‘It would be easy to give the public information and hope they change behaviour but we know that doesn’t work very satisfactorily. Otherwise, none of us would be obese, smoke or drive like lunatics’.

– Ian Potter. Director of New Zealand Health Sponsorship Council. NZ

Introduction

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Cervical screening identifies abnormal cells in the cervix. Early detection and treatment prevents ¾ of cancers developing. According to Cancer Research UK, this is the second most common cancer in women under 35. Regular cervical screening is the best way to identify abnormal cell changes in the cervix. Following the introduction of the national HPV vaccination programme in 2008, the NHS cervical screening programme continues to play an important role in checking women between the ages of 25 and 64 for early-stage cell changes.

Screening for cervical cancer, or HPV, has consistently shown to be effective in reducing the mortality rate due to cervical cancer. However, cervical screening attendance rates are still far from satisfactory in many countries. Following a period of consultation and information-gathering, the team have identified factors which influence attendance rates for cervical cancer screening.

Factors identified included knowledge of the disease itself and the importance of screening; emotions such as fear/confidence/denial; access and availability; ignorance and embarrassment; and clerical errors.

Image 1 – Reasons for low attendance. (NHS)

According to the British Medical Journal, until recently, one of the main obstacles for women participating in the cervical screening programme was administrative errors, mainly, incorrect contact details. This has been tackled by the payment incentive for GP’s. GP’s pay depends on the proportion of women aged 20-64 screened. The more women that are screened, the better the payment to the GP. This incentive suggests that the main reason women miss screening is due to the Doctors, however this may not be entirely the case.

In November 2011, a charity called Jo’s Trust produced new figures showing that one in five women don’t take up their invitations to have smear tests and looking more closely, one in three don’t turn up in under 35’s. Reasons that Jo’s Trust found for this are a lack of flexibility with employers, embarrassment of having to explain the absence from work, and lack of appointment choices.

The theory of reasoned action was developed by M. Fishbein and I. Ajzen, with it’s key application being to predict behaviour, attitude and behavioural intention, through their attitude toward said behaviour, and how they believe others would perceive them if they exhibited that behaviour. Relating this theory to the current situation, we must take into account the women’s attitude, subjective norms and their behavioural intention. Their attitude depends on the individual themselves and how important they consider cancer screening to be. Their attitude may also be one of ignorance, not wanting to know the outcome for fear of being told they have a life threatening disease. With subjective norms, these can highly influence decision making. If their mother recently had a screening and it was negative, they may feel there is no point them being tested, and vice versa with a positive result. Behavioural intention relates to attitude and social norm, to influence intention levels. It is basically the weight you place on the previous aspects, which in turn lead to a decision to attend or not attend screening (Fishbein et al, 1975).

Ajzen (1975) continued to revise the theory of reasoned action, and introduced the theory of planned behaviour. This theory originated from the self-efficiency by Bandura (1997). Bandura (1997) considered this the most important precondition for changes in behaviour du8e to the fact that it determines the initiation of copying behaviour. He defined self-efficiency as the conviction that one can successfully execute the behaviour required to produce the outcomes. This led to outcome expectancy, which was an estimation of the behaviour leading to outcomes. Applying this theory to the current case, it may aid us when explaining why there is a decrease in attendance. Self-efficiency is responsible for the attendance excuse of lack of transport. Attendance relies on the individual’s execution of the behaviour of planning to attend, which would in turn lead to the attendance.

Rutter (2010) discovered a 10% increase in attendance rates if women planned their attendance. Another explanation relates to outcome expectancy – the woman’s perceived belief that the reasons to attend outweigh reasons not to attend, in other words, the effectiveness of the preventative behaviour will effectively reduce the vulnerability to a negative outcome. Finally, social influence – the individuals consideration of expectance from friends and family, may explain an increase of attendance in 2009. This was the time that Jade Goody was in the media every day, up until her untimely death due to cervical cancer. The fear associated with this media panic affected peoples decision, having seen the consequences of not catching a problem quick enough. However, the attendance rates decreased since, suggesting that maybe the fear turned opinions from wanting to check themselves out, to ignoring the problem as it’s not a priority now.

Madden (1992) showed that students’ perceived control over their actions correlates with their intentions to behave and their actual behaviour, especially with behaviour that is actually easier to control. Terry (1993) applied the theory of planned behaviour to the issue of safe sex, and found that the degree of control that people believe they have substantially improves the prediction of behaviour from attitudes in this real world context. These theories could help to explain why women miss the appointments. If they have the intention of going, they will make the effort to go. If they book an appointment with no intention of going, they will most probably not go.

Bonelli et al (1996) found reasons women gave for not participating in the screening programme included lack of knowledge about the importance of the test, as well as considering the test to be of no benefit, considering themselves not to be at risk and a fear of embarrassment or pain. There was also an uncertainty pinpointed, as to whether the smear test is appropriate for certain age groups such as postmenopausal women, and also a link was found between low screening rates and ethnic-minority women, such as those of Asian origin.

No matter how important something is, if it causes embarrassment, stress or anxiety, people are less likely to continue. The trouble with medical appointments is that they are formally written by a stranger, from a hospital, requesting your attendance for something which most people admittedly, by choice, don’t really want to put themselves through. Many women have explained how the whole process leading up to the examination is very structured, formal and doesn’t allow for people to express their worry – they either have to turn up or not.

Bonelli also indicated a lack of understanding of an abnormal smear result in women. Although this result does not mean an existing cancer has been detected, it does indicate further testing is required to prevent a cancer forming. Bonelli found that women given an abnormal smear result were likely to believe they have cancer, therefore the worry of receiving such as result put them off having the test in the first place, when in reality, this result only suggests the presence of pre-cancerous cells.

Many women feel uncomfortable with male Doctors examining them and request the smear test done by a female. However, this cannot always be done, and is it likely that women will miss the appointment because of this. Campbell et al (1996) found that if women express this preference, assurance that this is possible will effectively increase the number of women who participate.

Another reason for low screening rates indentified was ignorance. The Health Belief Model (Becker et al, 1987) found behaviour towards screening depends on the patients motivation and beliefs about the likelihood of it affecting them and the severity of the illness. He also identified a need for the benefits of screening to outweigh the cost of the participation – is it worth it? Part of the study revealed an interesting concept that women who believe their health is in their hands were more likely to attend screening, as opposed to those who believed their health was down to chance.

New Challenges

In September 2008, a National programme was implemented to vaccinate girls aged 12-13 against the HPV virus, as well as a catch-up jab for 14-17 year olds. This is done through schools, and consists of 3 injections given over a 6 month period.

The idea behind this is to prevent children developing HPV before they become sexually active, hence the young age groups targeted (NHS 2010).

This is a great idea, as it helps to warn young girls of the importance of being tested and of the risks involved in not taking part. It is also a requirement that a parent/guardian signs a consent form. This indirectly informs the parents of the risks of the illness, and may, although there is no evidence to suggest so to date, encourage mothers, sisters and grandmothers to get tested too.

Conclusion

Strategies, health promotion and education programs need to be developed with clear evidence of the causes and factors relating to the low attendance rate.

Health promotion efforts need to focus on increasing women’s knowledge on risk factors and enhancing their perceived health control by providing more information on the link between screening and early detection with lower mortality rates.

It is also important not to scare women into taking the test. The evidence seems to suggest that a more positive approach would be to lessen the focus on the death aspect, and focus more on a ‘quick test that gives you peace of mind’. This would also appeal to people who miss appointments due to other commitments.

Also, it is a well known fact that money is a great encouragement. With such things as dental surgeries, if the patient does not turn up, they are still liable for the charge. This could be a good idea, to encourage women to keep their appointments. However, it does run the risk of deterring them from making the appointment in the first place.

As the results show, low attendance rates seem to be due more to the individuals than the National Health Service’s input. However, it does not mean it is less important. By changing the way they go about advertising the screening and promoting awareness, they can in turn change people’s opinions to the whole concept of being tested. By making it more available, with more opportunity to make flexible appointments, we would expect to find a dramatic decrease in the number of missed appointments.

To combat the problem of embarrassment when taking the time off from employment, we could implement the use of Doctor’s letters to employers explaining an ‘important medical exemption’ is needed for that period of time. This takes the pressure off the employee having to explain where she is going and makes the whole situation more formal.

The national implementation of the HPV vaccine in schools has been successful to date, however there have also been instances of missed appointments when it comes to follow ups. The HPV vaccine is given as a set of 3 separate injections, 3 months apart. Due to this, there is a higher possibility that girls miss one of more of these. This could be tackled using a more structured approach. Perhaps the students are given points, or some form of reward, when they have attended all 3. This would encourage them to return. It also needs reiterating to them the importance of having all 3, as they may have the first jab and then assume it won’t matter if they miss one.

All in all, the answer to how to increase the number of women who attend screening is not black and white. All the factors explained in this case study need to be looked at and manipulated to have a more positive approach. The main problem seems to be a lack of knowledge on the patient’s part. It is then up to GP’s and the NHS to increase awareness, without scaring women but also without lessening the sense of importance of the screening. As the process continues, obstacles such as the flexibility for appointments need changing, such as an online screening sign up where women could pick appointments that suit them from a database of available times. They key seems to be making sure the patient feels in control of the situation, whilst being fully aware of all aspects involved.

References

1. Bandura, A. (1994). Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopedia of human behavior (Vol. 4, pp. 71-81). New York: Academic Press. (Reprinted in H. Friedman [Ed.], Encyclopedia of mental health. San Diego: Academic Press, 1998).

1. Becker MH, Rosenstock IM. (1987) Comparing social learning theory and

the health belief model. In: Ward WB (ed.). Advances in Health

Education and Promotion. Greenwich, CT: JAI Press.

1. Bonelli L, Brance M, Ferreri M, et al. (1996) Attitude of women towards

early cancer detection and estimation of the compliance to a screening

program for cervix and breast cancer. Cancer Detect Prev

20: 342-352.

1. Campbell H, MacDonald, S, McKiernan M. (1996) Promotion of cervical

screening uptake by health visitor follow-up of women who repeatedly

failed to attend. J Publ Hlth Med; 18: 94-97.

1. Drug Safety Update Oct 2010, vol 4 issue 3: H2.

1. Fishbein, M., & Ajzen, I. (1975). Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley.

1. Jo’s Cervical Cancer Trust (2011), Cervical Cancer, The Facts. Retrieved from http://www.familymealtime.org

1. Madden, A (1992) ‘A comparison of the theory of planned behaviour and the theory of reasoned action’, Personality and Social Psychology Bulletin, 18

1. Sasieni PD et al. (1996) Estimating the efficacy of screening by auditing smear histories of women with and without cervical cancer. The National Co-ordinating Network for Cervical Screening Working Group. British Journal of Cancer, 73 (8), 1001-5.

1. Terry, B (1993), The Theory of Reasoned Action: Its Application to Aids-Preventive Behaviour, Pergamon

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