| Abstract
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Background. Follow-up completion rates for abnormal cervical cancer screening results remain much lower among low-income, African American women than Caucasian women despite numerous interventions aimed at improving adherence. The purpose of this grounded theory study was to explore how low-income, African American women understood cervical cancer screening as a process, derived meaning from the abnormal result, and to identify factors contributing to untimely and incomplete follow-up. Methods. In-depth interviews were conducted with eleven African American participants in the South Carolina Breast and Cervical Cancer Early Detection Program who had abnormal Pap tests. Snowball sampling yielded four additional interviews with social contacts. Open-ended questions elicited women's perspectives on screening, expectations, preferences, and evaluations related to the medical encounter, and decision-making. Open coding, narratives and constant comparative analyses were systematically conducted both at the intra-participant and the inter-participant levels. Findings. Two emergent themes directed the analysis: (1) patient-provider interactions, and (2) decision-making. Women's experiences during medical encounters were influenced by their expectations of the health care services, provider roles and communication, and personal preferences and beliefs. Provider attempts to relay information to the women were often ineffective due to lack of understanding and misinterpretation. Perceptions of provider communication influenced women's evaluations. They were actively engaged in iterative cognitive processes (questioning, reacting, and deliberating), and behavioral processes (seeking support, researching, coordinating) around the abnormal result and follow-up. Four dimensions of decision processes were also uncovered: Personal Philosophy of Health and Wellness, Family Experiences and Background, Personal Knowledge and Ownership of Health, and Personal Agency. Ten of the eleven were also found to be adherent. Conclusions and implications. These findings provide an explanatory framework to understand cervical cancer screening and follow-up among low-income, African American women. Further research is needed to determine the accuracy of the “non-adherent” label assigned to women and how this label might affect women's follow-up behavior. Additionally, further study assessing health literacy within medical encounters is critical to improve understanding and potentially, follow-up adherence. A more woman-centered approach to understanding cervical cancer screening and follow-up within programs is warranted if cervical cancer morbidity and mortality is to be reduced.
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