Health Literacy as a Predictor of Follow-Up After an Abnormal Pap Smear: A Prospective Study


Address correspondence and requests for reprints to Dr. Lindau: University of Chicago, 5841 S. Maryland, MC2007, Chicago, IL 60637 (e-mail:


BACKGROUND: Low literacy influences cervical cancer screening knowledge, and is a possible contributor to racial disparities in cervical cancer.

OBJECTIVE: To examine the hypothesis that literacy predicts patient adherence to follow-up recommendations after an abnormal Pap smear.

DESIGN: A prospective, continuity clinic-based study.

PARTICIPANTS: From a sample of 538 women undergoing literacy testing at the time of Pap smear screening, we studied 68 women with abnormal Pap smear diagnoses.

MEASUREMENTS: Literacy was assessed using the Rapid Evaluation of Adult Literacy in Medicine (REALM). We also measured other proxies for literacy, including educational attainment and physician estimates of patients' literacy level. Outcome measures included on-time and 1-year follow-up and duration of time to follow-up after an abnormal Pap smear.

RESULTS: Only one-third of the cohort adhered to follow-up recommendations. At 1 year, 25% of the women had not returned at all. Patients with inadequate literacy (as assessed by the REALM) were less likely to follow up within 1 year, although this result was not statistically significant (adjusted odds ratio [OR]=3.8, 95% confidence interval [CI]: 0.8 to 17.4). Patients subjectively assessed by their physician to have low literacy skills were significantly less likely to follow up within 1 year (adjusted OR=14, 95% CI: 3 to 65). Less than high school education (hazard ratio (HR)= 2.3; 95% CI: 1.2, 4.6) and low physician-estimated literacy level (HR=3.4, 95% CI: 1.4, 8.2), but not objective literacy level, were significant predictors of duration of time to follow-up, adjusting for recommended days to follow-up and other factors.

CONCLUSIONS: Among women with an abnormal Pap smear, those perceived by their physician to have low literacy were significantly more likely to fail to present for follow-up.