"just do it. get it over with, please!”: Designing interventions to increase cervical cancer screening among homeless women

Background: Cervical cancer incidence in the US is declining; yet, screening rates are still low for some groups, including homeless women. Screening among homeless women averages around 50%, compared to 80% for the general population. Previous studies have identified barriers to screening among homeless women, but few offer strategies to overcome them. This paper presents qualitative data from focus groups with homeless women in Boston, Massachusetts on Pap test decision-making. Methods: Eight focus groups were conducted with homeless women at healthcare and housing service sites. Women were representative of Boston's diverse homeless population (e.g., young mothers, older single adults, substance users). The interview protocol was designed to elicit narrative about health concerns, healthcare provision, and acceptance or rejection of Paps. Results: The mean age of the participants was 40 years; 47% were white and 28% Hispanic/Latina. Fifty-four percent had a high school education or less. Participants talked about barriers to acceptance, which included aversions to Pap tests, low likelihood of follow-up, substance abuse, and a history of negative medical encounters while homeless. Motivators to acceptance were responsibility to family, social support, and positive patient-provider engagement, which was more likely to occur with physicians specializing in caring for the homeless. Conclusions: The decision to accept cervical cancer screening was related to personal and environmental factors, some of which are amenable to intervention. Some factors varied by the subpopulation, indicating specific interventions; others were universal. Further research will test the effectiveness of different interventions to improve screening in this population.