Boosting uptake of cervical screening

With a third of women missing out on cervical screening, we look at why women in the UK fail to attend and what practices can do to change things

One in three women in the UK aged 25 and over do not attend their cervical cancer screening, as revealed by charity Jo’s Trust in a recent survey.¹

According to Cancer Research UK, the highest incidence of cervical cancer diagnoses in 2013 – 2015 was recorded in women between 25 and 29 years.² In 2016, 854 UK women died from cervical cancer,3 and the current figure for cervical cancer diagnoses is around 3,000 a year.²

Public Health England (PHE) has also reported a decline in uptake of screening invitations, especially in women aged 25 and 29 being tested,3 and is urging practices to do more to encourage screening attendance. PHE has also issued a direct appeal for young women to accept their invitation to be screened.

The importance of screening regularly features in the media, but with attendance levels dropping, is there more GP surgeries can be doing?

The Jo’s Trust survey highlighted a number of concerning reasons for the decline in uptake of cervical screening,1 and it is vital we understand these reasons and step up efforts to combat any anxiety so that more women accept their invitations for screening.

WORD OF MOUTH

Talking openly about medical issues is something to be encouraged, but word of mouth can be potentially very damaging when it comes to women being screened, as many can quickly become apprehensive having heard about their family members’ or friends’ negative experiences – and of course, we tend to trust the opinions of those closest to us.

Smear tests can sometimes be uncomfortable and may even be traumatic for some, but avoidance could result in a situation far worse. However, stories of pain and discomfort can be distressing for patients, whatever their age, especially around such a personal subject, and can be a powerful deterrent to attendance.

Other reasons for failing to attend are – to healthcare professionals – more trivial: according to Jo’s Trust, concerns around body image play a large part in the avoidance of smear tests, with 35% of 2,017 women surveyed saying they are embarrassed to attend because of their body shape. Embarrassment around body hair also factors, with 31% of women surveyed admitting they would not attend if they had not shaved or waxed beforehand. It is clearly concerning that women are putting their appearance before their health – and it doesn’t stop there: 34% said they were embarrassed by the size of their vulva, and 38% were concerned about smelling ‘normally’.

Furthermore, busy lifestyles mean that 35% of women surveyed wouldn’t attend if it meant taking time off work. At a time when health and fitness industries are booming, it is even more concerning to see that 16% of women surveyed would rather miss a smear test than a gym class!

A lack of knowledge about cervical screening has proven to be a factor, with some women assuming they are not at risk because they live a healthy lifestyle. In almost all cases, cervical cancer is the result of a change in cell DNA caused by the human papilloma virus (HPV), which is yet another reason why women are failing to attend their appointments – 1 in 10 don’t think smear tests are important if they have had the HPV vaccination.

But while HPV vaccination protects against the two most common HPV types that cause cancer (types 16 and 18), this only covers 70% of cervical cancers.⁴ It is therefore paramount that we do more in GP surgeries to educate women that cervical cancer does not discriminate, and we must all do what we can to minimise risk.

This can be done through promotional materials, such as leaflets and flyers in practices, uploading online information to surgeries websites, posting important information on social media, talking at events and many more ways to send the message out. Fundraising is another way in which medical organisations and charities across the globe can and do raise awareness of cervical cancer, but is it enough simply to ask for donations? Are we missing the vital point that there is a wholesale lack of understanding and knowledge around cervical cancer?

OPEN DAYS

Primary and community care provider The Practice Group has been championing the importance of cervical screening by running campaigns to encourage women of all ages to attend their appointments. First rolled out in November last year in the organisation’s West Midlands practices, our campaign targets women of all ages, but with a specific focus on encouraging younger patients, who could be coming up to the eligible age (25), to change their points of view on cervical screening, despite what they may have been told by family and friends.

The surgeries run open days where patients can see the consultation room, discuss the procedure and ask any questions they may have ahead of their screening in a friendly, informal setting. This allows general practice nurses to do their best to allay any fears or concerns patients may have and remind them of the importance of their attendance. Plenty of information is available on the day, both provided by Practice Group nurses and health promotion materials, and patients’ family members are encouraged to attend as well, as they may also have questions.

During our last open day alone, we saw many registered and non-registered patients who had never had a smear test, one patient who hadn’t had a screening in 10 years due to a previous experience, another who hadn’t been screened in five years due to embarrassment, and one patient who had been discouraged from attending by her female family members.

We have found that an honest, open dialogue can completely change a patient’s perspective on a procedure that is so vital to their health, and we’re hoping to roll this campaign out across more of our surgeries for maximum impact.

POSITIVE THINKING

According to a 2014 study by the Irish Cervical Screening Consortium (CERVIVA, Motivators for women to attend cervical screening: the influential role of GPs,5 attendance for screening has a lot to do with the person carrying out the procedure. The results show that some women involved in the study responded positively to being prompted by their GP (face-to-face) to be screened, since most women surveyed had a high level of trust in their GP.⁵ Perhaps, then, practices could be doing more to prompt cervical screening opportunistically during other appointments, which may also help to overcome any embarrassment that women feel.

But what about the reasons for attending? Can we do more to talk about the positives of having smear tests, aside from the fact that they can and do save lives (which could induce more anxiety that existed previously)? The women surveyed also stated other reasons for attendance such as reassurance, as once the screening is over and the patient is put at rest, there is no need for another appointment for a minimum of three years.

With a more direct, positive approach to the promotion of cervical screening in practices, we could improve attendance numbers across the UK and diagnose cases of cervical cancer much sooner.

By providing women with the facts, and without scaremongering, healthcare professionals can ensure patients are well-informed and work to allay any anxieties that so often prevent them from attending life-saving diagnostics.

REFERENCES

1. Jo’s Trust. Body shame responsible for young women not attending smear tests. England 2018. 22 January 2018. https://www.jostrust.org.uk/node/1073042

2. Cancer Research UK. Cervical Cancer Statistics. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer/incidence%20-%20heading-Zero

3. Public Health England. Call for women to get life-saving smear test after uptake drops. England 2017. 7 November 2017. https://www.gov.uk/government/news/call-for-women-to-get-life-saving-smear-test-after-uptake-drops

4. NHS Choices. Vaccinations: HPV Vaccine. Last reviewed 31 October 2017. https://www.nhs.uk/conditions/vaccinations/hpv-human-papillomavirus-vaccine/

5. Family Practice. Motivators for women to attend cervical screening: the influential role of GPs. 2014. Vol. 31. No. 4, 475–482. https://academic.oup.com/fampra/article-pdf/31/4/475/17051430/cmu029.pdf