Você está na página 1de 9


Lessons Learned
Providing a Mindfulness-based Stress Reduction
Program for Low-income Multiethnic Women With
Abnormal Pap Smears
■ Priscilla D. Abercrombie, PhD, RN, NP ■ Anita Zamora, BS, RN ■ Abner P. Korn, MD

Although the incidence rate of cervical cancer has decreased over the last several years, low-income ethnic
minority women remain at increased risk for morbidity and mortality from cervical cancer. We conducted a pilot
study to examine the feasibility and acceptability of mindfulness-based stress reduction (MBSR) program among
multiethnic low-income women with abnormal Pap smears. Spanish- and English-speaking women recruited
through convenience sampling participated in MBSR classes 2 hours each week over 6 consecutive weeks. State
anxiety and self-compassion were measured before and after the MBSR program. Focus groups and surveys were
used to evaluate the program. Although 51 women were initially recruited, pre- and post-MBSR data were available
only for 8 women. There was a significant reduction in anxiety and a trend toward increased self-compassion in this
group of women. The participants evaluated the MBSR program very positively. The high attrition rate highlights the
challenges of conducting MBSR research with this demographic of women. Potential strategies for improving
recruitment and retention of low-income multiethnic women are discussed. KEY WORDS: abnormal, Pap smear,
MBSR, multiethnic women Holist Nurs Pract 2007;21(1):26–34

Although overall rates of cervical cancer have the Healthy People 2010 objectives.4 Cervical cancer
declined over the last several decades, the incidence is a preventable disease that disproportionately affects
and mortality rates have increased among low-income low-income ethnic minority women.
women and those with less education.1 Hispanic Pap smear screening is an effective method of
women living in the United States are twice as likely detecting preinvasive cervical lesions, and has led to a
to be diagnosed with cervical cancer as non-Hispanic decline in the rates of cervical cancer.5 After an
whites.2 In addition, the death rate from cervical abnormal Pap smear diagnosis is made, either close
cancer is 40% higher among Hispanics than among monitoring with Pap smears or further diagnostic
other groups.2 African American women are testing with colposcopy is recommended.6 In cases
diagnosed with cervical cancer at a later stage than where a high-grade squamous intraepithelial lesion,
Caucasian women.3 Reducing cervical cancer deaths carcinoma in situ, or carcinoma is detected, treatment
from 3/100,000 females to 2/100,000 females is one of is indicated.6 Unfortunately, for many women, an
abnormal Pap smear diagnosis leads to a great deal of
psychological as well as physical morbidity.
From the Departments of Obstetrics, Gynecology, and Reproductive A holistic nursing approach to caring for women
Sciences (Drs Abercrombie and Korn), Family Health Care Nursing
(Dr Abercrombie), and Community Health Systems (Ms Zamora), Univer- with abnormal Pap smears includes attending to both
sity of California, San Francisco. their physical and psychological needs. Nurses are
We acknowledge our MBSR teachers, Nancy Bardacke, MA, CNM, and involved in almost all aspects of caring for women
Reverend Hilda Ryūmon Gutiérrez Baldoquı́n, MSEd, and the consultation with abnormal Pap smears: informing and counseling
of Shauna Shapiro, PhD. We thank Danielle Briggs for her contribution to the
literature review. We are particularly grateful to the women who participated women about abnormal results, providing education
in this program for offering their insights, sharing their experiences, and and emotional support, offering colposcopy and
giving their time.
treatment, referring women to outside providers, and
Corresponding author: Priscilla Abercrombie, PhD, RN, NP, Women’s
Health & Healing, 150 Jordan Ave, San Anselmo, CA 94960 (e-mail:
managing follow-up. Although guidelines have been
pdanp@pacbell.net). recently developed for addressing the physical needs

Lessons Learned: MBSR 27

of women with abnormal Pap smears,6 there is little Mindfulness-based stress reduction
consensus about how to effectively address their
psychological needs. The mindfulness-based stress reduction (MBSR)
program was developed by Kabat-Zinn at the Stress
Reduction Clinic at the University of Massachusetts
LITERATURE REVIEW Medical Center. The program was developed to help
Psychological effects of abnormal Pap smears patients cope with the physical and psychological
manifestations of illness. The focus of the program is
The psychological morbidity experienced by women to train mindfulness and moment-to-moment
related to being informed of their abnormal Pap smear awareness in daily life. Over the last couple of
result and to stresses encountered in subsequent decades, MBSR programs have proliferated across the
follow-up such as repeat Pap smears, colposcopy, and United States and worldwide, and can be found in a
treatment has been well documented in a review by variety of settings from medical clinics to the
Rogstad.7 Psychological reactions after being corporate workplace. A number of research studies
informed of an abnormal Pap smear result include have investigated the health benefits of MBSR.
psychosexual trauma,8 effects on self-esteem and
body image,9 and anxiety.10–18 Numerous studies have
MBSR research
indicated that fear is pervasive among women with
abnormal Pap smears. Women are primarily fearful of Two meta-analyses have concluded that MBSR can be
having cancer19–24 and of undergoing medical helpful for a broad range of clinical and nonclinical
procedures such as colposcopy.10,21,25,26 Since anxiety problems.38,39 It has been found to be successful in
and fear have been found to be deterrents to follow-up reducing psychological as well as physical symptoms.
after an abnormal Pap smear,20,22,27,28 it is imperative For instance, MBSR has been found to reduce
that we develop interventions that address anxiety symptoms of anxiety and panic40 and general
among women with abnormal Pap smears. psychological symptomatology.41 Mindfulness-based
Interventions to decrease anxiety cognitive therapy, an adaptation of MBSR by
psychologists, has been found to decrease relapse rates
The most studied approach to decreasing anxiety among depressed patients.42,43 MBSR appears to be
among women with abnormal Pap smears has been the effective in helping patients cope with a variety of
development of educational materials.12,29–33 The affective disorders and stressful life events.
results from these studies have been mixed; some MBSR may have an important role in reducing the
studies showed an improvement in anxiety scores, physiological effects of stress on the body as well.
while others did not. Similarly, studies that have This may have important implications for women with
sought to reduce anxiety by decreasing wait time for abnormal Pap smears. For instance, one study showed
biopsy results,34 by allowing patients to choose a relationship between stressful life events and
treatment or observation,15,35 and by offering increased cortisol levels among women with abnormal
music,36,37 have all had conflicting results. Many of Pap smears.44 Another study showed higher life stress
these studies were conducted outside the United States was related to progression and persistence of cervical
in relatively homogeneous patient populations. dysplasia among HIV-infected women with abnormal
Literacy and language issues must be considered when Pap smears.45 Preliminary studies suggest that MBSR
written educational materials are developed for may have an affect on stress hormones,46,47 the
multiethnic low-income women. Some of the immune response,47,48 and brain electrical activity.48
interventions have successfully provided short-term Future research in psychoneuroimmunology may help
reductions in anxiety but few have been evaluated over us gain insight into the role of MBSR in mediating the
the long term. Since abnormal Pap smear follow-up effects of stress and, perhaps, altering the progression
normally occurs over the course of at least 2 years,6 an of cervical neoplasia.
intervention with long-term effectiveness is required. Few MBSR research studies have been conducted
New innovative interventions are needed to decrease among multiethnic, low-income populations. One
anxiety and improve adherence to follow-up among nurse researcher working in inner-city community
low-income ethnic minority women with abnormal clinics with Spanish- and English-speaking patients
Pap smears. has reported an improvement in general health and

health-related quality of life,49 a significant decrease took place at an inner-city outpatient women’s clinic at
in chronic care visits,50 and a significant decrease in a public hospital that primarily serves low-income
medical and psychological symptoms and an increase women eligible for subsidized programs. During this
in self-esteem51 among patients who attended MBSR initial contact, the research assistant explained the
programs. These studies suggest that MBSR programs study and screened participants for the following
can be successfully implemented among low-income eligibility criteria: age more than 18 years, not
multilingual multiethnic populations, and that they can pregnant, fluent in English or Spanish, and abnormal
make an impact on health status and healthcare Pap smear within the last 12 months. Ethnicity,
utilization. language, and information about childcare needs were
also collected. Participants were also recruited through
flyers in Spanish and English advertising
METHODS stress-reduction classes for women with abnormal Pap
As part of a larger participatory action research study smears and by word of mouth. Our goal was to recruit
designed to improve adherence to abnormal Pap smear 30 Spanish- and 30 English-speaking women. After
follow-up, we held focus groups with women with the initial recruitment, participants were contacted via
abnormal Pap smears in English and Spanish to gather telephone to confirm attendance at the MBSR classes.
information about their experiences with abnormal On the first day of the MBSR program, all
Pap smears and the factors that affected follow-up. participants were asked to sign a written consent to
Participants in these focus groups identified fear and participate in the study. All study materials were
anxiety as one of the primary deterrents to receiving offered to participants in either English or Spanish.
follow-up care. This was similar to the findings of a Demographic information was collected at the initial
previous study among HIV-infected women with MBSR session: age, ethnic identity, sexual identity,
abnormal Pap smears.22 MBSR is a holistic living situation, years of education, caregiving to
patient-centered intervention that has demonstrated children/others at home, adequacy of income, and
effects on both psychological and physiological transportation to the clinic. Participants completed the
aspects of health. It could potentially help women with 20-item state portion of the State-Trait Anxiety
abnormal Pap smears cope with anxiety and fear by Inventory (STAI),52 which measures anxiety at the
developing self-regulatory behaviors and present moment. The items were rated on a scale of 1
self-compassion. We convened 2 panels to gather to 4, “not at all” to “very much.” The STAI is a
feedback about the proposed intervention; one with reliable, valid measure of anxiety that has been
providers and staff who care for women with translated into many languages including Spanish.52 It
abnormal Pap smears and another with patients who has been used extensively in many types of research
had abnormal Pap smears. Both panels and among ethnically diverse populations. Participants
enthusiastically endorsed MBSR as the study also completed the 26-item Self-Compassion Scale,53
intervention. The purpose of this pilot study was to which elicits responses to questions related to how one
explore the acceptability and feasibility of providing acts toward one’s self during difficult times. Each item
MBSR for low-income multiethnic women. In was rated on a scale of 1 to 5, “almost never” to
particular, we sought to determine whether MBSR “almost always.” It is composed of subscales for
decreased anxiety and improved self-compassion self-kindness, self-judgment, common humanity,
among low-income, multiethnic women with isolation, mindfulness, and overidentification. A
abnormal Pap smears and whether these women found higher score indicates higher self-compassion. The
the program helpful and continued to practice MBSR. Self-Compassion Scale is an instrument that was
recently developed and validated for assessment
Procedures within MBSR programs.53 The instrument was
translated into Spanish by the study staff.
Approval to conduct the study was obtained from the Participants completed the state portion of the STAI
institutional Committee on Human Research. Most and the Self-Compassion Scale at 3 time points: (1)
participants were recruited by a bilingual/bicultural the initial class session (baseline), (2) upon
(English/Spanish) research assistant who approached completion of the MBSR classes (post-MBSR) and (3)
women while they attended appointments for 3 months after the conclusion of the MBSR group
abnormal Pap smear-related follow-up. Recruitment (follow-up). During the first two time points, the
Lessons Learned: MBSR 29

instruments were read aloud to the group of techniques to reduce stress, improve self-esteem,
participants. The 3-month follow-up questionnaires manage pain, and reduce anxiety.
were mailed to the participants and returned by The program consisted of instruction and practice
prepaid mail. During the MBSR classes, participants of the following: (1) “mindful eating,” which involves
were given weekly incentives including refreshments, awareness of the sensations required in eating with
transportation vouchers, $10 in cash, and childcare. full attention (2) “sitting meditation,” which involves
The research assistant called the participants every awareness of breath, body sensations, thoughts, and
week as a reminder to attend the subsequent classes. emotions; (3) “body scan,” which involves a
The MBSR classes were evaluated by a written movement of attention through the body from toes to
evaluation and in focus groups. An 11-item written head while observing sensations in the different
evaluation was competed at the end of the last session. regions of the body; (4) “hatha yoga,” which consists
Each item was rated on a scale of 1 to 4, “do not of stretches and postures designed to enhance
agree” to “strongly agree.” The items assessed the awareness and to balance and strengthen the
experience of being in the MBSR program, the affect musculoskeletal system. Inherent in all these practices
it had on their abnormal Pap smear experience, and the is an emphasis on mindful breathing, continually
sustainability of MBSR in their lives. In addition, all bringing attention to the breath. These activities are
participants were invited to attend a focus group for designed to enhance awareness of one’s body,
the purpose of evaluating the MBSR classes and thoughts, and emotions and to teach participants to
discuss their experiences with MBSR. The focus choose their emotional responses to anxiety inducing
groups were held the week following the conclusion and stressful situations. As part of the program,
of the MBSR groups and were facilitated by the participants were encouraged to develop a realistic
principal investigator and research assistant in English plan of their own to sustain ongoing practice once the
and Spanish. The focus groups were audio taped. program was completed. Each weekly session was
Participants were paid $20 to attend the focus group divided among instruction and practice of meditation,
and refreshments were provided. teaching about the importance of coming back to the
present moment and working with whatever is arising,
MBSR curriculum group discussion, and experiences with individual
homework. In addition, participants were encouraged
The MBSR program were modeled after the MBSR to talk about how mindfulness might be helpful in
program at the University of Massachusetts Stress their experiences with abnormal Pap smears during the
Reduction Clinic. On the basis of discussions with course.
MBSR instructors experienced with this population,
the traditional curriculum was adapted to
accommodate the needs of low-income ethnically DATA ANALYSIS
diverse women. Rather than the traditional 2.5 hours
for 8 weeks with a full-day retreat, the group met for 2 The study sample characteristics were determined
hours each week over the course of 6 weeks. Two using descriptive statistics. The Friedman’s (ANOVA)
courses were taught by 2 experienced MBSR teachers; test was performed to assess main effect of time on
one in Spanish and one in English. Women were STAI and Self-Compassion Scale scores. Pairwise
encouraged to attend all 6 classes. Participants comparisons were performed using the Wilcoxon
received cassette tapes in either Spanish or English signed rank tests to determine if there were any
and handouts of yoga exercises to assist them in their significant differences between the 3 time points; first
daily home meditation practice. No expectations or day of the program, last day of the program, and 3
requirements about homework or at-home practice months after the program. The MBSR written
were placed on participants because of concerns about evaluation was analyzed using descriptive statistics.
literacy, limited access to a quiet, private place to The MBSR evaluation focus group audiotapes were
meditate, and lack of access to tape players. The translated and transcribed by a professional
participants were encouraged to devote time each day, transcription service. Constant comparative analysis
or as often as possible, to the mindfulness practices was used to develop the major themes derived from
learned in classes. The purpose of our MBSR program the data. The qualitative data analysis was conducted
was to offer women the opportunity to learn with the aid of the computer software program NVivo.

A summary of the findings from the qualitative data time points or between post-MBSR and follow-up
analysis is reported here. time points.

RESULTS Self-compassion

Fifty-one women (40 English-speaking, 11 A Friedman’s ANOVA showed no main effect of time
Spanish-speaking) women were initially recruited for on Self-Compassion Scale scores. Further pairwise
the MBSR classes. However, by the time of the comparisons using the signed rank test did not reveal
follow-up call 2 months later, 28 (54%) had dropped any significant differences between time points.
out or could not be contacted by telephone. In addition,
at the start of the programs, another 10 women (20%) MBSR program evaluation
did not attend. Reasons for dropping out included lack The written evaluation of the MBSR program was
of time, lack of interest, and family responsibilities. very favorable (mean score = 33.2, possible range =
Thirteen (10 English-speaking, 3 Spanish-speaking) 11–44). Five women (63%) attended the post-MBSR
women (25%) began the MBSR classes. Eight (5 focus groups. In the focus groups, women reported
English-speaking, 3 Spanish-speaking) women (16%) that as a result of the MBSR programs they were able
completed the program, defined as attending at least 4 to decrease stress in everyday life, better able to cope
of the 6 class sessions and completing the post-MBSR with health problems, more likely to attend
questionnaires. Analyses were conducted on data gynecological appointments, and planning to use
collected only from participants that completed the MBSR during gynecological examinations.
MBSR program (N = 8). Because of the small number
of participants, language groups were combined in the
Selected excerpts from the focus groups
The mean age of the 8 MBSR participants who Basically I found a balance between emotions and
completed the study was 39 years, with a range of 31 emotional versus being rational or mindful. It does
to 54 years. The mean age of the women who did not help tremendously and I think it’s a lifelong kind of
benefit to this . . . I’m not overwhelmed. I’m actually
complete the program was 43 years, with a range of 31
sort of calm. I have a control. About how I want it to
to 58 years. Ethnicities included 3 Latinas, 2 African be. And (for) the very first time I feel I can enjoy the
Americans, 1 Asian, 1 Caucasian, and 1 African. The moment and what does it really mean by enjoying the
ethnicities of the women who did not complete the moment.
study were 3 Caucasian, 1 African American, and 1 (In Spanish): Everything made me mad and desperate
Filipina. All participants who completed the study and now that I’ve started going [to the classes] I’ve
identified themselves as heterosexual. Two women become . . . more. . . . now I’ve learned that when I get
(25%) lived in recovery homes, 5 women (63%) lived mad about something I breathe and I say that I have to
in apartments, and 1 (12%) woman lived with control myself.
family/friends. Two women (25%) indicated that they Whatever you’re doing right now at the moment, you
cared for children or others at home. Most women should deal with that. Don’t trip on you know, an hour
took the bus (75%, n = 6) to the clinic. Four women from now or an hour ago, just, you know, trip on what
(50%) had less than a high school education. Six you’re doing right now. And she taught us how to do
that. Yeah. It was cool. I liked it.
women (75%) believed their income was not adequate
to meet their needs.
State anxiety
In this small pilot study, we were able to show a
A Friedman’s ANOVA showed no main effect significant decrease in anxiety among women with
of time on STAI scores. A Wilcoxon signed rank abnormal Pap smears who attended the MBSR
test revealed that the decrease in STAI scores was program. At baseline, the mean STAI score was 46.2.
significant between baseline (mean = 46.2) and This score is within the range of scores found in
post-MBSR (mean = 36.8) (Z = 2.197; 2-tailed other studies performed with women with abnormal
P = .028). No significant differences were found Pap smears,18,29 but much higher than that found
between STAI scores for baseline and follow-up among women with normal Pap smears (mean STAI
Lessons Learned: MBSR 31

score = 36.4).13 The mean anxiety score dropped to faced during this study. We recruited 51 women to
36.8 at the post-MBSR time period, and 3 months participate in the programs and only 8 (16%) from the
after the program, it still remained low at 36. There original recruitment group completed the study. We
have been two other intervention studies that have made a number of efforts to retain women in the study
successfully measured a reduction in state anxiety including weekly reminder phone calls. Reasons
using the STAI among women with abnormal Pap women gave for not attending the classes were illness,
smears. One used an educational video with a leaflet changing work hours, or shifting obligations. For
to decrease anxiety among women attending a “see instance, the women were juggling a myriad of
and treat” clinic.12 Another study used music to responsibilities such as attending substance abuse
decrease anxiety during colposcopy.36 Because our groups, court appointments, housing appointments,
sample size was small, further studies are needed to and medical appointments. Other reasons women may
confirm our findings. have dropped out of the study include the time
We were unable to demonstrate a significant change commitment involved, the meeting time was
in self-compassion in this study, though the trend was inconvenient, the program was unconventional, or they
toward improved self-compassion. There are a number may not have gotten along with other group members
of issues to consider. For instance, the sample size or the teacher. From our experience working with this
could have been too small to detect changes. There population, it seems more likely that the women’s
may have been literacy issues that affected both the hectic and unpredictable lives interfered with their
English- and Spanish-speaking participants’ ability to ability to participate in the study. For instance, the
conceptualize and then accurately respond to the items participants told us that they relied on our reminder
on the questionnaire. We had a team of 3 bilingual calls to help them remember to attend study
women experienced at translation and familiar with appointments. Other studies have found practical
the dialects of our clinic population to translate the issues such as time conflicts, working multiple jobs,
instrument into Spanish. In future studies, it will be transportation, lack of financial resources, and lack of
important to test the Spanish version of the childcare as barriers to research participation.54,55
Self-Compassion Scale for validity. Although we anticipated the need for child care
The MBSR classes were rated very favorably by the in our study, the participants did not bring their
women who completed them. In addition, the focus children to the free childcare offered, and they
groups revealed how the women had integrated told us in the evaluation that childcare was not a
mindfulness into many aspects of their lives. Although barrier to participating in the MBSR program. It is
most of the women did not talk about having a regular difficult to anticipate the needs of each unique study
formal meditation practice, they gave many examples population.
of practicing mindfulness informally. They gave There are a number of strategies that can be
examples of using mindfulness in stressful life implemented to counter the difficulties in recruiting
situations such as during an argument or to relieve the and retaining economically underserved research
pain of a migraine headache. One participant brought participants. A group recruiting for a cervical cancer
a tape player and the MBSR audiotape from class to prevention trial found that offering clinic visits during
her gynecological appointment to help her feel less off hours improved recruitment.56(p148) In addition,
anxious during her repeat Pap smear. The women they developed phone contact lists that included every
spoke of the importance of the social support that they possible means to contact participants and they
received from the members of the group and wanted obtained permission to leave messages with relatives
the programs to continue. These qualitative data, when needed. Phone calls were made in evenings and
coupled with the quantitative data obtained from the on weekends when participants were more likely to be
written evaluation, underline the broad impact that found at home. The nurse practitioner played a critical
mindfulness made on the lives of the women who role in developing a trusting relationship with the
participated in this program. participant, offering comprehensive education about
abnormal Pap smears and the research study protocol,
Lessons learned and facilitating participant-specific problem solving to
improve study appointment attendance. Creative
This discussion would not be complete without strategies are needed to improve recruitment and
addressing the recruitment and retention issues that we retention of research participants from underserved

communities, and nurses have many of the skills and integrated into encounters with Latino study
needed to develop these strategies. participants.62 Other ethnic groups will have other
Offering incentives is an important aspect of needs. For example, in our study, we were advised to
retention efforts for studies involving low-income delay recruitment of Asian participants until after the
ethnic minorities.55,57 The majority of our participants Chinese New Year celebration when it would be more
used the bus to get to the clinic, so we offered bus appropriate to discuss issues such as cervical cancer
tokens and taxi vouchers as incentives. In addition, we prevention. In one study, lay Vietnamese health
offered $10 for each session attended and workers who knew the language and culture
refreshments during the classes. In the MBSR written successfully educated and recruited Vietnamese
evaluation, the participants “somewhat agreed” that women for cancer screening.63 Our study was
they would be unlikely to attend classes in the future if particularly challenging because we did not focus on
they were not offered money. Therefore, it appears recruiting one specific ethnic group but instead
that the incentives did play a part in their attendance. recruited women from a number of ethnic groups to
To find out which incentives would work best with our capture the diversity of San Francisco. As a result, it
study population, we talked with other researchers was necessary for us to show competency in
who had conducted research with our population and understanding and working with a number of different
we discussed incentives in the focus groups as well. ethnic groups. We sought advice from our multiethnic
The Agency for Healthcare Research and Quality clinic staff, gleaned information from the literature,
has identified understanding health disparities among formed a multiethnic research team, and reflected
women and minorities as a research priority.58 In our upon on our years of clinical experience working with
attempt to investigate these disparities, it is important a multiethnic population to guide us in developing a
for researchers to consider some of the underlying culturally appropriate research program. In future
social political issues that ethnic minority communities studies, we would like to expand our efforts to hire
face. For instance, African Americans have a long more multiethnic women from the community into the
history of distrust of the medical community.55 This research staff.
distrust comes from a legacy of negative healthcare It is imperative that ethnic minority communities be
experiences such as the Tuskegee Syphilis Study, involved from the study’s inception, beginning with
ongoing racial discrimination, and reduced access to the development of the research questions through to
quality care. In fact, it has been postulated by the the dissemination of study findings.55,64,65 An example
Office of Minority Health that the high rates of of a research methodology that fosters the involvement
cervical cancer among minority women are a marker of ethnic communities in all aspects of research is
for reduced access to care in poor communities.59 For participatory action research, the methodology we
immigrant communities, fear of deportation and lack used for this study. Partnering with churches,
of information about health or research are barriers to community clinics, schools, and other community
care.54 To counter distrust and fear, it is essential to groups are great ways to involve the community. We
forge trusting relationships60 and to engage in attempted to partner with community clinics in our
face-to-face interactions with study participants.61 It is study but found that they lacked the resources and
helpful to recruit from sites where participants have staff time needed to take part in the study. In
established positive relationships with staff and where retrospect, we would have benefited from putting more
the staff would endorse study recruitment. Researchers emphasis on developing partnerships with a variety of
should be aware of the issues of racism, classism, and community-based organizations. In large well-funded
sexism that exist in healthcare and do their utmost to studies, community-based organizations can be
promote respectful collaborative relationships where reimbursed for their participation and receive other
individuals feel valued for their contributions. benefits such as offering services they could not
While working with multiethnic groups, it is normally afford. Community-based organizations can
important to be aware of the diversity of cultural be excellent resources for evaluating research
practices, values, and languages that exist. For materials to ensure that they are culturally appropriate
instance, the cultural values of familismo (family is and that translations accurately reflect the language
valued and male consulted), respecto (respect toward and dialect of the target population. The participation
males, elders, and professionals), and simpatı́a (warm of ethnic minority communities in research does not
interpersonal interactions) should be acknowledged only contribute to the integrity of the research but
Lessons Learned: MBSR 33

could play a vital role in improving the communities’ 2. Ries L, Eisner M, Kosary C, et al. Seer Cancer Statistics Review, 1975–
confidence in the quality of health research. 2001. Bethesda, Md: National Cancer Institute. 2004.
3. American Cancer Society. Cancer Facts and Figures 2005. Atlanta:
American Cancer Society; 2006.
4. US Department of Health and Human Services. Healthy People 2010
IMPLICATIONS FOR NURSING PRACTICE Objectives. 2nd ed. 2000. Available at: http://www.healthypeople.gov/
document/html/objectives/03-04.htm. Accessed November 13, 2006.
Nurses play a vital role in caring for women with 5. American Cancer Society. Cancer Facts and Figures for Hispan-
abnormal Pap smears. In addition to tending to the ics/Latinos. Atlanta: American Cancer Society; 2003.
physical and informational needs of women, holistic 6. Wright T, Cox JT, Massad LS, Carlson J, Twiggs L, Wilkinson E.
2001 consensus guidelines for the management of women with cer-
nurses also care for their psychological and spiritual vical intraepithelial neoplasia. Am J Obstet Gynecol. 2003;189:295–
needs. Many nurses employ mind/body interventions 304.
such as MBSR in the patient care setting because they 7. Rogstad KE. The psychological impact of abnormal cytology and col-
poscopy. Br J Obstet Gynaecol. 2002;109(4):364–368.
find these interventions clinically successful. For 8. Campion M, Brown J, McCance D, et al. Psychosexual trauma of an
instance, nurses find these interventions reduce stress abnormal cervical smear. Br J Obstet Gynaecol. 1988;95:175–181.
and anxiety and improve patient satisfaction. Yet, in 9. McDonald T, Neutens J, Fischer L, Jessee D. Impact of cervical in-
traepithelial neoplasia diagnosis and treatment on self-esteem and body
our current resource-depleted “evidence-based”
image. Gynecol Oncol. 1989;34:345–349.
healthcare environment, it is imperative that we have 10. Le T, Hopkins L, Menard C, Hicks-Boucher W, Lefebvre J, Fung Kee
research to support our interventions. Unfortunately, Fung M. Psychologic morbidities prior to loop electrosurgical excision
many of the mind/body interventions that we use are procedure in the treatment of cervical intraepithelial neoplasia. Int J
Gynecol Cancer. 2006;16(3):1089–1093.
not well studied, especially among low-income ethnic 11. Bekkers RL, van der Donck M, Klaver FM, van Minnen A, Massuger LF.
minority women, thus we have little evidence for their Variables influencing anxiety of patients with abnormal cervical smears
clinical effectiveness. Providing this evidence will referred for colposcopy. J Psychosom Obstet Gynaecol. 2002;23(4):
help us secure reimbursement for mind/body 12. Freeman-Wang T, Walker P, Linehan J, Coffey C, Glasser B, Sherr L.
interventions in the clinical setting and grant Anxiety levels in women attending colposcopy clinics for treatment for
legitimacy to holistic nursing care in this very cervical intraepithelial neoplasia: a randomised trial of written and video
information. Br J Obstet Gynaecol. 2001;108(5):482–484.
skeptical healthcare environment. For these reasons, it
13. Maissi E, Marteau T, Hankins M, Moss S, Legood R, Gray A. Psycho-
is essential that holistic nurses conduct and participate logical impact of human papillomavirus testing in women with border-
in research that is relevant to their clinical practice. line or mildly dyskaryotic cervical smear test results: cross sectional
questionnaire study. BMJ. 2004;328:1293–1299.
14. Marteau TM, Walker P, Giles J, Smail M. Anxieties in women under-
CONCLUSION going colposcopy. Br J Obstet Gynaecol. 1990;97(9):859–861.
15. Meana M, Stewart DE, Lickrish GM, Murphy J, Rosen B. Patient pref-
We conducted a pilot study to evaluate the erence for the management of mildly abnormal Papanicolaou smears.
J Womens Health Gend Based Med. 1999;8(7):941–947.
acceptability and feasibility of providing MBSR 16. Nugent LS, Tamlyn-Leaman K, Isa N, Reardon E, Crumley J. Anx-
among multiethnic low-income women with abnormal iety and the colposcopy experience. Clin Nurs Res. 1993;2(3):267–
Pap smears. We found a significant decrease in anxiety 277.
17. Reddy D, Wasserman S. Patient anxiety during gynecologic examina-
and a trend toward improved self-compassion in this tions: behavioral indicators. J Reprod Med. 1997;42(10):631–636.
small study. The MBSR classes were positively 18. Richardson P, Doherty I, Wolfe C. Evaluation of cognitive-behavioural
evaluated, and the focus groups illuminated the ways counseling for the distress associated with an abnormal cervical smear
result. Br J Health Psychol. 1996;1:327–338.
women had integrated MBSR into many aspects of 19. Lagro-Janssen T, Schijf C. What do women think about abnormal smear
their lives. The high attrition rate highlights the need test results? A qualitative interview study. J Psychosom Obstet Gynecol.
to develop innovative recruitment and retention 2005;26(2):141–145.
strategies tailored for multiethnic populations. We 20. Lerman C, Miller SM, Scarborough R, Hanjani P, Nolte S, Smith D. Ad-
verse psychologic consequences of positive cytologic cervical screen-
have discussed these strategies in the context of the ing. Am J Obstet Gynecol. 1991;165(3):658–662.
lessons we have learned from conducting this study. 21. Tomaino-Brunner C, Freda MC, Runowicz CD. I hope I don’t
Further studies with larger samples of multiethnic have cancer: colposcopy and minority women. Oncol Nurs Forum.
women are needed to confirm our study findings. 22. Abercrombie P. Factors affecting abnormal Pap smear follow-up among
women with HIV. J Assoc Nurses AIDS Care. 2003;14(3):41–54.
23. Posner T, Vessey M. Prevention of Cervical Cancer: The Patient’s View.
REFERENCES London: Kings’s Fund; 1988.
24. Idestrom M, Milsom I, Andersson-Ellstrom A. Women’s experience of
1. Singh G, Miller B, Hankey B, Edwards B. Persistent area socioeconomic coping with a positive pap smear: a register-based study of women with
disparities in the U.S. Incidence of cervical cancer, mortality, stage and two consecutive pap smears reported as CIN 1. Acta Obstet Gynecol
survival, 1975–2000. Cancer. 2004;101(5):1051–1057. Scand. 2003;82(8):756–761.

25. Neale J, Pitts MK, Dunn PD, Hughes GM, Redman CW. An observa- 46. Carlson L, Speca M, Patel K, Goodey E. Mindfulness-based stress reduc-
tional study of precolposcopy education sessions: what do women want tion in relation to quality of life, mood, symptoms of stress and levels
to know? Health Care Women Int. 2003;24(5):468–475. of cortisol, dehydroepiandrosterone sulfate (DHEAS) and melatonin
26. Beresford J, Gervaize P. The emotional impact of abnormal pap smears in breast and prostate cancer outpatients. Psychoneuroendocrinology.
on patients referred for colposcopy. Colposc Gynecol Laser Surg. 2004;29(4):448–474.
1986;2(2):83–87. 47. Robinson F, Mathews H, Witek-Janusek L. Psycho-endocrine-immune
27. Paskett ED, Carter WB, Chu J, White E. Compliance behavior in women response to mindfulness-based stress reduction in individuals infected
with abnormal pap smears: developing and testing a decision model. with the human immunodeficiency virus: a quasiexperimental study.
Med Care. 1990;28:643–656. J Complement Med. 2003;9(5):683–694.
28. Sanders G, Craddock C, Wagstaff I. Factors influencing default at a 48. Davidson R, Kabat-Zinn J, Schumacher J, et al. Alterations in brain
hospital colposcopy clinic. Qual Health Care. 1992;1(4):236–240. and immune function produced by mindfulness meditation. Psychosom
29. Howells RE, Dunn PD, Isasi T, et al. Is the provision of information Med. 2003;65(4):564–570.
leaflets before colposcopy beneficial? A prospective randomised study. 49. Roth B, Robbins D. Mindfulness-based stress reduction and health-
Br J Obstet Gynaecol. 1999;106(6):528–534. related quality of life: findings from a bilingual inner-city patient pop-
30. Peters T, Somerset M, Baxter K, Wilkinson C. Anxiety among women ulation. Psychosom Med. 2004;66(1):113–123.
with mild dyskaryosis: a randomized trial of an educational intervention. 50. Roth B, Stanley T. Mindfulness-based stress reduction and health-
Br J Gen Pract. 1999;49(442):348–352. care utilization in the inner city: preliminary findings. Altern Ther.
31. Tomaino-Brunner C, Freda MC, Damus K, Runowicz CD. Can precol- 2002;8(1):60–66.
poscopy education increase knowledge and decrease anxiety? J Obstet 51. Roth B, Creaser T. Mindfulness meditation-based stress reduction: expe-
Gynecol Neonatal Nurs. 1998;27(6):636–645. rience with a bilingual inner-city program. Nurse Pract. 1997;22(3):150-
32. Stewart D, Lickrish G, Sierra S, Parkin H. The effect of educational 152, 154, 157 passim.
brochures on knowledge and emotional distress in women with abnor- 52. Spielberger C, Goursuch R, Lushene R. State-Trait Anxiety Inventory
mal Papanicolaou smears. Obstet Gynecol. 1993;81:280–283. Test Manual. Palo Alto, Calif: Consulting Psychologists Press; 1970.
33. Wilkinson C, Jones JM, McBride J. Anxiety caused by abnormal result 53. Neff KD. The development and validation of a scale to measure self-
of cervical smear test: a controlled trial. BMJ. 1990;300(6722):440. compassion. Self Identity. 2003;2:223–250.
34. Naik R, Abang-Mohammed K, Tjalma WA, et al. The feasibility of a 54. Calderon J, Baker R, Fabrega H, et al. An ethno-medical perspective
one-stop colposcopy clinic in the management of women with low grade on research participation: a qualitative pilot study. MedScape Gen Med.
smear abnormalities: a prospective study. Eur J Obstet Gynecol Reprod 2006;8(2):23.
Biol. 2001;98(2):205–208. 55. Beech B, Goodman M, eds. Race and Research: Perspectives on Minor-
35. Kitchener HC, Burns S, Nelson L, et al. A randomised controlled trial of ity Participation in Health Studies. Washington, DC: American Public
cytological surveillance versus patient choice between surveillance and Health Association; 2004.
colposcopy in managing mildly abnormal cervical smears. Br J Obstet 56. Bailey J, Bieniasz M, Kmak D, Brenner D, Ruffin M. Recruitment and
Gynaecol. 2004;111(1):63–70. retention of economically underserved women to a cervical cancer pre-
36. Chan YM, Lee PW, Ng TY, Ngan HY, Wong LC. The use of music to vention trial. Appl Nurs Res. 2004;17(1):55–60.
reduce anxiety for patients undergoing colposcopy: a randomized trial. 57. Mask Jackson F. Considerations for community-based research with
Gynecol Oncol. 2003;91(1):213–217. African American women. Am J Public Health. 2002;92(4):561–
37. Rickert VI, Kozlowski KJ, Warren AM, Hendon A, Davis P. Adolescents 564.
and colposcopy: the use of different procedures to reduce anxiety. Am 58. Agency for Healthcare Research and Quality. AHRQ focus on research:
J Obstet Gynecol. 1994;170(2):504–508. disparities in health care. 2002. Available at: http://www.ahrq.gov/
38. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based news/focus/disparhc.htm. Accessed August 14, 2006.
stress reduction and health benefits: a meta-analysis. J Psychosom Res. 59. Freeman HP, Wingrove BK. Excess Cervical Cancer Mortality: A
2004;57:35–43. Marker for Low Access to Health Care in Poor Communities. Rockville,
39. Baer R. Mindfulness training as a clinical intervention: a conceptual and Md: National Cancer Institute, Center to Reduce Cancer Health Dispar-
empirical review. Clin Psychol Sci Prac. 2003;10:125–143. ities; 2005.
40. Kabat-Zinn J, Massion AO, Kristeller J, et al. Effectiveness of a 60. Corbie-Smith G, Thomas S, Williams M, Moody-Ayers S. Attitudes and
meditation-based stress reduction program in the treatment of anxiety beliefs of African Americans toward participation in medical research.
disorders. Am. J Psychiatry. 1992;149:936–943. J Gen Intern Med. 1999;14(9):537–546.
41. Astin J. Stress reduction through mindfulness meditation: effects on psy- 61. Gillis C, Lee K, Guiterrez Y, et al. Recruitment and retention of health
chological symptomatology, sense of control, and spiritual experiences. minority women into community-based longitudinal research. J Womens
Psychother Psychosom. 1997;66:97–106. Health Gend Based Med. 2001;10(1):77–85.
42. Ma S, Teasdale J. Mindfulness-based cognitive therapy for depression: 62. Miranda J, Azocar F, Organista K, Munoz R, Lieberman A. Recruiting
replication and exploration of differential relapse prevention effects. J and retaining low-income Latinos in psychotherapy research. J Consult
Consult Clin Psychol. 2004;72(1):31–40. Clin Psychol. 1996;64(5):868–874.
43. Teasdale J, Segal Z, Williams J, Ridgeway V, Soulsby J, Lau M. Pre- 63. Bird J, Mc Phee S, Ha N, Le B, Davis T, Jenkins C. Opening pathways to
vention of relapse/recurrence in major depression by mindfulness-based cancer screening for Vietnamese-American women: lay health workers
cognitive therapy. J Consult Clin Psychol. 2000;68(4):615–623. hold a key. Prev Med. 1998;27:821–829.
44. De Punzio C, Salvestroni C, Guazzelli G, et al. Stress and cervical 64. Levoff S, Sanchez H. Lessons learned about minority recruitment and
dysplasia. Eur J Gynaecol Oncol. 1997;19(3):287–290. retention from the centers on minority aging and health promotion.
45. Pereira DB, Antoni MH, Danielson A, et al. Life stress and cervical Gerontologist. 2003;43(1):15–17.
squamous intraepithelial lesions in women with human papillomavirus 65. Beck Kritek P, Hargraves M, Cuellar E, et al. Eliminating health dispar-
and human immunodeficiency virus. Psychosom Med. 2003;65(3):427– ities among minority women: a report on conference workshop process
434. and outcomes. Am J Public Health. 2002;92(4):580–587.