Cervical cancer screening and follow-up among women in the criminal-legal system

Objectives: The one million U.S. women under supervision of the criminal-legal (CL) system are a populuation with 4-5 times the rate of cervical cancer than the general population–a disparity that has persisted for over 50 years. CL-involved women include those who have recently left jails/prisons, are on probation, or are in community corrections but still under legal supervision. Up to 60% of CL-involved women have a history of an abnormal Papanicolaou (Pap) test due to sexual health risks, trauma histories, and tenuous life circumstances that increase their risk of cervical dysplasia and serve as barriers to preventative care. The purpose of this study is to understand how women with CL involvement navigate individual, social, and community level systems to maintain their cervical health in varied funding and healthcare access environments. Methods: Retrospective cross-sectional study that analyzed baseline data from an ongoing longitudinal (2019-2024) study with CL-involved women, the Tri-City study. Data was collected from January-June 2020 and includes 508 CL-involved women from Kansas City, KS/MO (KC); Oakland, California (Oak); and Birmingham, AL (Birm). Participants completed a 288-item survey that explored influences on health services use as guided by the behavioral model for vulnerable populations (BMVP). Categorical variables were reported using frequencies and continuous data was reported as means with standard deviations. Proportions and associations were tested with chi-square or fisher's exact test. Multivariate regression was performed after controlling for study site and reported as odds ratios (OR) with 95% confidence intervals (CI) and corresponding p-values. Results: CL-involved women in KC (68.9%) and Birm (71.3%) were less likely to have up-to-date Pap testing than women in Oak (84.5%, p=0.01). Of the CL-involved women who needed follow-up for abnormal Pap results, only 58% of Birm and 66% of KC women completed follow-up whereas 88% of women in Oak completed follow-up and other 5% had an appointment scheduled (p=0.1). Using a BMVP framework, predictors for up-to-date Pap test included lower belief score for barriers to screening (OR 0.3, 95% CI 0.2-0.7, p=0.003), personal doctor (OR 3.3, 95% CI 1.4-7.7, p=0.005), not using tobacco (OR 0.4, 95% CI 0.1-0.9, p=0.05), and HPV vaccination (OR 3.4, 95% CI 1.0-10.9, p=0.04). When comparing CL-involved women who did or did not obtain follow-up for an abnormal Pap result, factors associated with follow-up in the bivariate analysis included lower susceptibility score (2.4 follow-up vs 3.1 no follow-up, p=0.007), lower severity of disease scores (3.3 follow-up vs 4.0 no follow-up, p=0.008), using hormonal birth control (22.5% follow-up vs 11.1% no follow-up, p=0.05), and not using condoms (42.5% follow-up vs 11.1% no follow-up, p=0.05). However, none of these variables were significant predictors of abnormal Pap follow-up in the multivariate model. Conclusions: Pap testing and follow-up varied by study site with the highest rates observed in Oakland, which was the only city that offered health services through Medicaid expansion. The results of our baseline data suggest that patient level factors coupled with the complexity of navigating community health delivery systems impacts CL-involved women's cervical cancer prevention behaviors.