UCLA

Cervical cancer prevention has undergone significant changes over recent decades. Evolving evidence and practices have shifted towards upstream prevention, less frequent screening, and more conservative follow-up. Understanding how these changes have been adopted among ethnic minority and low-income populations, groups disproportionately impacted by cervical cancer in the U.S., is important to optimizing prevention strategies. In three distinct studies, this dissertation advances evidence on adherence to recommendations for primary prevention (human papillomavirus (HPV) vaccination) and secondary prevention (early detection) of cervical cancer among high-risk populations.

The first study assesses changes in adolescent HPV vaccination following vaccine approval in the U.S., using two cycles of population-based survey data from Los Angeles County. Between 2007 and 2011, ethnic and income differences in parental HPV vaccine awareness diminished, and HPV vaccine uptake rates markedly increased among older adolescent girls and those with access barriers. Yet, five years after vaccine approval, overall only half of adolescent girls had initiated vaccination.

The second study evaluates adoption of evidence-based guidelines for management of abnormal screening tests among young women, using four years of administrative claims data from California’s Medicaid family planning program. A difference-in-differences approach was used to estimate the impact of updated guidelines on receipt of a colposcopy, a procedure that could lead to potential harmful interventions. Among a sample of low-income, predominantly Hispanic women, results suggested the guideline was associated with a 2-fold reduction in colposcopies for young women relative to a comparison group, which has implications for reducing future risk of adverse obstetric outcomes.

Given provider recommendations can influence patient adherence, the third study explores provider communication around cervical cancer screening and follow-up recommendations, including lengthened screening intervals. Semi-structured interviews were conducted among safety net providers in Southern California. Findings revealed that clinicians perceived explaining the rationale for guidelines, in addition to addressing patient emotions, uncertainty, and preferences, facilitated patient understanding and acceptance of recommended care.

Collectively, these studies highlight opportunities to maximize the benefits of primary prevention and early detection strategies, while minimizing the harms of unnecessary intervention, among high-risk populations.