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A Systematic Review and Quantitative Meta-Analysis of the Accuracy Of A SYSTEMATIC REVIEW AND QUANTITATIVE META-ANALYSIS OF THE ACCURACY OF VISUAL INSPECTION FOR CERVICAL CANCER SCREENING: DOES PROVIDER TYPE OR TRAINING MATTER? by Susan D. Driscoll A Dissertation Submitted to the Faculty of the Christine E. Lynn College of Nursing In Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Florida Atlantic University Boca Raton, FL December 2016 Copyright 2016 by Susan D. Driscoll ii ACKNOWLEDGEMENTS My dear friend and fellow PhD student referred to her doctoral dissertation as an “excrementitious” process and I couldn’t agree more. I would like to acknowledge a few of the many people who helped me navigate through the winding road of life, career, and academia. Dr. Tappen always had faith in my abilities and her easy going nature made the climb a little easier than expected. Dr. Goodman’s undying commitment to nursing and education is contagious and inspired me to continue the long hard slog. Dr. David Newman can always make me laugh and guided me through complicated statistics. Dr. Drowos’ medical perspectives were welcomed and needed. My sincerest thanks to all the wonderful teachers and mentors in my academic and professional career. Dr. Moore gave me the best career advice ever, “don’t get into medicine unless you can’t see yourself doing anything else”…so I didn’t. Teri Richards gave me my first glimpse at nursing. Dick Keyser introduced me to the business of healthcare, Dr. Grinspoon and Dr. Dolan-Looby sparked my interest in clinical research, Dr. Andrist and Dr. Steele sharpened my clinical skills, Dr. Voege Harvey and Dr. Tsarnas kept me grounded in clinical nursing, Dr. Chinn and Dr. Schoenhofer showed me how to live and grow in caring, and Dr. Carl Taylor showed me the world of global public health. Thanks Dad for giving me some of your smarts, Mom for your love, my older brothers for keeping it real, and most importantly, thanks to my two girls for giving me the love, support, and space I needed to pursue my dreams. iv ABSTRACT Author: Susan D. Driscoll Title: A Systematic Review and Quantitative Meta-Analysis of the Accuracy of Visual Inspection for Cervical Cancer Screening: Does Provider Type or Training Matter? Institution: Florida Atlantic University Dissertation Advisor: Dr. Ruth Tappen Degree: Doctor of Philosophy Year: 2016 Background A global cervical cancer health disparity persists despite the demonstrated success of primary and secondary preventive strategies, such as cervical visual inspection (VI). Cervical cancer is the leading cause of cancer incidence and death for women in many low resource areas. The greatest risk is for those who are unable or unwilling to access screening. Barriers include healthcare personnel shortages, cost, transportation, and mistrust of healthcare providers and systems. Using community health workers (CHWs) may overcome these barriers, increase facilitators, and improve participation in screening for women in remote areas with limited access to clinical resources. Aim To determine whether the accuracy of VI performed by CHWs was comparable to VI by physicians or nurses and to consider the affect components of provider training had on VI accuracy. Methods A systematic review and quantitative meta-analysis of published literature reporting on VI accuracy, provider type, and training was conducted. Strict inclusion/exclusion criteria, study quality, and publication bias assessments improved rigor and bivariate linear mixed modeling v (BLMM) was used to determine the affect of predictors on accuracy. Unconditional and conditional BLMMs, controlling for VI technique, provider type, community, clinical setting, HIV status, and gynecological symptoms were considered. Results Provider type was a significant predictor of sensitivity (p=.048) in the unconditional VI model. VI performed by CHWs was 15% more sensitive than physicians (p=.014). Provider type was not a significant predictor of accuracy in any other models. Didactic and mentored hours predicted sensitivity in both BLMMs. Quality assurance and use of a training manual predicted specificity in unconditional BLMMs, but was not significant in conditional models. Number of training days, with ≤5 being optimal, predicted sensitivity in both BLMMs and specificity in the unconditional model. Conclusion Study results suggest that community based cervical cancer screening with VI conducted by CHWs can be as, if not more, accurate than VI performed by licensed providers. Locally based screening programs could increase access to screening for women in remote areas. Collaborative partnerships in “pragmatic solidarity” between healthcare systems, CHWs, and the community could promote participation in screening resulting in decreased cervical cancer incidence and mortality. vi A SYSTEMATIC REVIEW AND QUANTITATIVE META-ANALYSIS OF THE ACCURACY OF VISUAL INSPECTION FOR CERVICAL CANCER SCREENING: DOES PROVIDER TYPE OR TRAINING MATTER? LIST OF TABLES ............................................................................................................................ xii LIST OF FIGURES ......................................................................................................................... xiv ABBREVIATIONS .......................................................................................................................... xv CHAPTER 1: INTRODUCTION ....................................................................................................... 1 Background .................................................................................................................................. 1 Problem Statement ....................................................................................................................... 6 Purpose ........................................................................................................................................ 6 Research Questions and Hypotheses .......................................................................................... 6 research question 1. ................................................................................................................. 6 research question 2. ................................................................................................................. 6 Research Assumptions ................................................................................................................ 6 Definition of Terms ....................................................................................................................... 7 diagnostic test accuracy. .......................................................................................................... 7 provider type. ............................................................................................................................ 7 training. ..................................................................................................................................... 8 Significance .................................................................................................................................. 8 contributions to research. ......................................................................................................... 9 contribution to nursing practice. .............................................................................................. 10 relation to caring science. ....................................................................................................... 11 Summary .................................................................................................................................... 12 CHAPTER 2: LITERATURE REVIEW ........................................................................................... 14 Philosophical and Theoretical Paradigms .................................................................................. 14 vii critical social theory. ............................................................................................................... 15 empirical knowing. .................................................................................................................. 17 caring. ..................................................................................................................................... 18 Cervical Cancer .......................................................................................................................... 20 epidemiology. .......................................................................................................................... 20 risk factors. .............................................................................................................................. 21 cervical anatomy. .................................................................................................................... 22 human papillomavirus. ............................................................................................................ 23 cervical dysplasia. ................................................................................................................... 23 primary prevention. ................................................................................................................. 24 secondary prevention. ............................................................................................................ 27 accuracy of cytology. .............................................................................................................
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