DNP Project- Literature Review

DNP project covering females with cervical cancer in the Texas prison system

Introduction to the Clinical Problem

Women serving jail sentences and those in prisons often suffer a higher risk for cervical cancer which is also the most common type of cancer among the female prisoners.  While looking at the National survey, it is reported that women in the United States prisons jail are at a greater odd when compared to the entire population in the country of having cervical cancer. Women in Texas prisons systems also report a higher rate of high levels of cervical lesions than other women in the general population, however, the problem has to do with lower levels of biopsy and follow-up (Emerson et al., 2019). There is also another case of girls in juvenile detention reporting increased levels of abnormal Papanicolaou (Pap) tests that the general adolescents outside juvenile detention.  With the higher risks to incarcerated women and girls, one study in California also showed that women continuously have had Pap test in prisons and jails and are often willing to ensure Pap test through correctional settings, meaning that there need to be opportunities to ensure this intervention has taken shape in the criminal justice settings (Emerson et al., 2019).   

Also, there is still little evidence when it comes to the prevalence of abnormal Pap testing among other related factors in the full range of the Texas criminal justice system that is required to supervise women in the United States. The criminal justice population continues to increase every day, where there are over 10 million people under criminal justice surveillance (Emerson et al., 2019).  Of this population women are represented at 12% for the parole population, however, around 24% are those under the probation population.  Also, in the same manner, there is the issue of community supervision that is going to include probation and parole, which also entails being under the criminal justice supervision while they continue to live in the community (Duffett-Leger et al., 2008).  Studies also show that most women in the United States are detained in Jails as they continue to await trial, however, they will still be serving a short term jail sentence. 

 Being able to address the risk of cervical cancer among women in the Texas prisons is going to offer the chance to address the different health disparities and ensure that there is the implementation of various preventive health services to the underserved and underinsured population.  For example, when looking at the African American population and Latino women, most of them report higher incidences and mortality rates from cervical cancer than do white women (American Psychological Association., 2020).  The issue of limited access to care and underinsurance continues to be a huge problem for Latina and Africa American women. Also, there is so little known regarding women living in the community criminal justice setting,  however,  history indicates that women in prisons have often lacked access to the right preventive healthcare and are often underserved regarding their reproductive health (American Psychological Association., 2020).  By providing them with preventive health services, it means that they can get the right help in ameliorating the disparities in health and ensuring the prevention of poor health outcomes. Other aspects of Pap testing (cervical cytology) are also a manner that detects the cancerous and precancerous cervical lesions which are done through the identification of women that require additional treatment and diagnosis (Ramaswamy et al., 2014).  There are also very few studies regarding cervical cancer or screening which consider women in prisons and jails, and non to the common knowledge that includes women who live in the community and are involved with the criminal justice system like those taken for parole and probation.

Also when looking at the current literature,  none has examined the risk factors related to cervical cancer among female prisoners in Texas and other criminal justice populations. Among the common risk factors include irregular Pap tests and cervical cancer for women, also the issue of early sexual activity, increased levels of unprotected sex, and lack of health education related to cervical cancer in prison. There are also cases of multiple sexual partners among young women in juvenile prisons   which is said to increase the risk of HPV (Human Papillomavirus that is also implicated as being in 99% of cases of cervical cancer.  Also, other risk-related factors when it comes to cervical cancer will include pregnancy at a younger age, use of tobacco, parity, and failure to undertake the Pap testing (Ramaswamy et al., 2014).  For women that are involved in the Texas criminal justice system, they are also likely to be at a higher risk of cervical cancer due to the history of multiple sexual partners, trading sex for favors, early parity, and the increased use of tobacco.

PICOT Question

Among  Women prisoners ages 18-50 (P),  what is the impact of various educational programs on the knowledge of cervical cancer, screening intention and rates of Pap smear ( I), over three months, when compared to the standard practices ( T)

Review of Literature

In the review of literature, there is the application of theories that are important in the provision of a lens and a reference point where behaviors are supposed to be understood especially when coming to determine the interventions required in the facilitation of the different aspects related to behavior change.  In this section, the systematic review looks at the theoretical model to be used for the Evidence-Based Practice in the project (Reavy, 2016).  Also, there is going to be a description of literature synthesis and search of evidence when it comes to the construction of the best practice model recommendation for women with cervical cancer in federal prisons and particular Texas prison. 

Theoretical Framework

In this study, there will be the use of the Health Promotion Model (HPM) as formulated by Nola Pender which will be used for this project.  Several important concepts are going to assist in explaining the behavior of the surrounding cervical cancer screening thus providing the implementation of the most practical strategies in the promotion of healthy behaviors.

Description of the Theoretical Framework

The Health Promotion Model by Pender was initially published in 1982 and went through various revisions by incorporating the new studies that substantiate the theoretical concepts which lead to the new edition of Health Promotion in Nursing Practice. This model is also highly used as part of the Nursing guide for individual and societal behaviors regarding healthy lifestyles (Reavy, 2016). The model provides direct applicability for integrating communities, individuals, and the public regarding the promotion of public health. also, the model looks at the unique premise which looks at the unique and dynamic interactions of the environment and individuals which will affect the holistic state of an individual. The issue of health is also conceptualized regarding a continuum, based on the interventions for having the capacity to either support or detract from health.  Among the best methods for health promotion from the personal level will look at the most unique aspects of the person and their environment (Melnyk & Fineout-Overholt, 2019).  These aspects are also viewed from the personal level and will be addressed behaviourally, biologically, psychologically, and culturally.  By addressing these barriers the health and ways of overcoming the challenges are a very important component concerning health promotions.  The promotion of personal health through education and counseling will also improve the health of society and will reduce the future cost of healthcare-related to the disease and illness. 

Application of the Theoretical Framework to the DNP project 

Based on Pender's health promotion model,  it will be used in this project as a manner of focussing on the issue of health promotion as opposed to illness in addition to viewing the aspects of the individual and the relevance it brings to the aspects of health.

Also, the Health Promotion Model is also concerning the Model of Patient-centered  Medical Homes, holistic, primarily, and through a form of well-coordinated healthcare that is accessible to and focussed on the patient.  In any case, primary prevention is going to include various education interventions that see the improved aspects and attitudes towards the practices of preventative health. When looking at secondary prevention it is going to be viewed through early detection of cervical cancer through the use of cervical cancer screening (Melnyk & Fineout-Overholt, 2019).  Having an abnormal Pap smear need not be considered as part of the shift to lack of health or illness, instead, it needs to be viewed as an extension of health which also necessitates the various interventions and looks at the capabilities and resources of the person (Gonzalez et al., 2011). Also when looking at the patient-centered medical home setting it will afford the chances for the improvement of health through a much larger perspective that incorporates the mental and physical health of the individuals and family. Various studies indicate that when it comes to adherence to cervical cancer screening, there will be recommendations that are strongly related to the attitudes and the spouse, family or friend input (Holly et al., 2017). This also corresponds with Pender’s Model which looks at the importance of ensuring the satisfaction of relationships and establishing harmony with the care environment in addition to establishing health promotion for families and the communities to ensure successful outcomes.  The propositions and assumptions related to the Health Promotion Model are also very important when it comes to cervical cancer screening in a manner that most of the barriers limiting the success of screening will be validated through the theoretical assumptions as discussed by Pender.  One of the most important aspects when it comes to the practice of cancer screening will look at the understanding of the process and implications of the screening. According to Pender, the issue of self-efficacy and the ability to perform a particular behavior will lead to a direct correlation with the behavior being carried out. In the event the patient can understand the whole process and what it will imply regarding care and prevention of cervical cancer and can foresee the participation concerning examination, it means that the whole team is likely to adhere to care (Gonzalez et al., 2011).  In this regard, the HPM model will not look at the issue of the threat of disease as being the major course of action but will look and the issue of wellness and self-actualization. 

Inclusion and Exclusion Criteria

Based on the study topic the inclusion criteria were articles dated from 2015-2020 regarding evidence-based data.  The inclusion criteria also entailed academic, peer-reviewed journal, and electronic research of articles that also look at clinical and national guidelines and recommendations.  The study of literature was from various health and nursing databases like PubMed, Cochrane, NCBI, and CINAHL (Melnyk & Fineout-Overholt, 2019).  The study exclusion criteria include languages that were not in English, poor and unreliable evidence, articles that did not specifically talk about cervical cancer, cancer screening, and article that only focussed on specific ethnic subgroups. Other exclusion criteria also looked at art articles that focus on cervical cancer but did not look at the prison situation, or one that focussed on Alaska and Alaskan native women were also not included (Melnyk & Fineout-Overholt, 2019). There were citation chasing and hand searches that were done from the available study.  The study conducted a review of research abstracts to identify its relevance in the project, include full-text reviews that were identified for inclusion and suitability. 

Synthesis of evidence

Binswanger et al. (2011)  conducted an analysis of data based on two cross-sectional surveys for women in Jails and other community corrections based on two Southern cities (n=380) regarding their history when it comes to abnormal Pap tests and the related risk factors for cervical cancer. To do this the study utilized a univariate analysis (analysis of variance and chi-square in addition to a binary logistic regression analysis that looked at the relationship between individual history regarding Pap testing and other factors that are related to cervical cancer.   In the study, the research surveyed (n=163, 43%) reported having a case of abnormal pap tests.  The study also revealed a high prevalence of the risk factors related to cervical cancer for women with and without abnormal Pap tests.  After controlling for race and age there was a significant relationship between the abnormal pap tests and the abnormal use of the barrier protection odds ratio at 2.01, 95% and the intervals of confidence at 1.18-3.43, having other gynecologic infections 1/6894% and CI 1/05-2.67) also having a history of sexually transmitted infection OR 1.92 95%, CI 17-3.15). It is evident from the study that women in prison and those under the community justice supervision will continue to report increased prevalence when it comes to risk factors related to cervical cancer. This is due to their increased prevalence when it comes to abnormal Pap testing.  Also, women under the criminal justice setting would be the appropriate target when it comes to improved cervical cancer prevention, screening with the Human Papillomavirus (HPV) risk reduction education, vaccination, or treatment.  

Coughlin and King (2010) conducted a multivariate contextual analysis of telephone surveys that looked at the impact of the issue of transportation that affects breast and cervical cancer screening behaviors.  In one of the cities in the United States with public transportation, and analysis concerning self –reported county of residence which showed that most women were more likely to have a pap smear around the metropolitan areas.   The study also showed that less than 2% of the residences had cars in comparison to areas that more than 3% had cars. Also in areas that more than 4% or residents made use of public transportation, they were more likely to experience pap screening that areas in which 4 percent used public transportation. This shows that access to movement will also impact on the practice of screening. 

Also, Duffer-Leger, Letourneau, and Croll (2008) conducted a descriptive correlational and cross-sectional study where over 904 participants were sexually active by the age of17 years. From the study, it was established that there was a statistical relationship between the issue of age and of learning regarding the use of Pap screening and the intention of the individual to have the Pap screen test.  Also, this meant the provision of accurate information to the young sexually active women who are bound to increase behavior towards Pap screening.  The attitudes, knowledge, beliefs, and practices are also among the most important components when it comes to considering the interventions. In the same study, most of the young women were able to report positive attitudes related to the issue of Pap testing (Mean attitude score was reported at 39.09, SD= 5.91 and Range at 11.55). In the same study, the level of knowledge was able to show that that there is moderate knowledge when it comes to the issue of Pap tests however, the poor knowledge on the significance of HPV impacted on the care attitudes. The family behavior and that of close families were also impacting care and action towards the treatment and management of cervical cancer.  

In a systematic review study, Everette et al. (2014) were able to come up with a review that was based on the literature search of MEDLINE, CENTRAL, LILACS, EMBASE and Cochrane Gynaecological Cancer Group Trials Register to March 2009 for RCTs on the methods of interventions required to increase the rates of cervical cancer screening. Based on this, the search strategy was specific and reproducible regarding various pertinent studies assessed through two authors independently. Among the inclusion and the exclusion criteria related to the study was also clarified with the proposed interventions that focussed on reminders, invitations, education, counseling, the framing of messages, procedures, risk fact assessment among other economic incentives.  During the study, the detailed characteristics were included. There was a methodological limitation which was also graphically displayed.  The study used evidence that supported the use of personally written invitations in addition to telephone invitations that will increase cases of cervical screenings. From the review, the researcher came up with conclusions that were based on the presented evidence and are also applicable in this DNP project that looks at the females with cervical cancer in Texas prisons especially on the aspect of prevention and treatment.  Among the challenges of the literature, the review study is that the studies were heterogeneous, in this manner it limited the pooling of statistical data. However, were allowed, there was a performance of Meta-Analysis. Also, various studies from developing countries were included which in this case would not be so relevant to the project since this one is done in Texas, which is in the United States. 

Emerson et al. (2019)  conducted a randomized controlled study where they assessed the effectiveness of a 1-year post-intervention of a cancer-related program delivered in prisons with women as a way of improving the cervical health literacy ( CHL)  including having an up to date  Pap screening. During the study, a pre-post design was used to evaluate Pap screening and CHL impacts 1 year after the initial randomized waitlist control study.  the study was conducted in Kansas city between 2015-2017, with participate being female prisoners ( n=133)  through a one week ( 10 contact hour)  small group CHL program the surveys were important in assessing the CHL components including up to date Pap screening.  In the analysis, the researchers conducted a x2 and t-tests which were also followed by the right sub-sets in addition to logistic regressions using the socio-demographics also the CHL components that meet the optimal model regarding to up to date screening through a 1-year post-intervention.  The study indicated an improvement from pre-intervention, 6 of 8 CHL components 0.1> P>.001.  Also up to date screenings increased through the pre-intervention 72% -82%, P<.05.  Also, the right subset model was important in predicting the up to date screening that included medical insurance, public benefits, and 5 CHL components (benefits, knowledge, seriousness, barriers, and susceptibility).  The study shows that the intervention to promote cervical cancer health literacy for women in prison can ensure a sustained improvement in CHL among other prevention practices. 

Also, Fong (2013) conducted a systematic review study that conducted a summary of evidence regarding the Papanicolaou smear test for cervical cancer screening.   During the study, the Pap smear was found as being crucial when it comes to detecting abnormalities of the cervix and ensuring a reduction of mortality, in addition to being a very important part when it comes to the provision of routine care.  Based on the study, if the resources or access to care is limited, women between ages 35-45 are required to undergo screening and compliance. 

Gonzalez et al. (2011) also came up with various important factors related to adherence to cancer screening among the disadvantaged groups, especially Mexican American women.   In the study, the Behavioral Model concerning vulnerable populations was used as part of the study framework. Based on the level of unfamiliarity with the process of screening, embarrassment, and fear were identified as some of the barriers to adherence to screening.  According to the study also, there is a direct correlation between adherence to cervical cancer screening and the will to participate in other forms of preventative screening.  The findings in this study are also in line with other findings supporting the issue of adherence to preventive measures, treatment, healthcare visits, and the importance of having insurance coverage.  

Also, Saad-Harfouche et. al. (2011) studied the impact of training which lay health advisors as being outreach advocates and educators through being able to reach the underserving Latinas. This study was very important as it built on the previous studies that looked at African American cancer survivors as ambassadors in the community.  Also in the same study, the Latino males were included in the training sessions as a way to support the family's cultural dynamics when it comes to decision making.  There was a comparison of pre-post-test scores regarding knowledge surveys that indicated the significant increase in the LHA scores for the post-test.  

Han et al. (2010) conducted a meta-analysis for 18 randomized and non-randomized controlled trials that examined the methods of intervention that are aimed at promoting the issue of cervical cancer screenings, especially among the ethnic minorities.  From the study, the researcher was able to compare results between the Pap screening of treatment and that of the groups.  As part of the intervention,   there was the enhancement of access which produced the greatest impact followed by education in the community and individual counseling.  The matching materials between different cultures and the implementation of the multiple strategies in comparison to one particular strategy were also very beneficial.  

Ramaswamy et al. (2014), conducted a descriptive study that described the development and the pilot implementation of a brief jail-based cervical health promotion and intervention.  From the study, the intervention was also guided by the use of a preliminary study for incarcerated women's health knowledge about cervical cancer, awareness, and health literacy in addition to a feminist and socialist approach to the development of interventions.  Based on the study, the research was able to conduct a pilot implementation of the sexual health Empowerment project that is aimed at increasing cervical health knowledge, reduction of barriers leading to thoughts and beliefs about cervical cancer thus improving confidence and self-efficacy in the navigation of the health systems.  The study is thus important since it provides for a framework that can assure empirically and theory-based interventions have been established with the major focus being to meet the jail setting.  It is important to ensure that future tasks look at the evaluation of the long term impacts of cancer-related programs especially regarding health behaviors and results for high-risk populations like women in prison as they stay, leave and join the communities.

Systematic Review: Evidence Table

Synthesis Matrix: DNP project

References

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). https://doi.org/10.1037/0000165-000. 

Binswanger, I. A., Mueller, S., Clark, C. B., & Cropsey, K. L. (2011). Risk factors for cervical cancer in criminal justice settings. Journal of Women's Health, 20(12), 1839-1845. https://doi.org/10.1089/jwh.2011.2864

Coughlin, S. S., & King, J. (2010). Breast and cervical cancer screening among women in metropolitan areas of the United States by County-level commuting time to work and use of public transportation, 2004 and 2006. BMC Public Health, 10(1). https://doi.org/10.1186/1471-2458-10-146

Duffett-Leger, L. A., Letourneau, N. L., & Croll, J. C. (2008). Cervical cancer screening practices among University women. Journal of Obstetric, Gynecologic & Neonatal Nursing, 37(5), 572-581. https://doi.org/10.1111/j.1552-6909.2008.00276.x

Emerson, A. M., Smith, S., Lee, J., Kelly, P. J., & Ramaswamy, M. (2019). Effectiveness of a Kansas City, jail-based intervention to improve cervical health literacy and screening, one-year post-intervention. American Journal of Health Promotion, 34(1), 87-90. https://doi.org/10.1177/0890117119863714

Everett, T., Bryant, A., Griffin, M. F., Martin-Hirsch, P. P., Forbes, C. A., & Jepson, R. G. (2011). Interventions targeted at women to encourage the uptake of cervical screening. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd002834.pub2

Fong, E. (2013). Papanicolaou (Pap) Sear: Cervical Screening. JBI Database. AN: JBI1579. (updated 20140507). 

Gonzalez, P., Castaneda, S. F., Mills, P. J., Talavera, G. A., Elder, J. P., & Gallo, L. C. (2011). Determinants of breast, cervical, and colorectal cancer screening adherence in Mexican–American women. Journal of Community Health, 37(2), 421-433. https://doi.org/10.1007/s10900-011-9459-2

Han, H., Kim, J., Lee, J., Hedlin, H. K., Song, H., Song, Y., & Kim, M. T. (2010). Interventions that increase the use of pap tests among ethnic minority women: A meta-analysis. Psycho-Oncology, 20(4), 341-351. https://doi.org/10.1002/pon.1754

Holly, C., Salmond, S. W., & Saimbert, M. K. (2017). Comprehensive systematic review for advanced practice nursing. New York: Springer Publishing Co. 

Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-Based Practice in nursing & healthcare: A guide to best practices (4th ed.). Wolters Kluwer. 

Ramaswamy, M., Simmons, R., & Kelly, P. J. (2014). The development of a brief jail-based cervical health promotion intervention. Health Promotion Practice, 16(3), 432-442. https://doi.org/10.1177/1524839914541658

Reavy, K. (2016). Inquiry and leadership, a resource for the DNP project. Philadelphia, PA: F.A. Davis Company. ISBN: 9780803642041. 

Saad-Harfouche, F. G., Jandorf, L., Gage, E., Thélémaque, L. D., Colón, J., Castillo, A. G., Treviño, M., & Erwin, D. O. (2010). Esperanza Y Vida: Training lay health advisors and cancer survivors to promote breast and cervical cancer screening in Latinas. Journal of Community Health, 36(2), 219-227. https://doi.org/10.1007/s10900-010-9300-3