Our study demonstrates a high prevalence of self-reported abnormal Pap test results in a jail and community supervision population and a high prevalence of risk factors for cervical cancer, consistent with our first hypothesis. These results are consistent with other studies that demonstrate a higher prevalence of cervical cancer among women in prison and jail than in the general population,1
but prior studies have not examined the prevalence of abnormal Pap test results in the community corrections population or potential demographic, behavioral, and medical factors associated with abnormal Pap tests.
In our study, jail and community corrections populations were similar in terms of their prevalence of abnormal Pap test reporting. Our analysis suggests that differences between women who did and did not report abnormal Pap tests were related to differences in sexual behavior and medical factors. Consistent with our second hypothesis, we observed three factors that were significantly associated with abnormal Pap test results in these criminal justice populations: history of inconsistent condom use, history of STIs, and history of other gynecologic infections. In contrast, other classic risk factors for cervical cancer (tobacco use) may not be associated with abnormal Pap tests in this population with a high prevalence of both abnormal Pap tests and tobacco use.
Our results that many women reported a history of an abnormal Pap test suggest that it is appropriate for women with criminal justice involvement to have access to cervical cancer screening that at least meets guidelines set forth for the general population. The United States Preventive Services Task Force (USPSTF) review of cervical cancer screening suggests that use of Pap testing reduces the incidence of and mortality from cervical cancer. Their latest recommendations, published in 2003, suggest screening within 3 years of the onset of sexual activity or age 21 (whichever comes first) and a screening interval of every 3 years.30
Correctional-specific guidelines for providing Pap tests should at least meet guidelines set forth for the general public, although some individuals, correctional systems, and organizations suggest policies that exceed USPSTF guidelines. For instance, Lee et al. suggested that “cervical cancer screening via Pap testing or HPV genetic testing should be offered to all females with an intact cervix at facility admission and then annually.”30
The Federal Bureau of Prisons has also recommended that all females aged ≤30 have a Pap test at the intake physical and annually until the age of 31. For women aged 31–65 with previously negative Pap tests, they recommend a Pap test at the intake physical and every 3 years.31
It is likely to be logistically more complex to provide Pap testing in jails for women who are incarcerated for <1 week, but for those awaiting trial or serving sentences in jails, it is feasible in many jails with on-site medical facilities. Although our study was not designed to assess access to Pap testing, screening in community supervision settings (e.g., at parole or probation) is, to our knowledge, virtually nonexistent in the United States.
Our results also suggest that women involved in the criminal justice system are important targets for interventions designed to address cervical cancer because of their high risk of cancer and their high prevalence of risk factors.13,14
Incarceration offers an opportunity to provide reproductive health services to some high-risk women who might not otherwise seek or receive health services.14
In our study, approximately 40% of women did not have a current healthcare provider. This is higher than that in a 2002 survey of U.S. women, which suggested that 28.1% were uninsured, but lower than in a 2006 survey of incarcerated women in Rhode Island, which estimated that 54% entered the facility without health insurance. This finding emphasizes the significant barriers to care among criminal justice populations.13
Future work could assess the feasibility of providing cervical cancer screening in community supervision environments and the cost-effectiveness of enhanced screening in jails. The high prevalence of abnormal Pap test results suggests that women in criminal justice settings also have medical treatment and follow-up needs, particularly given their poor access to care.
Although many of the women in our study would not have been eligible for HPV vaccination because of their age, targeting HPV vaccination to girls and younger women involved in the criminal justice system may be one way to address the high prevalence of abnormal Pap testing reported by women in our study. The HPV vaccination is currently recommended for women up to age 26.32
The natural history of HPV infection and cervical cancer and the characteristics of girls in the juvenile justice system suggest implications for the prevention of cervical cancer that also extend to girls younger than those enrolled in this study. Youth involved in the criminal justice system are often disenfranchised from traditional healthcare services, and correctional healthcare may be the major provider of care to adolescents in the criminal justice system.33
Providing cancer prevention services to girls in juvenile detention affords an opportunity to address racial and ethnic disparities, given the disparities in cervical cancer incidence and mortality in this country.32
The criminal justice system involves populations of girls and young women appropriate for enhanced HPV vaccine access. Vaccination efforts should be considered as early as possible for this population, as the vaccine is more effective when administered before exposure to risks for cervical cancer.34
Correctional settings tend to emphasize acute healthcare needs, whereas vaccinations and other preventive healthcare services may be overlooked or underprioritized in criminal justice settings,34
especially community criminal justice settings (e.g., probation and parole). Many of the women in this study did not have a current healthcare provider; therefore, mechanisms to provide guideline-consistent screening tests, update immunization status, address developmental and psychosocial issues, and work to establish a medical home before release from correctional settings are needed.33
A national study reported that most women in prisons are likely to receive a gynecologic examination (90%), but only 22% of women being admitted into jails receive a gynecologic examination.35
For women who have short stays in correctional facilities, for example, youth who are detained at but not committed into juvenile correctional facilities, the first HPV vaccine dose can be administered in the facility and follow-up doses can be administered by a community-based provider.34
Providing health education and risk reduction education combined with preventive care at parole and probation offices would offer a novel, adjunctive means to target high-risk women. These preventive interventions, however, may require specialized funding, given competing demands in criminal justice budgets.
Our study was limited by the collection of self-reported data about Pap testing results, which may not always correspond to the cytologic findings on cervical samples.36
However, our use of survey data allowed us to obtain results from a large number of women involved in the criminal justice system, who gave us detailed behavioral data. Our participants may not have been as forthcoming if we had requested permission to examine identifiable medical or pathology reports. The presence of an abnormal Pap result was frequent, and, therefore, the use of an odds ratio may not accurately estimate a relative risk. Given that the surveys were designed to be brief self-administered surveys, they did not include questions about all potential risk factors for cervical cancer, including number of lifetime partners; did not specify condom use relative to partner risk; and did not assess HPV vaccination history or access to Pap testing. Nonetheless, this study provides preliminary prevalence estimates to help guide further research in this area. Finally, our study may not be generalizable to other jails and community supervision settings in other parts of the country. Despite this limitation, our integration of data from two different populations in different locales increased diversity and our ability to make comparisons between the two groups of women in the criminal justice system. In addition, this is the first study, to our knowledge, to examine this topic in a community supervision sample of women.
Based on our results, it is premature to target screening and prevention to subsamples of women in jails and community supervision settings. Many women involved with the criminal justice system reported a history of abnormal cervical cancer screening results and are at high risk for cervical cancer. Providing preventive healthcare, including screening, education, and immunization, to this population presents an opportunity to address a disease that is overrepresented in women in the criminal justice system.