INCREASING ANAL CANCER SCREENINGS By Heather Leadbetter, RN, MSN MSN, Chamberlain University, 2023 BSN, Chamberlain University, 2020 ASN, Clarion University, 2010 A DNP Project Submitted to Pennsylvania Western University In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree April 2026 ____________ Date ____________ Date ____________ Date ____________ Date ____________ Date ___________Emilie Kennedy DNP, CRNP, FNP-C_____ Committee Chair ___________Jill Fuller PhD, CRNP________________________ Committee Member ___________Pamela Karg DNP, CRNP__________________ Committee Member ___________Kristin Knapp RN MSN_____ Committee Member ___ Craig Coleman, M.A., CCC-SLP, BCS-SCF, ASHA-F_____ Dean of the College of Health Sciences and Human Services INCREASING ANAL CANCER SCREENINGS Committee Signature Page Student’s name Heather Leadbetter Committee Chairperson Emilie Kennedy Committee Member Jill Fuller Committee Member Pamela Karg Committee Member Kristin Knapp 2 INCREASING ANAL CANCER SCREENINGS Heather Leadbetter, MSN, RN Abstract Anal cancer diagnoses have been rising in recent decades. Among high-risk populations such as people living with Human Immunodeficiency Virus (HIV), anal cancer cases are much higher than in the general population. Anal cancer screenings are available but underutilized, even in high-risk populations. There is a need for increased interventions, especially in high-risk populations, to educate patients and screen for anal precancers and cancerous cells. This study will examine the use of nurse education including an evidence-based educational pamphlet for patients at the PA Thrive Partnership clinics to increase the number of high-risk patients who have anal cancer screenings completed. This is a quantitative study measuring statistics around the number of patients receiving anal cancer screenings before and after the implementation of anal cancer education. The theoretical framework most suitable for this project is the Iowa Evidence-Based Practice (EBP) framework. The Iowa EBP framework includes identifying a problem, researching to support it, designing an appropriate change process, and integrating and sustaining the change. 3 Table of Contents Chapter 1: Introduction Chapter 2: Review of Related Literature Chapter 3: Methodology Chapter 4: Results and Discussion Chapter 5: Summary, Conclusion, and Recommendations Page 7 Page 13 Page 17 Page 22 Page 26 4 List of Tables Table Page 1: Education Evaluation Tool ............................................................................ Appendix A 2: Literature Review Summary .......................................................................... Appendix B 3: Anal Cancer Screening Completed by Month ............................................... Appendix D 4: Education Evaluation Tool Results…………………………………………Appendix F 5: Clinic Visits November 2025-January 2026………………………………..Appendix H 6: Anal Cancer Screening completed by Age ..................................................... Appendix I 7: Anal Cancer Screening completed by Time Period........................................ Appendix J 5 List of Figures Figure Page 1: Anal Cancer Screening Guidelines ................................................................ Appendix C 2: Anal Cancer Pamphlet ................................................................................... Appendix D 3: Anal Cancer Education PowerPoint .............................................................. Appendix G 4: Institutional Review Board Approval ............................................................ Appendix K 5: Provider Consent .......................................................................................... Appendix L 6: Patient Consent ............................................................................................. Appendix M 7: Pamphlet Tracking Log ................................................................................. Appendix N 6 Chapter 1 Introduction There are rising rates of anal cancer, particularly within high-risk populations such as people living with HIV (PLWH). PA Thrive Partnership clinics focus on providing medical care and services to PLWH. Utilizing this setting to implement tools that reach patients where they are can improve patient understanding and positively impact overall outcomes. In this chapter, a more extensive summary of the healthcare problem will be provided, including background information, the need for the study, assumptions, and limitations. Background of the Problem Anal cancer screenings are a newer and less common practice. The Anal Cancer Foundation (ACF) has created the first International Anal Cancer Screening Guidelines (Table 1). Anal cancer has higher rates of prevalence in some populations, including PLWH. Women are diagnosed with anal cancer at a higher rate than men in the United States. Risk factors include persons with HIV, men who have sex with men (MSM) age 35+, Transgender women (TW) age 35+, age 45+, history of vulva dysplasia or vulva cancer, solid organ transplant recipients at 10 years post-transplant, Cervical or Vaginal high grade squamous intraepithelial lesion (HSIL), Cervical/Vaginal Cancer, Perianal Warts, persistent HPV, immunosuppression or chronic systemic steroid therapy. (ACF, 2024) Statement of the Problem At-risk individuals need to be screened for anal cancer at a higher rate. 7 Project Questions Will providing education to direct care staff at the PA Thrive clinics on an evidencebased best practice education pamphlet for patients related to the risk of anal cancer increase the number of patients who receive anal cancer screenings? Hypotheses Statistically, there is a rise in anal cancer occurrences, with the highest rates in some vulnerable populations. A single international guide has recently been released to aid in identifying and screening individuals at risk. PA Thrive Partnership clinics provide services to PLWH. This population is in the high-risk category for anal cancer. However, the rate of screenings completed remains low. The hypothesis questions if educational material is created to help patients better understand anal cancer, and if this is provided to direct care staff to deliver to patients, will more patients be agreeable to screening? Definition of Terms Anal Cancer Conceptual Definition: Anal cancer is a malignant neoplasm of the anal canal. Operational Definition: In this study, a diagnosis of anal cancer or the presence of cancerous cells confirmed through high-resolution anoscopy (HRA) and biopsy. People Living with HIV (PLWH) Conceptual Definition: Individuals who have been diagnosed with HIV, a virus that attacks the immune system and increases vulnerability to opportunistic infections and certain cancers (CDC, 2023). Operational Definition: For this study, PLWH are patients with confirmed HIV diagnosis in their medical records. 8 High-Risk Populations Conceptual Definition: Groups identified as having a statistically higher incidence of anal cancer. Operational Definition: High-risk individuals in this study include those who meet any of the criteria outlined in the International Anal Cancer Screening Guidelines. Anal Cancer Screening Conceptual Definition: A clinical procedure used to detect precancerous changes or early-stage cancer in the anal canal. Screenings are primarily completed through methods such as digital anal rectal examination, anal cytology, and HRA. Operational Definition: In this study, a completed anal cancer screening is defined as documentation of one or more of the above procedures in the patient’s medical record within the study's designated time frame. Educational Pamphlet Conceptual Definition: An evidence-based written health communication tool designed to increase knowledge and awareness of anal cancer risks and screening options among patients. (Nutbeam, 2000). Operational Definition: In this project, the educational pamphlet is a standardized document provided to patients by direct care staff at the PA Thrive clinics. Iowa Model of Evidence-Based Practice (EBP) Conceptual Definition: A systematic framework used to guide the implementation of EBP in clinical settings. It includes identifying a problem, forming a team, reviewing and synthesizing evidence, piloting change, evaluating outcomes, and sustaining change (Iowa Model Collaborative, 2017). 9 Operational Definition: This model guides the project's structure, particularly the steps involved in implementing and evaluating the educational pamphlet intervention within PA Thrive clinics. Need for the Study Anal cancer has few to no symptoms. Symptoms can include pain, bleeding, and lumps. These symptoms, or their absence, can be mistaken for benign disease processes. Due to the lack of symptoms and similarity to benign processes, anal cancer is not always identified, even at the onset of symptoms. Populations that are at high risk, including PLWH, have an overlap in socioeconomic distress that can often delay medical treatments. Some of the factors that already make a population at high risk for anal cancer also affect the curative nature of the disease, including HIV status. (Temperley et al., 2024) The rate of anal cancer diagnosis is on the rise. Individuals with an HIV diagnosis, highest risk MSM, Human Papillomavirus (HPV) diagnosis, women with gynecological HPV cancer or precancerous lesions, individuals who have undergone an organ transplant, or other immunosuppressive disorders. Anal cancer identified in more advanced stages has a higher likelihood of recurrent disease and poor prognosis. (Gondal et al., 2023) Significance of the Problem The clinical significance of this project lies in promoting health education at the patient level and increasing the frequency of appropriate anal cancer screenings for high-risk individuals. Anal cancer screenings are a newer process within many settings and are not regularly implemented. Assumptions 10 It is assumed that direct care staff will accurately report their experience with the educational presentation on the evidence-based anal cancer patient education pamphlet. It is assumed that direct care staff at PA Thrive clinics will consistently distribute the educational pamphlets to patients as intended. It is assumed that the educational pamphlet is clear, accessible, and understandable to patients of varying levels of health literacy. It is assumed that electronic health records (EHRs) are accurately updated to relate to all completed screenings during the study period. It is assumed that clinic workflow and staffing levels will remain stable enough to support the proper delivery and documentation of the intervention. It is assumed that the Iowa EBP framework is a suitable framework to guide the intervention in this clinical setting. Limitations Limitations of this project include that the study is limited to a single site, the PA Thrive Partnership clinics. This may not reflect practices, populations, or operations in other healthcare settings. The study will be completed within a short timeframe and, therefore, may not capture the long-term effects. Direct care staff will self-report feedback on the survey provided before and after the education session; this could result in bias if feedback is dishonest. The impact of the pamphlet may be limited by inconsistent staffing, staff motivation, or adherence. Varying health literacy, language proficiency, or cognitive ability may limit the effectiveness of the pamphlet. Summary of the Problem Anal cancer rates have increased in recent years, with significantly higher prevalence among high-risk groups, particularly PLWH. Despite the availability of anal cancer screenings, these services are underutilized, even in high-risk clinical populations. This project aims to address this gap by implementing an evidence-based educational pamphlet within the PA Thrive 11 Partnership clinics, which serve a large PLWH population. The goal is to increase patient awareness and uptake of anal cancer screenings. This quantitative study will measure the number of screenings completed before and after the educational intervention. Guided by the Iowa Model of EBP, the study incorporates structured steps to identify the problem, relate research, implement change, and evaluate outcomes. The need for this study is supported by the limited symptom presentation of anal cancer, its rising incidence, and the challenges faced by vulnerable, high-risk populations. Early detection remains crucial for improving outcomes. The significance of this project lies in its potential to promote preventive health and enhance clinical practices for early cancer detection. 12 Chapter 2 Review of Related Literature The next chapter will explore the existing body of literature surrounding anal cancer, its prevalence in high-risk populations, and current screening practices. This chapter will also review the role of patient education in preventive care and summarize prior findings on the implementation of educational interventions in similar clinical settings. Finally, the theoretical framework underpinning this project, the Iowa Model of EBP, will be discussed in greater detail to establish its relevance and applicability to this study. What is known about the problem? Current literature establishes that PLWH, transgender individuals, and MSM are at elevated risk for anal cancer, primarily due to persistent high-risk HPV infection (Barquet et al., 2024; Cachay et al., 2024; Deshmukh et al., 2020). Epidemiological evidence demonstrates rising anal cancer incidence and mortality, especially among older adults and immunocompromised individuals (Deshmukh et al., 2020; National Cancer Institute, 2024). Screening programs have shown efficacy in detecting high-grade lesions and reducing cancer burden in high-risk populations (Espirito Santo et al., 2025; Leclerc et al., 2024). Updated clinical guidelines now recommend HRA and anal Papanicolaou tests (Pap tests) as part of routine care for PLWH (Fuller, 2025; NIH, 2024). Behavioral and systemic barriers, including stigma, low-risk perception, provider discomfort, and institutional gaps, continue to hinder screening uptake (Fein et al., 2021; Geba et al., 2024; Higashi et al., 2022; Sam et al., 2025). Provider education and structured implementation models are recognized as key to improving clinical practice (Fuller, 2025; Byrnes & Liu, 2022). What is not known about the problem 13 Despite these advances, gaps remain in understanding the long-term outcomes of organized screening on morbidity and mortality, especially in diverse subgroups within the PLWH population (Leclerc et al., 2024). Little is known about the cost-effectiveness and scalability of sustained screening programs across varied healthcare settings (Espirito Santo et al., 2025). There is limited research on the impact of interventions and culturally tailored education in reducing screening disparities, particularly among transgender individuals and MSM (Fein et al., 2021; Sam et al., 2025). Additional research would be needed to explore strain-specific risks of HPV and its relationship to cancer progression (Barquet et al., 2024). Theoretical Framework The theoretical framework that guides this study is the Iowa Model of EBP. This model provides a systematic approach to implementing evidence-based changes in clinical practice, making it particularly applicable in settings that aim to improve patient outcomes through structured interventions (Iowa Model Collaborative, 2017). The Iowa Model begins with identifying a triggering issue, such as the low rate of anal cancer screening among PLWH and moves through a series of steps: forming a team, gathering and synthesizing evidence, piloting a change, evaluating outcomes, and, if successful, sustaining the change in practice. In this study, the Iowa Model is applied to the design and implementation of an evidencebased educational intervention. The problem of underutilized anal cancer screening in a high-risk population serves as the trigger. A committee is formed to collaborate on the development of an educational pamphlet based on current guidelines, which will be delivered directly to patients by direct care staff. The intervention's effectiveness is evaluated through the number of screenings completed before and after implementation, as well as feedback from staff involved in the educational process. 14 The Iowa Model emphasizes collaboration, ongoing evaluation, and patient-centered care. These central concepts align with this research project. The model provides an outline for integrating research into practice. The approaches of this model ensure rigor and relevance in the search for improved health outcomes for high-risk individuals. Summary of the Review of Related Literature A review of the existing literature reveals a growing concern regarding anal cancer, particularly among individuals considered high-risk due to factors such as compromised immune systems, specific sexual behaviors, and persistent HPV infection (Deshmukh et al., 2020; National Cancer Institute, 2024). Research consistently shows that specific populations, including PLWH, MSM, transgender individuals, and others with immunosuppressive conditions, experience higher rates of anal cancer (Barquet et al., 2024; Byrnes & Liu, 2022; Tisler et al., 2024). Although screening methods have been developed and refined, their implementation in clinical practice remains inconsistent (Leclerc et al., 2024; Stier et al., 2024). Studies have identified both individual-level barriers, such as lack of awareness and stigma (Fein et al., 2021; Sam et al., 2025), and system-level challenges, including inadequate provider training and insufficient clinical protocols (Higashi et al., 2022; Sanger et al., 2023), that can deter the effectiveness of anal cancer prevention efforts. Healthcare agencies have begun to issue screening guidelines, emphasizing the need for more inclusive and accessible care (NIH, 2024; Stier et al., 2024; ACF, 2024). Despite these advances, important gaps remain in the research. There is limited evidence on the long-term impact of screening programs, the effectiveness of educational tools in diverse populations, and strategies to increase screening uptake in high-risk groups (Geba et al., 2024; Fuller, 2025). 15 Literature supports the need for practical, evidence-based approaches that promote awareness, reduce barriers, and improve outcomes with early detection (Nutbeam, 2000; Iowa Model Collaborative, 2017; Kirkpatrick & Kirkpatrick, 2006). Educational interventions that address health literacy and incorporate patient-centered strategies are crucial for ensuring the implementation and sustained participation in anal cancer screening (Nutbeam, 2000; Bastable, 2019). 16 Chapter 3 Methodology Chapter 3 will cover the methodology portion of this research project. The chapter will review project design, setting, sample, ethical considerations, and data collection. Project Design This project utilizes a quasi-experimental, single-group posttest design to evaluate the effectiveness of an educational intervention aimed at increasing anal cancer screenings among PLWH. Project design reviewed with the project committee and approved by Pennsylvania Western University Institutional Review Board (Figure 4). The intervention consists of education and training to PA Thrive Partnership clinic nurses on anal cancer and an evidencebased educational pamphlet distributed by direct care staff. Nurses will be provided will a consent for voluntary participation in the project (Figure 5). Direct care staff will complete a post-education survey (Table 2) to measure the effectiveness of education. Direct care staff will provide a patient education pamphlet to all patients attending PA Thrive Partnership clinics for their provider visits. After three months, the data will be reviewed. Data will be collected from the EHR. Data will include the number of patients that received anal cancer screenings over the 3 month-long time period. Data will not include any identifying information. Data will include the number of patients who received anal cancer screenings, and per the Institutional Review Board, gender and age with patient consent (Figure 6). This data will then be analyzed and compared to the prior months’ data to determine the effectiveness of the intervention. Setting The study will take place at the PA Thrive Partnership clinics. Clinics are located in Pennsylvania. The population of patients at the PA Thrive Partnership clinics is PLWH. 17 Sample The sample of nurses targeted includes all nurses working as direct care providers at the PA Thrive clinics. The sample will be a random sample of patients seen at the PA Thrive Partnership clinics over a 3-month period. The goal is to provide a patient education pamphlet to all patients seen at the clinics during the time period. Inclusion is patients being seen at the PA Thrive Partnership clinics. Exclusion would include patients not being seen at the clinic. Ethical Considerations Patient autonomy, equity, and beneficence must be considered. Strict confidentiality must be maintained. Confidentiality is a priority when working with the HIV-diagnosed population (Marellapudi et al., 2022). All individuals working with HIV patients must understand and agree to confidentiality agreements. Patient identifying information is only stored in a secure network. This study will evaluate the number of patients that receive anal cancer screening; this statistic can be published without including any patient identifying factors. Patients have the autonomy to be fully informed about anal cancer screening and consent to screenings. Anal cancer screening has little to no patient discomfort. Educating patients, staff, and providers has little to no risk of harm to patients. Consideration must be made to ensure materials meet the needs of all patients, regardless of their health literacy. Instrumentation The Post-Education Evaluation Tool is an instrument used to evaluate the effectiveness of the education session for direct care staff on the patient education pamphlet. The purpose of this tool is to evaluate staff confidence and intended practice changes after education related to anal cancer screening. 18 This tool incorporates two sections: Section A uses self-reported confidence, and Section B uses application and feedback. Each item was structured to align with best practices in healthcare education evaluation, emphasizing both learner confidence and the likelihood of behavior change. Section A uses a Likert scale to evaluate confidence across key areas, such as understanding risk factors and knowing how to deliver education using the patient pamphlet. This reflects level two of Kirkpatrick's Four-Level Training Evaluation Model, which assesses the extent to which participants gain knowledge, skills, and attitudes. Section B addresses level 3 of Kirkpatrick’s Four-Level Training Evaluation Model, which assesses the extent of knowledge gain, skills, and attitudes. (Kirkpatrick & Kirkpatrick, 2006) Theoretical Underpinnings The inclusion of health literacy principles is informed by Nutbeam (2000), who emphasizes that public health communication must be clear, accessible, and tailored to improve outcomes among populations with varying levels of literacy. This is particularly relevant in settings like PA Thrive clinics, where socioeconomic and educational disparities may impact patient comprehension. Evaluating whether staff can deliver such information effectively is key to improving screening uptake. This tool also reflects the educational theory described by Bastable (2019), who identifies the importance of learner-centered teaching and evaluating whether nurses can integrate new knowledge into practice. Bastable highlights that feedback tools should not only assess learning but also explore how education influences attitudes and self-efficacy. Effectiveness and Use in Practice 19 This evaluation tool supports quality improvement by assessing confidence and preparedness, identifying key areas where further support is needed, and predicting the likelihood of practice change. This tool also ensures that educational content meets the diverse needs of staff. Providing a patient education pamphlet is an effective strategy for increasing awareness, knowledge, and engagement in preventive health behaviors, such as anal cancer screening, particularly among high-risk populations. Health education materials that are evidence-based, accessible, and tailored to the target population can improve understanding and allow patients to participate more actively in their care (Nutbeam, 2000). For individuals living with HIV, who are at increased risk for anal cancer, an educational pamphlet can address common barriers, low perceived risk, stigma, and lack of knowledge. These factors have been shown to reduce screening uptake (Fein et al., 2021; Sam et al., 2025). When delivered by trained direct care staff in a trusted clinical setting, the pamphlet is effectively used as an informative resource and a conversation starter, facilitating shared decision-making and increasing the likelihood of screening completion (Geba et al., 2024). The use of plain, easily understood language in printed materials enhances comprehension across a range of health literacy levels. This tool is both inclusive and practical (National Cancer Institute, 2024). Overall, integrating a structured educational intervention into routine care is a feasible, cost-effective, and scalable method to promote early detection of anal cancer in vulnerable populations. Summary of Methodology This study employs a quasi-experimental, single-group posttest design to evaluate the impact of an educational intervention aimed at increasing anal cancer screening rates among PLWH at PA Thrive Partnership clinics. The intervention centers on an evidence-based patient 20 education pamphlet, which is introduced to patients by direct care staff who first receive targeted training. The project takes place in Pennsylvania-based clinics that serve the PLWH population. The sample includes all patients seen during a 3-month intervention period. Ethical considerations emphasize confidentiality, informed consent, and equitable access to education, which are particularly important when working with the HIV-positive population. The project avoids collecting identifying information, instead focusing on aggregate data such as age, gender, and screening completion rates. The data collection process involves reviewing secure EHR to track the number of completed anal cancer screenings before and after the intervention. A custom education evaluation tool will be used to assess staff confidence and intention to apply knowledge, grounded in Kirkpatrick’s Four-Level Training Evaluation Model and informed by theories of health literacy and adult learning (Kirkpatrick & Kirkpatrick, 2006; Nutbeam, 2000; Bastable, 2019). Nurses are asked to track the number of patients seen at each clinic and the number of patients they provided the anal cancer education pamphlet to (Figure 7). Number of patients seen at each clinic can also be tracked through the EHR system. Data analysis will involve comparing the number of screenings completed before and after the intervention, organized by patient age and gender. The implementation and data collection timeline will start after nurse education is completed. The data collection period will last a minimum of 3 months after the education. This structured approach, guided by evidencebased frameworks, aims to improve health outcomes and reduce disparities in cancer prevention among high-risk populations. Chapter 4 21 Results and Discussion The purpose of this chapter is to review the statistical results of this study. Findings discussed will include the survey results of nurses after the educational session. Data collected on anal cancer pamphlet distribution and anal cancer screenings were completed. This chapter will also discuss the interpretations of these results. Results Education sessions were provided to the nurses at the PA Thrive Partnership clinics. See figure 3: Anal Cancer Education PowerPoint. 5 of the 5 nurses working at the clinics completed the education. It is noted that 4 of the 5 nurses present for the education had completed previous education at the PA Thrive Clinic related to anal cancer and anal cancer screening. Following the education session, surveys were available to the nurses to complete to evaluate the effectiveness of the education session. Surveys were completed by 4 of the 5 nurses present for the education session. Results displayed in Table 4: Education Evaluation Tool Results. Question 1: “I feel confident discussing anal cancer screening with patients.” The results were 2 responses strongly agree, 1 result agrees, and 1 result strongly disagrees. Question 2: “I understand the risk factors for anal cancer in high-risk populations.” The results were 2 responses strongly agree, 1 result agrees, and 1 result strongly disagrees. Question 3, “I know how to use the educational pamphlet during patient education,” resulted in 2 responses strongly agree, 1 result agree, and 1 result strongly disagree. Question 4: “I understand when and how to refer patients for anal cancer screening.” The results were 2 responses strongly agree, 1 result agrees, and 1 result strongly disagrees. Question 5 “This education session improved my confidence in supporting patients at risk” resulted in 2 responses strongly agree, 1 result agree, and 1 result strongly disagree. Question 6 “I will incorporate anal cancer screening education into my patient teaching” 22 response 4 yes. Question 7 “ I plan to initiate more discussions about anal cancer screening with appropriate patients” Response 4 yes. Question 8 “ I understand where to find resources for anal cancer screening if patients need more support” response 4 yes. The nurses were provided with a tracking form to track the number of patients that received the educational pamphlet on anal cancer. Over the 3-month tracking period 131 patients were seen at clinic. See table 5. The number of patients reported to receive the pamphlet 10. The 121 difference is unknown if pamphlets were distributed. The number of patients that had anal cancer screening was completed prior to intervention shown in table 3. March 2025: 2, April 2025: 4, May 2025: 4, June 2025: 2, July 2025: 1, August 2025 2, September 2025: 2, October 2025:0. Post intervention anal cancer screenings shown in figure 3. November 2025: 0, December 2025: 1, January 2026: 6, February 2026: 0, March 2026:4. In the 3 months following the intervention, data collected by age/gender with consent. Of the 7 anal cancer screenings completed, 2 unknown age group and gender, two male in the 40-49 age range, one male in the 50-59 age range, two male in the 60-69 age range. See figure 6. Discussion of Results Anal cancer screening rates were examined across three distinct time periods to evaluate the potential impact of the educational intervention. During the initial pre-intervention period (May–July 2025), a total of 7 anal cancer screenings were completed, with an average of 2.33 screenings per month. In the subsequent pre-intervention period (August–October 2025), screenings declined to 3 total, representing a decrease to average 1.00 screening per month. Following implementation of the educational intervention, screening rates increased to 7 total screenings during the post-intervention period (November 2025–January 2026), returning to an 23 average of 2.33 screenings per month. This pattern demonstrates a decline in screening uptake prior to the intervention, followed by an increase after implementation. Although postintervention screening levels did not exceed the highest pre-intervention period, the observed improvement compared to the immediate pre-intervention decline suggests that the intervention may have been effective in restoring screening rates. These findings support a potential positive effect of the intervention in reversing decreased screening uptake among the target population. Limitations The following limitations should be considered as having an effect on the results of the study. Limitations of this project include that the study is limited to a single site, the PA Thrive Partnership clinics. This may not reflect practices, populations, or operations in other healthcare settings. The study will be completed within a short timeframe and, therefore, may not capture the long-term effects. Patients, on average, are seen every 6 months. The 3 month time period may not fully show if this intervention was effective as all patients in the clinic were not seen during this time period. Direct care staff will self-report feedback on the survey provided before and after the education session; this could result in bias if feedback is dishonest. The impact of the pamphlet may be limited by inconsistent staffing, staff motivation, or adherence of the pamphlet distribution to patients. A significant limitation discovered in this study is staff adherence to completing the pamphlet tracking form. Though results could suggest effectiveness in education of nurses by increasing their knowledge and confidence, it is unknown if the pamphlets were used as a tool in patient education. Limitations noted at this time in the clinic setting included clinic process changes, and limited staffing during the data collection time. Summary 24 This chapter presented the statistical results of the educational intervention, including nurse survey outcomes, pamphlet distribution, and anal cancer screening rates. Completed evaluation surveys generally indicated improved knowledge, confidence, and intent to incorporate screening education into practice, although one dissenting response was noted across several items. During the 3-month implementation period, 131 patients were seen, but only 10 pamphlets were confirmed as distributed, with the majority untracked due to documentation gaps. Screening data showed a decline in pre-intervention rates followed by a post-intervention increase, returning to earlier baseline levels and suggesting a potential restorative effect of the intervention. Post-intervention screenings were distributed across age groups, primarily among males, though some demographic data were missing. Despite these findings, limitations— including small sample size, short timeframe, single-site design, reliance on self-reported data, and inconsistent tracking of pamphlet use—restrict the ability to fully determine intervention effectiveness, though results indicate a positive trend in nurse preparedness and screening uptake. 25 Chapter 5 Summary, Conclusions, and Recommendations Summary of Findings Anal cancer diagnoses are on the rise, especially among high-risk populations. A literature review supports the idea that a knowledge deficit contributes to the underutilization of anal cancer screenings, such as anal Pap tests. The hypothesis of this project asks whether providing education to direct care staff at the PA Thrive clinics on an evidence-based bestpractice patient education pamphlet about the risk of anal cancer will increase the number of patients who receive anal cancer screenings. This project examined the effectiveness of an educational intervention aimed at increasing anal cancer screening rates among the high-risk population of PLWH seen at the PA Thrive partnership clinics. The intervention included nurse education and the implementation of an evidence-based patient education pamphlet. Results indicated that nurses generally reported improved confidence, knowledge, and intent to incorporate anal cancer screening education into practice following the educational session. Conversely, responses suggest that not all participants experienced the same level of benefit. Limitations include gaps in data collection on the number of patients who received the anal cancer education pamphlet. Screening data showed a decline in rates prior to the intervention, followed by an increase in rates post-intervention. These findings suggest a potential positive impact of the intervention on screening uptake, although limitations in data tracking and study design must be considered. Conclusion The findings of this study suggest that the educational intervention had a positive effect on both nurse preparedness and anal cancer screening rates within the PA Thrive Partnership 26 clinics. The increase in screenings following a period of decline indicates that targeted education and patient-focused materials can contribute to improved preventive care practices in high-risk populations. Additionally, nurse-reported increases in confidence and intent to educate patients show the importance of education in aiding in practice change. However, due to limitations such as small sample size, short duration, inconsistent pamphlet tracking, and reliance on self-reported data, the results should be interpreted with caution. While the intervention shows promise, further evaluation is needed to determine its sustained impact and generalizability across broader clinical settings. Implications for Nursing This study suggested a positive outcome on nursing knowledge and confidence, and the effect on increased anal cancer screenings completed. This finding supports existing literature suggestive of a positive outcome with education as an intervention for practice change. The findings of this study can support positive practice change in healthcare. Direct care education can be used to increase knowledge, confidence, and practice change. Recommendations for Further Project Limitations were present with nurse compliance in tracking pamphlet distribution. Improvements need to be made for ease and the ability to complete pamphlet distribution tracking. The study showed an increase in anal cancer screenings compared to the previous three-month period. Further study should be completed to determine the validity of anal cancer education to providers as a tool to increase anal cancer screenings in high-risk populations. Due to the size and limit of one office network for the study, it cannot be definitively determined that the educational intervention was fully effective or would be effective for all populations. Expanded time of study is needed to evaluate the effectiveness of the anal cancer education on 27 the entire population of patients at the PA Thrive clinics. Additional sites should be included to reach broader populations of high-risk individuals. 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Challenging and newly emerging neoplastic diseases in the anal canal and their mimics. Challenging and newly emerging neoplastic diseases in the anal canal and their mimics ScienceDirect Cachay, E. R., Gilbert, T., Qin, H., & Mathews, W. C. (2024). Clinical predictors and outcomes of invasive anal cancer for people with HIV in an inception cohort. Clinical Infectious Diseases, 79(3), 709–716. https://doi.org/10.1093/cid/ciae124 Centers for Disease Control and Prevention. (2023). HIV basics. https://www.cdc.gov/hiv/basics/index.html Deshmukh, A., Suk, R., Shiels, M., Sonawane, K., Nyitray, A., Liu, Y., Gaisa, M., Palefsky, J., Sigel, K. (2020). Recent trends in squamous cell carcinoma of the anus incidence and mortality in the United States, 2001–2015, JNCI: Journal of the National Cancer Institute, Volume 112(8), 829– 838, https://doi.org/10.1093/jnci/djz219 Espirito Santo, I., Kefleyesus, A., Chilou, C., Faes, S., Clerc, D., Hübner, M., Hahnloser, D., & Grass, F. (2025). Anal cancer screening: 10 years experience in a specialized Outpatient clinic. Cancers, 17(2), 193. https://doi.org/10.3390/cancers17020193 29 Fein, L. A., Cunha, I. R., Wong, A., Schlumbrecht, M. P., Duthely, L. M., & Potter, J. E. (2021). Low perceived anal cancer risk and screening utilization among high-risk transgender men and women living in an HIV / STI epicenter. AIDS & Behavior, 25(7), 2210–2218. https://doi.org/10.1007/s10461-020-03149-w Fuller, J. M. (2025). Incorporating anal Papanicolaou tests into clinical practice: New consensus guidelines. Journal for Nurse Practitioners, 21(3), N.PAG. https://doi.org/10.1016/j.nurpra.2024.105286 Geba, M. C., Kalluri, D., Mitchell, E. M., Flickinger, T., Cardenas, B., Dillingham, R., & Thomas, T. A. (2024). Identifying motivators, facilitators, and barriers to engagement and retention in anal cancer screening among men and women with HIV in one Ryan White HIV/AIDS Clinic. AIDS Patient Care & STDs, 38(11), 530–538. https://doi.org/10.1089/apc.2024.0171 Kirkpatrick, D. L., & Kirkpatrick, J. D. (2006). Evaluating training programs: The four levels. BerrettKoehler. eval-training-3-pr.pdf Higashi, R. T., Rodriguez, S. A., Betts, A. C., Tiro, J. A., Luque, A. E., Rivera, R., & Barnes, A. (2022). Anal cancer screening among women with HIV: provider experiences and system-level challenges. AIDS Care, 34(2), 220–226. https://doi.org/10.1080/09540121.2021.1883512 Iowa Model Collaborative. (2017). The Iowa model of evidence-based practice to promote quality care: An illustrated example in oncology nursing. Clinical Journal of Oncology Nursing, 21(2), 157–160. Leclerc, E., Jacomet, C., Siproudhis, L., Abramowitz, L., Pereira, B., & Buisson, A. (2024). Impact of the screening program to prevent anal cancer in high‐risk patients with HIV. HIV Medicine, 25(4), 454– 461. https://doi.org/10.1111/hiv.13594 National Cancer Institute. (2025) Cancer stat facts: Anal cancer. https://seer.cancer.gov/statfacts/html/anus.html 30 National Institute of Health (NIH). 2024. National Institutes of Health (NIH) | Nutbeam, D. (2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15(3), 259–267. Sam, I., Dang, W., Iu, N., Luo, Z., Xiang, Y.-T., & Smith, R. D. (2025). Barriers and facilitators to anal cancer screening among men who have sex with men: A systematic review with narrative synthesis. BMC Cancer, 25(1), 1–12. https://doi.org/10.1186/s12885-025-13980-w Sanger, C. B., Kalbfell, E., Cherney-Stafford, L., Striker, R., & Alagoz, E. (2023). A qualitative study of barriers to anal cancer screenings in US veterans living with HIV. AIDS Patient Care & STDs, 37(9), 436–446. https://doi.org/10.1089/apc.2023.0144 Stier, E. A., Clarke, M. A., Deshmukh, A. A., Wentzensen, N., Liu, Y., Poynten, I. M., Cavallari, E. N., Fink, V., Barroso, L. F., Clifford, G. M., Cuming, T., Goldstone, S. E., Hillman, R. J., Rosa-Cunha, I., La Rosa, L., Palefsky, J. M., Plotzker, R., Roberts, J. M., & Jay, N. (2024). International anal neoplasia society's consensus guidelines for anal cancer screening. International journal of cancer, 154(10), 1694–1702. https://doi.org/10.1002/ijc.34850 Tisler, A., Toompere, K., Bardou, M., Diaz, J., Orumaa, M., & Uusküla, A. (2024). HPV-associated cancers among people living with HIV: Nationwide population-based retrospective cohort study 2004–21 in Estonia. European Journal of Public Health, 34(6), 1199–1204. https://doi.org/10.1093/eurpub/ckae152 31 Table 1: Education Evaluation Tool Appendix A Section A: Self-Reported Confidence Instructions: Indicate how much you agree or disagree with each statement based on your confidence after completing the education. Statement Strongly Disagree Disagree Neutral Agree Strongly Agree I understand the risk factors for anal cancer in high-risk populations. ☐ ☐ ☐ ☐ ☐ I feel confident discussing anal cancer screening with patients. ☐ ☐ ☐ ☐ ☐ I know how to use the educational pamphlet during patient education. ☐ ☐ ☐ ☐ ☐ I understand when and how to refer patients for anal cancer screening. ☐ ☐ ☐ ☐ ☐ This education ☐ ☐ ☐ ☐ ☐ 32 session improved my confidence in supporting patients at risk. Section B: Application and Feedback Statement Yes No Not Sure I will incorporate anal cancer screening education into my patient teaching. ☐ ☐ ☐ I plan to initiate more discussions about anal cancer screening with appropriate patients. ☐ ☐ ☐ I understand where to find resources for anal cancer screening if patients need more support. ☐ ☐ ☐ 33 Figure 2: Literature Review Summary Authors and Date Theoretical Framework Appendix B Rese arch Ques tions Method s Results Analysis Conclusi on Implication s for Future Research Implications for Future Practice APA Reference Barquet et al. (2024) Epidem iologic al framew ork What is the prevalence of high-risk HPV types in PLWH with a cancer history? Crosssection al study; HPV testing in PLWH with cancer history High prevalenc e of HRHPV types in anal canal of PLWH with cancer history Routine screenin g is critical in this populati on Explore HPV strainspecific risks in longitudina l cohorts Consider incorporating strainspecific HPV screening in HIV care protocols Barquet, M. S. A., et al. (2024). Prevalence of anal high‐risk human papillomavirus (HR‐HPV) types in people living with HIV and a history of cancer. HIV Medicine, 25(10), 1145–1153. https://doi.org/10.1111/h iv.13684 Byrnes & Liu (2022). Patholo gical diagno stic review What are the diagnostic challenges and mimics of anal neoplasms ? Narrativ e review of rare and emergin g anal neoplas ms Outlined difficulttodiagnose tumors and histologic al mimics Need for accurate patholog y for effective treatmen t Develop better histological tools Enhanced pathologist training and diagnostic accuracy Byrnes, K., & Liu, X. (2022). Challenging and newly emerging neoplastic diseases in anal canal and their mimics. Cachay et al. (2024). Epidem iologic al cohort analysi s What are clinical predictors and outcomes of anal cancer in PLWH? Inceptio n cohort study of HIVpositive individu als Older age, low CD4 count, and lack of screening predicted worse outcome s Routine monitori ng and screenin g are critical in PLWH Longitudin al studies on immune suppressio n and cancer progressio n Implement structured follow-up and early detection protocols Cachay, E. R., et al. (2024). Clinical Predictors and Outcomes of Invasive Anal Cancer for People With HIV in an Inception Cohort. Clinical Infectious Diseases, 79(3), 709–716. https://doi.org/10.1093/c id/ciae124 Deshmu kh et al. (2020). Populat ionbased surveill ance analysi s What are the incidence and mortality trends for anal squamous cell carcinoma ? SEER databas e analysis 2001– 2015 Rising incidence and mortality, especiall y in older adults Anal cancer is increasin g and underscreened Need to evaluate the effectivene ss of new screening methods Promote early detection and public health education Deshmukh, A., et al. (2020). Recent trends in squamous cell carcinoma of the anus incidence and mortality in the United States, 2001–2015. JNCI: Journal of the National Cancer Institute, 112(8), 829– 838. https://doi.org/10.1093/j nci/djz219 Espirito Santo et Clinical screeni ng outcom What are the outcomes of 10 years Retrosp ective analysis of High detection rate of high- Supports sustaine d screenin Evaluate costeffectivene Expand screening clinic models Espirito Santo, I., et al. (2025). Anal Cancer Screening: 10-Year Experience of a 34 al. (2025) e analysi s of anal cancer screening? screeni ng clinic records grade lesions; screening is feasible in the long term g in highrisk populati ons ss over decades Fein et al. (2021). Health behavi or and risk percept ion How do transgende r individuals perceive anal cancer risk and screening? Surveybased study in highHIV/STI areas Low perceived risk correlate d with low screening uptake Misperce ptions hinder screenin g in highrisk trans commun ities Culturally tailored education impact studies Improve provider training on trans-specific risk communicati on Fein, L. A., et al. (2021). Low Perceived Anal Cancer Risk and Screening Utilization Among High-Risk Transgender Men and Women Living in an HIV / STI Epicenter. AIDS & Behavior, 25(7), 2210– 2218. https://doi.org/10.1007/s 10461-020-03149-w Fuller (2025) Guideli ne implem entatio n model How can new anal Pap test guidelines be incorporate d into nursing practice? Review and synthesi s of clinical consen sus Provided impleme ntation steps for clinical settings Guidelin e adoption can normaliz e anal screenin g Study adoption barriers in nursing-led settings Standardize anal Pap test protocols across primary care Fuller, J. M. (2025). Incorporating Anal Papanicolaou Tests Into Clinical Practice: New Consensus Guidelines. Journal for Nurse Practitioners, 21(3), N.PAG. https://doi.org/10.1016/j. nurpra.2024.105286 Geba et al. (2024). Behavi oral health model What motivates or prevents HIV+ individuals from engaging in anal cancer screening? Qualitat ive intervie ws in the Ryan White Clinic Barriers include fear and stigma; facilitator s include provider trust Addressi ng psychos ocial barriers could improve screenin g uptake Develop interventio ns addressing emotional barriers Use motivational interviewing techniques in care Geba, M. C., et al. (2024). Identifying Motivators, Facilitators, and Barriers to Engagement and Retention in Anal Cancer Screening Among Men and Women with HIV in One Ryan White HIV/AIDS Clinic. AIDS Patient Care & STDs, 38(11), 530–538. https://doi.org/10.1089/a pc.2024.0171 Higashi et al. (2022). System s theory What challenges do providers face in offering anal cancer screening Semistructur ed intervie ws Barriers include institutio nal policy gaps, time constrain ts Provider training and system support are key Interventio ns for improving systemlevel coordinatio n Create EMR prompts and workflow aids Higashi, R. T., et al. (2022). Anal cancer screening among women with HIV: provider experiences and systemlevel challenges. AIDS Care, 34(2), 220–226. https://doi.org/10.1080/0 9540121.2021.1883512 35 Specialized Outpatient Clinic. Cancers, 17(2), 193. https://doi.org/10.3390/c ancers17020193 to women with HIV? Leclerc et al. (2024) Public health screeni ng model Does organized screening reduce anal cancer in HIVpositive patients? Cohort study of screene d vs. unscree ned Significan t reduction in highgrade lesions among screened Organize d screenin g improves outcome Assess long-term impacts on morbidity/ mortality Adopt universal screening strategies Leclerc, E., et al. (2024). Impact of screening programme to prevent anal cancer in high‐risk patients with HIV. HIV Medicine, 25(4), 454– 461. https://doi.org/10.1111/h iv.13594 Nationa l Cancer Institute (2024) Epidem iologic al surveill ance What are the rates and demograph ic patterns of anal cancer in the US? SEER databas e descript ive statistic s Higher rates in older adults and PLWH Anal cancer incidenc e is rising in certain populati ons Explore regional variation and trends Target highrisk populations with education and screening National Cancer Institute. (2024). Cancer stat facts: anal cancer. https://seer.cancer.gov/s tatfacts/html/anus.html NIH (2024a) Screeni ng innovat ion model What recent advances improve anal cancer screening access? Policy and literatur e summar y Emerging tech and new guideline s support early detection Innovatio n is key to preventi on Study the real-world application of tools Adopt evidencebased technology in care National Institutes of Health. (2024). Anal cancer advances open door to screening and prevention. NCI. NIH (2024b) Clinical guideli ne develo pment What are the updated screening recommen dations for PLWH? Clinical guidelin e update High Resolutio n Anoscopy is now recomme nded HRA should be routine for PLWH Evaluate HRA implement ation effectivene ss Train providers in HRA use and interpretation NIH. (2024). HIV clinical guidelines now recommend High Resolution Anoscopy as part of anal cancer screening program for people with HIV. Sam et al. (2025). Behavi oral theory and stigma What are the barriers/fac ilitators to anal cancer screening among MSM? System atic review and narrativ e synthesi s Stigma, lack of knowledg e, and discomfo rt are barriers Tailored educatio n can increase screenin g rates Test behaviorchange interventio ns Normalize screening conversation s Sam, I., et al. (2025). Barriers and facilitators to anal cancer screening among men who have sex with men: a systematic review with narrative synthesis. BMC Cancer, 25(1), 1–12. https://doi.org/10.1186/s 12885-025-13980-w Table 2: Literature Review Summary 36 Appendix C Figure 1: International Guideline for Anal Cancer Screening 37 Appendix D Figure 2: Anal Cancer Education Pamphlet Understanding Anal Precancer & Cancer What You Need to Know to Stay Healthy 🌟🌟 What Is Anal Precancer? • Anal precancer means there are changes or growths in the skin around the anus. These changes are not cancer, but they could turn into cancer later if not watched closely. • Many of these changes are caused by a virus called HPV (human papillomavirus). HPV can cause problems in both boys and girls. It can lead to growth inside or outside the anus. 🧠🧠 What Are the Signs? 🧪🧪 How Do You Get Checked? Sometimes, there are no signs at all. But some people may notice: There are a few ways doctors can check for anal precancer: • Itching • Bleeding • Lumps or warts 👩👩👩👩 Who Is at Risk? You may be at higher risk if you: • Have HPV • Are HIV-positive • Are over 50 • Smoke • Have had a transplant Anal Cancer Foundation. (2024). Understanding anal precancer and cancer: What you need to know to stay healthy. https://www.analcancerfoundation.org • Anal Pap Test: Like a cervical pap smear, but for the anus • Digital Exam (DARE): Doctor uses a finger to feel for lumps • Anoscopy: A small tube helps the doctor look inside • High-Resolution Anoscopy (HRA): A more detailed look 🏥🏥 Why Is Screening Important? Even if you feel fine, regular screening can: • Find problems early • Help stop cancer before it starts • Give you peace of mind Appendix E Table 3: Anal Cancer Screenings Completed by Month Month Year Anal Cancer Screening Completed March 2025 2 April 2025 4 May 2025 4 June 2025 2 July 2025 1 August 2025 1 September 2025 2 October 2025 0 November 2025 0 December 2025 1 January 2026 6 February 2026 0 March 2026 4 Note. Anal cancer screenings completed per month across the study period. Appendix F 3 Table 4 : Education Evaluation Tool Results 4 5 6 7 8 9 10 Appendix G Figure 4: Anal Cancer Education Power Point INCREASING ANAL CANCER SCREENINGS (ANAL PAP) Heather Leadbetter MSN RN DNP Candidate DNP Project Pennsylvania Western University 11 F • Rising anal cancer rates in high-risk groups INTRODUCTION • PLWH particularly affected 12 BACKGROUND OF THE PROBLEM • Education as a strategy to improve screening • Anal cancer increasing • Higher prevalence in PLWH and other risk groups 13 • New screening guidelines (ACF, 2024) 14 15 SUMMARY OF THE PROBLEM 16 • Rising incidence in high-risk groups • Underutilized screenings 17 • Education as a solution 18 19 SETTING AND SAM • PA Thrive clinics, PA 20 • PLWH patients o three-month per ETHIC CONSIDERATIO • CONFIDENTIALITY • AUTONOMY AND INFORMED CONSENT 21 • HEALTH LITE CONSIDERAT DATA COLLECTION A ANALY • • EHR data on screening uptake • • Variables: number, age, gender • • Compare pre- and post-intervention 22 TIMEL Implement use of Anal Cancer pamphlet after this session - 10/28/25 Collect data for three months – Ending 1/28/25 23 SUMMARY OF IMPLEMENTATION Each nurse will be provided with a folder containing the education pamphlet and patient consents. There will be a log on the front of the folder – you will keep track of how many patients are seen at each clinic and how many were provided the pamphlet to 24 Patients can sign and return the consent immediately upon receiving the information. SUMMARY OF IMPLEMENTATION Keep completed consents in the provided folder. 25 DATA COLLECTION If patients do not sign consent their age and gender will not be recorded when collecting data. After this session you will complete a survey related to the education today. 26 Anonymous results of post-education survey. Number of patients seen at each clinic Number of patients documented as receiving the anal cancer education pamphlet. Number of patients that received anal paps in the 3 months before intervention. Number of patients who received anal paps in the 3 months after the intervention In overall patient numbers, grouping by gender and age range 27 •S •U •R •V •E •Y 28 SURV • https://docs.google.com/forms/d/e/1FAIpQLSdC0g d6NeLNBImLn1W2ja7LlWLlMdCFeSFQQr1lkA50WwA wform?usp=header 29 REFERENC • • • • • • • • • • • • • Key sources included: ACF (2024) Barquet et al. (2024) Byrnes & Liu (2022) Deshmukh et al. (2020) Fein et al. (2021) Fuller (2025) Geba et al. (2024) Iowa Model Collaborative (2017) Kirkpatrick & Kirkpatrick (2006) Nutbeam (2000) NIH (2024) Sam et al. (2025) 30 Appendix H Table 5: Clinic Visits November 2025–January 2026 Clinic Nov 2025 Dec 2025 Jan 2026 Total Clarion 3 5 3 11 Dubois 6 0 0 6 Erie 20 20 16 56 Meadville 6 6 0 12 New Castle 11 8 11 30 Seneca 5 0 6 11 Warren 0 5 0 5 Totals 51 44 36 131 Note. HIV medical appointments seen by provider and RN. 31 Appendix I Figure 6: Anal cancer screening completed by Age Group Note. Distribution of anal cancer screenings by age group, including unknown age category. 32 Appendix J Table 7: Anal cancer screening Completed by Time Period Time Period Total Screenings Monthly Average May–July (Pre) 7 2.33 Aug–Oct (Pre) 3 1.00 Nov–Jan (Post) 7 2.33 Note. Monthly averages calculated based on number of months within each time period. 33 Appendix K Figure 4: Institutional Review Board Approval 34 35 Appendix L Figure 5: Provider Consent 36 Appendix M Figure 6: Patient Consent 37 Appendix N Figure 7: Pamphlet Tracking Form 38