ENHANCING ADHERENCE FOLLOWING ABNORMAL PAP SMEARS AMONG LOW-INCOME MINORITY WOMEN - A PREVENTIVE TELEPHONE COUNSELING STRATEGY

Background: Although the incidence of precancerous conditions of the c ervix has recently been increasing, prompt initial and long-term follo w-up care can effectively reduce unnecessary morbidity and mortality, For example, the 4-year survival rates among those individuals at grea test risk for cervical cancer (i.e., minority women of low socioeconom ic status) approach 95% with early detection, Women who present with a dvanced disease have a much poorer outlook (0%-39% survival), Yet, hig h-risk individuals are least likely to adhere to recommended diagnosti c regimens, Purpose: We tested the effectiveness of a brief telephone counseling intervention directed to low-income, inner-city women after they had received an abnormal Pap smear result, The women were counse led on the importance of having an initial and 6-month repeat follow-u p diagnostic procedure (i.e., colposcopic examination of the cervix), Methods: A randomized trial design was used to compare the effects on these women of telephone counseling with (n = 192) or without (n = 203 ) a booster counseling telephone call prior to the appointment for a r epeat colposcopy 6 months later, with a telephone appointment confirma tion/reminder call (n = 216) and with standard care (i.e., no telephon e contact) (n = 217), The telephone counseling protocol probed for and addressed three psychologic barriers to adherence (i.e., attendance a t appointment for colposcopy examination): 1) encoding/expectancy (e.g ., did the patient understand her risk of developing cervical cancer?) ; 2) affective/emotional (e.g., was the woman worried about the condit ion and its consequences?); and 3) self-regulatory/practical (e.g., wa s the woman likely to forget medical appointments?), Logistic regressi on was used to analyze the effects of the intervention group and the t ype of psychologic barriers elicited on colposcopy adherence, Results: The results of logistic regression analysis (using those who received an appointment confirmation/reminder telephone call as the comparison group) revealed that telephone counseling produced significantly high er adherence rates to the initial colposcopy visit compared with telep hone confirmation (300 [76%] of 395 women versus 147 [68%] of 216; odd s ratio [OR] = 1.50; 95% confidence interval [CI] = 1.04-2.17), Additi onally, standard care resulted in significantly lower adherence rates than did telephone confirmation (109 [50%] of 217 women versus 147 [68 %] of 216; OR = 0.47; 95% CI = 0.32-0.73), Regarding attendance at the 6-month repeat colposcopy appointments, the 80 patients who had recei ved telephone counseling prior to the initial visit (and were recommen ded for follow-up colposcopy) were significantly more likely to adhere than were the 47 patients who had received telephone confirmation (49 [61%] of 80 women versus 17 [36.2%] of 47; OR = 2.70; 95% CI = 1.15-6 .51), The 6-month adherence rates for patients in the telephone confir mation group and the standard care group (n = 30) were low and did not differ significantly (17 [36.2%] of 47 women versus nine [30.0%] of 3 0; OR = 1.08; 95% CI = 0.40-2.89), Forgetting medical appointments (OR = 0.31; 95% CI = 0.19-0.51) and having scheduling conflicts (OR = 0.4 5; 95% CI = 0.28-0. 72) were also associated with lower rates of adher ence, Conclusion: The use of telephone counseling appears to be an eff ective strategy for enhancing initial and long-term adherence to a fol low-up cervical diagnostic procedure in a traditionally underserved po pulation, Patients who respond to a positive Pap test result with a pa rticular profile of psychologic barriers may require more intensive an d targeted counseling interventions.