By Laura Marlow, Mairead Ryan and Jo Waller.

Having cervical screening (smear tests) when you are older is just as important as when you’re younger, yet many women aged 50-64 years do not attend when invited. One reason older women decide not to attend anymore is because screening can become more uncomfortable after the menopause. We previously explored the potential for doing screening without a speculum as an alternative for these women. Another reason that some older women give for not attending their screens, is that they no longer feel it is relevant for them because they are no longer sexually active or have had the same partner for a long time.

Cervical cancer is caused by HPV, an infection which is passed on through sexual contact. But it can take a long time for HPV to develop into cervical cancer, so past rather than current sexual behaviour is what’s important. For an older woman, HPV can be the result of an infection acquired many years ago. In our latest study, published this week in Sexually Transmitted Infections, we wanted to see if explaining this long timeline between acquiring HPV and developing cervical cancer could help to increase the extent to which older women saw screening as relevant to them.

We recruited women aged 50-64 years who said they would not go for screening again and asked them to read some information about HPV. We then looked at changes in their perceptions of cervical cancer risk and intention to go for screening. All women read basic information about HPV but some of the women also read the statement:

“Women aged 50-64 should be aware that HPV can take a long time to develop into cancer (10-30 years). This means that even if you have not been sexually active for a long time or have only had one partner for a long time, you could still be at risk of cervical cancer”

Women who read this additional information were more likely to increase their perceived risk of cervical cancer and to increase their intentions to attend when next invited. In the group who read this information a quarter of women increased their intentions to be screened compared with just 9% of the control group (who only read basic information about HPV). While this study is experimental, and measured intention to go for screening (not actual behaviour), it suggests that explaining the long time interval between getting HPV and developing cervical cancer may be a useful way to increase cervical screening intentions in those who do not plan to attend.

Over the last two years we have blogged about our work exploring different groups of non-participants at cervical screening (aka the smear test). We have shown that women who do not attend for their smear test can be either unaware of screening, unengaged with screening, undecided about screening, intending to get screened (but not yet got around to it) or they may have decided not to get screened.

In our most recent study funded by Cancer Research UK and published in Psycho-oncology, we interviewed women aged 26-65 years (n=29) from these different ‘non-participant’ groups to gain a deeper understanding of their screening decisions. We found that there are differences in the salience of particular barriers to screening, for example women who intend to get screened often focus on more practical barriers to screening and women who have decided not to attend often focus on past negative experiences of screening. However, there were also examples where even within groups of non-participants women had quite varied views e.g. some decliners felt the smear test procedure was not something they wanted to do, even though they knew the risks, other decliners thought smear tests were no big-deal but didn’t think they needed one because they weren’t at risk of cervical cancer.

Our findings also suggested that the distinction between different non-participant groups is ‘fuzzier’ than we originally thought. For example, many of the undecided women described not really wanting to have a smear test, but feeling less strongly about this than decliners. For women who intended to get screened, there were some that did not really want to attend, but felt they ought to (more similar to decliners or undecided women), while other intenders were happy to have a smear but practical barriers stopped them from participating.

This ‘fuzziness’ could mean that distinct interventions for one type of non-participant group may not work for some people in that group, but might work for others classified in a different way. Alternatively, there may be one intervention that could be successful across groups for different reasons, for example HPV self-sampling could address practical barriers (relevant to intenders) and concerns about the screening procedure (relevant to some decliners).

The falling cervical screening rates in younger women could be explained by their hectic lifestyles

It is a familiar story, every day you add a few more things on your to-do list, book a haircut; pay that cheque in; send a birthday card to your best friend.  In theory you should tick them off in order, first on first done or even better prioritise, ticking off the most important jobs first.  In reality the list grows and grows and although you tick off a few jobs each week (if you don’t post that birthday card before you friend’s birthday, it won’t be worth posting it), there are a handful of old-timers that remain week after week, month after month.  And going for a smear test might be one of these.

In our first blog we talked about how our research suggests the more some people think about the nitty gritty of doing a screening test, the less appealing it is to them.  Another reason for not doing screening could be that it simply drops to the bottom of your list, because life gets in the way.  Our recent study suggests that this could be one reason why fewer young women are going for cervical screening in England.  Since 1999, there’s been a drop of 12% in attendance for smear tests in 25-29 year olds, and we’ve been trying to understand why.

We interviewed and ran focus groups with 46 women who weren’t up to date with their smear tests, making sure we included young and older women so we could compare them.  The women discussed their reasons for not going for screening.  There seemed to be two distinct patterns of non-attendance.  Some of the women described how they had actively decided not to be screened.  These women either felt they were not at risk of cervical cancer or had weighed up the risks and benefits of screening and decided not to attend.  The second group of women described how although they intended to go for screening, they did not get round to it.  A variety of reasons were given, such as finding it difficult to make appointments to fit in with work commitments or childcare arrangements and feeling that cervical screening was at the bottom of their list: “I’ve got to have blood tests, I’ve got to go to the dentist, I’ve got to get my hair cut, so what’s low in priority, and a cervical smear test would be right down there I think”.  Interestingly, it seemed to be the older women who were making informed decisions not to attend, while the younger women just didn’t get round to going.

The findings complement a survey study that we published in 2009.  The study included a population-based sample of 580 women aged 26-64 years.  Women answered questions about their cervical screening uptake and selected which statements they agreed with from a list of possible barriers to attending screening.  While the most common barrier was embarrassment, this was chosen equally by women who did and did not attend screening regularly.  The second most common barrier was: “I intend to go… but don’t always get round to it”. This barrier was chosen more by women in the younger age group (26-34 years: 25%) than the older age group (55-64 years: 8%) and alongside “it is difficult to get an appointment” and “I do not trust the smear test” was associated with being overdue for screening.

Our findings have some interesting implications for how cancer screening is offered to younger women.  Using prompts (e.g. advertisements or text reminders) could be a useful way of overcoming the gap between intention and behaviour, reminding women that ‘Go for a smear’ is still on their to-do list.  Making screening more convenient (e.g. available at locations near work places or offering extended clinic hours) could also make it easier for women to fit in going for a smear test.  It can then be marked job done.

References:

Waller J, Jackowska M, Marlow L, Wardle J. Exploring age differences in reasons for non-attendance for cervical screening: a qualitative study. BJOG, in press. DOI: 10.1111/j.1471-0528.2011.03030.x

Waller J, Bartoszek M, Marlow L, Wardle J. (2009) Barriers to cervical cancer screening attendance in England: a population-based survey. Journal of Medical Screening, 16:199-204. DOI: 10.1258/jms.2009.009073

Laura (l.marlow@ucl.ac.uk)