Effectiveness of a Kansas City, Jail-Based Intervention to Improve Cervical Health Literacy and Screening, One-Year Post-Intervention

Abstract

Purpose:

To assess effectiveness, 1-year post-intervention, of a program delivered in jails with women to improve cervical health literacy (CHL) and up-to-date Papanicolaou (Pap) screening.

Design:

Pre-post design to evaluate Pap screening and CHL effects 1 year after our original randomized wait-list control study.

Setting:

Surveys conducted in Kansas City, 2015 to 2017 (baseline in 2014).

Participants:

Adult women (n = 133).

Intervention:

One-week (10-contact-hour), small-group, CHL program.

Measures:

Surveys to assess CHL components and up-to-date Pap screening.

Analysis:

χ² and t tests, followed by best-subsets logistic regression using sociodemographic and CHL components to fit an optimal model for up-to-date screening 1-year post-intervention.

Results:

73% (133/182) women retained at 1-year. From pre-intervention, 6 of 8 CHL components improved (.01 > P > .001). Up-to-date Pap screenings increased over pre-intervention (72%−82%, P < .05). Best-subset model to predict up-to-date screening included age; public benefits; medical insurance; 5 CHL components (knowledge, benefits, barriers, seriousness, susceptibility).

Conclusion:

A brief intervention to promote cervical health literacy, delivered with women during a jail detention, can lead to sustained improvements in CHL and prevention practices.

Purpose

The Sexual Health Empowerment (SHE) study investigated effectiveness of a brief intervention with women in jails to improve cervical health literacy (CHL) and up-to-date cervical cancer screening.¹ Jail-incarcerated women report 4 to 5 times higher rates of cervical cancer than women who are not incarcerated.^2–4 Previous work with incarcerated women has demonstrated incarcerated women both report higher rates of abnormal Pap exams and cervical cancer diagnosis and also lack understanding of the purpose of Pap exams, the relationship between sexually transmitted disease and cervical cancer, and their ability to prevent cervical cancer.^5–7 Sexual Health Empowerment is the only longitudinal intervention to address a range of factors associated with cervical cancer risk among justice-involved women. This report describes the 1-year postintervention results of SHE on CHL and cervical cancer screening.

Method

Design

This study follows up on a parent study in which we used a randomized waitlist-control design to evaluate initial effects of the SHE program on CHL.¹ We used a pre-post design in the follow-up to measure changes in up-to-date Pap screening and CHL after 1 year. It was necessary to use a pre-post design, since by end of week 2 for each week of the initial study all of the women had received the intervention. We elected to provide the intervention to both groups because of the cervical health disparity incarcerated women face and lack of other interventions.

Sample

The 1-year follow-up surveys were administered 2015 to 2017. Our Kansas-City-based study team enrolled an initial convenience sample of 182 women (mean age 34.5) in 3 Kansas City-area urban jails for participation in the SHE intervention.¹ Women were eligible if they were 18 years of age or older, could speak and understand English, and did not display disruptive behaviors. Participants were recruited weekly by study staff visiting facilities and by jail staff through word of mouth. Eligible volunteers gave written informed consent with institutional review board (IRB)-approved procedures.

Measures

Surveys (146 items) for 1-year follow-up were administered in-person in the community, by phone, or in jail if women were still detained or rearrested. The primary dependent variable was up-to-date Pap screening, defined as having had a Pap test in the past 3 years. The baseline survey (158 items) was delivered during the intervention on day 1 each week, before random assignment of participants to groups. Survey questions were selected from validated instruments to address 8 components of CHL: Pap test knowledge, beliefs (benefits, barriers, seriousness, susceptibility, motivation), self-efficacy, and confidence for screening.¹ Other items included up-to-date Pap screening and other health history—reproductive, mental, trauma, and substance use—health-care interactions; insurance and medical home; past criminal justice involvement, and sociodemographic characteristics. We provide details about the survey development and SHE curriculum in a previous publication.¹

Intervention

Sexual Health Empowerment was conducted in jails over 5 days (10 contact hours, mostly mid-morning) with 2 to 10 participants each week. Based on a needs assessment and literature on health literacy adapted to a cervical health focus,^5–6 lessons addressed CHL and community-building through shared knowledge and experience.^1,6 Sessions were administered by an experienced sexual health educator and assistant. The study protocol was approved by the IRB at the University of Kansas Medical Center.

Analysis

Bivariate tests (eg, χ² test, t test, correlation), comparing baseline to 1-year follow-up, evaluated CHL components, changes in cervical health prevention practices, and aspects of socioeconomic context associated with increased risk of cervical cancer. Best-subsets logistic regression identified components of CHL and socio-demographic factors that optimally explained up-to-date Pap screenings. Best-subsets calculates all possible combinations and provides optimal sets based on predictability, model parsimony, and model-data fit.⁸

Results

A total of 133 (73.1%) of 182 women who completed the intervention completed the follow-up survey.¹ Completers had socio-demographic characteristics and cervical health risk factors similar to those who did not participate in the survey (P ≥ .1). Table 1 shows statistically significant differences in participant, CHL, and Pap screening characteristics pre- and postintervention.

Table 1.

Participant Characteristics.^a

	Baseline	1-Year Post
Hard drug use (cocaine/crack, heroin, meth, PCP)	80 (60.2)	20 (15.0)b
Exchange of sex (in past 1 year)	41 (30.8)	17 (12.8)b
Up-to-date Pap test	96 (72.2)	109 (82.0)c
Pap test knowledge	11.46 ± 2.82	13.14 ± 1.80b
Pap test beliefs
Seriousness	3.11 ± 0.74	2.92 ± 0.69d
Susceptibility	2.72 ± 0.87	2.33 ± 0.78b
Motivation	2.94 ± 0.92	3.26 ± 0.85b
Pap test self-efficacy	3.10 ± 0.87	3.49 ± 0.75b
Health-care navigation confidence	3.01 ± 0.97	3.34 ± 0.73b

^aN = 133. Baseline surveys: Conducted in jail, prior to intervention. 1-year post-intervention surveys: Conducted 82% community; 18% reincarcerated, jail/prison.

^bStatistically significant variables pre-post intervention are shown: P ≤ .001.

^cP ≤ .05.

^dP ≤ .01.

At 1-year postintervention, 82% (n = 109) of participants reported up-to-date Pap screenings, compared to 72.2% at baseline (P < .05, d = 0.38). Women up-to-date on Pap screening perceived significantly lower barriers for screening than those not up-to-date (P < .001, d = 0.74). Although not statistically significant, at 1-year postintervention women who were newly screened (n = 15) perceived greater benefits (d = 0.69) and lower barriers (d = 0.50) for screening compared to those who remained unscreened (n = 12).

Best-subsets logistic regression fitted a total of 8192 possible models (= 2p − 1, where p = number predictors = 13) and identified a set of socio-demographic factors and intervention components as optimal for predicting up-to-date Pap screenings: age, public benefits, medical insurance, and cervical cancer knowledge and beliefs (ie, benefits, barriers, seriousness, and susceptibility; R² = 0.17, C_p = 4.16, BIC = −27.74, area under the curve = 0.84). Among predictors in the optimal sets, only age was statistically significant—for example, odds of up-to-date Pap screening decreased by 5% for each 1-year increase in age (P < .05).

Discussion

Summary

Women with a history of incarceration report much higher rates of cervical cancer and abnormal Pap test results than women without this history.^2,3,8 One year after our brief jail-based CHL intervention, we found higher CHL scores, higher rates of up-to-date Pap screening, and significant relationships between intervention components of CHL and up-to-date Pap screening.

Significance

Interventions delivered in jails or prisons to increase Pap screenings are rare⁹; most research on cervical cancer prevention with incarcerated women measures cervical cancer, abnormal Pap prevalence, Pap screening and follow-up rates, and factors associated with those variables.^2,7,10 Studies show rates of screening for incarcerated women are comparable to non-justice-involved women’s rates.^11–13 Our participants’ preintervention rates (72%) were atypical: nearly 10 percentage points lower than the local average (80.1%).¹⁴ Yet 1-year postintervention, our participants surpassed that average, with 82% reporting up-to-date Pap screening. With deaths from cervical cancer continuing to number in the tens of thousands each year and disparately high rates of cervical cancer diagnosis for justice-involved women, findings for low-cost, easy-to-deliver interventions in novel settings are important.

Limitations

The 1-year follow-up study was limited by the lack of control group and self-reported Pap screening data. The wait-list design ensured that all women received the intervention— an ethical strength, given our setting and population—but absence of control in the follow-up study meant our results could reflect influence of other factors. We know of no major changes in the external environment that would affect scores with women in our study (eg, no change during the study period in the lack of Medicaid expansion in either Missouri or Kansas or local programming to increase Pap screenings). Future interventionalists might attempt similar studies if possible with a no-intervention or comparison group to better control for internal validity.

So What?

What is already known on this topic?

Justice-involved women experience abnormal Pap exams and develop cervical cancer at higher rates than other women. Few interventions have attempted to increase screening rates with this population or have sought to follow-up to measure effects longitudinally.

What does this article add?

We offer evidence that cervical health literacy and up-to-date Pap screenings can be significantly improved at 1-year after a brief intervention delivered during a jail detention.

What are the implications for health promotion practice or research?

Our results suggest that a brief CHL empowerment-based intervention implemented with women during a jail detention may reduce health disparities in an under-served population.