Why Women Don’t Return: Nurse Perspectives on Follow-Up Care After Abnormal Cervical Cancer Screening Results in Mississippi’s Public Health System

Abstract

Objective:

To explore public health nurses’ perspectives on reasons women in Mississippi may fail to receive follow-up care after abnormal cervical cancer (CC) screenings.

Background:

Mississippi’s high cervical cancer mortality rate poses a significant public health challenge. Understanding public health nurses’ perspectives on barriers to follow-up may help improve timely diagnostic care.

Methods:

This qualitative descriptive study used focus groups to examine barriers and facilitators to follow-up care. Sixteen registered nurses who manage follow-up care in Mississippi public health clinics participated in five virtual focus groups. Participants represented diverse ages and experience levels (mean age 45.5 years; mean 10 years’ experience). Semi-structured interviews elicited perspectives on patient, nursing, and system-level barriers and facilitators. Data was thematically analyzed.

Results:

Three overarching barriers emerged: patient-level (limited health literacy, financial constraints, unreliable contact information), nursing-level (language differences, staffing shortages, declining motivation), and system-level (underuse of electronic health records, limited access to specialty care). Facilitators included early patient education, proactive communication, language resources, adequate staffing and training, and full utilization of electronic health record tools.

Conclusion:

Nurses identified multilevel barriers and facilitators influencing CC follow-up in Mississippi. These insights can inform strategies to improve follow-up care and reduce CC disparities in rural and underserved populations.

1 |. Background

Cervical cancer (CC) remains a significant U.S. public health concern, marked by disparities in incidence and mortality (Burger et al. 2016). National analyses indicate that cervical cancer incidence and mortality are markedly higher among women living in rural areas and among Black women, including 40% higher mortality in rural counties and persistently elevated mortality among Black women (Amboree et al. 2025). Although largely preventable, control depends on completing a multi-step process—HPV/Pap testing, timely colposcopy and biopsy, and treatment of detected lesions (Perkins et al. 2023).

In the state of Mississippi, where nearly 80% of counties are rural and the population includes a higher proportion of Black residents (37.8% vs. 13.4% nationally), CC mortality remains disproportionately high at 3.6 per 100,000 vs. the national average of 2.2 per 100,000 (Mississippi State Department of Health 2021; National Cancer Institute 2023). Although CC disparities are linked to insufficient screening, Mississippi reports Pap testing rates are above the national average (Centers for Disease Control and Prevention and National Cancer Institute 2020). Despite having higher-than-average screening rates, Mississippi continues to experience a high burden of CC (Risley et al. 2020).

A statewide cohort analysis observed that 57% of women requiring follow-up colposcopy did not have documentation of the recommended follow-up, leaving them at an elevated risk for undetected or untreated progression to cancer (Reaves et al. 2024; Risley et al. 2021). Related work has further identified specific individual and geographic factors associated with follow-up completion in this same population, reinforcing the need to understand the barriers that nurses observe firsthand (Hall et al. 2026). In comparison, national analyses indicate that between one-half to two-thirds of patients complete diagnostic colposcopy or other guideline-concordant evaluation following an abnormal cervical cancer screening result (Cheng et al. 2024; Doubeni et al. 2018). A recent national study similarly found that the overall rate of colposcopy completion following an abnormal cervical cancer screening result was 3.9% across all races, ethnicities, and age groups, and that this rate declined nearly three-fold—from 6.4% to 2.1%—as age increased (Soltani et al. 2026). According to the National Cancer Institute Center, high CC rates may reflect systemic issues in health care access, such as limited availability of specialty colposcopy services in rural areas, inconsistent care coordination between screening and follow-up providers, and underutilization of tracking systems to identify patients lost to follow-up, underscoring the need for comprehensive strategies to improve follow-up care (Freeman and Wingrove 2005; Varon et al. 2024). Public health nurses directly communicate abnormal results and coordinate follow-up, giving them a distinct, firsthand view of the patient and system factors that influence whether women return for care—making their perspectives central to understanding this problem.

1.1 |. Research Question

This investigation explored the perspectives of nurses in Mississippi’s public health system on: “Why do some women in Mississippi fail to receive follow-up care after an abnormal cervical cancer screening test result?”

1.2 |. Design

We conducted a qualitative, descriptive study that examined public health nurses’ perspectives on the interplay of patient, practice, and system variables to identify key barriers and facilitators to patients’ return for cervical care. Qualitative descriptive designs provide a low-inference summary of participants’ experiences in their own words, making them well suited to capturing nurses’ firsthand perspectives on follow-up care (Villamin et al. 2024). Reporting was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al. 2007).

1.3 |. Sample

Participants were registered nurses employed in Mississippi public health clinics who facilitated follow-up efforts. Nurses were recruited via statewide email invitation to ensure geographic representation. Practice setting (rural vs. urban) was not collected; however, participants were drawn from a public health system serving a predominantly rural state. Sixteen nurses participated across five focus groups. No compensation was provided. No prior relationships existed between the researchers and participants.

1.4 |. Ethical Considerations

The study was IRB-approved, with electronic consent obtained via REDCap. Participant identities were anonymized, and data were securely stored with access restricted to the research team.

1.5 |. Measures

The principal investigator, an experienced qualitative researcher, applied prior focus-group experience to guide facilitation and minimize bias. Two additional research team members attended each session to take notes. All focus groups were conducted in a private virtual setting to maximize confidentiality and avoid any influence from workplace dynamics. Video capability was disabled and participants were instructed not to use names or other identifying information. Group size ranged from two to five participants, and discussions averaged 39 min.

A semi-structured interview guide was developed a priori to broadly explore barriers and facilitators to follow-up care. Guide development was informed by clinical experience, relevant literature, and input from six women’s health experts. The guide was intentionally open-ended to remain consistent with a qualitative descriptive approach—which prioritizes a rich, low-inference summary of participants’ own accounts rather than interpretation through a pre-existing theoretical lens (Villamin et al. 2024). Participants were asked to describe the typical sequence of care—from the initial screening appointment through follow-up efforts—and to explain how missed (“no-show”) appointments are managed.

Core questions focused on:

• Patients’ ability to return

• Patients’ motivation to return

• Staff or nursing efforts

• System processes

• Identifying actions or strategies to improve follow-up

Data saturation was monitored, and by the fifth focus group, no new concepts emerged. Sessions were recorded and transcribed verbatim by the research team.

1.6 |. Analytic Strategy

Data was analyzed using an inductive thematic analysis approach (Braun and Clarke 2006). The principal investigator and two research team members coded and compared the data using a three-stage iterative process of initial coding, category development, and theme generation. Coding differences were resolved through discussion, with transcripts revisited for clarification. An audit trail was maintained to support reliability.

2 |. Results

Five virtual focus groups were conducted with a total of 16 clinic nurses, with a mean age of 45.5 years and 10 years of nursing experience. Three overarching barriers to follow-up care were identified: patient-level, nursing-level, and system-level (Table 1). Patient-level barriers included limited health literacy, financial constraints, and unreliable contact information. Nursing-level barriers included language differences and staffing-related constraints that affected follow-up efforts. System-level barriers included underutilization of electronic health record (EHR) and limited access to specialty care.

Table 1.

Perceived Barriers and Facilitators to Follow-up Care

Theme/Subtheme	Brief Description	Sample Quote
Barriers: Patient-Level Factors – Health Literacy	Patients having limited understanding of seriousness and urgency	“They’re afraid of cancer and it’s better to not know than it is to prevent something from happening. Even though you take the time, you explain it, you go through it, the health literacy is so low.” “Sometimes you talk to them as much as you can, they don’t feel bad. So, they don’t really think that this is really bad, so they just kind of put it on the back burner, even though you talk to them and talk to them.”
Barriers: Patient-Level Factors – Financial Constraints	Patients experiencing transportation, cost, and work barriers	“I’ve had people tell me before that they just didn’t have a ride and couldn’t make it back.” “In a 10-county area, we have one site that does colpos and it can be some of the area is an hour to hour and a half away. … people just don’t have the money to drive great distances with the fuel cost.” “They just can’t afford to be off (work) that day.”
Barriers: Patient-Level Factors – Unreliable Contact Information	Patient-driven changes in contact details limiting follow-up	“Having a good contact number is also another issue that we have… their phone number is a good number, but it gets disconnected because they don’t have the sources to pay it, but we still don’t have another way to contact them.” “Most cases their phone number has changed by the time they left our clinic. And one of our big barriers is that they change phone numbers constantly, or they change addresses.”
Barriers: Nursing-Level Practice Impediments – Language Differences	Nurse–to-patient communication challenges	“One of our main barriers is the language barrier. We have a lot of patients that speak different languages. Mostly Spanish. So that will be a problem as far as, you know, follow-up letters and things. They send a letter. They may not be able to read it.” “We do have lot of Hispanic patients, so sometimes the language can be a barrier. Getting them to understand what exactly this is for and the importance of it.”
Barriers: Nursing-Level Practice Impediments – Staffing Shortages and Declining Motivation	Nursing workload impacts on follow-up efforts	“It gets lost in the shuffle. We have 100 people that we have to get in touch with. And if I tried you one time, and I didn’t get you, or I left you a voicemail, - my box is checked, I’m not going back.” “ To devote the time to make a phone call and then follow that up with a letter or, you know, - it just takes time and, you know, we don’t always have that.”
Barriers: Health System-Level Processes – Electronic Health Records (EHR) Underutilization	Delayed adoption of messaging features and limited EHR training	“I’m not sure when we will get to that point; sending a letter in My Chart. I mean the younger generation, they like My Chart and they like notifications, so I think that would be a good thing. You know, once we are able to use a letter in My Chart than by mail, because then maybe they would receive it.” “One barrier for us is just knowing the program, it’s kinda new to us, just learning and having the proper training on the programs that we’re using to see our patients with.”
Barriers: Health System-Level Processes – Access to Care	Limited appointment availability and distance to clinics	“I’m in a nine-County district and there’s only two clinics that do Colpo. So, they may live a good piece away from where they need to go to have that procedure done. It’s not like they’re in the same town.” “We’re short staffed, so we’re not available 5 days a week at a lot of clinics. So that’s, unfortunately, that’s a disadvantage to some of our patients, especially for their work schedule and things like that…our biggest barriers, you know, the clinics not being open every day for patients.”
Facilitators: – Targeted Patient Education	Early education improves engagement	“Take 5 or 10 minutes before placing hands on the patient to engage the patient in why screening and the importance of follow-up.” “Don’t tack the education at the end when they are already thinking of 10 other things”
Facilitators: – Proactive communication	Use of reminders and communication tools	“Texting system for follow-up remarks, confirmations, and reminders.” “My Chart app… anytime we’re putting anything in there - if they see it… I’ve had a patient call, she saw it in the notes. So, then when she was able to call back, so we can talk about, you know. And, of course, she had told me she had changed your number and things like that. But that was a good way for us to get that patient in particular back.”
Facilitators: – Language resources	Interpreter and translation support	“Having someone here to interpret when they’re here and provide the education because, you know, there is a language barrier.”
Facilitators: – Sufficient Staffing and Improved Training of Personnel	Adequate staffing and training	“That keeps them coming back and, um, just availability of, you know, staff being here.” “Availability of the nurse, or the provider, keeps them coming back when they feel like they’re going to be treated with dignity and concern.” “Would be helpful for nurses coming in to have a little bit of exposure to the COLPO process, see it hands on,”
Facilitators: – Full Utilization of the EHR	Use of patient portal and scheduling tools	“Send a link allowing patients to pick an appointment themselves.” “Give the patient multiple options to access scheduling or information… because everybody’s going to come from a different place.”

Participants also identified facilitators to improve follow-up, including targeted patient education, proactive communication strategies, availability of language resources, adequate staffing and training, and improved use of EHR tools. Detailed descriptions and representative quotes for each theme and subtheme are presented in Table 1.

3 |. Discussion

This study identified three overarching, multilevel barriers to follow-up care after an abnormal cervical cancer screening result—patient-level, nursing-level, and system-level—along with corresponding facilitators identified by public health nurses across Mississippi. These findings directly address the study and contribute a frontline nursing perspective on barriers to follow-up care after an abnormal cervical cancer screening.

Prior studies have documented gaps in follow-up after abnormal CC screening, particularly in underserved and rural settings (Reaves et al. 2024; Risley et al. 2021). However, most investigations focus on failure to follow-up data rather than the experiences of those attempting to facilitate follow-up. This study illustrates how nurses interpret and navigate barriers at the patient, nursing, and system levels, adding depth to current evidence on why follow-up disparities persist. These findings are in-line with additional literature that support missed follow-up results from intersecting—not isolated—factors, underscoring the need for coordinated system- and practice-level interventions rather than approaches focused solely on patient behavior change (Aguilar et al. 2026). This is also consistent with work from the PROSPR Consortium, which emphasized that improving follow-up after abnormal cancer screening requires systems-based accountability across organizations and care processes (Doubeni et al. 2018). While grounded in Mississippi’s public health system clinics, the themes reflect barriers that can arise in rural or resource-constrained settings. Therefore, the implications may extend to comparable public health systems working to strengthen follow-up care.

Facilitators identified were consistent with prior literature suggesting that enhanced electronic communication processes, culturally appropriate patient education, and improved staff training represent scalable strategies to improve follow-up after abnormal cervical cancer screenings (Aguilar et al. 2026; Doubeni et al. 2018). These approaches address multilevel contributors to follow-up care and have the potential to inform public health practices and policies aimed at reducing persistent disparities in cervical cancer care. These findings suggest several areas for future intervention—enhanced EHR notification tools, stronger staffing models, and culturally tailored education. Future studies should incorporate patient perspectives and evaluate multilevel interventions informed by the operational challenges that nurses described. Lastly, this study adds to existing literature by providing frontline nurse perspectives on operational barriers to follow-up, which are less frequently captured in prior research.

3.1 |. Public Health Implications

Our findings illustrate how social determinants of health, such as economic stability, health literacy, and access to care, influence follow-up care after abnormal CC screening. Prior work has shown that patient-level barriers are often rooted in these factors and are further compounded by challenges at the nursing and system levels (Aguilar et al. 2026; Doubeni et al. 2018). Improving outcomes will require interventions that address both care processes and the underlying social context. The identified facilitators offer practical strategies to promote health equity and reduce cervical cancer prevention care disparities.

Our findings highlight the role of social determinants of health—including economic constraints, health literacy, and access to care—in shaping follow-up after abnormal cervical cancer screening. These factors contribute to persistent disparities, particularly in underserved populations (Doubeni et al. 2018; Freeman and Wingrove 2005; Varon et al. 2024). Consistent with prior evidence, gaps in follow-up reflect both patient-level challenges and system-level inefficiencies (Cheng et al. 2024; Aguilar et al. 2026). Improving follow-up will require coordinated strategies beyond patient education, including strengthened care processes, communication strategies, and access to services. Identified facilitators—such as proactive communication, culturally appropriate education, and improved staffing—offer practical approaches to promote health equity and reduce disparities.

3.2 |. Strengths and Limitations

This study provides important insight by highlighting the perspectives of public health nurses who directly manage follow-up after abnormal CC screening. The use of a semi-structured guide informed by women’s health experts and a systematic analytic approach strengthened the credibility of findings.

Several limitations should be noted. The small, Mississippi-only sample limits generalizability, and findings reflect only nurses’ perspectives. Virtual focus groups without video limited engagement by reducing interaction and nonverbal cues. Nonetheless, the study provides an important foundation for understanding barriers and facilitators to follow-up care and guiding future interventions.

4 |. Conclusion

Public health nurses in Mississippi identified multilevel, intersecting barriers spanning patients, nursing practice, and health system processes—that impede follow-up care after an abnormal cervical cancer screening result, along with concrete facilitators that may improve return-to-care rates. These frontline perspectives emphasize that improving follow-up requires coordinated, systems-level strategies rather than patient-focused interventions alone. Addressing these multilevel barriers offers a meaningful opportunity to reduce persistent cervical cancer disparities among rural and underserved populations in Mississippi and in comparable public health systems.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.