Facilitating Follow-Up Adherence for Abnormal Pap Smears
Facilitating Follow-Up Adherence for Abnormal Pap Smears
Objective: Previous studies have suggested that psycho-educational interventions delivered by
 telephone improve adherence to initial colposcopy after an abnormal Pap smear. To further
 explore strategies for enhanced follow-up to medical care recommendations, we studied the
 impact of a theory-guided cognitive-affective barriers counseling intervention, delivered at
 2-4 weeks before the colposcopy appointment, for inner city women. The comprehensive
 telephone barriers intervention was compared to an enhanced comparison group and a group that
 received tailored print materials.

 Methods: Participants (N = 211) were recruited through a colposcopy clinic and randomly
 assigned to: 1) telephone assessment of barriers to follow up adherence recommendations
 combined with tailored telephone barriers counseling; 2) telephone assessment combined with
 tailored barriers print brochure; or 3) telephone assessment with no barriers counseling.
 Participants were assessed at baseline, 1-week, 9 and 15 months post-colposcopy.
Objective: Previous studies have shown that theory-based, tailored telephone barriers
 counseling significantly improves adherence to a colposcopy appointment after an abnormal pap
 smear result among low-income, minority women. This study built on these research findings
 and explored the efficacy of a state-of-the-science telephone counseling intervention
 utilizing a more rigorous study design. This enhanced counseling intervention was tailored to
 individual's distinctive cognitive-affective barriers profile, as assessed by the
 Cognitive-Social Health Information Processing (C-SHIP) model-guided barriers assessment
 tool, and with counseling messages targeted to all five domains of individual's barriers to
 adherence. In addition, the current study design was improved in two ways. First, the
 comparison group in this current study was an enhanced one that received a notification
 letter, assessment of cognitive-affective barriers by telephone, and a telephone appointment
 reminder. Second, this study had a longer follow-up period to allow testing of the
 intervention effect beyond initial colposcopy adherence. The participants were followed for
 15 months post-colposcopy so that participants' adherence to medical follow-up
 recommendations (if any) within the 12 months after initial colposcopy can be collected and
 studied. Adherence to medical follow-up at 6 months and 12 months was measured at 9 months
 and 15 months, respectively, to allow 3 months for rescheduling, attending, and recording of
 the appointment. Overall, this study tested whether an enhanced tailored telephone barriers
 counseling intervention improve adherence to medical follow-up after abnormal pap smear among
 low-income, minority women.

 Methods:

 METHODS Participants (211) were randomized to the following baseline conditions: a) standard
 care (SC), i.e., a cognitive-affective barriers (CAB) assessment delivered via phone, receipt
 of a notification letter from physician regarding abnormal Pap test result and need to
 undergo colposcopy, and also including appointment date and clinic contact numbers, plus
 telephone confirmation and post-card appointment reminder; b) SC plus CAB counseling
 delivered by phone (CAB-C -T), i.e., culturally-relevant/sensitive barrier-specific messages
 drawn from a pre-developed library designed to counsel individuals regarding their specific
 barriers to adherence, e.g., by increasing risk-related knowledge, providing accurate outcome
 and self-efficacy expectancies, addressing health-related values and goals, moderating
 risk-related affect, or offering active plans and strategies to assist with self-regulation;
 c) SC plus CAB counseling delivered via Mail-Home Print Material (CAB-C-P), which included
 exactly the same applicable messages as were delivered by phone, but in print form. The
 tailoring of messages to a participant's cognitive-affective barriers profile was based on
 the two barriers in each of the five Cognitive-Social Health Information Processing (C-SHIP)
 categories (a total of 10 messages) that she rated most important on a five-point scale.
 There were 23 cognitive-affective adherence barriers grouped into the following C-SHIP
 categories: 1) risk-related encodings/perceptions (i.e., purpose of colposcopy, presence and
 progression of HPV-related disease); 2) risk-related expectancies and beliefs (i.e.,
 confidence in ability to keep appointment, fatalistic beliefs about cancer); 3) risk-related
 values and goals (i.e., maintaining modesty, importance of having children); 4) risk-related
 affect (i.e., worries about necessary procedures and/or progression of disease, concerns
 regarding fertility); and 5) risk-related self-regulation (i.e., remembering appointment,
 overcoming child-care or work-related conflicts, transportation difficulties, ability to
 manage any negative risk-related affect). With regard to assessments, they were conducted at
 the following time points: baseline, and 1-week, 9-month, and 15-month post-colposcopy and
 included the following: the CAB assessment; background variables, including demographic
 (e.g., gender, age, ethnicity, education, marital and employment status, household income,
 number of children); medical and screening history (e.g., cancer diagnosis, previous Pap
 smears and frequency; breast exams (self and clinical); mammograms and abnormal results;
 results of the index colposcopy and physician recommendations from medical records; a
 potential moderating dispositional variable, attentional style (Monitoring-Blunting Style
 Scale); potential mediating variables, including affective variables (Spielberger State-Trait
 Anxiety Inventory, the Center for Epidemiological Studies-Depression Scale), and
 cognitive-affective process variables (knowledge, risk perceptions, expectancies and beliefs,
 affect, values and goals, regulatory skills); outcome variables, including adherence to
 initial diagnostic colposcopy and to 6- and 12-months colposcopically-based follow-up
 diagnostic and medical management recommendations, and an intervention evaluation. All
 assessments used scales developed in previous research, except the Powe Fatalism Inventory
 used to assess fatalism and the Revised Impact of Events Scale used to assess affect (i.e.,
 stress-related intrusive and avoidant thoughts). Assessed at baseline were background
 variables (except medical recommendations), the moderating variable, and all mediating
 variables. The cognitive-affective barriers were assessed only at baseline. Assessed at
 1-week post-colposcopy and at the 9-month and 15 month follow-ups were all mediating
 variables (except the cognitive-affect barriers) and outcome variables. The medical
 recommendations were assessed only at the 1-week post-colposcopy. Medical history was also
 re-assessed at the 15-month follow-up relating to the interim period from baseline.
Inclusion Criteria:

 -  women 18 years old or older

 -  have recently received an abnormal Pap smear indicative of oncogenic HPV

 -  have been referred for initial colposcopic evaluation at the Women's Care Center at
 Temple University Hospital

 -  able to communicate with ease in English

 Exclusion Criteria:

 -  unable to communicate readily in English

 -  do not have access to a telephone

 -  have a history of any malignancy

 -  display current evidence of positive invasive carcinoma of the cervix

 -  display presence of another life-threatening medical condition

 -  show evidence of dementia

 -  prior participation in research study

 -  HIV