SOCIOECONOMIC BARRIERS 1 Identifying Barriers to Cervical Cancer Screening in Rural Women Lacey T. Parkman Edson College of Nursing and Health Innovation, Arizona State University Author Note Lacey T. Parkman is a women’s health nurse practitioner student at Edson College of Nursing and Health Innovation, Arizona State University. She has no known conflict of interest to disclose. Correspondence should be addressed to Lacey T. Parkman, Edson College of Nursing and Health Innovation, Arizona State University, Downtown Campus, 550 N. 3rd Street, Phoenix, AZ 85004. Email: ltparkma@asu.edu SOCIOECONOMIC BARRIERS 2 Abstract Problem Statement & Purpose: Cervical cancer screening rates for a Federally Qualified Health Center (FQHC) in rural Northern Arizona is 78%, which is below the Healthy People 2030 goal of 84.3%. Identification of socioeconomic barriers unique to rural women through the use of an intake survey can improve cervical cancer screening rates. This project was guided by the Social Cognitive Theory (SCT). SCT proposes that behavioral change is determined by environmental, social, personal, and behavioral elements. Methods: At a one-day well-woman event called, “See, Test, and Treat” hosted by the FQHC, an anonymous intake survey was implemented that identified participant demographics, basic cervical cancer knowledge, and perceived socioeconomic barriers to routine cervical cancer screening. Participants were recruited through the FQHC. Participant inclusion criteria: Arizona resident, uninsured, underinsured, 21-65 years old, English or Spanish speaking. Results: Descriptive statistics were utilized to evaluate the survey responses, reliability, and validity of responses unknown due to self-reported responses. A total of 18 surveys were completed with a final yield of (n = 10). Surveys didn’t identify barriers to routine cervical cancer screening; however, an unawareness of cervical cancer risk factors including multiple sexual partners (n = 5, 50.00%), sex at an early age (n = 4, 40.00%), and misperception that cervical cancer is genetic (n = 7, 70.00%) was identified. Implications for Practice: A need for cervical cancer education exists within the surveyed community. Providing rural women with knowledge regarding cervical cancer can improve screening rates. Keywords: rural women, cervical cancer screening, socioeconomic barriers SOCIOECONOMIC BARRIERS 3 Identifying Barriers to Cervical Cancer Screening in Rural Women Cervical cancer is a prevalent and devastating cancer that primarily affects women between the ages of 35 to 44 (American Cancer Society [ACS], 2021). Approximately 93% of cervical cancer cases can be prevented with cervical cancer screening (Centers for Disease Control and Prevention [CDC], 2020). Cervical cancer screening detects cellular changes in the cervix and the presence of HPV through Papanicolaou (pap) smear testing (The American College of Obstetricians and Gynecologists [ACOG], 2020). Therefore, the U.S. Preventive Services Task Force (USPSTF) recommends cervical cancer screening for women ages 21 to 65 years old. The type of screening and frequency of screening is recommended based on the patient's age (U.S. Preventive Services Task Force [USPSTF], 2018). Overall, increasing cervical cancer screening rates among women can help prevent cervical cancer by detecting abnormal cytology and the presence of HPV (ACOG, 2016). Background & Significance Approximately 99% of cervical cancer is caused by the Human Papilloma Virus (HPV), a sexually transmitted disease (World Health Organization [WHO], 2021). There are 15 high-risk types of HPV, with the most prevalent high-risk strains known as HPV 16 and HPV 18 (Beckmann et al., 2019). Additionally, the U.S. cases of cervical cancer are 14,500 women per year and the mortality rate is 4,290 women per year (ACS, 2021). With these statistics in mind, there are several risk factors for cervical cancer. These risk factors include multiple sexual partners, the first age of intercourse below 18 years old, having a male sexual partner who has had a sexual partner with cervical cancer, smoking, HIV, organ transplant, sexually transmitted infection, diethylstilbestrol (DES) exposure, history of cervical cancer, history of high-grade SOCIOECONOMIC BARRIERS 4 squamous intraepithelial lesions (HSIL), and infrequent or absent cervical cytology screening tests (Beckmann et al., 2019). Purpose and Rationale A national health initiative developed by the CDC provides free breast and cervical cancer screening, diagnostic testing, and treatment to low-income, underinsured, and uninsured women to help bridge the gap in health care access (CDC, 2021). Another national health initiative created to improve cervical cancer screening is Health People 2030. The Healthy People 2030 objective is to increase the proportion of women who receive cervical cancer screening to a baseline of 80.5% and a target goal of 84.3% (USDHHS & ODPHP, 2020). Currently, the cervical cancer screening rate for the rural Northern Arizona health care organization is 78%, which is below the target goal of 84.3% set by the Healthy People 2030 national initiative (USDHHS & ODPHP, 2020). Improving cervical cancer screening rates can help diminish the rates of cervical cancer through the detection of high-risk HPV, cervical dysplasia, or cervical intraepithelial neoplasia (ACOG, 2016). Overall, identifying socioeconomic barriers to health care access for rural women can promote evidence-based interventions that positively affect cervical cancer screening outcomes. Internal Evidence The rural health care organization in Northern Arizona has identified soft data that impacts their routine cervical cancer screening rates. This soft data includes socioeconomic barriers, population education, and provider education. Furthermore, the socio-economic barriers that are the strongest predictors of deficient cervical cancer screening are rural location and insurance coverage (Harper et al., 2020). SOCIOECONOMIC BARRIERS 5 Hard data provided by the key stakeholders shows an average cervical cancer screening rate of 78% for the health care organization located in Coconino County, Arizona. Although this rate does not seem significant, the Coconino County health care facility is the only location within the organization that did not see change, positive or negative, in their cervical cancer screening rates within the last year. PICO Overall, the soft and hard data identified by the health care organization is clinically significant and identifies potential community barriers to routine cervical cancer screening. Therefore, the data identified by the health care organization has led to the question, “in women dwelling in rural communities (P), how does administering a screening tool that identifies socioeconomic barriers to cervical cancer screening (I), compared to no screening tool (C), affects cervical cancer screening rates (O)?” Evidence Synthesis Search Strategy An exhaustive review of current evidence was utilized to answer the PICOT question. Three databases were used to gather research including PubMed, ProQuest, and Cochrane as well as a review of the grey literature and hand-searching of references. Likewise, the databases were searched using keywords that addressed the components of the PICOT question. Words used to search for the population were combined using the Boolean connectors and included rural women, United States, cervical cancer, cervical cancer screening, cervical cancer screening rates, and United States rural women. Intervention search words include screening tools, screening interventions, screening barriers, and cervical cancer screening barriers. Filters utilized included publications between the years 2016-2021, English language, and peer- SOCIOECONOMIC BARRIERS 6 reviewed journals. Inclusion criteria included rural women and cervical cancer screening. Exclusion criteria included studies greater than five years old. Cochrane An initial search in Cochrane with the keywords screening tool and cervical cancer produced 4,022 results. To reduce the number of results, keywords rural women were added. The final search with these limitations and keywords produced 56 results. These 56 results were further reduced to a final yield of 10 studies through a rapid critical appraisal. ProQuest The initial search in ProQuest utilized the database PsychInfo and the keywords United States rural women, cervical cancer, and screening barriers with filters placed for results after 2016. This initial search yielded seven results. The final search was done through ProQuest utilizing 58 different databases and the keywords used were the United States, rural women, cervical cancer screening rates, and screening interventions which produced 3,920 results. These final results were further reduced through rapid critical appraisal and exclusion of predatory journals. Overall, 15 articles were retained for the applicability to the PICOT questions and their high level of evidence. PubMed The initial search in PubMed with the keywords rural women, United States, and cervical cancer yielded 283 results with the limits of 2016 or more recent. To narrow results, additional searches were conducted utilizing the keywords the United States, rural women, cervical cancer screening barriers, and screening tools. The final search using cervical cancer rates and screening tools produced 67 results. Additional searches using the keywords cervical cancer screening and rural women were utilized to find studies outside of the United States that were SOCIOECONOMIC BARRIERS 7 qualitative, cross-sectional, or quantitative as these types of studies were limited in the US studies. The search yielded 363 results. After further appraisal through the rapid critical analysis, six studies were chosen due to the type of study, level of evidence, and validity. Critical Appraisal The rapid critical appraisal checklist developed by Melnyk and Fineout-Overholt (2019) was used to determine the quality of the chosen articles. Overall, the quality of the evidence was moderately high due to most studies being qualitative, a systematic review, or cross-sectional surveys without bias. Although the studies had different sample sizes and were conducted over different periods (see Appendix A, Table A1), the sample characteristics were similar. The majority of participants were women in rural settings between 35-65 years of age. All of the studies focused on different factors affecting cervical cancer screening in rural women. Four studies focused on cervical cancer screening barriers, three studies focused on patient knowledge of cervical cancer risks, and three studies focused on cervical cancer screening interventions. All studies produced similar concepts; geographical location correlates with cervical cancer screening uptake and cervical cancer risk knowledge. Studies focusing on interventions showed a significant increase in cervical cancer screening uptake compared to control groups. Overall, evidence shows that defining and addressing specific socioeconomic barriers unique to rural women will improve cervical cancer screening rates. Common socioeconomic barriers identified in the literature exist at individual, institutional, community, and public policy levels. These themes include decreased cervical cancer screening follow up, negative family and social influences, decreased cervical cancer screening knowledge, fear or embarrassment of screening, convenience, self-efficacy, time, medical mistrust, and cost (Atere-Roberts et al., 2020; Binka et al., 2019; Hall et al., 2018; Liu et al., 2017; McGinnis et al., 2017; Megersa et al., SOCIOECONOMIC BARRIERS 8 2020; Moss et al., 2017; Wang et al., 2019; Weng et al., 2020; Yang et al., 2019). Applying this evidence to rural women in Coconino County by developing a screening tool to identify socioeconomic barriers to cervical cancer screening can pave the way for specific intervention development. Additionally, common interventions identified in the literature utilized to address decreased cervical cancer screening rates include increasing patient education, reducing structural barriers, decreasing costs, and increasing health care provider access (Atere-Roberts et al., 2020; Barrington et al., 2019; Falk et al., 2018; Smith-Gagen et al., 2019). Theory Application The outcomes suggested by the evidence apply to the Social Cognitive Theory (SCT) (see Appendix B, Figure 1). SCT proposes that behavioral change is determined by environmental, social, personal, and behavioral elements, and all of the elements influence one another (Bandura, 2004). The main concepts of SCT include self-efficacy and the ability to control health outcomes, outcome expectations such as benefits versus risks of health habits, an individual’s health goals, and hindrances to overall health changes (Bandura, 2004). The four studies that identified barriers to cervical cancer screening in rural women had a common theme of self-efficacy, the ability of an individual to believe in themselves and obtain a certain outcome (Bandura, 2004). Likewise, the three studies focused on rural women’s concept of cervical cancer risks help promote increased self-efficacy and cervical cancer screening uptake through patient education. Additionally, this self-efficacy can lead to improved cervical cancer screening, which further leads to goals of increased screening compliance. The four studies that reviewed barriers to cervical cancer screening correlate with the impediments portion of SCT (Bandura, 2004). Led to the three studies focused on cervical cancer screening interventions to overcome identified barriers. Overall, all of these studies reinforce the impact of environmental, social, SOCIOECONOMIC BARRIERS 9 personal, and behavioral elements on behavioral change, specifically in rural women, and cervical cancer screening rates (Bandura, 2004). Change can be promoted through knowledge of health risks and the implementation of interventions to overcome socioeconomic barriers in rural women. Only two of the studies explicitly stated the use of SCT. However, the remaining studies infer a health promotion model to better understand the influences of different factors and their impact on cervical cancer screening. Lastly, these factors are considered when developing interventions. For example, geographical location is a negative indicator of cervical cancer screening rates; therefore, interventions developed helped overcome geographical locations by use of patient navigators or telehealth services (Atere-Roberts et al., 2020; Barrington et al., 2019; Falk et al., 2018). Overall, SCT is an appropriate guiding framework for the proposed evidence-based practice project, developing a screening tool that identifies socioeconomic barriers in rural women. This framework is appropriate because behavioral change is influenced by environmental, social, personal, and behavioral elements (Bandura, 2004). Therefore, evaluating socioeconomic barriers can identify specific barriers that can be addressed and overcome to improve cervical cancer screening rates in rural women as well as other preventive health services. Implementation Framework The implementation of this project is guided by the Lean Sigma Six framework (see Appendix B, Figure 2). This framework promotes work standardization and is fact-based and data-driven. The five components of Lean Sigma Six include defining, measuring, analyzing, improving, and controlling (American Society for Quality [ASQ], 2021). This framework is an SOCIOECONOMIC BARRIERS 10 appropriate fit for the evidence-based practice project due to its ability to define socioeconomic barriers to cervical cancer screening in rural women, as well as its ability to define the selected intervention. Next, the framework can measure intervention outcomes, analyze areas of strengths and weaknesses, and provide opportunities for improvement. Finally, once the intervention has been evaluated through the Lean Sigma Six components, it can be fine-tuned until it is efficient and controlled (ASQ, 2021). The Lean Sigma Six framework components build upon one another and are a processoriented approach that helps lead providers to develop focused interventions (ASQ, 2021). The first step in this approach defines the socioeconomic barriers faced by rural women in Coconino County, Arizona. Next, these specific socioeconomic barriers can be measured and analyzed to develop an intervention to improve cervical cancer screening. Subsequently, this intervention is also subjected to the SCT and Lean Sigma Six framework to measure and analyze strengths and weaknesses to further refine and adapt the intervention to best address the socioeconomic barriers of rural women in Coconino County and improve cervical cancer screening outcomes (ASQ, 2021). Methods Ethical Considerations Ethical principles should be evaluated when implementing a project to ensure participant and organization rights are protected. The development and utilization of a screening tool to evaluate socioeconomic barriers in rural women require the evaluation of several ethical factors, including intrapersonal, interpersonal, and organizational factors (Boutin-Foster et al., 2013; Stanford University, n.d.). Intrapersonal factors include the participant's knowledge, attitude, and individual behaviors towards cervical cancer screening. Next, interpersonal factors include SOCIOECONOMIC BARRIERS 11 potential ethical considerations such as the provider-patient interaction. Developing a screening tool evaluating socioeconomic barriers to cervical cancer screening can promote the ethical principle of beneficence and justice by allowing equal preventive screening to participants despite barriers to health care access. Lastly, organizational factors such as rules and policies will promote non-maleficence by ensuring optimal evidence-based practice is utilized in participant screening and that participant information will be de-identified and stored appropriately according to the facility's requirements (Boutin-Foster et al., 2013; Stanford University, n.d.). Human Subject Protection Human subject protection will be ensured through the use of written informed consent (see Appendix C). Written informed consent will be provided before the initiation of the written project survey. This informed consent will outline the purpose of the survey and will ensure the participant that no identifying personal information will be obtained. Likewise, the participant will be assured that they may skip questions or stop the survey at any point. Overall, written informed consent will be provided to participants to provide participants with autonomy in decision-making processes. Project Setting The setting for the EBP project is an FQHC in rural Northern Arizona. The health care facility provides several services including behavioral health, care management, dental, diabetes support, lactation & breastfeeding support, OB/GYN, pediatrics, pharmacy, physical therapy, primary care, and virtual visits. A service developed and executed at this facility to address the health needs of the rural and underserved female population is the Well Woman HealthCheck Program (Arizona Department of Health Services [ADHS], 2021). The Well Woman HealthCheck program implements a one-day event called “See, Test, and Treat” that provides SOCIOECONOMIC BARRIERS 12 comprehensive services such as clinical breast exams, mammograms, pelvic exams, and cervical cancer screening (ADHS, 2021). Stakeholders Key stakeholders for this event include personnel who work for or with the FQHC in Coconino County. This personnel includes program coordinators, program managers, education directors, women’s health providers, event participants, and their families, as well as ancillary personnel vital to coordinating and implementing the one-day event. Participants who are recruited for the one-day event through the health care organization's Well Woman HealthCheck Program must meet certain criteria. Inclusion criteria are women who are Arizona residents, uninsured or underinsured, between the ages of 21 to 65, below the poverty level or economically disadvantaged, and English or Spanish speaking. Exclusion criteria are women who are non-Arizona residents, below 21 years old, are not a participant of the “See, Test, and Treat” event, has Medicare Part B, have Arizona Health Care Cost Containment System (AHCCCS), or is currently diagnosed with cervical cancer. Project Description Project Instrument The survey utilized at the one-day event was developed by Akinlotan et al. (2017). This survey was chosen due to its population and setting similarity to Coconino County. The survey identifies participant demographics, perceived physical and mental health, basic cervical cancer knowledge, perceived socioeconomic barriers to health care, family cancer history, and HPV vaccination knowledge and status (see Appendix D). This survey will be vital to the health care organization to address and overcome barriers to routine cervical cancer screening within their SOCIOECONOMIC BARRIERS 13 community, which will ultimately promote practice change and the development of an intervention to overcome identified socioeconomic barriers to routine cervical cancer screening. Project Timeline The timeline of project implementation includes the use of the survey developed by Akinlotan et al. (2017) at the “See, Test, and Treat” event on September 18, 2021. This survey will be provided to both English and Spanish-speaking participants through the utilization of Citi-trained interpreters. After the event, the surveys will be analyzed and evaluated to determine statistically significant information that will be provided to the health care organization to determine socioeconomic barriers to routine cervical cancer screening as well as populationspecific cervical cancer risk knowledge and the potential need for participant's education. Data Analysis A total of 50 participants received cervical cancer screening at the “See, Test, and Treat” event on September 18, 2021. Additionally, 17 project surveys were collected from women who met the inclusion and exclusion criteria. The collected surveys will be analyzed and evaluated through Intellectus to identify statistically significant data that can be utilized by the health care organization to address and improve participant and population outcomes. “See, Test, and Treat” Event Budget Cost Reimbursement Cost Reimbursement (Actual Expenditures) Federal Personnel State Personnel Federal Screening Navigation Only State Screening State Other Operating Expenses State Indirect Expenses ADOT Screening Total Approved Budget $94,000.00 $30,000.00 $60,000.00 $6,600.00 $6,000.00 $3,000.00 $3,500.00 $12,000.00 $215,100.00 SOCIOECONOMIC BARRIERS 14 Approved Grant Supplied by College of American Pathologists Category Medical Equipment Exam, Laboratory, and Testing Supplies Temporary Program Coordinator Support Personnel Marketing/Promotion Translation Services (print materials and on-site) Transportation Children’s Activities Meals Total Requested Amount Requested Grant Amount $0 $0 $4,000.00 $4,000.00 $2,500.00 $0 $0 $272.00 $2,500.00 $13,272.00 Funding Sources Approved Grants Contribution National Breast and Cervical Cancer Early NBCCEDP will cover allowable procedures Detection Program (NBCCEDP) and relevant CPT codes (see Appendix E) Arizona Department of Health Services $215,100.00 (Indirect rate 22.71%) College of American Pathologists $13,272.00 Arizona Complete/Health Care First Approved – unknown amount Budget Justification After the event, the Well Woman Health Check Program provides all the follow-up services for the participants. Likewise, they cover the costs of the screening services provided to the participants as long as the CPT codes fall within the NBCCEDP Allowable Procedures and Relevant CPT Codes (see Appendix E). Lastly, if more services are provided than anticipated, the Arizona Department of Health Services will provide additional funding to cover the negative costs. Results Participant Demographics SOCIOECONOMIC BARRIERS 15 The sample consisted of rural women (n = 10) receiving free breast and cervical cancer screening at a Federally Qualified Health Center in Northern Arizona. The sample consists of adults with the average age of the subjects being 47.50 (SD = 12.76) and the ages ranging from 24.00 to 63.00 years. The average Annual Income was 12,514.20 (SD = 14,442.18) which ranged from $0.00 to $50,000). Most of the sample lived in Coconino County (n = 9, 90.00%). Half of them attended College (n = 5, 50.00%). Also, over half of them were Uninsured (n = 7, 70.00%) or utilized Private Insurance (n = 3, 30.00%) indicating that over 70.00% were low-income. The majority of the sample was White or Caucasian (n = 5, 50.00%), English speaking (n = 6, 60.00%), and Single (n = 5, 50.00%). Frequencies and percentages are presented in Tables 1 & 2 (see Appendix F). General Health Demographics The majority of participants answered Yes (n = 7, 70.00%) to “Do you have a health care provider?” Also, the majority of the sample answered <6 months (n = 7, 70.00%) when asked, “When was the last time you visited your provider?” The majority of the sample described their health as Good (n = 4, 40.00%). Frequencies and percentages are presented in Table 3 (see Appendix G). The participants were provided a Likert scale ranging from 1 to 5, with 1 being “never” and 5 being “always.” The most frequently observed category of “How often do you prepare a list of questions for your doctor?” was Always (n = 4, 40.00%). The most frequently observed category of “How often do you ask questions about the things you want to know and the things you don’t understand?” was Always (n = 5, 50.00%). The most frequently observed category of “How often do you discuss any personal problems that may be related to your illness?” was Always (n = 4, 40.00%). The most frequently observed category of “How confident are you in SOCIOECONOMIC BARRIERS 16 filling out medical forms by yourself?” was Always (n = 6, 60.00%). Frequencies and percentages are presented in Table 4 (see Appendix G). All of the participants (n = 10) answered “How many days in the past month was your physical health not good?” with 0.00. The participants' responses to “How many days in the past month has your mental health not been good?” had a mean response of 1.70, with an SD of 3.13. The range was from 0.00 to 10.00. The summary statistics can be found in Table 5 (see Appendix G). Pap Smear History In addition to demographics, the survey asked participants about their pap smear history. When asked “Have you had a hysterectomy?” the majority of participants answered No (n = 9, 90.00%). The majority of participants identified their “Last pap smear” as Within the past 1 year (n = 6, 60%). Additionally, the majority of participants answered No (n = 5, 50.00%) to a history of “Abnormal pap smear.” They also answered False to “Have you or a member of your family had cervical cancer?” (n = 9, 90.00%). Most of the participants answered No to “Are you aware of the 3-part HPV vaccine series?” (n = 6, 60.00%). Similarly, the majority of participants answered No to “Have you received the HPV vaccine?” (n = 8, 80.00%) and “Have you completed the HPV vaccine series?” (n = 9, 90.00%). Frequencies and percentages are presented in Table 6 (see Appendix H). Cervical Cancer Risk Factors The participants were provided a 10-item True/False questionnaire to determine cervical cancer risk factor knowledge. Half of the participants responded TRUE (n = 5, 50.00%) to the question “…She has many sexual partners” as a risk factor for cervical cancer. The participant responses were divided, both TRUE and FALSE for the cervical cancer risk factor of “…She SOCIOECONOMIC BARRIERS 17 smokes cigarettes” with an observed frequency of (n = 4, 40.00%). Likewise, the risk factor of “…She started having sex at a young age” was also divided between TRUE and FALSE, each with an observed frequency of (n = 4, 40.00%). Nearly half of the participants responded FALSE to the question “…She has unprotected sex” (n = 4, 40.00%). Conversely, the majority of participants responded TRUE to the question “…She does not go for regular pap smear tests” (n = 8, 80.00%), and the majority of responses to “…She has a sexually transmitted disease or virus” was TRUE (n = 7, 70.00%). Nearly half of the participants responded FALSE (n = 4, 40.00%) to the question “…She used birth control pills for a long time.” The responses were majority FALSE (n = 5, 50.00%) for the question of “…She has many children.” Less than half of the participants perceived “…She has a weakened immune system” as a cervical cancer risk factor with a response of FALSE (n = 4, 40.00%). Lastly, the majority of participants considered cervical cancer to have a genetic risk factor with an (n = 7, 70.00%) TRUE response rate to the question “…It runs in her family.” Frequencies and percentages are presented in Table 7 (see Appendix I). Socioeconomic Barriers to Routine Cervical Cancer Screening The participants were provided a Likert Scale survey that identified perceived socioeconomic barriers to routine cervical cancer screening. The responses ranged from 1 to 5, with 1 being “Strongly Disagree” and 5 beings “Strongly Agree”. The majority of participants Strongly Disagreed that “Feelings of embarrassment” (n = 8, 80.00%), “Fear of finding cancer” (n = 7, 70.00%), “Transportation” (n = 9, 90.00%), “Cost” (n = 5, 50.00%), “Anxiety about procedure” (n = 8, 80.00%), “Lack of knowledge” (n = 9, 90.00%), “Lack of time” (n = 9, 90.00%), “Anticipation of pain” (n = 7, 70.00%), “Forgetting to schedule an appointment” (n = 6, 60.00%), “Other health problems” (n = 8, 80.00%), Language barriers” (n = 7, 70.00%), SOCIOECONOMIC BARRIERS 18 and “Male physician” (n = 6, 60.00%) were barriers to routine cervical cancer screening. Frequencies and percentages are presented in Table 8 (see Appendix J). Impact of Project & Sustainability Identifying barriers to cervical cancer screening through an intake survey can have a positive impact on patients, providers, the FQHC, and policy development. The intake surveys identified a need for cervical cancer risk factor education within the surveyed community. Providing education can improve patient cervical cancer risk factor awareness, which can promote healthy lifestyle changes such as smoking cessation and increased routine cervical cancer screening. Additionally, healthcare professionals can promote improved cervical cancer education at well-woman exams and following up screening results from the “See, Test, and Treat” event. Lastly, the FQHC can promote the sustainability of the DNP project through a continuation of the intake survey. The survey can be revised and adapted to continue to meet the educational needs of the community identified by the participant responses. Additionally, health policy changes can be developed by the FQHC to develop educational resources and services to promote further learning for the community. Discussion Project Strengths & Facilitators The intake survey has several strengths and facilitators for continuation. First, the survey applies to all rural settings because the survey questions are general and not specific to the FQHC community. Next, the surveys were implemented at a one-day event, allowing participants to have ease of accessibility and promote response uptake. Additionally, the survey was translated into Spanish, so more participants were able to respond to the intake survey. Lastly, the survey identified an unawareness of cervical cancer risk factor knowledge, which will SOCIOECONOMIC BARRIERS 19 allow the FQHC to develop population-specific interventions to overcome this lack of cervical cancer risk factor knowledge. Project Limitations & Barriers The intake survey had a few limitations and barriers. First, the inclusion and exclusion criteria for the participants were too narrow. Eight survey responses had to be omitted because participants did not fall in the correct age range or had Medicaid. Additionally, the event was open to the public, but attendees who were not enrolled in the Well Woman HealthCheck Program were not able to participate in the intake survey. Having more broad criteria would allow for a greater range of responses that would better reflect the community. Next, the survey respondents were self-reported, which may influence the accuracy of responses. Similarly, participants were recruited by the FQHC, so the participants were intentional about receiving cervical cancer screening, therefore their knowledge of risk factors may not be an accurate depiction of cervical cancer knowledge for the community. Lastly, the survey was not able to be revised by the FQHC before the event, so the language was not evaluated for its inclusivity. For example, one of the questions used the language “male physician” rather than the more appropriate term “male provider.” Survey Results & Current Literature The intake survey results correlate with current literature regarding barriers to cervical cancer screening. Although the survey did not identify any socioeconomic barriers to cervical cancer screening, the survey did identify an unawareness of cervical cancer risk factors knowledge. Likewise, the literature identifies education as an influence on cervical cancer screening. The more aware women are of cervical cancer and risk factors, the more likely they SOCIOECONOMIC BARRIERS 20 are to receive routine cervical cancer screening (Binka et al., 2019; Liu et al., 2017; Megersa et al., 2020; Weng et al., 2020; Yang et al., 2019). Future Recommendations Future recommendations based on the intake survey results include the development of evidence-based interventions to evaluate the impact of education on routine cervical cancer screening. Development of educational interventions can be achieved through the participant, provider, healthcare system, and policy involvement. The healthcare system can develop policy changes to promote educational services and the healthcare providers can facilitate the implementation of the educational services to patients in the community. Evaluation of the educational interventions through a pre and post-test of cervical cancer risk factor knowledge can further evaluate the efficacy of the education and promote further adaptations of education, with the ultimate goal of improving community cervical cancer screening rates. Conclusion Designing and implementing a screening tool that identifies socioeconomic barriers to cervical cancer screening in rural women will provide the foundation for future interventions to address the identified barriers to preventive health screenings. Ultimately, if this evidence is utilized to change health practices, it is the goal that cervical cancer screening rates will increase and meet the Healthy People 2030 objective, ultimately improving community health outcomes (USDHHS & ODPHP, 2020). Lastly, it is the future aspiration that the screening tool can be utilized in different populations and adapted to meet different medical conditions to identify and overcome barriers to other health outcomes. Overall, this provides the opportunity to identify and improve multiple barriers to health care services across the healthcare organization, leading to improved patient and community quality of life. SOCIOECONOMIC BARRIERS 21 References Akinlotan, M., Bolin, J. 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Two studies SOCIOECONOMIC BARRIERS 25 examining the negative effect of self-efficacy on performance. Journal of Applied Psychology, 87(3), 506–516. https://doi.org/10.1037/0021-9010.87.3.506 Wang, S.-X., Wu, J.-L., Zheng, R.-M., Xiong, W.-Y., Chen, J.-Y., Ma, L., & Luo, X.-M. (2019). A preliminary cervical cancer screening cascade for eight provinces rural Chinese women: A descriptive analysis of cervical cancer screening cases in a 3-stage framework. Chinese Medical Journal, 132(15), 1773–1780. https://doi.org/10.1097/CM9.0000000000000353 Weng, Q., Jiang, J., Haji, F. M., Nondo, L. H., & Zhou, H. (2020). Women’s knowledge of and attitudes toward cervical cancer and cervical cancer screening in Zanzibar, Tanzania: A cross-sectional study. BMC Cancer, 20(1). https://doi.org/10.1186/s12885-020-6528-x World Health Organization. (2021). Cervical cancer. https://www.who.int/health-topics/cervicalcancer#tab=tab_1 Yang, H., Li, S. P., Chen, Q., & Morgan, C. (2019). Barriers to cervical cancer screening among rural women in eastern China: A qualitative study. BMJ Open, 9(3). https://doi.org/10.1136/bmjopen-2018-026413 SOCIOECONOMIC BARRIERS 26 Appendix A Evaluation and Synthesis Tables Table A1 Evaluation Table Citation (Yang et al., 2019). Barriers to cervical cancer screening among rural women in eastern China: A qualitative study Funding: China Medical Board Open Competition Grant [Grant #CMB14195] Theory/ Conceptual Framework Inferred HPDPT Design/Method/ Sampling Design: QS Purpose: To explore barriers to free CCS among RW in China from the perspective of women, HC providers and husbands Sample/Setting (Describe) N: 39 n: 21 women n: 14 providers n: 4 husbands Setting: 2 counties in Jining Prefecture of eastern China Sample Demographics: Women: MA: 48 Ages: 37 to 60 years Married: 95.2% EL: primary or below Previous CCS: 52.4% Major Themes Studied/Defini tions IV1: Knowledge of CC IV2: Barriers to CC DV: CCS rates Measurement/I nstrumentation Analysis Semi-structured IDI Transcribed IDI & FGD subjected to thematic analysis 17-item questionnaire (pretest before interview) FGD All IDI & FGD - digitally recorded Findings Five major themes: (1) gaps in knowledge of CC and health awareness (2) fear of cancer and screening outcomes (3) cultural barriers (4) influence of close contacts Decision for Use LOE: VI Strengths: Detailed/in-depth responses Relevant information to policy makers to create interventions for CCS Weaknesses: Purposive sampling: May bias findings Possible social acceptability bias w/FGD QS may limit generalizability for different settings Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS Bias: None recognized 27 (5) inconvenien ce HC Providers: MA 42.6 EL junior college or greater Medical Practitioners: 50% Country: China Conclusions: This QS identified common themes among RW in China and their perception of CCS F&A pt. population: The themes identified are F&A to RW and may help HC organizations overcome barriers to CCS. Husbands: MA: 50.7 All: small-hold farmers Inclusion Criteria: Women, Ages 35-64 Resides in study township UE No CCS or failure to attend FU Citation Conceptual Framework (Binka et al., 2019). Barriers to the uptake of cervical cancer screening Socioecological Model of McLeroy et al. Design/Method Design: QS Purpose: To explore the barriers to the uptake of CCS and treatment in Attrition: None Sample/Setting Group 1: N: 15 CC patients who attended the gynecology unit of the Battor Catholic Hospital Major Variables & Definitions IV: Barriers to CCS DV: CCS rates & treatment Measurement Group 1: IDIs Group 2: IDIs FGD Analysis 3 RA: Transcribed TRI to English TRI – sent to experts for validity Findings Barriers: Individual, institutional, community, & policylevel Decision for Use LOE: VI Strengths: Not explicitly stated. Potential strengths include implementing intervention Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS and treatment among rural women in Ghana Funding: None stated Bias: None recognized Country: Ghana the North Tongu district of Ghana 28 in the North Tongu District, Volta Region, Ghana Group 2: N: 10 Women MA 3065 registered at the Battor Catholic Hospital who have no CCS FGD: N: 30 3 groups Ages 35-65 Setting: Battor Catholic Hospital in the North Tongu District of the Volta Region, Ghana Sample Demographics: Group 1: Age 30-50 EL: Secondary ≤ RQDA that address the identified barriers Weaknesses: Limited sample sizes and the limited feasibility to apply this study to other HC settings Conclusions: Several barriers were identified that may impact CCS. This includes individual knowledge, and funding for screening/treatment F&A pt. population: Although these specific barriers may apply to other rural HC facilities and women, there may be different personal barriers and specific organizational barriers that may make this study difficult to apply to other HC facilities. Inclusion Criteria: Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS 29 Selection based on thematic saturation from the hospital setting Citation (Weng et al., 2020). Women's knowledge of and attitudes toward cervical cancer and cervical cancer screening in Zanzibar, Tanzania: A crosssectional study Funding: National Natural Conceptual Framework Inferred HPDPT Design/Method Attrition: Group 1: 45, due to death or unable to contact Sample/Setting Design: XSS N: 1483 Purpose: To describe RW’s awareness of CC and to explore the attitudes toward, acceptability of and barriers to CCS (CCS) in Zanzibar Setting: 5 wards from 10 administrative districts Sample Demographics: Women MA: 32.86, Majority: Muslim & married MP: 2.96 EL: Secondary Previous CCS: 4.83% Inclusion Criteria: Women ages 14-65 Major Variables & Definitions IV: Factors associated w/screening DV: CCS Measurement 33 item questionnaire: general demographics 3 close-ended questions: attitude towards screening 14 close-ended questions: determine awareness of CC Analysis STATA Pearson Chisquare Fisher’s exact tests ANOVA Meta Analyses: Multiple logistic & linear regression model Findings Women had inadequate knowledge on CCS Screening decision associated with education, family income, and family history of cancer Decision for Use LOE: V Strengths: Situation-based use of a mixed refinement of previous questionnaires Face-to-face interviews that were double checked The study was conducted in all districts of Zanzibar, including remote rural areas, which could to some extent represent the cognitions of and attitudes toward CC and screening in the general population in Zanzibar Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS Science Foundation of China (81701475) Bias: None recognized Country: China 30 Attrition: 17 The first to indicate that schistosomiasis infection was a significant positive predictor of CCS uptake Weaknesses: The district effect on women’s willingness to participate in free or nonfree screening was not checked Cross-sectional studies only show implied correlation Conclusions: This study showed the need for education to promote CCS and diminish misperceptions of CC causes F&A pt. population: This crosssectional study specifically applies to the 5 wards chosen within the 10 districts, although several of the correlations may pertain to different RW, the outcomes may not be the same. Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS 31 Citation Conceptual Framework Design/Method Sample/Setting Citation (Musa et al., 2017). Effect of cervical cancer education and provider recommenda tion for screening on screening rates: A SR and metaanalysis SCF & SEM Design: SR & Meta-analysis N: 28 studies Funding: Grant #D43TW00 9575 from NIH Fogarty International Center and the National Cancer Institute Bias: None recognized Purpose: To evaluate the effect of CC education and PE on CCS rates Setting: Studies were chosen from several countries: Australia, Belgium, Canada, Finland, France, Germany, Italy, Japan, Kenya, Malaysia, Mexico, Sweden, Taiwan, Thailand, and USA Sample Demographics: Women Inclusion Criteria: RCT, cluster RCT, & quasiexperimental designs Attrition: N/A Major Variables & Definitions IV1: CC education Theory-based CC education interventions 1. CC education 2. Provider recommendatio n IV2: Provider recommendatio ns DV: Participation in CCS programs Measurement Analysis Findings Decision for Use PICO “What is the effect of CC education on CCS rates in women population eligible for CCS?” PRISMA Polling effect: RevMan 5.3 Review Manager software Theorybased educational intervention s significantly increased CCS rates (OR, 2.46, 95% CI: 1.88, 3.21) selfsampling for Human Papillomavir us (HPV) testing increased CCS rates by nearly 2fold (OR = 1.71, 95% CI: 1.32, 2.22 LOE: I “What is the effect of provider recommendation for CCS on CCS rates in women population eligible for CCS?” Heterogeneity: Higgins I² statistic. Graphic display: Relevant forest plots Statistical estimates of interventions OR and random effects models meta-analysis Publication bias: funnel plots generated by RevMan 5.3 Strengths: Comprehensive search, study guided by a published SR protocol Weaknesses: No secondary outcome data Conclusions: SR supports the use of theory-based CC education interventions F&A pt. population: The interventions identified in the meta-analysis can be applicable to CC education in developed and developing countries. This information is limited to CC education only. Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS 32 Country: USA Citation Conceptual Framework Design/Method Sample/Setting Citation (AtereRoberts et al., 2020). Intervention s to increase breast and cervical cancer screening uptake among rural women: a scoping review SCF Design: SR N: 8 Purpose: To review literature for interventions to increase BCC screening Setting: USA Funding: None stated Bias: None stated Country: USA Sample Demographics: RW Inclusion Criteria: Peerreviewed journal, English, published January 2006 to October 2019, provided intervention for cervical or breast cancer, reported outcome data, Attrition: N/A Major Variables & Definitions Interventions include PN strategies, educational outreach programs, peer counseling, and small media initiatives Measurement Analysis Findings Decision for Use Scoping review of PubMed to identify BCC screening interviews conducted in rural settings PRISMA Group Education: English speaking Latina women showed decreased CCS odd (OR 0.66 (0.47-0.92) Spanish speaking Latina women showed increased odds (OR 1.64 (1.222.20) LOE: I One on One Education: Increased CCS w/individual lay health advisor Strengths: First study to focus on BCC interventions in rural populations Weaknesses: Search restricted to PubMed, strict inclusion criteria Conclusions: This study reviewed literature that may help promote the development of BCC interventions F&A pt. population: Limited feasibility. Applicable to rural communities in the USA for BCC interventions Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS 33 education (OR 1.70; 1.31, 2.221) Citation Conceptual Framework Design/Method Sample/Setting Citation (Harper et al., 2020). Three large scale surveys highlight the complexity of cervical cancer underscreeni ng among women 4565 years of age in the United States Inferred HPDPT Design: 3 National Health Surveys N: 44,065 Funding: Purpose: To describe predictors of CC underscreening in women 46-65 BRFSS: n=41,747 HINTS: n=745 HCPC: n=1,573 Setting: USA Sample Demographics: Women, ages 4565 Inclusion Criteria: women, MA 45-65, without hysterectomy Attrition: N/A Major Variables & Definitions IV: Elderly women & socioeconomic predictors DV: CCS Measurement Analysis National Health Surveys Univariate & Multivariate Analysis BRFSS – telephone survey by each state’s health department HINTS – questionnaire HCPC – one on one interview Multicomp onent Education: No significant changes noted Findings Elderly RW locations were less likely to receive CCS Decision for Use LOE: V Strengths: Description of results from 3 large national surveys Weaknesses: Different survey years, self-reported responses, different sampling frames, different survey sample sizes, changing professional guidelines; limited specified age range Conclusions: CCS for older women is below the 70% national goal. Age, insurance, and education impact CCS Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS 34 Michigan Institute for Clinical and Health Research UL1TR0022 40 & The University of Michigan Rogel Cancer Center P30CA0465 92 grants F&A pt. population: The analysis applies to women ages 45-65 across the USA. Bias: None stated Country: USA Citation Conceptual Framework Design/Method Sample/Setting Citation (Liu et al., 2017). Assessing knowledge and attitudes towards cervical cancer screening Inferred HPDPT Design: XSS N: 420 Purpose: To assess knowledge and attitude towards CC and screening among rural women Setting: 4 counties of Jining Sample Demographics: Women, 30-65yo Major Variables & Definitions IV: Attitudes & knowledge about CC DV: CCS Measurement Analysis Findings Decision for Use Face-to-face interviews using questionnaires with trained interviewers Binary logistic regression Majority of participants had positive attitudes towards CCS LOE: V HC providers impact Strengths: None stated Weaknesses: Not generalizable, questionnaire used only analyzed quantitative data, not qualitative Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS 35 Inclusion Criteria: Women, MA 30-65, without hysterectomy, sexually active among rural women in eastern China Funding: None stated health promotion of CCS Age, level of income, and education impact knowledge of CC Attrition: 15 Bias: None stated Conclusions: Overall positive attitude towards CC, but limited knowledge on CCS F&A pt. population: Not generalizable, specific to the 4 counties of Jining Country: China Citation Conceptual Framework Design/Method Sample/Setting Citation (Megersa et al., 2020) Community cervical cancer screening: Barriers to successful home-based HPV selfsampling in HBM Design: QS N: 47 Purpose: To explore barriers to self-sampling CCS Setting: University of Gondar Sample Demographics: Women, MA 2840, primarily married, uneducated Major Variables & Definitions IV: Barriers to HPV selfsampling DV: HPV selfsampling rates Measurement Analysis Findings Decision for Use IDI, FGD Audio recorded data transcribed, thematic analysis Lack of knowledge about CC LOE: VI Common barriers to selfsampling HPV: lack of education, perceived Strengths: Identified screening barriers Weaknesses: Men’s opinion was not evaluated; study was conducted 2 years after the pilot study Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS Dabat district, North Gondar, Ethiopia. A qualitative study 36 Inclusion Criteria: Women who had participated in a home-based HPV sampling pilot study Funding: Open Society Foundation; BadenWu¨rttember g Ministry of Science; Research and the Arts; RuprechtKarlsUniversita¨t Heidelberg healthy status, social influence, husband disapproval, religion Conclusions: This study identified additional barriers to self-sampling Attrition: None stated F&A pt. population: Feasible to the hospital setting at the University of Gondar due to specific women socioeconomic factors Bias: None stated Country: Ethiopia Citation Conceptual Framework Design/Method Sample/Setting Citation Inferred HPDPT Design: Intake survey & 10- N: 524 Major Variables & Definitions IV: SB Measurement Analysis Findings Decision for Use 10-item questionnaire – Descriptive & Multivariate Education attainment LOE: V Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS (Akinlotan et al., 2017). Cervical cancer screening barriers and risk factor knowledge among uninsured women Funding: Cancer Prevention and Research Institute of Texas (Grant # PP130090) Bias: None stated Country: USA 37 item true/false questionnaire Setting: 17 counties in Texas Purpose: To identify correlations between CC risk factor knowledge and examine SB to screening among a group of low-income uninsured women Sample Demographics: uninsured women, race/ethnicity: Black, nonHispanic white, Hispanic Inclusion Criteria: Women with income below 250% PL, 21 or older, without hysterectomy Attrition: 145 DV: CC risk knowledge true/false to determine CC risk factor knowledge 10-item questionnaire with Likert scale to measure patient’s perceived barriers Chi Square inversely correlates with risk knowledge 3.2% of participants unaware of any CC risk factors 70% of participants knew CC correlated w/sexual activity 60% knew CC risk correlated w/multiple sex partners Strengths: None stated Weaknesses: Questionnaire was given to women already presenting for CCS Conclusions: Study highlights level of awareness of CC risk factors F&A pt. population: The surveys in this study could be utilized for all women to evaluate CC risk knowledge 64.4% knew CC risk correlated w/being immunocom promised Only 8% knew all risk Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS 38 Citation Conceptual Framework Design/Method Sample/Setting Citation (Barrington et al., 2019). Patient navigator reported patient barriers and delivered activities in two large federallyfunded cancer screening programs Inferred HPDPT Design: XSS N: 582 Purpose: Characterize PNs within NBCCEDP & CRCCP n: 410 breast & cervical n: 172 colorectal Funding: None stated Bias: None stated Country: USA Collect data directly from PN’s within federally funded screening programs Setting: PN’s working for NBCCEDP or CRCCP Sample Demographics: majority female, college education, English, heterosexual, health professional Major Variables & Definitions IV: PN DV: Perceived patient barriers Measurement Analysis Online survey Descriptive statistics z-statistic factors for CC Findings Common patient barriers identified were related to SB. Unique findings from PN’s included patient transportatio n and scheduling Decision for Use LOE: V Strengths: Data from a large nationally represented navigator Weaknesses: Low response to survey Conclusions: Common SB identified by PN’s. F&A pt. population: Feasible in rural and underserved communities due to similar SB identified Inclusion Criteria: PN’s working for NBCCEDP or CRCCP Attrition: None stated Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS 39 Table A2 Synthesis Table Study Characteristics Yan et al. Year XSS SR QS Survey # Participants Theory 2019 Measurement Tools IDI, Questionnaire , FGD Country Demographics Mean Age Independent Variables Binka et al. 2019 Weng et al. 2020 • Musa Atereet al. Roberts et al. 2017 2020 • • 39 Inferred HPDPT Harper et al. Liu et al. Megers a et al. Akinlotan et al. Barringto n et al. 2020 2017 • 2020 2017 2019 • • • 55 Socioecologica l Model of McLeroy et al. IDI, FGD • 1483 Inferred HPDPT China Ghana Questionnair e 3 closeended questions, 14 close-ended questions China 48 30-65 32.86 • 44,065 Inferred HPDPT 420 Inferred HPDPT 47 HBM Scoping review of PubMe d 3 Nationa l Health Surveys Face-toface interview s IDI, FGD 10-item questionnair e true/false & Likert Online survey USA USA USA China Ethiopi a USA USA N/A N/A 45-65 30-65 28-40 21< <40 28 SCF & SEM PIC O 8 SCF • 524 Inferred HPDPT 582 Inferred HPDPT Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS Knowledge of CC Barriers to CC Factors associated w/screening CC education Provider recommendatio n Peer counseling Small media initiatives Socioeconomic predictors Elderly women PN SB Barriers to HPV self-sampling Dependent Variables CCS rates CCS treatment Participation in CCS programs 40 • • • • • • • • • • • • • • • • • • • • • • • Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS HPV selfsampling rates CC risk knowledge Perceived patient barriers Findings Gap in CC knowledge & health awareness Fear of CC & screening outcomes Cultural barriers Social influence Inconvenience Organizational barriers Education increased CCS rates Self-sampling HPV increases CCS rates Group education 41 • • • • • • • • • • • • • • • • • • • Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS increases CCS rates One on one education increases CCS rates Multicomponen t education does not impact CCS rates Elderly RW have decreased CCS rates Positive attitude towards CCS HC providers positively impact CCS rates SB correlate w/CC knowledge 42 • • • • • • • Key: ANOVA- analysis of variance; BCC – breast and cervical cancer; BRFSS - Behavioral Risk Factor Surveillance System; CC – cervical cancer; CCS - cervical cancer screening; CRCCP – Colorectal Cancer Control Program; DV – dependent variable; EL – education level; F&A – feasibility and applicability; FGD – focus group discussion; FU – follow-up; HBM – health belief model; HC – health care; HCPS - Health Center Patient Survey; HINTS -Health Information National Trends Survey; HPDPT – Health Promotion Disease Prevention Theory; HPV – Human Papilloma Virus; IDI – In-depth interview; IV – independent variable; LOE – level of evidence; MA – mean age; MP – mean parity; N – number of participants; N/A – not applicable; NBCCEDP – National Breast and Cervical Cancer Early Detection Program; OR – odds ratio; PE – provider education; PICO – population, intervention, comparison, outcome; PL – poverty level; PN – patient navigator; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-analysis; pt – patient; QS – qualitative study; RA – research assistants; RCT – randomized control trial; RQDA - R programming language package for Qualitative Data Analysis; RW – rural women; SB – socioeconomic barriers; SCF – social cognitive framework; SEM – social ecological model; SR – systematic review; TRI – tape recorded interviews; UE – unemployed; USA – United States of America; XSS – cross-sectional survey SOCIOECONOMIC BARRIERS 43 Appendix B Figure 1 Social Cognitive Theory Vancouver et al. (2002). SOCIOECONOMIC BARRIERS Figure 2 Lean Sigma Six Model Rastogi (2021). 44 SOCIOECONOMIC BARRIERS 45 Appendix C Written Informed Consent Socioeconomic Barriers in Rural Women and Cervical Cancer Screening: A Gap Analysis I am a graduate student under the direction of Dr. Patricia Janicek in the Women’s Health Nurse Practitioner program in the Edson College of Nursing and Health Innovation at Arizona State University. I am conducting a research study to identify socioeconomic barriers in rural women that prevent routine cervical cancer screening. I am inviting your participation, which will involve 20 to 30 minutes in completing a survey that identifies demographic information, basic cervical cancer knowledge, and perceived barriers to routine cervical cancer screening. You have the right not to answer any question, and to stop participation at any time. Your participation in this study is voluntary. If you choose not to participate or to withdraw from the study at any time, there will be no penalty. You must be 21 or older to participate in this study. Your responses to the survey will be used to identify socioeconomic barriers that impact routine cervical cancer screening which can lead to the development of interventions to overcome the identified socioeconomic barriers. There are no foreseeable risks or discomforts to your participation. Your responses will be anonymous and no identifiable participant information will be collected. The results of this study may be used in reports, presentations, or publications but your name will not be used. If you have any questions concerning the research study, please contact the research team at: ltparkma@asu.edu or PatriciaJanicek@asu.edu. If you have any questions about your rights as a subject/participant in this research, or if you feel you have been placed at risk, you can contact the Chair of the Human Subjects Institutional Review Board, through the ASU Office of Research Integrity and Assurance, at (480) 965-6788. Please let me know if you wish to be part of the study. SOCIOECONOMIC BARRIERS 46 Appendix D Project Survey SOCIOECONOMIC BARRIERS 47 SOCIOECONOMIC BARRIERS 48 SOCIOECONOMIC BARRIERS 49 Appendix E 2021 NBCCEDP Allowable Procedures and Relevant CPT Codes SOCIOECONOMIC BARRIERS 50 SOCIOECONOMIC BARRIERS 51 SOCIOECONOMIC BARRIERS 52 SOCIOECONOMIC BARRIERS 53 SOCIOECONOMIC BARRIERS 54 SOCIOECONOMIC BARRIERS 55 SOCIOECONOMIC BARRIERS 56 SOCIOECONOMIC BARRIERS 57 SOCIOECONOMIC BARRIERS 58 SOCIOECONOMIC BARRIERS 59 SOCIOECONOMIC BARRIERS 60 Appendix F Participant Demographic Variables Table 1 Frequency Table for Demographic Variables Variable Marital Status Single Married Living with Partner Race American Indian or Alaskan Native White or Caucasian Other County Coconino Yavapai Education College High School Vocational College Middle School Graduate School Insurance Private Insurance Uninsured Primary Language English Spanish Hispanic or Latino No Yes n % 5 3 2 50.00 30.00 20.00 2 5 3 20.00 50.00 30.00 9 1 90.00 10.00 5 2 1 1 1 50.00 20.00 10.00 10.00 10.00 3 7 30.00 70.00 6 4 60.00 40.00 6 4 60.00 40.00 SOCIOECONOMIC BARRIERS 61 Table 2 Summary Statistics Table for Age, Annual Income, and Household Size Variable Age Annual Income Household M 47.50 12,514.20 2.58 SD 12.76 14,442.18 1.26 n 10 10 10 Min 24.00 0.00 1.00 Max 63.00 50,000.00 5.00 SOCIOECONOMIC BARRIERS 62 Appendix G General Health Demographic Variables Table 3 Frequency Table for General Health Demographic Variables Variable Do you have a health care provider? Yes No When was the last time you visited your provider? <6 months >1 year 6 months - 1 year General Health Good Fair Excellent Very Good n % 7 3 70.00 30.00 7 2 1 70.00 20.00 10.00 4 2 2 2 40.00 20.00 20.00 20.00 Table 4 Frequency Table Likert Scale General Health Demographics Variables Variable How often do you prepare a list of questions for your doctor? Always Often Rarely Sometimes Never 0.00 0.00 0.00 0.00 0.00 How often do you ask questions about the things you want to know and the things you don’t understand? Always 0.00 SOCIOECONOMIC BARRIERS 63 Table 4 Frequency Table Likert Scale General Health Demographics Variables Variable Sometimes 0.00 Often 0.00 Rarely 0.00 How often do you discuss any personal problems that may be related to your illness? Always 0.00 Sometimes 0.00 Often 0.00 Rarely 0.00 How confident are you in filling out medical forms by yourself? Always 0.00 Often 0.00 Sometimes 0.00 Rarely 0.00 Table 5 Summary Statistics General Health Demographic Variables Variable How many days in the past month was your physical health not good? How many days in the past month was your mental health not good? M 0.00 1.70 SD 0.00 3.13 SOCIOECONOMIC BARRIERS 64 Appendix H Pap Smear History Table 6 Frequency Table for Pap Smear History Variable Have you had a hysterectomy? No Yes Last pap smear 1-2 years Not sure Within past 1 year Abnormal pap smear No n/a Yes Have you or a member of your family had cervical cancer? FALSE TRUE Are you aware of the 3-part HPV vaccine series? Yes Not sure No Have you received the HPV vaccine? Yes No Not sure Have you completed the HPV vaccine series? Yes No n % 9 1 90.00 10.00 1 3 6 10.00 30.00 60.00 5 4 1 50.00 40.00 10.00 9 1 90.00 10.00 3 1 6 30.00 10.00 60.00 1 8 1 10.00 80.00 10.00 1 9 10.00 90.00 SOCIOECONOMIC BARRIERS 65 Appendix I Cervical Cancer Risk Factors Table 7 Frequency Table for Cervical Cancer Risk Factors Variable …She has many sexual partners TRUE Not sure FALSE …She smokes cigarettes FALSE TRUE Not sure …She started having sex at a young age Not sure TRUE FALSE …She has unprotected sex TRUE Not sure FALSE …She does not go for regular pap smear tests TRUE Not sure FALSE …She has a sexually transmitted disease or virus TRUE Not sure FALSE …She used birth control pills for a long time FALSE TRUE Not sure …She has many children FALSE TRUE Not sure n % 5 3 2 50.00 30.00 20.00 4 4 2 40.00 40.00 20.00 2 4 4 20.00 40.00 40.00 3 3 4 30.00 30.00 40.00 8 1 1 80.00 10.00 10.00 7 1 2 70.00 10.00 20.00 4 3 3 40.00 30.00 30.00 5 1 4 50.00 10.00 40.00 SOCIOECONOMIC BARRIERS …She has a weakened immune system TRUE Not sure FALSE …It runs in her family TRUE Not sure FALSE 66 3 3 4 30.00 30.00 40.00 7 1 2 70.00 10.00 20.00 SOCIOECONOMIC BARRIERS 67 Appendix J Socioeconomic Barriers to Routine Cervical Cancer Screening Table 8 Frequency Table for Socioeconomic Barriers to Routine Cervical Cancer Screening Variable Feelings of embarrassment Strongly Disagree Disagree Neither Agree nor Disagree Fear of finding cancer Strongly Disagree Disagree Agree Transportation Strongly Disagree Agree Cost Strongly Disagree Strongly Agree Disagree Anxiety about procedure Strongly Disagree Neither Agree nor Disagree Disagree Lack of knowledge Strongly Disagree Disagree Lack of time Strongly Disagree Disagree Anticipation of pain Strongly Disagree Disagree Neither Agree nor Disagree Forgetting to schedule an appointment n % 8 1 1 80.00 10.00 10.00 7 1 2 70.00 10.00 20.00 9 1 90.00 10.00 5 1 4 50.00 10.00 40.00 8 1 1 80.00 10.00 10.00 9 1 90.00 10.00 9 1 90.00 10.00 7 2 1 70.00 20.00 10.00 SOCIOECONOMIC BARRIERS 68 Table 8 Frequency Table for Socioeconomic Barriers to Routine Cervical Cancer Screening Variable Strongly Disagree Neither Agree nor Disagree Agree Disagree Other health problems Strongly Disagree Disagree Language barriers Strongly Disagree Neither Agree nor Disagree Agree Disagree Male physician Strongly Disagree Strongly Agree Neither Agree nor Disagree Disagree n 6 2 1 1 % 60.00 20.00 10.00 10.00 8 2 80.00 20.00 7 1 1 1 70.00 10.00 10.00 10.00 6 1 2 1 60.00 10.00 20.00 10.00