Predictors of cervical cancer screening for rarely or never screened rural Appalachian women.

Women who have not had a Papanicolaou (Pap) test in five years or more are at increased risk for developing invasive cervical cancer (ICC), 1 as one of the most common risk factors for this type of cancer is a deficient screening history.2 Pap smear screening can detect precancerous lesions which may be treated effectively and can result in the prevention of cancer development. The American Cancer Society1 reports that 60–80% of women newly diagnosed with ICC had not received a Pap test in the previous five years. Indeed, ICC is nearly completely preventable if screenings are consistent with established recommendations. Despite these encouraging facts, cervical cancer screening rates remain at less than optimal levels. Studies have shown that certain women, including minorities and low-income women, are less likely than other groups to be screened for cervical cancer and less likely to be diagnosed at early and more treatable stages of cancer.3–6 Lack of a regular care provider, absence of provider’s recommendation, high cost of health care/insurance, inconvenience, inadequate English proficiency, and lack of social support have been identified as barriers to timely screening among many of these women.4, 7–9 Although cervical cancer mortality has decreased over recent decades, certain groups continue to experience a greater burden from ICC. Like other groups of historically underserved women, Appalachian women have a lower prevalence of Pap testing and a higher rate of ICC than women in other parts of the United States.5, 10 Appalachian Kentucky has an ICC incidence rate (15.0/100,000) approximately 67% above the national average (9.0/100,000).11,12 At particularly elevated risk are those who are rarely- or never-screened, operationalized as those who have not had a Pap test in the previous five years or more, or ever, in their lifetimes. Since these rarely- or never-screened women are at the highest risk for developing ICC, they constitute an important target for screening interventions to reduce the incidence of ICC in Appalachian Kentucky. Several studies have examined the determinants of cervical cancer screening among Appalachian women. These studies have elucidated screening barriers that include the health care system (i.e., availability of services, cost of care), the environmental or community context, and individuals’ characteristics.13 For example, the Appalachian region struggles to maintain an adequate supply of health care professionals. 14 This endemic shortage makes access to preventive health care a challenge for Appalachian women, directly contributing to lower screening rates than are reported nationally.15 Environmental and community factors thwarting screening include poverty, lack of transportation, and low rates of adequate health insurance.16 Finally, individual characteristics, including culturally-based beliefs and inadequate knowledge, may exert a strong influence on the receipt of Pap tests. For example, some researchers have posited that culturally-based beliefs like fatalism undermine Pap tests and other cancer screening 17, Schoenberg and colleagues18 found that middle-aged and older Appalachian women may not receive Pap tests due to a constellation of these factors, including lack of regular reproductive health care, competing demands, and uncertainty about screening recommendations, given the change from one to two year screening interval recommendations and ambiguity about the ages at which to start and stop screening. Although these insights are essential to stem elevated rates of ICC, one limitation of most existing research is a nearly exclusive focus on women who have not been screened within the previous five years. Since the risk of ICC becomes much higher for women unscreened for five or more years, critical information is lacking on a most susceptible subgroup: Appalachian women who have not been screened in five years or more, or ever in their lifetimes.1 The purpose of this paper is to address this gap in knowledge regarding cervical screening behaviors by conducting an analysis of baseline data from a community-based intervention trial, Faith Moves Mountains, which aimed to increase Pap test use among Appalachian women who were out of compliance with screening recommendations. 19 The current analysis examined the unique sociodemographic and personal characteristics that predicted belonging to the group of rarely- or never-screened Appalachian women (i.e., last Pap test five or more years ago, or never), compared with the group of more recently-screened women (i.e., last Pap test more than 12 months but less than five years ago). Rarely- or never-screened women often are considered “hard to reach” and therefore have not been included in studies of barriers to cervical cancer screening. This study compares the characteristics of the more recently-screened women typically examined in the literature with those who are much more vulnerable to developing cervical cancer: rarely- or never-screened women. Identification of predictors of belonging to the rarely- or never-screened group may guide the development of intervention and policy strategies targeted toward this high-need population.