Guidelines Chap.8: Management of poor and minority women10. Feb 2003
CHAPTER 8 Guidelines for management of women
with cervical cytological abnormalities
by C. Anthony, 4 pages
8.Guidelines for management of women with cervical cytological abnormalities.
8.1Management of Poor and Minority women
Careful consideration must be given to community-based and other approaches outside of the traditional purview of medicine to enhance management of cervical abnormalities among poor and minority women. Additionally, community and church-based support programs should be compared with a range of alternative programs targeting poor and minority women who have limited access to cervical follow up and treatment. The use of social infrastructures, screening social staff, church pastoral care workers, screeningcenter volunteers, close family members, friends can be effective tools in encouraging women to go for further assessment or treatment. (Siegel and Clancy, Health Serv Res 35(5):905-909, 2000) Where women are stricken by poverty special care is needed in arranging appointments, and assisting in the transportation of women to the appropriate site. Kindness and caring on the part of the screening workers is of vital importance. Studies have found that negative attitudes about cancer screening may play a role in the disproportionate number of cancer deaths among minority or poor women compared with majority women. Knowledge of screening recommendations and access to free screening and follow up are not enough to get some low income women to keep their appointments. Most of the women who skipped their appointments said they were embarrassed or believed that the particular follow up was unnecessary if they didn't have any symptoms. (Crump, Mayberry, Taylor, et al., J Nat Med Assoc 92:237-246, 2000 )
Creative thinking must be employed, taking into account the needs of each particular community setting, as to how to reach out to women with these special social conditions. For example the use of multimedia, of "enhanced compassion" videotapes depicting a doctor who acknowledges the patient's concerns, expresses partnership and support, validates her emotional state and the difficulty of making a decision, touching her hand, and trying to reassure her has been show as very effective. Anxiety is greatly reduced and the woman after viewing many times is more open to further exploration of her needs. (Fogarty, Curbow, Wingard, et al., J Clin Oncol 17(1):371-379, 1999 )
(Howard, Penchansky, and Brown, Fam Med 30(3):228-235, 1998 )
(Kiefe, Funkhouser, Fouad, et al, J Gen Intern Med 13:357-365, 1998)
Once a woman is diagnosed with a positive or suspicious smear the usual result pathways can be employed. Though women may be members of a minority, poor, or rural society they may still interact in a similar manner as women with social advantage. In the event that this does not occur, then steps must be taken by the screening staff in order to do the utmost in a compassionate manner to reach out to her and her family. This will take dedication and love on the part of the social support staff but is worthwhile and meaningful.
After the initial abnormal result is sent through the usual pathways suggesting further diagnostic procedures or treatment, a personal meeting may be arranged at the initiative of the Screening Center. This meeting should take place in a warm and friendly environment, in a room where comfortable chairs are present, some sort of refreshment, and a setting that has natural light. There the woman can be invited together with a family member that she trusts, if she so wishes. This should be encouraged since it will serve to further enhance the chances of her compliance with the next steps of her diagnosis or treatment. If the woman has difficulties in communication the social staff should be prepared to offer assistance in making the appointment for the next step of her assessment. Issues such as transportation and companionship to the appointment should be addressed by the social worker. A medical staff person should be on hand in the event questions need to be answered that the social worker does not feel comfortable in addressing. Once the woman leaves the screening center, follow up should be closely conducted to verify if indeed she made it to her appointment and what the result was. In the event that she did not go for her further assessment then this must be addressed with the woman again, by phone. Reasons for her non-attendance can be dealt with. Once again the need for further assessment must be reinforced. This close monitoring though many times tedious is worthwhile since it will lead to the resolution of her diagnosis and proper treatment. The social staff engaged in this needs to be sensitive to the fact that their efforts may in the end save the life of the woman and therefore are meaningful.
Informed Consent:
To be able to properly give informed consent, a woman must: 1) be able to understand cervical cancer, the methodology employed, and the potential benefits and harm from screening participation, 2) have an information base sufficient to critically read and understand an informed consent document, and 3) have the ability to allow for personal risk (Allen 1994, Henderson 1994). In our effort to include minorities and women in screening, the medical community must recognize that some people within these groups may be vulnerable or less advantaged and need special recruitment consideration and safeguards (NIH 1994b, Spilker and Cramer 1992).
Levine describes vulnerable populations as those people who have insufficient “…resources, strength, or other needed attributes to protect their own interests through negotiations for informed consent” (Levine 1986). Because women and members of minority groups may experience discriminatory societal customs, a high proportion of them may be vulnerable due to such things as poverty, poor health, and low educational attainment or feel vulnerable due to cultural and historical factors. They may, therefore, be in a disadvantaged, less-powerful position when interacting with the health care system. Nonetheless, it is not appropriate to treat all women or an entire minority group as if they were vulnerable. As Levine notes, this sort of treatment, “among other things, … adds unnecessarily to the burden of stereotypes already borne by such groups” (Levine 1986).
All screening involves personal, culturally based interactions between patients and staff. These human interactions involve values and needs as well as differences between cultures; the culture of the medical profession, the culture of “being a patient,” and the ethnic cultures of individuals (Morrow and Bellg 1994). As with clinical practice, workers who don’t take these factors into account when designing and implementing Cervical Screening for women and minority groups risk problems with participant compliance and poor screening program retention.
Goal:To identify interventions that enhances the participation of under represented populations as participants in cancer prevention and screening, by overcoming barriers caused by cultural, religious and linguistic differences:
Major Objectives:
- To develop, implement, and test interventions for target participant populations that will increase their recruitment, compliance, retention, and referral from physicians and other health care providers.
- To evaluate the effectiveness and costs of cervical cancer screening.
- To disseminate program results to the cancer research community.
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