Since 1995, the Rhode Island Women's Cancer Screening Program has provided no-cost Pap tests and mammograms to eligible women in the state.33
This has undoubtedly contributed to Rhode Island's having the highest percentage of women in the nation getting screening mammograms.33
Although WWD still had lower rates of routine mammogram and Pap tests in our unadjusted analyses, these differences were not noted once we adjusted for demographic characteristics. This indicates that the differences in routine mammogram and Pap tests rates between these two groups can be explained by the confounding influence of sociodemographic and health behavior characteristics. Consistent with published reports, disability was associated with indicators of socioeconomic disadvantage, such as unemployment, lower education, and lower income.34,35
Whereas most studies have suggested WWD have lower cancer screening rates compared with WND,36–40
several have found no overall differences between the two groups.34,41,42
We found that type of cancer screening mattered. WWD and WND had comparable breast cancer screening. The proportion of middle-aged and older unmarried women in our sample who received mammograms at the recommended intervals was higher than previously reported in the literature8,43
and exceeded the Healthy People 2010
This differs from other studies that reported that women with mental health or cognitive problems were less likely to attend breast screening.45,46
In contrast, WWD in our study had lower rates for all measures of cervical cancer screening compared with WND, similar to previously reported results.40
In particular, the gap between the desired and actual proportion of WWD who reported a Pap test within the last 3 years was significant, falling below the Healthy People 2010
It is crucial to understand the series of steps that contribute to successful participation in routine and on-schedule cancer screening. These include receiving and acting on appropriate information about cancer screening, adequate transportation and assistance to the cancer screening facility, and having the healthcare professional perform the examination with minimal pain or patient discomfort. In addition, similar to other studies, we found that reasons for putting off or delaying a routine cancer screening included transportation and taking time off from work.47,48
Previous research has documented how such entry barriers lead to limited uptake of preventive care services among WWD.5,49
For example, healthcare clinicians may erroneously assume that disability limits a woman's sexual activity and not provide adequate patient education about cancer screening.5
A previous study found that WWD did not have routine gynecological cancer screening services despite having seen a general healthcare provider within the last 6 months.50
Similarly, a high proportion of women in our sample had a current primary care provider (91%, data not shown), but the proportion of our sample reporting routine Pap tests was still below the national objectives.
Beyond entry barriers, all WWD may experience other difficulties with the procedure and the cancer screening experience itself. Communication difficulties, difficulties with the screening experience, and staff attitudes contribute to the quality of the cancer screening experience, especially for WWD. Factors that contribute to the quality of the experience, such as privacy and respect, can be grouped as secondary access factors, which impact the ability of an individual to continue care after she is in the healthcare system.20
Previous studies found that having additional reassurance and privacy50
and clear patient-doctor communication were associated with regular participation in mammography.51
In addition, an earlier study found that women who rated the overall quality of their healthcare as excellent had higher odds of receiving an annual Pap smear.52
Our study is one of the first studies to specifically examine how quality of the cancer screening experience and disability status are associated with receiving routine breast and cervical cancer screening among an older, unmarried female population. Although there have been recent gains in eliminating disparities in cancer screenings rates, it is imperative to also ensure the quality of the cancer screening experience for all women. Our results support the hypothesis that quality of the screening experience affects routine mammogram and Pap test rates, even after controlling for important individual characteristics and primary healthcare access factors. Consequently, there is a need to identify appropriate strategies that will ensure an optimal cancer screening experience for all women. These strategies should explore how best to provide information and equitable access. In addition, they should address the need to specifically tailor interventions to specific types of disabilities as needed. Our findings suggest that public health strategies for increasing the proportion of older WWD who obtain routine cancer screening should focus on improvement of quality of the screening experience instead of focusing only on individual patient behavior.
Study limitations and strengths
This study had several limitations. Disabilities encompass a wide range of limitations, including cognitive or psychological problems. WWD are a heterogeneous group with enormous diversity in limitations, underlying conditions, and duration of disability. Previous studies found differences in cancer screening rates according to disability severity, so using a general self-report of disability might dilute any association between disability and cancer screening.14,43
Second, this study was based on self-reported behaviors, which may underestimate53
cancer screening prevalence. Third, nonprobability-based sampling procedures may lead to limited generalizability of our results. Generalizability may also be limited because our sample focused on women who received most of their medical care in Rhode Island. Finally, we were unable to interpret the causal relationship between individual cancer adherence and the other variables because of the cross-sectional nature of the study design.
Nevertheless, this study extends previous knowledge by taking initial steps to assess whether there are differences in quality of the cancer screening experience in a group of middle-aged and older unmarried women with overall high rates of cancer screening. Information on this subpopulation of older unmarried women is not readily available. One of the strengths of the CSPW is its focus on unmarried women between the ages of 40 and 75, a subpopulation of women for whom large sample sizes have not been previously available. Further research efforts will include refining our quality of cancer screening experience variable. Although the quality of cancer screening experience variable in this current study is rudimentary, it does provide some evidence that less tangible barriers may be affecting cancer screening practices. In addition to including more information about type and severity of disability, future research directions should explore barriers to quality and the relationship between consumer satisfaction and cancer screening.