Cervical Cancer Literacy and COVID-19 Attitudes and Knowledge Among Women with Criminal Justice Involvement

Background and Purpose:

Research shows that health literacy as a social determinant of health may be a contributor to health disparities in minority populations. Justice involved women are a disproportionately medically vulnerable population impacted negatively by SDOH, experiencing more medical mistrust and having multiple risk factors for poorer health outcomes in comparison to the general population. Women with a history of justice involvement experience up to 5 times increased incidence of cervical cancer and are burdened with co-morbid conditions correlated with worse health outcomes including more severe COVID-19. Although the reasons for this are multifactorial, research demonstrates that low cervical cancer health literacy in this population is associated with lower engagement in protective health behaviors that include prevention practices, beliefs and understanding. The current analysis aims to examine the relationship between cervical cancer literacy and COVID-19 beliefs and attitudes to determine: 1) If lower health literacy is correlated with lower COVID-19 treatment and vaccine hesitancy, and 2) If cervical cancer literacy is associated with lower COVID-19 prevention knowledge.

Methods:

This research was a secondary analysis of the Tri-City C.R.E.W Annual longitudinal survey study which started in 2019 to investigate cervical cancer risks in a population of women with a history of criminal justice involvement. Supplemental questions were added to explore the impact of COVID-19 on this medically disadvantaged population more susceptible to severe complications from COVID-19 infection. This analysis included 362 participants at baseline, and follow-up years one and two. Participants were aged 21-79 and included 27% White, 61% African American/Black, and 11% other race/ethnicities. The main independent variable included cervical cancer literacy operationalized through participant responses to, “Human Papilloma Virus can lead to cervical cancer”, and “Women who have gone through menopause do not need to have Pap tests”, measured dichotomously. The dependent variables, COVID-19 vaccine and treatment hesitancy were measured using 5-point Likert scales, and COVID-19 prevention knowledge, measured dichotomously. Binary and ordinal regressions were conducted to assess outcomes using age, race/ethnicity, education, income, and job status post COVID-19 as covariates.

Results:

Women with higher cervical cancer literacy were more likely to show COVID-19 treatment hesitancy (AOR=1.66; p<0.05). Women with higher cervical health literacy were more likely to demonstrate better understanding of COVID-19-related knowledge (AOR=0.47; p<0.05). However, the association between cervical cancer literacy and COVID-19 vaccine hesitancy were not significant. We were unable to identify and significant interactive effects for testing age, race/ethnicity and income as potential moderators.

Conclusions and Implications:
Findings of this study partially challenge published literature correlating higher health literacy with higher protective health behaviors, beliefs, and knowledge. While we found that higher cervical cancer health literacy was correlated with better COVID-19 knowledge, women with higher health literacy showed more hesitance to taking a treatment for COVID-19.

We found that trust might be related to COVID-19 behaviors and beliefs outside of health literacy effects and recommend further exploration of how these contribute to persons declining to receive beneficial health care services that may reduce health outcome disparities in vulnerable populations.