摘要：Objectives. We examined whether a sexually transmitted disease (STD) clinic could reach women who had not received a Papanicolau (Pap) test in the past 3 years. We also explored staff attitudes and implementation of cervical cancer screening. Methods. Women (n = 123) aged 30 to 50 years were offered cervical cancer screening in an Indiana STD clinic. We measured effectiveness by the patients' self-reported last Pap test. We explored adoption of screening through focus groups with 34 staff members by documenting their attitudes about cervical cancer screening and screening strategy adaptation. We also documented recruitment and screening implementation. Results. Almost half (47.9%) of participants reported a last Pap test 3 or more years previously; 30% had reported a last Pap more than 5 years ago, and 11.4% had a high-risk test outcome that required referral to colposcopy. Staff supported screening because of mission alignment and perceived patient benefit. Screening adaptations included eligibility, results provision, and follow-up. Conclusions. Cervical cancer screening was possible and potentially beneficial in STD clinics. Future effectiveness-implementation studies should expand to include all female patients, and should examine the degree to which adaptation of selected adoption frameworks is feasible. Cervical cancer morbidity and mortality rates have remained stable in the United States for the past several years, 1,2 with disparities rooted in sociodemographic and health system characteristics. These disparities are well documented and indicated by the lack of screening and follow-up for abnormal Papanicolau (Pap) tests. 3–6 The few studies with systems implications for cervical cancer screening observed reductions in screening, colposcopy, or survival disparities when the health system and services barriers were removed. Doyle et al. found that providing breast and cervical cancer screening in an urban walk-in medical clinic increased access to follow-up colposcopies. 7 Farley et al. found that equal and unfettered access to cervical cancer screening in a military care system eliminated differences in survival rates for women with cervical carcinoma. 8 Castle et al. observed that cervical cancer screening increased among underserved, rural Mississippi women when they were offered the opportunity to self-collect samples for human papillomavirus (HPV) testing compared with completing free Pap testing at a clinic site. 9 Finally, Hitt et al. found that tele-colposcopy services increased access to follow-up for abnormal Pap tests among women in rural Arkansas. 10 These studies are encouraging and lead the way for additional system-related studies to reduce cervical cancer screening and follow-up disparities. Venues that can provide high-risk HPV (hrHPV) screening access and navigation to colposcopy will be critical to cervical cancer prevention efforts as diagnostic strategies evolve. The sexually transmitted disease (STD) clinic is an example of a system opportunity that may increase access to cervical cancer screening. STD clinics provide services at low or no cost to the patient, and are safety net providers of care for racially/ethnically diverse populations who are likely under- or uninsured and have tenuous relationships with the traditional health care system. 11–13 These characteristics have been associated with reduced utilization of cancer screening. 14–17 Further, recent Centers for Disease Control and Prevention STD policy guidelines 18 have highlighted the importance of STD clinics for cervical cancer reduction because the prevalence of hrHPV among female STD clinic patients ranges from 27% to 42%. 19,20 Two recent studies found that some STD clinics provide Pap or HPV testing, although the extent of cervical cancer screening in STD clinics generally remains unknown. 21,22 Although STD clinics might be likely venues for cervical cancer screening, the central challenge remains one of organizational–cultural orientation as STD clinics are epidemiologically oriented and provide episodic care, screening, and follow-up primarily for HIV, syphilis, gonorrhea, chlamydia, and trichomoniasis. The persistent strains of a sexually transmitted infection (HPV) cause cervical cancer, yet it is not clear whether STD clinics could provide cervical cancer screening, and if they could, whether these services would contribute to the reduction of health disparities. With health care costs in mind, the ability of a clinical setting to provide cervical cancer screening is not sufficient. What must be demonstrated is that such a setting actually reaches women who are underscreened, or by definition have “not had a Pap test in at least 3 years.” 23 We examined the effectiveness of STD clinic-based cervical cancer screening in reaching women who had not received a Pap test in the past 3 years, and explored the clinical implementation of cervical cancer screening in this setting. Our study had 2 goals: innovation strategy effectiveness and implementation. We used an effectiveness–implementation hybrid type 1 design, which allowed for the testing of this innovation strategy while gathering information on its adoption and delivery. 24 Thus, our primary research aim was screening effectiveness, and our secondary aim was the adoption and implementation of cervical cancer screening. This design reflected the need to shorten the long delay between innovation and translation in public health settings. 25,26 The multilevel adoption framework of Frambach and Schillewaert 27–29 provided the primary conceptual orientation for the implementation study aim. This framework had sufficient construct flexibility that allowed for varied approaches to measuring adoption elements, and for adaptation in real-world contexts. 30 In addition, like other multilevel adoption frameworks, 31 it focused on both organizational and individual characteristics. The framework informed variables selection for the implementation study component, but because of the exploratory nature of this study, all framework components were not operationalized. Selected constructs included staff receptiveness and readiness for the innovation, attitudes, and opinions about cervical cancer screening as an innovation, innovation alignment or fit with the clinic mission, trialablity, and problem solving around encountered barriers. Two additional constructs were integrated into the study from other models because of their close alignment with our primary framework. They included innovation characteristics of complexity and adaptability, 32 and the perceived advantage of innovation. 33 Our specific study aims were (1) to determine whether offering cervical cancer screening in an STD clinic venue would reach women who needed it, as measured by reported last Pap smear, and (2) to explore the STD clinic’s adoption and implementation of cervical cancer screening as measured by staff attitudes and observed screening implementation.
