1. Understanding Lack of Pap Follow-up: Women Clients’ Perspectives Jill M. Abbott, DrPH 1, Kathryn J. Luchok, PhD 2, Ann L. Coker, PhD 3, and Irene Prabhu Das, MSPH 4 1 Ohio State University, Comprehensive Cancer Center 2 University of South Carolina, Department of Health Promotion, Education, and Behavior 3 University of Texas at Houston Health Science Center, School of Public Health 4 South Carolina Department of Health and Environmental Control

2. Study Objective To better understand women’s perspectives concerning adherence to abnormal Pap test follow-up Identify facilitating and hindering factors Describe primary coping strategies Explain how these factors affect women’s adherence to follow-up recommendations

3. Background Pap test screening has increased dramatically in recent decades Understanding multiple factors that affect adherence can increase program effectiveness

4. Provider Client Abnormal Pap Detected Intention to Adhere to Follow-Up Adherence to Follow-Up Nature of Provider – Client Communication Practice support Self-Efficacy Knowledge Expectations Competing priorities Fear of cancer System/Environment Working Conceptual Model

5. Cervical Cancer in South Carolina *8 th in USA in cervical cancer mortality *10.25 per 100,000 cervical cancer incidence

6. Study Population SC Breast and Cervical Cancer Early Detection Program clients Had an abnormal Pap test between 1999 and 2000 African American and Caucasian women Acknowledge receipt of abnormal Pap test results Both adherent and non-adherent women

7. Methods Semi-structured Interview Guide 40 items Expert reviewed, pilot-tested and revised Content: Facilitating and hindering factors Coping strategies Sociodemographic variables

8. Methods Data Collection 19 in-depth, in-person interviews Approximately 60 minutes each Audiotaped with consent $20 incentive Data Management Interviews transcribed verbatim Reviewed for quality control

9. Methods Data Analysis Constant comparison method “Paper and pen” note-based analysis Qualitative data managed using NVivo 2.0 (QSR Inc.) Descriptive statistics analyzed in Excel

10. Participant Characteristics N=19 Women Mean age = 59.47 years 53% African American (n=10) 68% had GED, high school diploma or higher (n=13) 37% married (n=7) 53% adherent (n=10)

11. Results Barriers to obtaining complete and timely follow-up care Client/personal factors Living on restricted income Meeting the competing needs of significant others Living with co-morbid conditions Environmental factors Transportation

12. “Well, I desire to have medical insurance, but I can’t afford it…and I want the care. I want to take care of myself.” “Well, my husband, he had to go to the doctor on Monday and wanted me to go with him…So, that made me cancel mine and go with him…” “My father was really sick in Oklahoma, and he passed away during that time, and I put this off until I could get that took care of.” “Oh, transportation because, where I had to go, it’s about 60/65 miles one way. Sometimes I had to borrow the money to get there, you know, for gas.”

13. Results Factors facilitating adherence to follow- up recommendations Provider factors Clinicians’ sensitivity and concern Clinic staff’s friendliness Assistance with scheduling follow-up appointments Reminders about needed follow-up or previously scheduled follow-up appointments

14. “Just to know that somebody is concerned about my health is good…and they made me feel comfortable.” “He was really great about that. He saw that I did not want to have the surgery, so he came up with these other things.” “Other than be nice and friendly…They shouldn’t just scoot you in there and scoot you out, you know, like you don’t have it.”

15. Results Most women (n=17) identified concern for their own health as a facilitating factor “Just knowing that I was going to get the results…get help for myself and just thinking about the good that it is going to be for me.”

16. Results Predominant coping strategies Problem management Emotional regulation “At first, I asked, ‘Why?’ Secondly, I got at home by myself, cried, and I got upset, and you have to relieve this built in tension. And then I prayed and asked God to help me and guide and give me strength to go through this. That was it.”

17. Results Few differences between adherent and non-adherent women More non-adherent women identified transportation as a barrier Only non-adherent women used planning More adherent women used prayer and active coping

18. Discussion Low-income women in SC face numerous challenges in their daily lives Support of family and friends may not be an important consideration Interactions with clinicians and clinic staff play a major role in women’s experiences

19. Recommendations Develop clinical and community interventions to increase adherence that are tailored for higher-risk populations Incorporate components that acknowledge and mediate their daily struggles Develop clinical and community interventions to include aspects of the coping process Use of adaptive coping responses may improve adherence rates

20. Acknowledgments Thanks to the women who gave freely of their time to recount their experiences. This project was supported by a grant from the Centers for Disease Control and Prevention (CDC). Grant Number U48/CCU409664-09. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of CDC.