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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
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Date
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Date
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Date
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Date
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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
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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.
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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
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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
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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
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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.
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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.
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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).
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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
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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
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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.
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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
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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.
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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).
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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).
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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.
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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.
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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
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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
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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
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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”
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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
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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
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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.
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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
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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. The gender data collection showed 100% of
the known gender for screening that was collected was male patients. This study could be applied
to settings focusing on women’s healthcare and bridge the gap in increasing screenings for
women as well.
28
References
Anal Cancer Foundation. (2024). International anal cancer screening guidelines.
https://www.analcancerfoundation.org/
Barquet, M. S. A., López, M. R. A., Stier, E. A., Mejorada, P. E., Solís, R. D., Jay, N., Moctezuma, P., Morales,
A. M., García, C. A., Méndez, M. R., Martin, O. A., Pérez, M. D., Mendoza, P. M. J., & Volkow, P.
(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/hiv.13684
Bastable, S. B. (2019). Nurse as educator: Principles of teaching and learning for nursing practice (5th ed.).
Nurse As Educator: Principles of Teaching and Learning for Nursing Practice
Byrnes, K., Liu, X. (2022). 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
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. The gender data collection showed 100% of
the known gender for screening that was collected was male patients. This study could be applied
to settings focusing on women’s healthcare and bridge the gap in increasing screenings for
women as well.
28
References
Anal Cancer Foundation. (2024). International anal cancer screening guidelines.
https://www.analcancerfoundation.org/
Barquet, M. S. A., López, M. R. A., Stier, E. A., Mejorada, P. E., Solís, R. D., Jay, N., Moctezuma, P., Morales,
A. M., García, C. A., Méndez, M. R., Martin, O. A., Pérez, M. D., Mendoza, P. M. J., & Volkow, P.
(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/hiv.13684
Bastable, S. B. (2019). Nurse as educator: Principles of teaching and learning for nursing practice (5th ed.).
Nurse As Educator: Principles of Teaching and Learning for Nursing Practice
Byrnes, K., Liu, X. (2022). 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
Media of