To date, little has been known about the referral practices and referral facilitation behaviors of FP providers for FP clients with abnormal Pap smears or the follow-up action taken by FP clients who receive referrals from their FP providers. Our study fills this gap by providing several new findings to the existing literature on this subject.
Among our most important results, we found that private office-based FP providers were significantly more likely to provide treatment for clients with abnormal Pap smears personally or within their practice. And, should they make referrals for follow-up care for these abnormal Pap smears, they were significantly less likely to engage in referral facilitation activities compared with referring FP providers based in health departments and other types of clinics. Conversely, we found that health department-based FP providers were significantly more likely to refer clients with abnormal Pap smear results and less likely to provide treatment.
Referring providers from health departments were significantly more likely to engage in referral facilitation activities than referring providers from other institutional settings. We also found that clients who received a referral from their FP provider were more likely to seek care for the abnormal Pap smear. In addition, clients who actually received some treatment from their FP provider for abnormal Pap smears along with a referral were more likely to actually receive additional follow-up care than those who did not receive treatment. This may be because they were better able to use the resources of the BCCEDP after having received additional diagnostic procedures from their FP provider. We also found an association between having a usual source of general medical care and an increased likelihood of seeking and receiving care for an abnormal Pap smear, suggesting that general access to care issues play a role in Pap smear follow-up completion rates.
As other studies have suggested, there are several mediating factors that affect clients' receipt of follow-up care for abnormal Pap smears, no matter what actions are taken by the FP provider. Women younger than age 30 and women with more college education were most likely to receive follow-up care. These factors are important, but difficult to alter with an intervention at the FP provider level. However, we found an association between higher trust in physicians and a greater likelihood of seeking care, as well as between measures of self-efficacy and being less likely to seek and receive treatment. The latter finding suggests that clients were not aware of or convinced of the negative implications of having an abnormal Pap smear. However, given the positive association found with physician trust, this may indicate an important intervention point for FP providers to educate patients on these implications.
Health departments are among the largest providers of Title X and Medicaid FP demonstration waiver services21,22
and are thus in a position to provide initial cervical cancer screenings for a substantial number of women. However, health departments are less likely than other providers to offer additional diagnostic services on-site (e.g., colposcopy)13–15
and do not provide on-site treatment for precancerous lesions and cervical cancer. Where follow-up treatment is not available at the FP site, referrals are critical and a driving factor in whether women seek care for the condition. We found that referring FP providers based in health departments were significantly more likely to engage in referral facilitation activities compared with referring providers from other settings. This may be due in part to health department providers' access to resources available through BCCEDP, which is funded by the Centers for Disease Control and Prevention but operated by state health departments. Although these programs differ by state,23
they provide funds for diagnostic services and case management.6
Other studies have shown that provider facilitation activities, such as those reported by health department providers in our study, are effective in improving follow-up adherence.24
Given the importance of these activities, interventions to increase client follow-up rates should focus on provider and system features, rather than clients. Such interventions may include educational programs aimed at improving providers' knowledge of referral resources, or programs aimed at expanding diagnostic and treatment services within health departments.
Our study had several limitations. This study relied on the FP providers' self-report of their referral and facilitation behavior and on FP clients' report of FP providers' referral and facilitation behavior. Given the discordance between providers' self-reported behavior (nearly all reported they treated or referred clients with abnormal Pap smears) and clients' reports of providers' referral behavior (one-third reported their provider neither treated nor referred them), these reports may not reflect actual referral and facilitation practices. However, the results may also reflect a problem in communication between providers and patients.
While our provider survey had a low overall response rate (26%), the response rate among public providers was much higher (59%). This is important because these providers serve the majority of the low-income women of interest to this study in Arkansas (79%)21
and Alabama (71%).22
In addition, low response rates from health-care providers compared with the general population are not uncommon in survey research.25
Also, because some of the providers to which the instrument was mailed are no longer practicing, our denominator may be inflated, meaning our true response rate is higher.
We had a relatively low sample size of those reporting an abnormal Pap smear on the client survey, thereby limiting the robustness of the multivariate analysis. Also, because the questions were generic to multiple health conditions, we do not know the content of the treatment that clients reported receiving for abnormal Pap smears from their FP providers. Thus, it is possible that clients who reported being treated and also referred elsewhere for care were being referred based on the results of a colposcopy or other biopsy procedure.