Improving Adherence to Screening Follow-Up Among Women with Abnormal Pap Smears: Results from a Large Clinic-Based Trial of Three Intervention Strategies

TLDR

The study randomized over 2,000 women with abnormal Pap smears to test three clinic‑based interventions—personalized letters and pamphlets, a slide‑tape education program, and transportation incentives—to improve screening follow‑up rates. Interventions were compared in a 2 × 2 × 2 factorial design across 12 clinics. Overall, 29 % of women failed to return for follow‑up, but transportation incentives and the combined personalized letter plus slide‑tape program significantly increased return rates, with transportation incentives especially effective among socioeconomically disadvantaged patients and the combined intervention most beneficial for advantaged patients.

Abstract

In a large randomized trial involving over 2,000 women with abnormal cervical cytology (pap smear), three clinic-based interventions were tested as strategies to increase return rates for screening follow-up: 1) a personalized followup letter and pamphlet; 2) a slide-tape program on pap smears; and 3) transportation incentives (bus passes/parking permits). The three interventions were evaluated using a 2 × 2 × 2 factorial design. Results of this study confirm a high rate of loss to screening follow-up (i.e., no return visits) among women with abnormal pap smears (29% overall), with substantial variability among the 12 participating clinics (13% to 42/%). For the sample as a whole, both transportation incentives and the combined intervention condition of personalized follow-up and slide-tape program had a significant positive impact on screening follow-up. However, transportation incentives emerged as the dominant intervention condition among patient subgroups that can be characterized as more disadvantaged socioeconomically and at higher risk of developing cervical cancer, including patients receiving care from the county health department (odds ratio (OR) = 1.51; P<.05); patients without health insurance (OR = 1.77; P<.01); and patients with more severe pap smear results (OR = 1.71; P<.05). In contrast, among patient subgroups that can be characterized as relatively more advantaged and at lower risk of developing cervical cancer, only the combined intervention condition of personalized follow-up and slide-tape program was associated with a higher patient return rate. Subgroups reflecting this pattern included patients seen in noncounty clinics (OR = 4.54; P<.05) and patients with less severe pap smear results (OR = 5.16; P<.01). The implications of these findings are discussed in terms of designing clinic-based interventions to improve screening follow-up.