Kelly Ackerson

A decision theory perspective on why women do or do not decide to have cancer screening: systematic review

AIM This paper is a report of a review in which decision theory from economics and psychology was applied to understand why some women with access to care do not seek cancer screening. BACKGROUND Mammography and cervical smear testing are effective modes of cancer screening, yet many women choose not to be screened. Nurses need to understand the reasons behind womens choices to improve adherence. DATA SOURCES Research papers published between January 1994 and November 2008 were identified using the Cumulative Index to Nursing and Allied Health Literature, MEDLINE and PsycINFO data bases. The search was performed using the following terms: cervical cancer screening, breast cancer screening, decision, choice, adherence and framing. Forty-seven papers were identified and reviewed for relevance to the search criteria. METHODS Nineteen papers met the search criteria. For each paper, reasons for obtaining or not obtaining cancer screening were recorded, and organized into four relevant decision theory principles: emotions, Prospect Theory, optimism bias and framing. FINDINGS All women have fears and uncertainty, but the sources of their fears differ, producing two main decision scenarios. Non-adherence results when women fear medical examinations, providers, tests and procedures, do not have/seek knowledge about risk and frame their current health as the status quo. Adherence is achieved when women fear cancer, but trust care providers, seek knowledge, understand risk and frame routine care as the status quo. CONCLUSION Nurses need to address proactively womens perceptions and knowledge about screening by openly and uniformly discussing the importance and benefits.

Personal Influences That Affect Motivation in Pap Smear Testing Among African American Women

OBJECTIVE To explore personal influencing factors that contribute to Papanicolaou (Pap smear) testing in African American women who do (routine-use group) and do not (non-routine-use group) obtain routine testing. DESIGN Qualitative using the interaction model of client health behavior. SETTING Community programs, homes, and churches. PARTICIPANTS Twenty four African American women aged 19 to 60. METHODS Face-to-face interviews. Data were analyzed using a constant comparison approach. RESULTS Routine-use group was socially influenced to value preventive health care while the non-routine-use group was not. Previous health care experiences with having a Pap smear and pelvic exam were positive for routine-use group and negative for non-routine-use group. Cognitively, both groups believed Pap smears tested for cancer and sexually transmitted diseases. Vulnerability to cervical cancer was thought to run in families; participants believed they were either safe from risk or hoped that the odds were in their favor. In addition, there was a link between avoiding routine preventive care and a trauma history (sexual, physical, medical), eliciting negative perceptions towards Pap smears and pelvic exams. CONCLUSION Differences and similarities in personal influencing factors associated with cervical cancer screening were found in the two groups. Further research is needed to explore these differences and similarities because they may contribute to the reason that African American women have a greater mortality rate from cervical cancer than White women.

A History of Interpersonal Trauma and the Gynecological Exam

Cervical cancer is preventable, in part, by routine Papanicolaou (Pap) testing, but some women avoid routine screening. African American women have the greatest mortality among all groups of women in the United States. Personal reasons have been found to contribute to screening avoidance behavior, such as a history of sexual abuse and intimate partner violence. Fifteen African American women with a trauma history participated in personal interviews. The Interaction Model of Client Behavior was employed for exploring the women’s social influence, previous health care experience, cognitive appraisal, affective response, and motivation associated with routine Pap testing. Study findings suggest that providers need to assess and provide accurate information about Pap testing and cervical cancer to increase patients’ knowledge. Personally reflecting on one’s approach to conducting a woman’s gynecologic exam (and how it is performed) might prevent triggering unwanted memories, making that visit a positive experience and facilitating repeat screening behavior.

Home Birth After Hospital Birth: Women's Choices and Reflections

INTRODUCTION The number of US women choosing home birth is increasing. Little is known about women who choose home birth after having experienced hospital birth; therefore, the purpose of this research was to explore reasons why these women choose home birth and their perceptions regarding their birth experiences. METHODS Qualitative description was the research design, whereby focus groups were conducted with women who had hospital births and subsequently chose home birth. Five focus groups were conducted (N = 20), recorded, and transcribed verbatim. Qualitative content analysis was undertaken allowing themes to emerge. RESULTS Five themes emerged from the womens narratives: 1) choices and empowerment: with home birth, women felt they were given real choices rather than perceived choices, giving them feelings of empowerment; 2) interventions and interruptions: women believed things were done that were not helpful to the birth process, and there were interruptions associated with their hospital births; 3) disrespect and dismissal: participants believed that during hospital birth, providers were more focused on the laboring womans uterus, with some experiencing dismissal from their hospital provider when choosing to birth at home; 4) birth space: giving birth in their own home, surrounded by people they chose, created a peaceful and calm environment; and 5) connection: women felt connected to their providers, families, newborns, and bodies during their home birth. DISCUSSION For most participants, dissatisfaction with hospital birth influenced their subsequent decision to choose home birth. Despite experiencing challenges associated with this decision, women expressed satisfaction with their home birth.

Planned home birth: benefits, risks, and opportunities

While the number of women in developed countries who plan a home birth is low, the number has increased over the past decade in the US, and there is evidence that more women would choose this option if it were readily available. Rates of planned home birth range from 0.1% in Sweden to 20% in the Netherlands, where home birth has always been an integrated part of the maternity system. Benefits of planned home birth include lower rates of maternal morbidity, such as postpartum hemorrhage, and perineal lacerations, and lower rates of interventions such as episiotomy, instrumental vaginal birth, and cesarean birth. Women who have a planned home birth have high rates of satisfaction related to home being a more comfortable environment and feeling more in control of the experience. While maternal outcomes related to planned birth at home have been consistently positive within the literature, reported neonatal outcomes during planned home birth are more variable. While the majority of investigations of planned home birth compared with hospital birth have found no difference in intrapartum fetal deaths, neonatal deaths, low Apgar scores, or admission to the neonatal intensive care unit, there have been reports in the US, as well as a meta-analysis, that indicated more adverse neonatal outcomes associated with home birth. There are multiple challenges associated with research designs focused on planned home birth, in part because conducting randomized controlled trials is not feasible. This report will review current research studies published between 2004 and 2014 related to maternal and neonatal outcomes of planned home birth, and discuss strengths, limitations, and opportunities regarding planned home birth.

Feasibility of a longitudinal study of women anticipating first pregnancy and assessed by multiple pelvic exams: Recruitment and retention challenges

OBJECTIVE To better understand the relationship between childbirth and pelvic floor disorders the ideal study design would begin with data collection prior to but close in time to first pregnancy and follow participants through postpartum. We conducted a feasibility study to determine the following: a) whether women desiring to get pregnant would agree to pre-pregnancy data collection including a one-time urethral catheter measure and repeat pelvic exams to ascertain a baseline within 6 months of pregnancy; b) effectiveness of various recruitment and retention methods, c) number achieving pregnancy, and then d) number expressing willingness to continue follow-up through pregnancy and postpartum. METHODS Advertising included newspaper ads, targeted emails and flyers. Post-enrollment, four data collection visits were scheduled and occurred every 6 months or until pregnant. If pregnancy occurred, women were asked to indicate their willingness to continue assessments. RESULTS The most successful advertising strategy for both recruitment and retention was local newspaper ads. Ninety-four women inquired about the study, 30 enrolled. Post-baseline retention was 23 women at 6 months, 17 at 12 months, and 13 at 18 months. Nine of the 30 women achieved pregnancy; two remained eligible and willing to participate through pregnancy and postpartum. CONCLUSIONS This study provides data on feasibility of recruiting women to establish near-pregnancy clinical baseline measures that include pelvic exams. Close to 30% reached pregnancy within 2 years of study start and within 6 months of most recent pelvic exam measure. Of those who became pregnant, 22% expressed willingness to continue follow-up into the childbearing year.

Female college students’ beliefs about cervical cancer screening

Purpose To explore female college students’ perceived benefits and barriers to cervical cancer screening and perceived vulnerability to cervical cancer. Method The study was exploratory and cross sectional. The Pap Smear Belief Questionnaire was distributed online to a sample of 267 female undergraduate baccalaureate nursing students. Findings Students who obtained routine Pap smears perceived greater benefits and fewer barriers to routine screening than the students who did not obtain routine Pap smears. Personal vulnerability to cervical cancer was not a significant finding. Students who were in a long-term relationship, non-smoking and initiated sexual intercourse at a younger age were more likely to obtain routine screening. Conclusion Stressing importance of preventive health care associated with routine cervical cancer screening is important to promote women’s health regardless of age or level of education. Further studies with a broader range of college students as participants are needed to better understand their beliefs about the benefits and barriers to obtaining routine screening, and their perceptions of vulnerability to cervical cancer.

Factors influencing use of family planning in women living in crisis affected areas of Sub-Saharan Africa: A review of the literature

BACKGROUND far too many women continue to die from pregnancy and childbirth related causes. While rates have decreased in the past two decades, some areas of the world such as sub-Saharan Africa continue to have very high maternal mortality rates. One intervention that has been demonstrated to decrease maternal mortality is use of family planning and modern contraception, yet rates of use in sub-Saharan countries with the highest rates of maternal death remain very low. AIM to review available research and summarize the factors that inhibit or promote family planning and contraceptive use among refugee women and women from surrounding areas living in Sub-Saharan Africa. DESIGN a review of the literature. DATA SOURCES Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), OVID, power search, and PubMed databases. REVIEW METHODS studies included were: (1) published in English from 2007 to present; (2) primary research; and (3) focused on family planning and contraceptive use among refugee women and women in surrounding areas. Findings were discussed within the framework of the Interaction Model of Client Health Behavior. FINDINGS twelve studies met the inclusion criteria. Utilization of modern contraceptive methods was low. Women were socially influenced to avoid the use of contraceptives by husbands and others in the community. Reasons were a lack of trust in western medicine and the desire to have large families. Low socioeconomic status and proximity of family planning clinics were barriers to access. Women believed that health care providers were unqualified, many described being treated with disrespect in the health clinics. Knowledge and understanding of contraceptives was low; while most women knew different methods were available, there were many misconceptions. Believing that certain contraceptives cause death, infertility and side effects, contributed to fear of use. This lack of knowledge and fear, even with the desire to space and limit births, affected motivation to use contraception. CONCLUSIONS developing new approaches to educating women, men (husbands), community leaders as well as healthcare providers is needed to address the multi-factorial issues that contribute to underuse of family planning services, thus contraceptive use. IMPLICATIONS FOR PRACTICE while lack of access to family planning is a barrier to use, interventions that improve access must be affordable and include education regarding contraceptive methods, preferably from those within the community. However, education and access is not sufficient unless the issue of disrespect by healthcare providers is addressed. Respectful and culturally sensitive care for all women, regardless of socio-economic status or country of origin, must be provided by midwives and other women health providers.

Psychometric testing of the pap smear belief questionnaire: Measuring women's attitudes and beliefs toward cervical cancer screening

Background and Purpose: Some women avoid routine Pap testing because of negative attitudes and beliefs. The ability to measure these factors is limited by lack of valid and reliable tools. Therefore, this article describes steps taken to test a measure. Methods: Validity and reliability testing of psychometric scales was conducted. Results: Sample consisted of 344 women. Using principal component analysis resulted in 4 components: Exam-Related Factors, Benefits, Vulnerability, and Risks and Barriers. Revised scale included 28 items explaining 46% variance, with good internal consistency (α = .84). Women who did not routinely screen exhibited significantly more negativity. Conclusions: The measure demonstrates validity and reliability across different groups of women and can be used to inform the design of individualized interventions to promote repeat screening.

Modifying and Pilot Testing the Pap Smear Belief Questionnaire

This study is a report on modifications and pilot testing of a measurement tool to predict Pap testing based on the Interaction Model of Client Health Behavior. Women have been found to avoid routine cervical cancer screening (CCS) due to personal influencing factors. For this study, the Pap Smear Belief Questionnaire (PSBQ) was modified by adding items and evaluated through content validity index (CVI = .89) and cognitive interviews (think-aloud protocol), resulting in a 31-item instrument with four subscales (Benefits, Barriers, Vulnerability, Experiences). Pilot testing the modified PSBQ was conducted at a local agency. Fifty-three women completed and returned the PSBQ, which had good internal consistency, with a Cronbach’s alpha coefficient of .81 (Benefits α = .51; Barriers α = .85; Vulnerability α = .78; Experiences α = .87). Test–retest reliability of the 31-item PSBQ was also good (.878). Univariate logistic regression indicated that the only significant predictor of seeking/avoiding routine screening by women’s background characteristics was social influence (p = .04). Subscales found to be significant predictors in Pap testing were Barriers (p = .003) and Gynecological Exam Experiences (p = .04). The refined 31-item PSBQ has good psychometric data supporting its use in predicting CCS. However, this research should be replicated in a larger sample enabling further validity and reliability testing of the PSBQ. Understanding women’s attitudes toward CCS will help health care providers, who deal with gynecological health, develop more effective screening programs and interventions facilitating better experiences for women contributing to an increase in routine screening.