherence. However, study group did exert a statistically significant independent effect on adherence (odds ratio [OR] = 2.6; P < .003). This result indicates that the odds of adherence among women who received telephone counseling were 2.6 times greater than the odds of adherence among women in the control group. Among the 50 patients who adhered to colposcopy, 36 (72%) were scheduled for a return visit for treatment of CIN. About 53% of patients in the control group adhered to this appointment, compared with 74% in the telephone counseling group (P > .1; Table 4). The lack of statistical significance of this 21% increment in adherence is attributable to reduced power associated with the smaller sample of patients eligible for this analysis. DISCUSSION This study examined the impact of a telephone barriers counseling intervention on colposcopy adherence among patients who failed to attend their initial colposcopy appointment. The most common barriers to colposcopy adherence included fear of cancer, forgetting, and lack of knowledge about the purpose or efficacy of the procedure. In fact, one half of patients reported that they did not understand why they had been referred for the examination. Additionally, about 40% of patients attributed their nonadherence to a financial or access Table 4. Treatment Adherence By Group Complier
23.3 14.4 14.4 13.3
Group*
%
No.
%
9
52.9 73.7
8 5
47.1 26.3
Control (n = 17) Telephone counseling (n = 19)
Noncomplier
No.
14
2 Y test of association = 1.67; P > .1.
Downloaded from ascopubs.org by University of Newcastle Upon Tyne on August 26, 2019 from 128.240.208.034 Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
333
TELEPHONE COUNSELING AND COLPOSCOPY ADHERENCE barrier. Telephone counseling was found to be highly effective in improving adherence to the rescheduled colposcopy appointment. Of patients who received this intervention, 67% adhered, compared with 43% of control patients. Telephone counseling also led to a 21% increment in adherence to treatment among the subgroup of patients who had been referred for treatment of CIN. These findings may have important implications for the management of patients in the course of cervical cancer screening. Educational barriers reported by patients suggest that adequate information often was not provided at the time of the colposcopy referral. Primary care providers could address this deficiency by explaining the purpose of colposcopy examination when communicating Pap test results to patients. Written educational materials, provided in conjunction with postal or telephone notification of results, also may be beneficial in this regard. 6 Additionally, our results highlight the importance of psychosocial barriers to colposcopy adherence. Communication strategies should address psychologic concerns about the meaning of a positive Pap test result, as well as fears about cervical cancer and its
treatment." The potential for prevention of cervical cancer through early detection should be emphasized, as this information can ameliorate psychologic distress and promote subsequent adherence.15" The results of the present study suggest that telephone counseling is an effective mechanism for simultaneously addressing the interplay of educational, psychosocial, and practical barriers to adherence. Telephone counseling has been used widely to provide information on health care services,"9 to advise patients on overcoming obstacles to healthcare use," and to promote and maintain smoking cessation." This intervention also may be a cost-effective, office-based mechanism for promoting adherence to mammography and diagnostic follow-up for women with abnormal mammogram results. Additionally, we expect that this approach is applicable to a wide variety of patient populations, including other underserved minority groups. ACKNOWLEDGMENT The authors thank Eunice King, PhD, for her assistance in developing the telephone counseling protocol and Alicia Blake for her help in instrument development.
REFERENCES 1. American Cancer Society: Cancer Facts and Figures-1991. New York, NY, American Cancer Society, 1991 2. Greenwald P, Sondik EJ: Cancer Control Objectives for the Nation: 1985-1990 (NIH publ no. 86-2880, no. 2). Bethesda, MD, US Department of Health and Human Services, 1986 3. Oyer R, Hanjani P: Endocervical curettage: Does it contribute to the management of patients with abnormal cervical cytology? Gynecol Oncol 25:204-211, 1986 4. Christopherson WM, Parke JE: A study of relative frequency of carcinoma of the cervix in Negros. Cancer 13:711-713, 1960 5. Creasman WT, Clarke-Pearson DL: Abnormal cervical cytology: Spotting it, treating it. Contemp Obstet Gynecol 21:53-76, 1983 6. Lerman C, Rimer B, Engstrom PF: Reducing avoidable cancer mortality through prevention and early detection regimens. Cancer Res 49:4955-4962, 1989 7. Lane DS: Compliance with referrals from a cancer-screening project. J Fam Pract 17:811-817, 1983 8. Mitchell H, Medley G: Delay times to definitive diagnosis after an abnormal pap smear. Aust N Z J Obstet Gynaecol 27:283-286, 1987 9. Russo JF, Jones DED: Abnormal cervical cytology in sexually active adolescents. J Adolesc Health Care 5:269-271, 1984 10. Michielutte R, Diseker RA, Young LD, et al: Noncompliance in screening follow-up among family planning clinic patients with cervical dysplasia. Prev Med 14:248-258, 1985 11. Lerman C, Miller SM, Scarborough R, et al: Adverse psychological consequences of positive cytologic screening. Am J Obstet Gynecol 165:658-662, 1991
12. Reelick NF, De Haes WFM, Schuurman JH: Psychological side-effects of the mass screening on cervical cancer. Soc Sci Med 18:1089-1093, 1984 13. Beresford JS, Gervaize PA: The emotional impact of abnormal pap smears on patients referred for colposcopy. Colposcopy Gynecol Laser Surg 2:83-87, 1986 14. Lerman C, Caputo C, Brody D: Factors associated with inadequate cervical screening among lower income primary. J Am Board Fam Pract 3:151-156, 1990 15. Lerman C, Rimer B, Engstrom P: Cancer risk notification: Psychosocial and ethical implications. J Clin Oncol 9:1275-1282, 1991 16. Paskett ED, White E, Carter WB, et al: Improving follow-up after an abnormal pap smear: A randomized controlled trial. Prev Med 19:630-641, 1990 17. Janis IL, Mann L: Decision-making: A psychological analysis of conflict choice and commitment. New York, NY, Free Press, 1977 18. Wilkinson C, Jones JM, McBride J: Anxiety caused by abnormal result of cervical smear test: A controlled trial. Br Med J 300:400-440, 1990 19. Hornblow AR: Does telephone counselling have preventive value? Aust N Z J Psychiatry 20:23-28, 1986 20. Schwartz JL: Review and Evaluation of Smoking Cessation Methods (NIH publ no. 87-2940). Washington, DC, US Department of Health and Human Services, 1987
Downloaded from ascopubs.org by University of Newcastle Upon Tyne on August 26, 2019 from 128.240.208.034 Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
IN
1991, ABOUT 13,000 women will develop cervical cancer, and 4,500 women will die of this disease.' There is strong evidence that invasive cervical cancer
these barriers and improving adherence to diagnostic follow-up and treatment. Of patients in the control condition, 43% complied with a rescheduled colposcopy appointment, compared with 67% in the telephone counseling condition. Logistic regression analysis indicated that the effect of telephone counseling was independent of sociodemographic confoundervariables (odds ratio = 2.6; P < .003). Additionally, 74% of patients who received the initial telephone counseling adhered to recommended treatment, compared with 53% of patients in the control condition. Conclusion: Brief, structured telephone contact may be a cost-effective mechanism for improving adherence to diagnostic follow-up and treatment for a variety of cancer screening tests. J Clin Oncol 10:330-333. © 1992 by American Society of Clinical Oncology. Patient adherence to diagnostic follow-up and treat-
ment of suspected CIN is critical to reduce morbidity and mortality from cervical cancer.6 However, as many
can be prevented through early detection and treatment of dysplasia and carcinoma in situ (cervical intraepithelial neoplasia [CIN]). 2 Such precursor lesions are being
as 40% of patients with positive Papanicolaou (Pap) test
identified in increasing numbers of adolescents and
microinvasive cervical cancer had delayed seeking fol-
young women 3 and are most prevalent among women of
low-up for more than 8 weeks.8 Moreover, as many as 20% of patients with biopsy-confirmed CIN do not keep
4
lower socioeconomic status.
If left untreated, about
results fail to adhere to recommendations for colpos-
copy and/or biopsy.' In one study, 37% of patients with
50% of mild dysplasias (CIN I) will progress to more
their appointments for treatment. 9
severe lesions (CIN III), and 70% of women with CIN III will develop invasive cervical cancer.5
to colposcopy after a positive Pap test result. Nonadher-
Several factors have been associated with adherence ers tend to be younger, unmarried, and less well edu-
cated."0 Additionally, psychologic distress has been obFrom the Division of PopulationScience, Fox Chase CancerCenter, Philadelphia;Section of Pelvic Oncology, Department of Obstetrics and Gynecology, and Section of General Internal Medicine, Department of Medicine, Temple University School of Medicine, Philadelphia;and Departmentof Psychology, Temple University, Philadelphia, PA. Submitted June 12, 1991; acceptedAugust 21, 1991. Supported by institutional grants awarded to Fox Chase Cancer Center (NationalInstitutesof Health grantno. RR05895), an appropriationfrom the Commonwealth of Pennsylvania, and grants awarded to Temple University (NationalInstitutes of Health R01 CA46591). Presented in part in the Proceedings of the American Society of Clinical Oncology and in a poster session at the May 1991 Annual Meeting. Address reprint requests to Caryn Lerman, PhD, Fox Chase Cancer Center, 510 Township Line Rd, Cheltenham, PA 19012. © 1992 by American Society of Clinical Oncology. 0732-183X192/1002-0011$3.00/0
330
served in a substantial proportion of women after
receipt of positive Pap test results.11,12 These psychologic consequences of screening cannot be ignored because of the possible negative impact on patient adherence to diagnosis follow-up and treatment.11,13-15 Previous research suggests that proper education and counseling of women with positive Pap test results can
enhance adherence to diagnostic follow-up. In a recent randomized trial, written educational materials emphasizing the importance of early detection led to significant
improvements in subsequent adherence to repeat screening among women with positive Pap test results.' 6 However, for more recalcitrant and noncompliant women, more intensive outreach efforts may be necessary.
Journalof Clinical Oncology, Vol 10, No 2 (February), 1992: pp 330-333
Downloaded from ascopubs.org by University of Newcastle Upon Tyne on August 26, 2019 from 128.240.208.034 Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
331
TELEPHONE COUNSELING AND COLPOSCOPY ADHERENCE
Here we report on a randomized trial to evaluate a brief telephone counseling intervention to improve adherence to diagnostic follow-up and treatment among women who were noncompliant with their initial colposcopy appointment. This intervention was tested in a predominantly lower-income, African-American study population, as these women tend to be at greatest risk for 10nonadherence to cervical screening and followup. ,14
METHODS Subjects Subjects were females aged 14 years and older who missed their initial scheduled appointment for colposcopy to evaluate positive class III-V results of a Pap test. Eligible patients for this study were those who had a telephone and did not have any prior history of cervical cancer. All subjects had been referred for colposcopy to the Pelvic Oncology Section of the Department of Obstetrics and Gynecology of Temple University Hospital. This clinic serves the predominantly lower-income community of North Philadelphia. Historical data from this clinic indicate that the base rate of colposcopy adherence after a missed appointment is about 38%. In accordance with the guidelines for human subjects experimentation, all respondents had provided verbal consent to participate in this study. The overall response rate to the telephone contact was 70%; 24% of patients could not be reached after 10 attempts, 3% of women were ineligible due to a language barrier, and 3% refused to be surveyed. The resulting sample of respondents included 90 women. Demographic characteristics of subjects are listed in Table 1.
Procedures Within 1 week of the initial missed appointment, all subjects were contacted by telephone by a health educator from Fox Chase Cancer Center. They were asked to participate in a study to understand reasons why women do not attend the Colposcopy Clinic for recommended follow-up for positive Pap test results. Eligible subjects were randomized to one of two conditions Table 1. Sociodemographic Characteristics of Respondents (n = 90) Variable Age (years) 14-19 20-24 25-29 30+ Race Black Hispanic White Marital status Married Unmarried Education < High school High school graduate > High school
No.
%
29 25 21 15
32.2 27.8 23.3 16.7
76 8 6
84.4 8.9 6.7
7 83
7.8 92.2
involving a brief telephone contact: the control condition (n = 42) or the telephone counseling condition (n = 48). The control condition reflected usual care, which involves a telephone call to reschedule the missed appointment plus assessment of barriers to adherence. The telephone counseling condition included components of the control condition plus the barriers counseling intervention. Barriers to adherence to the initial colposcopy appointment were assessed by asking patients, in an open-ended fashion, the reason(s) why they did not attend this appointment. Predetermined categories, based on barriers elicited in our pilot research, were used to code these data. These categories included: educational barriers (ie, lack of understanding regarding the purpose of the colposcopy, believing colposcopy is unnecessary if subject is asymptomatic, and lack of confidence in Pap test results); psychologic barriers (ie, anxiety about the procedure and fear of cancer and/or treatment); and practical barriers (ie, forgetting, cost, transportation/child care problems, and lack of time). During the same telephone contact, patients randomized to the telephone counseling condition received a barriers counseling intervention designed to reduce educational, psychosocial, and practical barriers to adherence. This 15- to 20-minute standardized protocol was based on the decisional counseling approach of Janis and Mann.'7 During barriers counseling, scripted health education messages were delivered for each barrier to adherence that was elicited from the patient. These messages ranged from 30 to 60 seconds in duration. For example, if a patient reported that she did not understand the purpose of the colposcopy, the counselor explained that "the purpose is to find abnormal changes in cells on your cervix at an early stage ... " and that, "if untreated, these abnormal cells in the cervix can develop into cancer .... " Patients who reported fear of cancer as a barrier were told "a positive Pap test usually does not mean cancer. Most show abnormal cells in the cervix ... if found and treated early, cancer of the cervix can be prevented . . ." For patients reporting practical barriers to adherence, such as transportation and child care, concrete action plans for attending the clinic were offered. The colposcopy appointment was rescheduled for all patients at the conclusion of the phone contact. Adherence to the rescheduled colposcopy appointment was determined for all patients from medical records. Nonadherence was validated by patient self-report during a subsequent telephone contact. Six patients indicated that they had obtained a colposcopy at an alternate hospital and were coded as adherers. Adherence to recommended treatment was assessed similarly for those subjects who received the colposcopy examination and had been advised to receive treatment for CIN. The x2 test of association was used to compare adherers and nonadherers in terms of group assignment (ie, control v telephone counseling) and sociodemographic characteristics. Logistic regression analysis was used to test the impact of the intervention, controlling for the effects of potential sociodemographic confounder variables. RESULTS Sociodemographic Characteristics
43 31 16
47.8 34.5 17.7
Over one half of respondents were aged 24 years or
younger (Table 1). Twenty-three percent were aged 25 to 29 years, and only 17% were aged 2 30 years. The majority of respondents were black (85%) and unmarried (92%). Almost one half of respondents had less
Downloaded from ascopubs.org by University of Newcastle Upon Tyne on August 26, 2019 from 128.240.208.034 Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
332
LERMAN ET AL
than a high school education. There were no significant differences in demographic variables between patients in the control and telephone counseling conditions. Barriersto Colposcopy Adherence Patient-reported barriers to adherence to the initial colposcopy appointment are listed in Table 2. Eighteen percent of patients reported a single barrier to adherence, 54% reported two barriers, and 31% reported three or more. When individual barriers were collapsed into barrier categories, the results showed that 54% of patients reported an educational barrier, 31% reported a psychologic barrier, and 61% reported a practical barrier to colposcopy adherence. In addition, about 20% of patients reported an educational barrier together with a psychosocial or practical barrier. The single most commonly reported barrier to adherence was a lack of understanding of the purpose of colposcopy: one half of patients reported that they did not adhere to the colposcopy appointment for this reason. Fear of cancer and possible treatment (24%) and forgetting (23%) also were reported by a substantial proportion of patients. Other important barriers to adherence included cost (14%), transportation/child care difficulties (14%), and lack of time (13%). Overall, 40% of patients attributed their nonadherence to at least one of these three barriers. Anxiety about the procedure (11%), believing it is unnecessary (2%), and lack of confidence in Pap test results (2%) were relatively less important. Impact of Telephone Counseling on Adherence Proportions of women who adhered to the rescheduled colposcopy appointment are listed in Table 3 by group. Forty-three percent of patients in the control group adhered to colposcopy, compared with 67% in the Table 2. Barriers to Colposcopy Adherence (n = 90) Barrier Reported*
Educational barriers Purpose unclear Not necessary; no symptoms Do not trust results Psychologic barriers Fear of cancer and/or treatment Anxiety about procedure Practical barriers Forgot Cost Transportation/child care No time *Barriers not mutually exclusive.
%of Respondents
50.0 2.2 2.2 24.4 11.1
Table 3. Colposcopy Adherence By Group Complier
Noncomplier
Group*
No.
%
No.
%
Control (n = 42) Telephone counseling (n = 28)
18 32
42.9 66.7
24 16
57.1 33.3
2 *x test of association = 4.2; P < .05.
telephone counseling group. A X2 test of association indicated that this difference in proportions is statistically significant (x 2 = 4.2; P < .05). Logistic regression analysis was conducted to examine the effect of study group (control v telephone counseling) on adherence to colposcopy, while controlling for the effects of potential sociodemographic confounder variables (ie, age, race, education, and marital status). None of the sociodemographic variables were found to predict adherence. However, study group did exert a statistically significant independent effect on adherence (odds ratio [OR] = 2.6; P < .003). This result indicates that the odds of adherence among women who received telephone counseling were 2.6 times greater than the odds of adherence among women in the control group. Among the 50 patients who adhered to colposcopy, 36 (72%) were scheduled for a return visit for treatment of CIN. About 53% of patients in the control group adhered to this appointment, compared with 74% in the telephone counseling group (P > .1; Table 4). The lack of statistical significance of this 21% increment in adherence is attributable to reduced power associated with the smaller sample of patients eligible for this analysis. DISCUSSION This study examined the impact of a telephone barriers counseling intervention on colposcopy adherence among patients who failed to attend their initial colposcopy appointment. The most common barriers to colposcopy adherence included fear of cancer, forgetting, and lack of knowledge about the purpose or efficacy of the procedure. In fact, one half of patients reported that they did not understand why they had been referred for the examination. Additionally, about 40% of patients attributed their nonadherence to a financial or access Table 4. Treatment Adherence By Group Complier
23.3 14.4 14.4 13.3
Group*
%
No.
%
9
52.9 73.7
8 5
47.1 26.3
Control (n = 17) Telephone counseling (n = 19)
Noncomplier
No.
14
2 Y test of association = 1.67; P > .1.
Downloaded from ascopubs.org by University of Newcastle Upon Tyne on August 26, 2019 from 128.240.208.034 Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
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TELEPHONE COUNSELING AND COLPOSCOPY ADHERENCE barrier. Telephone counseling was found to be highly effective in improving adherence to the rescheduled colposcopy appointment. Of patients who received this intervention, 67% adhered, compared with 43% of control patients. Telephone counseling also led to a 21% increment in adherence to treatment among the subgroup of patients who had been referred for treatment of CIN. These findings may have important implications for the management of patients in the course of cervical cancer screening. Educational barriers reported by patients suggest that adequate information often was not provided at the time of the colposcopy referral. Primary care providers could address this deficiency by explaining the purpose of colposcopy examination when communicating Pap test results to patients. Written educational materials, provided in conjunction with postal or telephone notification of results, also may be beneficial in this regard. 6 Additionally, our results highlight the importance of psychosocial barriers to colposcopy adherence. Communication strategies should address psychologic concerns about the meaning of a positive Pap test result, as well as fears about cervical cancer and its
treatment." The potential for prevention of cervical cancer through early detection should be emphasized, as this information can ameliorate psychologic distress and promote subsequent adherence.15" The results of the present study suggest that telephone counseling is an effective mechanism for simultaneously addressing the interplay of educational, psychosocial, and practical barriers to adherence. Telephone counseling has been used widely to provide information on health care services,"9 to advise patients on overcoming obstacles to healthcare use," and to promote and maintain smoking cessation." This intervention also may be a cost-effective, office-based mechanism for promoting adherence to mammography and diagnostic follow-up for women with abnormal mammogram results. Additionally, we expect that this approach is applicable to a wide variety of patient populations, including other underserved minority groups. ACKNOWLEDGMENT The authors thank Eunice King, PhD, for her assistance in developing the telephone counseling protocol and Alicia Blake for her help in instrument development.
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