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Improving uptake of cervical screening

Sarah Kraszewski  B Ed RGN MA FHEA
Programme Leader
Primary Care and Public Health
Anglia Ruskin University

The National Cervical Screening Programme is an excellent example of how screening for cervical cancer can save lives; but its success is dependent upon eligible women attending

Cervical screening is an essential aspect of every woman's sexual health. The national call and recall system was introduced in 1988 and has had a significant impact on the incidence and mortality of cervical cancer.1 Statistics indicate a reduction in the incidence of invasive cervical cancer of 42%, and this is an indicator of the success of the programme.2

The cervical screening test is intended to identify changes in the cervix before they develop into cancer and is a simple test with the potential for a huge impact in terms of public health improvement and health promotion. The success of this initiative depends upon the target population participating in the screening programme; accurate interpretation of results; and appropriate referral and treatment. Similar principles apply to other large-scale screening initiatives, such as the breast cancer screening campaign.

Women are called every three to five years between the ages of 25 and 64 in England. Recent developments in the programme have included the introduction of liquid-based cytology (LBC), which reduces the incidence of inadequate samples; the introduction of the human papillloma virus (HPV) vaccination programme and the introduction of HPV triage for women with borderline or mild changes. The HPV test will be automatically carried out on the LBC samples of these women, and future screening and treatment planned accordingly.3 The Department of Health announced that from March 2011 HPV testing would be rolled out across the country - however, until now it has not been extended further than six pilot sites.

[[Box 1. Screening]] 

Health promotion
Health promotion is everybody's business and an understanding of concepts of health will support professionals working at local level to promote health screening messages and encourage women to attend. The World Health Organization (WHO) has famously described health as: 'A state of complete physical, mental and social wellbeing, not merely the absence of disease'.5

This definition has evolved as time has gone on. The important issue is that people hold many different beliefs about their health. There is no 'one size fits all' approach and our health beliefs are influenced by many factors, including religion, culture, socio-economic status, life experiences, family mores, personal expectations and beliefs. Further influences will emanate from the environment and communities in which people live. The WHO defines health promotion as: 'The process of enabling individuals to increase control over the determinants of health and thereby improve their health'.6 This requires holistic approaches in the planning of policy and services to meet the needs of a community.7

Promoting uptake
Promoting the uptake of cervical cytology is a core health promotion activity and a key responsibility for primary care nurses. Whether or not the nurse is a trained smear-taker, there are responsibilities in encouraging women to attend and in being able to answer questions in relation to attendance, results, treatment where necessary and follow-up.

Some women may be reluctant to attend and some may experience barriers to attendance. These include issues such as clinic timing and location, or because the woman is part of a hard to reach group, such as those with a learning disability, women in transition from an abusive relationship, travellers, those from ethnic minority groups, those for whom English is a foreign language, those with no fixed address or those living within socio-economically deprived groups. It is important that the practice profile is taken into account when planning services to ensure women can attend.

Researchers have investigated why women are reluctant to attend and what strategies might be used to increase attendance. The West Midlands adopted the first regional NHS fully integrated social marketing approach to increase awareness and identify any behavioural changes in terms of cervical screening uptake. They identified a number of reasons why women may be reluctant to attend for screening (see Box 2). The list is not conclusive but gives some indication of the areas to consider. The findings can help primary care nurses to consider ways in which they may promote attendance for cervical cytology and offer screening for sexually transmitted infections. These may be local initiatives that are cheap and easy to implement, others may be higher-profile campaigns to target a wider audience.

[[Box 2. Screening]]
  
At a local level, consideration needs to be given to how, when and where services are promoted. The majority of women attend their GP surgery for screening, but the availability of screening as part of other services, such as sexual health clinics, should also be publicised.

The timing of clinic sessions is crucial. Many women work and have family responsibilities that mean arranging an appointment becomes a military exercise, requiring precision planning. Providing evening and weekend appointments that avoid women having to take time off work or arrange childcare is key in not only making services accessible but also in reducing the stress and anxiety around attendance.
The location needs to be accessible (for example, what are the parking or public transport facilities, particularly if an evening session?). Reception staff should be trained in ensuring they book appointments appropriately.

The facilities should be reviewed to ensure they provide privacy and dignity. In addition to having appropriate screens and covers, the provision of a lockable door can help the woman to relax without the threat of a door opening unexpectedly.

Some of these messages can be communicated via displays in GP surgeries and on the practice website, promoting the availability of female smear takers and the surgery times that
are available.

On a wider scale, the production of media campaigns can disseminate positive messages about cervical screening and other sexual health screening in areas where females will see them.8 A primary care trust in Essex has collaborated with a cinema chain to carry posters that promote cervical cytology and chlamydia screening both in the public areas and the women's toilets.9 The 'Jade Goody' effect, where attendance for screening temporarily increased, was well documented around the time the reality television star underwent treatment and subsequently died from cervical cancer in 2009. However, the ongoing impact was short lived and, by mid-2010, there were reports of the effect fading, highlighting the need for more sustained campaigns. Television programmes also take up the mantle occasionally. Coronation Street broached this topic in 2001 with the character of 'Alma', who found she had inoperable cervical cancer after a missed smear test, and Eastenders recently commenced a cervical cancer storyline with one of the main characters, 'Tanya'.

The internet is an amazing tool, full of excellent resources; but it is also a great source of potential misinformation. Nurses can familiarise themselves with the evidence-based resources, not only for their own education but also to be able to recommend appropriate resources to women providing more information and increasing confidence when attending for screening. 

Diverse groups
We live in a diverse society where many groups of people will have varying needs. A practice profile will help the primary care nurse in ensuring, for example, that an appropriate range of leaflets are available in different languages. It will also help meet the needs of, and promote uptake in, groups such as women with a learning disability or visual impairment. The needs of diverse groups may require consideration on an individual basis to ensure access for all.

HPV vaccination
Many women will be aware of the HPV vaccination campaign as they receive notification for their daughter's vaccination. There is an opportunity to impart messages about screening via this route as well.

Call-recall systems
The national call-recall system ensures that every woman who is registered with a GP receives an invitation at the appropriate time. General practice nurses can further support this by ensuring notes are flagged in cases of non-attendance, and taking the opportunity to remind women and promote attendance through personal invitations and offering opportunistic screening, where appropriate.

Review of the attendance statistics for the practice can highlight where uptake is low and identify potential solutions. For example, it is documented that women with a learning disability have a lower uptake of cervical screening. There may be many factors involved, such as not understanding the reason for the test, fear of the unknown or assumptions on the part of carers and health professionals about sexual activity and screening. Auditing the uptake of screening for the practice and then breaking this down into groups and areas can provide the necessary data to target particular groups and provide services that meet their needs.

Such strategies may identify the need for additional staff training to promote the screening agendas. On a wider scale, if an area displays significantly low uptake, there may be a need to look at targeted outreach projects for particular women's groups.
 
Conclusion
The National Cervical Screening Programme is a leading example of how lives can be saved through effective promotion of the benefits of screening for women. Its success depends on a number of factors; but a key activity is that of frontline staff promoting uptake, as well as the larger social marketing campaigns to ensure that women come forward to be screened. Non-attendance may be the greatest risk factor for cervical cancer.

References
1.     Patnick J (ed). NHS Cervical Screening Programme Annual Review 2010. Sheffield: NHS Cancer Screening Programmes; 2010.
2.     Office for National Statistics. Health Statistics Quarterly 33. London: ONS; 2000.
3.     NHS Cancer Screening Programmes. Cervical cancer - incidence, mortality and risk factors. Available from: www.cancerscreening.nhs.uk/cervical/cervical-cancer.html
4.    NHS Cancer Screening Programmes. About cervical screening. Available from: www.cancerscreening.nhs.uk/cervical/index.html#whatis
5.     World Health Organization (WHO). Constitution of the World Health Organisation. Geneva: WHO; 1946.
6.     World Health Organization (WHO). Health Promotion Glossary. Geneva: WHO; 1998.
7.     PapScreen Victoria. Promoting Cervical Screening in your Community. Available from: www.papscreen.org.au/forhealthprofessional/resourcesforhealthprofessiona...
8.     West Midlands Cervical Screening Quality Assurance Reference Centre/NSMC. What's Pants but Could Save Your Life? Available from: http://thensmc.com/resources/showcase/whats-pants-could-save-your-life?v...
9.     NHS South East Essex. Big Screen Opportunities at the Odeon. Available from: www.see.nhs.uk/news/newsitem.asp?news_id=14

Resources
Jo's Cervical Cancer Trust  www.jostrust.org.uk
Lab Tests Online  www.labtestsonline.org.uk
NHS Cancer Screening Programme  www.cancerscreening.nhs.uk
NHS Choices  www.nhs.uk