Examining the perceived impact of the COVID-19 pandemic on cervical cancer screening practices among clinicians practicing in Federally Qualified Health Centers: A mixed methods study
Curation statements for this article:-
Curated by eLife
eLife assessment
This US study presents findings from an online survey and in-person interviews of healthcare providers in areas associated with cervical screening provision during the post-acute phase of the pandemic. The findings are valuable as they provide insights into a range of areas, from healthcare characteristics to screening barriers and HPV self-sampling. The evidence supporting the claims of the authors is solid, although the inclusion of a nationally-representative sample of healthcare providers and a greater gender/ethnicity/racial mix of interviewees would have strengthened the study. The work will be of interest to public health scientists and a cancer prevention and control audience.
This article has been Reviewed by the following groups
Listed in
- Evaluated articles (eLife)
- Medicine (eLife)
Abstract
The COVID-19 pandemic led to reductions in cervical cancer screening and colposcopy. Therefore, in this mixed methods study we explored perceived pandemic-related practice changes to cervical cancer screenings in federally qualified health centers (FQHCs).
Methods:
Between October 2021 and June 2022, we conducted a national web survey of clinicians (physicians and advanced practice providers) who performed cervical cancer screening in FQHCs in the United States during the post-acute phase of the COVID-19 pandemic, along with a sub-set of qualitative interviews via video conference, to examine perceived changes in cervical cancer screening practices during the pandemic.
Results:
A total of 148 clinicians completed surveys; a subset (n=13) completed qualitative interviews. Most (86%) reported reduced cervical cancer screening early in the pandemic, and 28% reported continued reduction in services at the time of survey completion (October 2021- July 2022). Nearly half (45%) reported staff shortages impacting their ability to screen or track patients. Compared to clinicians in Obstetrics/Gynecology/Women’s health, those in family medicine and other specialties more often reported reduced screening compared to pre-pandemic. Most (92%) felt that screening using HPV self-sampling would be very or somewhat helpful to address screening backlogs. Qualitative interviews highlighted the impacts of staff shortages and strategies for improvement.
Conclusions:
Findings highlight that in late 2021 and early 2022, many clinicians in FQHCs reported reduced cervical cancer screening and of pandemic-related staffing shortages impacting screening and follow-up. If not addressed, reduced screenings among underserved populations could worsen cervical cancer disparities in the future.
Funding:
This study was funded by the American Cancer Society, who had no role in the study’s design, conduct, or reporting.
Article activity feed
-
-
Author Response
Reviewer #1 (Public Review):
Overall, this manuscript exposes key gaps in patient care resulting from the pandemic, as well as the challenges and unmet needs felt by healthcare workers in cervical cancer screening. The authors’ findings on the struggles while regaining screening volume across the nation in a sustainable way, demonstrate that pre-existing weaknesses in the cancer control system were exacerbated by the pandemic and are integral to amend. The authors were able to identify these gaps in care and work environments through their synthesis of qualitative interviews. I applaud the use of such mixed methods, which emphasizes the complementary need for both quantitative and qualitative data. What could be better strengthened in the manuscript is the authors’ justification for statistical analyses within the …
Author Response
Reviewer #1 (Public Review):
Overall, this manuscript exposes key gaps in patient care resulting from the pandemic, as well as the challenges and unmet needs felt by healthcare workers in cervical cancer screening. The authors’ findings on the struggles while regaining screening volume across the nation in a sustainable way, demonstrate that pre-existing weaknesses in the cancer control system were exacerbated by the pandemic and are integral to amend. The authors were able to identify these gaps in care and work environments through their synthesis of qualitative interviews. I applaud the use of such mixed methods, which emphasizes the complementary need for both quantitative and qualitative data. What could be better strengthened in the manuscript is the authors’ justification for statistical analyses within the context of the research question, and reporting of survey administration and management.
The authors thank the reviewer for a thorough assessment of the manuscript. We have addressed the reviewer’s concerns regarding justification of statistical analyses in the Data Analysis, Quantitative survey data section, and reporting of survey administration and management in the Results, Quantitative survey data section.
Reviewer #2 (Public Review):
Fuzzell et al. conducted a mixed-method study looking into the possible impact of COVID-19 on clinician perceptions of cervical cancer screening. The authors examined how the pandemic-related staffing changes might have affected the screening and abnormal results follow-up during the period October 2021 through July 2022.
They found that 80% of the clinicians experienced decreased screening during the start of the pandemic and that ≈67% reported a return to pre-pandemic levels. The general barriers for not returning to pre-pandemic levels were staffing shortages and problems with structural systems for tracking overdue patients and those in need of follow-up after abnormal screening tests.
Strengths:
There is a high focus on the consequences and the need for action to prevent the ongoing impact of COVID-19 on cervical cancer screening. Some of the actions mentioned by the authors could be the use of HPV self-sampling kits, and it is interesting to be provided knowledge on the clinicians' views on HPV self-sampling. Both are of high interest to the general population in the US. Throughout the discussion, the authors and their claims are supported by other studies.
Weaknesses:
The lack of a National representative sample, where 63% of the responding clinicians were practicing in the Northeast, affects the possibility of generalization of the results found in the study. The overrepresentation of white females is not addressed in the discussion. This composition could have affected the results, especially when the authors report a need to look at higher salaries and better childcare to maintain adequate staffing.
The conclusions are mostly supported by the data, however, some aspects of the data analysis need to be clarified.
We thank the reviewer for their constructive feedback. Despite our best efforts, we were unable to recruit a sample more representative of all US regions. We note this limitation in the discussion: “Notwithstanding efforts to achieve a regionally diverse sample, 63% of responding clinicians were practicing in the Northeast at the time of their participation. Given that COVID-19 policies varied widely by state, this regional imbalance may limit the generalizability of our results. Despite the oversample of clinicians in the Northeast, region was not a significant predictor of either outcome.” Also, we acknowledge the high enrollment of White women in our provider sample and now address this point in the discussion: “Similarly, our sample was 85% female and 70% White. Although ideally we would have included a sample that was more diverse with respect to race and gender, these characteristics are not disparate from the majority of clinicians who perform cervical cancer screening (e.g., race: Women’s Health NPs [77% White], active Ob/Gyns [67% White], all active physicians [64% White]; gender: all NPs [92% female], Ob/Gyns [64% female], all active physicians [37% female]).” Data describing these characteristics are reported in the Association of American Medical Colleges (AAMC) 2022 Physician Specialty Data Report and Executive Summary, the 2018 NPWH Women’s Health Nurse Practitioner Workforce Demographics and Compensation Survey: Highlights Report, and a published paper describing the characteristics of nurse practitioners in the US, which are cited in text.
Reviewer #3 (Public Review):
This US study presents findings from an online survey and in-person interviews of healthcare providers regarding themes associated with cervical screening in federally qualified health centres (FQHCs). The study provides insights during the post-acute phase of the pandemic into a range of areas, including perceived changes in the provision of cervical cancer screening services and the impact of the pandemic, staffing and systems barriers to cervical cancer screening, strategies for tracking missed screens and catch-ups, follow-up of abnormal screening results, as well as attitudes towards HPV self-sampling. Results indicate persisting pandemic-related impacts on patient engagement and staffing, as well as system barriers to effective screening, catch-up of missed screens and follow-ups. Taken together, these issues may lead to increases in cervical cancer in the long-term in populations serviced by these centres, if measures are not taken to adequately support them. Participants were recruited from various regions in the US, however, the study was not conducted using a nationally-representative sample. Although highlighted issues are informative, findings cannot be generalised and larger studies are warranted in the future to monitor cervical screening provision and outcomes in FQHCs.
We thank the reviewer for their thorough assessment of the manuscript. In the discussion, we have made sure to note the non-nationally representative sample and need for continued monitoring of cervical cancer screening and related outcomes in underserved settings and communities.
-
eLife assessment
This US study presents findings from an online survey and in-person interviews of healthcare providers in areas associated with cervical screening provision during the post-acute phase of the pandemic. The findings are valuable as they provide insights into a range of areas, from healthcare characteristics to screening barriers and HPV self-sampling. The evidence supporting the claims of the authors is solid, although the inclusion of a nationally-representative sample of healthcare providers and a greater gender/ethnicity/racial mix of interviewees would have strengthened the study. The work will be of interest to public health scientists and a cancer prevention and control audience.
-
Reviewer #1 (Public Review):
Overall, this manuscript exposes key gaps in patient care resulting from the pandemic, as well as the challenges and unmet needs felt by healthcare workers in cervical cancer screening. The authors' findings on the struggles while regaining screening volume across the nation in a sustainable way, demonstrate that pre-existing weaknesses in the cancer control system were exacerbated by the pandemic and are integral to amend. The authors were able to identify these gaps in care and work environments through their synthesis of qualitative interviews. I applaud the use of such mixed methods, which emphasizes the complementary need for both quantitative and qualitative data. What could be better strengthened in the manuscript is the authors' justification for statistical analyses within the context of the …
Reviewer #1 (Public Review):
Overall, this manuscript exposes key gaps in patient care resulting from the pandemic, as well as the challenges and unmet needs felt by healthcare workers in cervical cancer screening. The authors' findings on the struggles while regaining screening volume across the nation in a sustainable way, demonstrate that pre-existing weaknesses in the cancer control system were exacerbated by the pandemic and are integral to amend. The authors were able to identify these gaps in care and work environments through their synthesis of qualitative interviews. I applaud the use of such mixed methods, which emphasizes the complementary need for both quantitative and qualitative data. What could be better strengthened in the manuscript is the authors' justification for statistical analyses within the context of the research question, and reporting of survey administration and management.
-
Reviewer #2 (Public Review):
Fuzzell et al. conducted a mixed-method study looking into the possible impact of COVID-19 on clinician perceptions of cervical cancer screening. The authors examined how the pandemic-related staffing changes might have affected the screening and abnormal results follow-up during the period October 2021 through July 2022.
They found that 80% of the clinicians experienced decreased screening during the start of the pandemic and that ≈67% reported a return to pre-pandemic levels. The general barriers for not returning to pre-pandemic levels were staffing shortages and problems with structural systems for tracking overdue patients and those in need of follow-up after abnormal screening tests.
Strengths:
There is a high focus on the consequences and the need for action to prevent the ongoing impact of COVID-19 …
Reviewer #2 (Public Review):
Fuzzell et al. conducted a mixed-method study looking into the possible impact of COVID-19 on clinician perceptions of cervical cancer screening. The authors examined how the pandemic-related staffing changes might have affected the screening and abnormal results follow-up during the period October 2021 through July 2022.
They found that 80% of the clinicians experienced decreased screening during the start of the pandemic and that ≈67% reported a return to pre-pandemic levels. The general barriers for not returning to pre-pandemic levels were staffing shortages and problems with structural systems for tracking overdue patients and those in need of follow-up after abnormal screening tests.
Strengths:
There is a high focus on the consequences and the need for action to prevent the ongoing impact of COVID-19 on cervical cancer screening. Some of the actions mentioned by the authors could be the use of HPV self-sampling kits, and it is interesting to be provided knowledge on the clinicians' views on HPV self-sampling. Both are of high interest to the general population in the US. Throughout the discussion, the authors and their claims are supported by other studies.
Weaknesses:
The lack of a National representative sample, where 63% of the responding clinicians were practicing in the Northeast, affects the possibility of generalization of the results found in the study. The overrepresentation of white females is not addressed in the discussion. This composition could have affected the results, especially when the authors report a need to look at higher salaries and better childcare to maintain adequate staffing.
The conclusions are mostly supported by the data, however, some aspects of the data analysis need to be clarified.
-
Reviewer #3 (Public Review):
This US study presents findings from an online survey and in-person interviews of healthcare providers regarding themes associated with cervical screening in federally qualified health centres (FQHCs). The study provides insights during the post-acute phase of the pandemic into a range of areas, including perceived changes in the provision of cervical cancer screening services and the impact of the pandemic, staffing and systems barriers to cervical cancer screening, strategies for tracking missed screens and catch-ups, follow-up of abnormal screening results, as well as attitudes towards HPV self-sampling. Results indicate persisting pandemic-related impacts on patient engagement and staffing, as well as system barriers to effective screening, catch-up of missed screens and follow-ups. Taken together, these …
Reviewer #3 (Public Review):
This US study presents findings from an online survey and in-person interviews of healthcare providers regarding themes associated with cervical screening in federally qualified health centres (FQHCs). The study provides insights during the post-acute phase of the pandemic into a range of areas, including perceived changes in the provision of cervical cancer screening services and the impact of the pandemic, staffing and systems barriers to cervical cancer screening, strategies for tracking missed screens and catch-ups, follow-up of abnormal screening results, as well as attitudes towards HPV self-sampling. Results indicate persisting pandemic-related impacts on patient engagement and staffing, as well as system barriers to effective screening, catch-up of missed screens and follow-ups. Taken together, these issues may lead to increases in cervical cancer in the long-term in populations serviced by these centres, if measures are not taken to adequately support them. Participants were recruited from various regions in the US, however, the study was not conducted using a nationally-representative sample. Although highlighted issues are informative, findings cannot be generalised and larger studies are warranted in the future to monitor cervical screening provision and outcomes in FQHCs.
-
