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Brief communication 141 PAP SMEAR TESTING AMONG HOMELESS AND VERY LOW-INCOME HOUSED MOTHERS Although long-term trends demonstrate a decreasing incidence of cervical cancer in U.S. women, a disproportionate share of low-income and minority women experience high rates of precancerous cervical abnormalities and invasive cervical cancer.1-2 Despite this, women of lower income and education levels are less likely to receive recommended Pap smear testing than women of higher socioeconomic status.3,4 Numerous studies have attempted to identify the underlying causes of this pattern of care by examining psychosocial and health-related burdens present in the lives of poor women. Associations between receipt of Pap smear screening and homelessness,5 race/ethnicity,6,7 child care needs,8 language barriers,9 culturally based belief models,10 chronic medical disease,11 poor functional health status,12,13 and high-risk lifestyle practices14 have been previously demonstrated. Other studies have emphasized the importance of having access to medical care as the key determinant of receiving adequate Pap smear screening.13,15,16 Yet, with the exception of a single study with a small sample of homeless women,17 the relative contribution of access factors compared with a broad range of social, physical, and mental health barriers to cervical cancer screening among poor women has not been well described. The rates and correlates of receipt of Pap testing among a sample of homeless and very low-income housed women with dependent children are reported here, with data available on a wide variety of psychosocial, physical, and mental health domains. This information was obtained during in-depth interviews with study participants in the Worcester Family Research Project.18 Method The Worcester Family Research Project18 is an ongoing observational study of the determinants and consequences of homelessness. This study of poor women is based in Worcester, Massachusetts. Its participants, enrollment procedures , and data collection have been extensively described elsewhere.18,19 In brief, a case-control design was used to recruit a sample of sheltered homeless mothers and a comparison group of very low-income housed female heads of household. Between August 1992 and July 1995, 220 homeless women were enrolled from nine Worcester homeless shelters. A comparison group of 216 Received February 1,2001; revised August 22,2001; accepted September 19,2001. Journal of Health Care for the Poor and Underserved · Vol. 13, No. 2 · 2002 142 Pap Smear Testing low-income housed women who were receiving Aid to Families With Dependent Children (AFDC) were enrolled during visits to the Worcester Department of Public Welfare office over the same period. Of the 361 homeless families approached to participate, 102 refused, and 39 dropped out before completing the interview sessions. While no significant differences with respect to race, marital status, and number of children were found between homeless women who completed the study and those who refused, homeless women who were younger and less likely to have graduated from high school were more likely to refuse study participation. Among the comparison group of housed women, 148 women of the 395 women approached refused to participate ; 31 dropped out before study completion. Those who refused to participate were similar with respect to age, marital status, and number of children to those who completed the study. They were less likely, however, to have completed high school and more likely to be Hispanic. Women who dropped out of the study were similar to those completing the study with the exception of being less likely to have graduated from high school. Study subjects completed a comprehensive, semistructured interview with trained female interviewers requiring an average of 10 hours (over three to four sessions) to complete. The multisession format was used to reduce respondent burden. Information was gathered about demographic, economic , and social support variables (using the Personal Assessment of Social Supports [PASS])20 as well as health status (using the 36-item Short Form Health Status Survey [SF-36])21 and mental health (Structured Clinical Interview for DSM-III).22 Information was also collected about health risk behaviors , childhood and adult victimization (contextualized version of the Conflict Tactics Scale),23 medical service utilization, and access to medical care (see Table 1 for listing of...

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