Disparities in cervical cancer diagnosis and survival in the United States have been linked to socioeconomic status and race. However, low literacy may influence cervical cancer screening behavior as well, because follow-up for an abnormal Pap smear requires complex communication between physician and patient. This study examined 68 women with abnormal Pap smears to determine whether literacy level would predict adherence to follow-up recommendations after cervical cancer screening. The researchers analyzed adherence to follow-up recommendations in relation to physicians' subjective assessment of literacy level, the educational level of the study participants, and physicians' predictions of on-time follow-up, in addition to an objective test of literacy skills (REALM).

Key findings:

• Patients assessed with low literacy by their physicians were 13 times more likely not to present for follow up on an abnormal Pap smear than those perceived to have adequate literacy.
• Among those patients who did follow-up, less than high school education and low subjective literacy level, but not objective literacy level, were significant predictors of delay.

These findings suggest that subjective assessment of literacy levels by physicians and information about educational level should be integrated into strategies for communication, counseling and scheduling. Further research, perhaps using qualitative study of patient-physician interactions, may help decipher how physicians make informal judgments regarding literacy. This could be an important next step in understanding how to reduce disparities in the incidence and burden of cervical cancer in the United States.