If detected early and treated properly, cervical cancer is the most preventable form of cancer in women.1 However, each year approximately 13,000 women in the United States are diagnosed with cervical cancer, and 4,000 women die from it.1 In 2012, 8 million U.S. women between the ages of 21 and 65 years reported not having a Pap test in the last five years, even though 93% of cervical cancers could be prevented with routine screening and human papillomavirus (HPV) vaccination.2

Hispanic and Latina women are of specific concern, as they have the highest incidence of cervical cancer in the United States, but have significantly lower screening rates, are diagnosed with more advanced cancers, and are less likely to return for follow-up care.3, 4 Hispanic women have a 40% higher rate of cervical cancer diagnosis than non-Hispanic white women and a 26% higher death rate.5 Specific risk factors that contribute to disparities in care and outcomes include a higher incidence of obesity and higher rates of HIV infection, which increase the risk of cervical cancer.3 Barriers to care include lack of access to health care services, migration status, being uninsured, lower educational levels, language barriers and the lack of access to providers who speak Spanish, less smoking cessation support and services, structural barriers such as lack of transportation and childcare, and decreased rates of follow-up care after abnormal screening test results.3, 6-8

With the increase in migration across the U.S.–Mexico border in 2018 and 2019, we believe that quality improvement (QI) projects such as ours are more important and relevant than ever. In 2016, an estimated 35,000 undocumented immigrants lived in Tucson, Arizona,9 where this QI project was conducted.

Being undocumented often leads to delays in care, screening, and diagnosis; in 2014, an estimated two-thirds of undocumented immigrants had lived in the United States for 10 years or more,10 which can contribute to ongoing vulnerability and poor health outcomes. Uninsured adults, for example, were 25% more likely to die prematurely than insured adults,8 and a 2017 review of studies on health insurance and health outcomes found that the odds of dying among the insured was 0.71, compared with 0.97 among the uninsured.11 These statistics suggest that effective ways to provide health care access to uninsured people who don't qualify for state or federal health insurance must be explored.

When looking specifically at cervical cancer screening and prevention, both the Centers for Disease Control and Prevention (CDC) and the American Cancer Society Cancer Action Network (ACSCAN) have stated that expanding federal preventive services for uninsured and underinsured women is critical to eliminating the racial and ethnic disparities in cervical cancer screening.6, 12 As highlighted in the 2018 ACSCAN statement on the importance of the CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP), a program to improve screening rates among women who are uninsured or underinsured and lack access to care, women who already lack access to health care are further failing to receive care because of the underfunding of federal and state programs6:

“Despite NBCCEDP's proven success, federal and state funding is woefully inadequate and has failed to keep pace with inflation. A general decline in federal funding over the past 5 years, on top of widespread spending reductions at the state level, have left many women unable to receive potentially lifesaving screenings. Fewer than 1 in 10 eligible women are currently able to receive screenings through the NBCCEDP due to underfunding [emphasis in the original].”

This QI project takes on increased significance given the continuing coronavirus disease 2019 (COVID-19) pandemic. A recent study found an 86% to 94% decrease in cancer screening (including cervical cancer screening) between last January and March.13 A recent survey found that minority women were twice as likely as white women to be concerned about receiving cervical cancer screening during the pandemic, with 43% saying they would forgo or postpone screening because of the pandemic.14 COVID-19, then, adds another imperative for health care providers to implement effective strategies that help all patients—especially those at increased risk for cervical cancer—receive screening in a timely manner to avoid delays in diagnosis.13

Disparities in cervical cancer screening at a federally qualified health center (FQHC) in Tucson, Arizona, were the impetus for selecting cervical cancer screening for the QI project. The FQHC made cervical cancer screening a priority in 2017, after it was found that only 40% of women seen in the clinic were screened appropriately in the previous year, while the rate in Pima County, where Tucson is located, was nearly twice that (78.8%).15 The clinic's cervical cancer working group, which consisted of the clinic's medical director, nursing director, QI director, women's health medical assistant, and two women's health NPs, performed a causal analysis to identify the reasons for insufficient cervical cancer screening. The key factors that emerged included outdated enrollment guidelines for the Well Woman HealthCheck Program (WWHP, the Arizona arm of the NBCCEDP), the erroneous exclusion of women 21 to 40 years of age from enrollment in the WWHP because of a misunderstanding about the guidelines (clinic staff thought women under 40 were not eligible for the program), insufficient documentation and tracking of Pap tests, incomplete implementation of age-based screening protocols, and a lack of patient education and engagement tools pertaining to cervical cancer screening.

Available knowledge. At the time of the QI project, national cervical cancer screening guidelines recommended that women 21 to 29 years of age be offered a Pap test every three years with HPV testing, as indicated (meaning that if a Pap test finds abnormal cells of undetermined significance, then HPV testing is performed), and that all women 30 to 65 years of age be offered a Pap test with HPV co-testing every five years.6

The Arizona Department of Health Services (ADHS) follows guidelines that require WWHP-funded clinics to provide cervical cancer screening at appropriate intervals, document and track Pap test results, and train all providers in cervical cancer screening protocols and WWHP enrollment guidelines.16 Because the FQHC received WWHP funding, the ADHS requirements were followed in the assessment and evaluation of the clinic's cervical cancer screening practices throughout the planning, implementation, evaluation, and sustainability phases of the project.

The Community Preventive Services Task Force (CPSTF), an independent panel of public health experts that provides evidence-based recommendations for the promotion of population health, conducted a systematic review of cervical cancer screening designed to support clinics and health care systems in improving their cervical cancer screening rates.7 Based on the findings of the review, the CPSTF recommended an evidence-based team approach with a multicomponent cervical cancer screening program to increase demand for and access to such screening. Effective cervical cancer screening programs include individual education sessions with providers and staff, the provision of patient education printouts in appropriate languages, and the use of outreach workers in the clinical setting. We incorporated all these components in our QI project's design and implementation.

Barriers to appropriate cervical cancer screening may be eliminated by providing same-day Pap test screening to all women who haven't had a documented, up-to-date Pap test and same-day enrollment in no-cost cervical cancer screening programs. These two key interventions were implemented in the QI project and led to significant increases in cervical cancer screening rates, both during the project and after its completion.

Rationale. The multicomponent, evidence-based team approach outlined in the CPSTF systematic review was employed to increase access to care for underserved women. The existing cervical cancer working group at the FQHC became the advisory group for the QI project. The advisory group met twice before the project's design and implementation to discuss the factors contributing to the clinic's low cervical cancer screening rates, identify the barriers to care, and develop the interventions needed to improve screening rates based on the required NBCCEDP guidelines and the CPSTF evidence-based recommendations.

The CDC's Division of Cancer Prevention and Control developed guidelines, Increasing Population-Based Breast and Cervical Cancer Screenings: An Action Guide to Facilitate Evidence-Based Strategies, that provided us with a theoretical framework for the project.12 The CDC adapted a social ecological model of change that focuses on expanding beyond individual screening to a population-based screening and systems change approach that comprehensively provides for the ongoing care of all women, both in the clinic system as well as through advocacy that leads to change at the local, state, and national levels.

Interventions were designed to increase patient engagement in all areas of the clinic, including registration, scheduling, care visits, and waiting areas. The aim of this QI project was for 75% of all women 21 to 65 years of age to receive WWHP and Pap test eligibility screening, enrollment in the WWHP, and case management during the 60-day project period. The project ran from January 14 to March 11, 2018.

METHODS

The goal of this project was to improve equitable access to cervical cancer screening at a nonprofit FQHC with a history of serving the uninsured and underserved in Tucson, Arizona. Forty-five percent of the population at the clinic is uninsured and 60% are Hispanic. The clinic served 6,900 patients and provided 24,900 patient visits in 2017, a 20% increase in visits over 2016.

The QI project's methodology was based on the Institute for Healthcare Improvement (IHI) Model for Improvement, also known as the plan–do–study–act (PDSA) model, which uses small-scale changes that are progressively implemented and evaluated over time to assess for effective interventions and positive change.17 The choice of this design allowed for the implementation of four rapid PDSA cycles in 60 days. Data from each cycle were analyzed to assess, design, and implement the tests of change.

Interventions. The core interventions of this project included team meetings; a patient engagement tool on cervical cancer screening that was provided in both English and Spanish; a WWHP eligibility screening tool for registration staff that included updated registration guidelines; a WWHP registration log in which to record all women enrolled in the program; and the implementation of a case log for case management. Patient education printouts on cervical cancer screening from the CDC were provided in both English and Spanish, and staff members and providers who spoke both English and Spanish provided all registration and clinical services.

The first QI session for clinic staff was a health care provider training on the updated cervical cancer and WWHP screening protocols. This training included all the clinic health care providers and focused on the cervical cancer screening changes that were being implemented, including same-day screening of all women without a documented Pap test result; screening of women 21 to 29 years of age with a Pap test and HPV testing as needed, per protocol; and screening of all women 30 to 65 years of age with a Pap test and HPV co-testing. The providers reviewed the updated WWHP screening protocols, including the eligibility of women 21 to 40 years of age who had previously not been referred to or enrolled in the clinic's WWHP, as well as the new policy of same-day enrollment.

Team engagement was measured as part of the QI process by a team engagement survey that was a modification of the IHI's Healthcare Team Vitality Instrument.18 One of us (LHK) modified the instrument's core questions so the wording applied specifically to cervical cancer screening in the clinic, with questions focused on the perceived importance of screening to team members, the availability of time and resources to screen effectively, the perceived importance of screening to patients, and any increased stress among staff and providers from participation in the project.

Subsequent training sessions were provided to those involved in the intervention to be implemented in each cycle, including medical assistants and staff members responsible for registration, scheduling, and eligibility counseling; there were also two meetings for the entire clinic staff. The team engagement survey was administered at all-staff meetings and the results assessed over the four PDSA cycles.

One of us (LHK) also adapted the Ottawa Personal Decision Guide, a tool developed by the Ottawa Hospital Research Institute and the University of Ottawa that supports patients in making health care decisions based on conceptual models of personal and interprofessional shared decision-making, modifying it specifically to address cervical cancer screening and the question of whether or not to be screened.19 The questions adapted concerned the patient's knowledge of the health issue, resources available for decision-making, and a five-point readiness-for-change scale. One of us, JB, the project chair, reviewed the tool and both of us evaluated it in each of the four PDSA cycles for wording, appropriateness to the patient population and their literacy level, and patient responses. The tool is available to the public without copyright restriction, and we made it available in both English and Spanish (see Figures 1 and 2 at http://links.lww.com/AJN/A187).

With input from the registration staff, we also developed a WWHP eligibility screening tool to more efficiently determine patients' eligibility for the WWHP, as well as a WWHP registration log to facilitate the documentation of women registered in the program across all four PDSA cycles. The Pima County WWHP staff partnered with the clinic to create an updated enrollment protocol that facilitated same-day WWHP enrollment.

Women who sought care at the clinic and requested either a Pap test or WWHP enrollment were entered into the case log, which was used to determine whether these women received effective care, defined as same-day WWHP enrollment and a same-day Pap test or an appointment to return for a well-woman visit. The case log was used in subsequent cycles to track whether women came to their scheduled appointments, were given a Pap test, and received follow-up care as indicated. Women who missed appointments or Pap tests were referred to the scheduling department for follow-up.

Study of interventions. Data on each of the four core interventions were collected every three days. Team engagement was measured with a survey based on the IHI's Healthcare Team Vitality Instrument. Data from the patient engagement tools were tallied and analyzed, which led to iterative changes in the tool every cycle. Some of these changes included shortening the tool, condensing the introduction, clarifying whether the woman needed a Pap test or a pelvic examination alone, and adding the date that the last Pap test was performed, per patient recall.

The WWHP tracking forms were used to collect data on the number of women who were offered screening by the registration staff and who requested enrollment in the WWHP. The analyzed data were compared to clinic-wide data to track enrollment rates. Run charts were created to determine how well the interventions and tests of change were performing and to identify the direction of change detected.20 The data and analysis of the run charts were then used to help modify the interventions to improve outcomes. Each cycle's interventions and outcomes were recorded in an ongoing table to track the project's progression, and this was reviewed with the faculty project chair at the end of each cycle. Ongoing input regarding the trends identified and changes needed was received weekly from the clinic staff and the clinic's project advisor. See Table 1 for a summary of each cycle's outcomes and the changes implemented in the next cycle's interventions.

Measures. The key measures evaluated in this project were the level of team engagement, the number of women who requested Pap tests and WWHP enrollment, the number of women who received Pap tests and WWHP enrollment, the number of women entered into the case log who received effective care, and the level of stress reported by team members as a balancing measure to assess for potential harms and benefits to the clinic's staff members. Data entered into the case log were compared with data in the clinic registration, scheduling, and electronic health record (EHR) systems to help evaluate the reliability and validity of the data and confirm data completeness.

Analysis. Subjective data on the patient engagement survey were limited to the history and date of the most recent Pap test. These were tallied from the paper patient engagement forms filled out by the patients, entered into the case log, and compared with the clinic EHR. Run charts were used to evaluate the shifts, trends, and variation in the data. The most significant positive trends were the increased number of requests for cervical cancer screening and WWHP enrollment from the women who were identified through eligibility screening and the consistently positive staff engagement. The positive responses from the women and the staff were sustained across all four project cycles. To measure the improvement in screening and enrollment requests, the number of women who were offered cervical cancer screening and WWHP enrollment was compared with the number who said yes. Similarly, the team engagement tool was used after all the staff meetings to assess changes in the staff response and perceived stress levels across the four project cycles.

The most significant negative trend was the small number of women who were offered the patient engagement tool. This was assessed by comparing the number of women seen in the clinic each day with the number of women of eligible age (21 to 65 years) who completed the tool. Multiple changes were made in the patient engagement tool, including changes in the wording of the survey questions, the training of staff members, and the department in which the tool was offered to the patient. After the project was completed, the cervical cancer screening committee decided that paper patient engagement tools were not an effective method for increasing screening rates.

This project was excused from review by the institutional review board at Frontier Nursing University because it did not qualify as human subjects research and met federal requirements for QI. A $1,000 grant from the Beta Mu Chapter of Sigma Theta Tau International was received to provide educational materials in the women's health clinic to support the work of this project.

RESULTS

The aim of this QI project was exceeded by the end of the project period, with 87% (119/137) of the women who were entered into the case log receiving effective care (see Table 2). Eighty percent (102/128) of the women who completed care were uninsured, and 86% (110/128) were Hispanic. Out of the 100 women enrolled in the WWHP, 30 (30%) were under the age of 40 years, up from the baseline of zero (because the staff mistakenly thought that women under 40 were not eligible for the program). Nine of 137 (7%) women entered into the case log were lost to care, while 93% (128/137) received an appointment for a well-woman visit or a Pap test by the end of the project period.

Team engagement. The success of this project was the result of a high level of team engagement and support. Strong attendance rates at team meetings and positive team engagement scores were seen throughout all four project cycles, with a median attendance rate of 85% (84/99) and a median team engagement score of 83%. Team engagement was enhanced through interactive team activities, all-staff project updates after cycles two and three, and ongoing check-ins with team members to receive feedback during each cycle.

Patient engagement worked best when patients interacted one-to-one with the clinic's staff members. These results were consistent with the literature on successful interventions with this population.7 The patient engagement tool was partially effective: women used the paper tool and requested cervical cancer screening, but the number of women who were offered the tool declined over the four cycles. One reason for this was an unexpected shortage in staff that worsened over the project period. Changes to the form and the process of distribution were made in each cycle but to little effect.

Two other patient engagement interventions were also piloted: the production of public service announcement (PSA) videos (in English and in Spanish, with patients as advocates) in cycle two and, in cycle four, a bilingual volunteer nursing student promotora (health advocate) to help patients in the clinic waiting areas. These interventions were added to test other methods of improving patient engagement after the patient engagement tools didn't work as anticipated. The PSA videos were posted to the clinic's website and social media in cycle four. While the impact of the videos on patient engagement was not fully assessed—a question regarding the effectiveness of the PSA videos was added to the patient engagement form in cycle four—the key takeaway from the videos was that patients were capable of being strong advocates in the clinic, and their participation should be expanded for future projects (to see one of the PSAs, go to http://links.lww.com/AJN/A188). This was true as well for the nursing student promotora, who approached patients in the waiting room to ask about their knowledge of cervical cancer screening and the WWHP. Patients responded positively to the promotora, and she was able to direct interested patients to the registration and scheduling staff for further information and assistance.

What was clear was that women wanted cervical cancer screening and enrollment in the WWHP: among the screened eligible women, 98% (125/128) requested a Pap test and 94% (100/106) requested enrollment in the WWHP. (Not everyone who was eligible for a Pap test requested enrollment in the WWHP because they were already insured.)

WWHP eligibility. The changes to the WWHP enrollment protocols and processes resulted in a much greater response than anticipated, and the increased enrollment in the WWHP was key to this project's success. Enrollment rates doubled and 100 women were enrolled in the WWHP during the 60-day period. The total percentage of women ages 21 to 64 years (cutoff for enrollment in the WWHP was 64) seen in the clinic and offered WWHP enrollment was low but increased over the four cycles, with a median of 29% at the project's end. This was because WWHP enrollment was offered only by the registration staff, and patient registration is renewed only once a year, so many women hadn't yet been screened during registration using the new WWHP screening guidelines. Another key intervention was that registration staff members walked all women who registered for the WWHP to the scheduling staff at the end of the registration appointment so they could then be scheduled for a well-woman visit prior to leaving the clinic.

Case log. A total of 137 women were entered into the case log during the project. The biggest challenge was the result of a change implemented in cycle three: to further increase patient engagement, three family practice providers were added to the two existing women's health providers participating in the QI project. However, this led to an uneven increase in the use of the patient engagement forms and made it difficult to determine which patients should be entered into the case log. Therefore, the family practice providers were excluded in cycle four. Some data included in the case log in the first cycle were unnecessary, so those data were no longer collected in subsequent cycles. Effective care was also redefined after the first cycle to include providing either a Pap test or an appointment to get one, because not all women completed their scheduled appointments by the end of each cycle. In keeping with the purposes of the PDSA cycles, which allow for incremental changes to interventions as they're being implemented, this led to an expansion of the use of the case log to include case management: only 7% of women were lost to care and 48% of women (66/137) received cervical cancer screening by the end of the project.

DISCUSSION

Eighty-seven percent of women received the effective care of a cervical cancer screening and WWHP enrollment in an FQHC that serves a high percentage of uninsured women and Hispanic women, two groups that are at highest risk for inadequate cervical cancer screening. Initiating same-day enrollment and care and increasing cervical cancer screening rates for Hispanic, uninsured, and underserved women are in keeping with the aims of increasing timely and equitable care put forth in the Institute of Medicine's landmark 2001 report, Crossing the Quality Chasm: A New Health System for the 21stCentury.21 Doubling enrollment in the WWHP, providing same-day cervical cancer screening, and having patients engage with multiple clinic staff resulted in underserved and uninsured women having greater access to care and the clinic having an improved revenue source for care that was previously undercompensated.

The key changes that were implemented during the project were continued after the project's completion, including offering same-day WWHP enrollment to all new and renewing patients at registration and providing a same-day Pap test or a same-day appointment for all women due for screening. Both the medical assistants and the provider staff are responsible for assessing cervical cancer screening status with patients at appropriate intervals, in accordance with the WWHP guidelines.22 After the QI project ended, this information was entered into the EHR instead of using a paper form.

Interpretation and implications for practice. There were three key findings from this project. First, women were active partners in their care. Ninety-eight percent of all eligible women requested a Pap test. All women 30 years old or older who were educated on the new Pap test guidelines preferred to receive a Pap test with HPV co-testing, half of the women the promotora approached in the waiting room said they wanted enrollment in the WWHP or a Pap test, and two women took on leadership roles in the creation of public service videos. These results support the findings of previous QI projects to improve cervical cancer screening rates, which have demonstrated that patients must be at the center of QI projects and that they should be recruited to help construct, promote, and lead these projects (see www.thecommunityguide.org/stories/black-corals-gem-cancer-screening-program-south-carolina, and scroll to “Community Involvement Empowers Local Women”).

Second, updating the clinic's guidelines on cervical cancer screening and WWHP enrollment resulted in a significant increase in access to care, as demonstrated by the increase from 40% of eligible women screened for cervical cancer in 2016 to 87% of eligible women receiving effective care in the project period. We found it encouraging that the entire team was supportive of these changes and had multiple opportunities to engage in the project design and implementation of these guidelines.

Finally, this project demonstrated that preventive health services can be significantly expanded in underserved populations when effective funding programs are in place. This project verified the established efficacy of the NBCCEDP program in providing preventive women's health services to women who otherwise would not have access to care, as well as providing increased support and revenue for an FQHC clinic.

These findings ultimately support the CDC's social ecological framework for change, in that a systems-based approach led to clinical interventions that were sustainable over time. The increased funding from enrolling more women in the WWHP was a critical component of the project's success and ongoing viability. Thus, a final finding from this project is that health care providers must be prepared to partner with local, state, and federal agencies to both maximize services available to their patients as well as advocate at all levels of government for increased funding for these programs.

Limitations. There were multiple issues with the paper patient engagement tool and this limited the effectiveness of the intervention. The clinic then made changes to the EHR to better track cervical cancer screening and prompt providers and staff to engage patients. The results of the WWHP intervention were promising, but may not be replicable in other clinics where funding is more limited. Finally, providing equitable and effective care is difficult in a population that is vulnerable, uninsured, and fearful of seeking care, and other communities may have different barriers to care than those identified in this project.

CONCLUSIONS

This project resulted in equitable care for uninsured and underserved women, confirmed the efficacy of a multicomponent approach to increasing cervical cancer screening rates, and demonstrated that same-day services resulted in greater access to care. The fact that patients were active partners in their care and willing to become advocates for others speaks to the need for further research and project design with patients as the leaders of QI initiatives. Finally, health care providers need to advocate for increased funding for preventive health programs like the NBCCEDP that address disparities in care and promote more equitable outcomes for all women, especially those who are most vulnurable.

The current challenges to our health care system necessitate that health care providers proactively assess ways to improve access to care for those living in and contributing to their communities but who are uninsured or underinsured; improved access to care improves both individual and population health.8 The women who participated in this project provided critical services to their community, and it's imperative that they, in turn, have equitable access to health care, including cervical cancer screening.