Three years ago, I was asked to write a report on the possible reasons behind low screening rates for cervical cancer here in the UK. Although it feels very amateur compared to my knowledge now, I was so proud of my 98% grade, but most importantly, I feel that it needs to be shared.
‘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
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.
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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
·
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).
·
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.
·
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.
·
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.
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Drug Safety Update Oct 2010, vol 4 issue 3: H2.
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Fishbein,
M., & Ajzen, I. (1975). Belief, Attitude, Intention, and Behavior: An
Introduction to Theory and Research. Reading, MA: Addison-Wesley.
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Madden, A (1992) ‘A comparison of the theory of planned behaviour and
the theory of reasoned action’, Personality
and Social Psychology Bulletin, 18
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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
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Terry, B (1993), The Theory of
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