Cervical cancer attorney

ABSTRACT

Background: Female prison inmates are underscreened and are at higher risk of cervical cancer. The impact of a nurse-led Pap screening intervention was examined, which included information sessions and Pap testing clinics.

Method: Pap screening rates for 650 inmates at the Burnaby Correctional Centre for Women were compared both before and during the 20-week intervention period. These rates were determined by record linkage of Correction Branch inmate records and Cervical Cancer Screening Program patient records. Associations between socio-demographic factors and Pap screening rates were also examined.

Results: A higher proportion of inmates was screened during the intervention period (26.9%) than during the preintervention period (21.0%) (although the difference was not statistically significant (p=0.06)). Very short-stay inmates were less frequently screened in the preceding two years before the intervention. Inmates with no high school education and longer lengths of incarceration were significantly more likely to receive Pap testing during the intervention period as compared to the preintervention period.

Conclusion: The nurse-led intervention resulted in a modest improvement in the proportion of inmates receiving Pap screening. Unfortunately, the benefit of the nurse clinician did not reach, to a greater extent, inmates who had not been previously screened or who were inadequately screened. There is need for further work to target this hardest-to-reach group.

British Columbia has been a world leader in cervical cancer screening with the establishment of its population-based Cervical Cancer Screening Program in the early 1950s. However, some British Columbian women still suffer morbidity from, and die of, cervical cancer because they do not get regular Pap screening.1,2 Recent local initiatives have consulted with, and addressed, underscreened high-risk groups, such as Aboriginal and Chinese populations.3-5 However, there are no reported cervical cancer screening initiatives among Canadian prisoners.

Female inmates receive Pap screening less frequently, present with more severe abnormalities on screening and at younger ages, as compared to the general population.6-9 Burnaby Correctional Centre for Women housed approximately 1,200 inmates who were serving federal sentences (more than two years, including life sentences), provincial sentences (less than two years) or who are remanded to custody (awaiting sentencing). In 1998, 75% of surveyed Burnaby Correctional Centre for Women inmates said that they would accept Pap screening if it was offered during their incarceration.10 Pap screening in prisons has been recommended by others.11-14

A Pap screening intervention for Burnaby Correctional Centre for Women inmates was developed, implemented and evaluated in the years 2000 and 2001, with the following goals: to provide inmates with appropriate information regarding the importance of Pap screening; to make Pap testing available to them in a respectful and efficient manner; and to have the screening results communicated to the inmate in a quick and efficient manner. This paper examines the impact of the intervention by comparing proportions of inmates receiving Pap testing both before and during the intervention period.

METHOD

Two time periods, each of 134 days duration, were selected for study: the preintervention period (from January 11 to May 24, 2000) and the intervention period (from October 5, 2000 to February 16, 2001). 847 inmates were incarcerated at Burnaby Correctional Centre for Women at some point during these two periods. The lag time between the two periods permitted the development and introduction of the intervention, which was based upon the findings of three focus groups of inmates and periodic consultation with the prison inmate advisory committee and with prison staff. The suggestions of the inmates and the prison staff were then incorporated into the intervention design.

The intervention included the establishment of a nurse-led Pap clinic for one-on-one education about cervical cancer and its early detection, Pap testing, reporting of Pap test results and arranging for appropriate treatment. It was made available to all inmates, and clinics were held several times a week, with scheduled appointments for Pap tests and discussion of results. Community follow-up was done for women released from prison. In order to promote awareness of the clinic, the nurse practitioner engaged in a variety of creative activities, such as wearing a plastic pelvic model on her head, offering candy to the women, and "hanging out" in the living units in order to establish rapport and a trust relationship with the inmates.15

Two databases were linked to determine Pap screening practices for these two periods: British Columbia Ministry of Attorney General, Corrections Branch, inmate records and Cervical Cancer Screening Program patient records. The Cervical Cancer Screening Program maintains a database of all Pap smears taken in British Columbia from 1976 to present. Its patient records contain patient surnames, first and middle given names, date of birth, dates and results of each Pap smear, and the physician's name and clinic where the smear was taken. The Corrections Branch inmate records contain information on socio-demographic characteristics and movements within prison, such as incarceration dates, release dates, and dates for transfers between facilities. Socio-demographic factors included age (30 years), ethnicity (Caucasian, Aboriginal, other), education (no high school, some high school, grade 12 and higher), type of incarceration (on remand awaiting sentencing, sentenced) and length of incarceration during the relevant period (30 days).

A number of inmate records had multiple names and aliases, which would increase the likelihood of false matches when linked with the extremely large Cervical Cancer Screening Registry database. Since the distribution of multiple names in the inmate records decreased at > or =5 surnames or > or =4 first given names, a judgement decision was made to set this as the cut-off for excluding inmates with aliases. This left 650 inmates eligible for study. Chi-square testing showed that the excluded inmates were more likely to be older (p=0.01), Aboriginal (p

Automatch, a probabilistic record linkage software package,16 was used to link all eligible Corrections Branch inmate records with all Cervical Cancer Screening Program patient records. Fields matched were the surname, given names and date of birth as they were the only identifying information common to both databases. An exact match was required for date of birth, and a probabilistic match for surnames and given names. Every match identified by Automatch was then individually reviewed by a member of the research team before assigning the matching status.

Pap smear records for inmates matched to Cervical Cancer Screening Program patient records were extracted for the time covering the two years prior to the start of the preintervention period (January 11, 1998) until the end of the intervention period (February 16, 2001). Pap screening was analyzed for: Pap tests taken in the two years prior to the start of the specified period, that is from January 11, 1998 to January 10, 2000 for the preintervention period, and from October 5, 1998 to October 4, 2000 for the intervention period; and Pap tests taken during the specified period, that is during the preintervention period (from January 11 to May 24, 2000) and during the intervention period (from October 5, 2000 to February 16, 2001).

The chi-square test was used to test for differences in the socio-demographic profile of the inmates incarcerated during the preintervention and intervention periods, and to test for differences in the proportion having Pap tests. Out of 650 inmates, 274 were incarcerated in the preintervention period, 293 in the intervention period, and 83 during both periods. The 83 inmates incarcerated during both periods were included in each period. To test for associations between socio-demographic factors and Pap testing, the analysis was restricted to inmates incarcerated during the intervention period. Odds ratios and confidence intervals were calculated within categories of socio-demographic factors. Logistic regression was used to build models of Pap test uptake which allowed for multiple explanatory variables. Factors with a significance of p

RESULTS

No significant differences were found in the age, ethnicity, education, type and length of incarceration for inmates incarcerated during the preintervention and intervention periods (Table i).