Predictors of non-participation in cervical screening in Denmark

Educational inequalities in cervical cancer screening participation in 24 European countries

OBJECTIVES

Cervical cancer screening (CCS) is an important public health measure for early detection of cervical cancer and prevents a large proportion of cervical cancer deaths. However, participation in CCS is relatively low and varies substantially by country and socio-economic position. This study aimed to provide up-to-date participation rates and estimates on educational inequalities in CCS participation in 24 European countries with population-based CCS programmes.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Using data from the European Health Interview Survey (EHIS) conducted in 2019, 80,479 women aged 25-64 years were included in the analyses. First, standardized participation rates and standardized participation rates by educational attainment were calculated for all 24 countries based on each country-specific screening programme organization. Second, a series of generalized logistic models was applied to assess the effect of education on CCS participation.

RESULTS

Screening participation rates ranged from 34.1% among low-educated women in Romania to 97.1% among high-educated women in Finland. We observed that lower-educated women were less likely to attend CCS than their higher-educated counterparts. Largest educational gaps were found in Sweden (odds ratio [OR] = 6.36, 95% confidence interval [CI] = 3.89-10.35) and Poland (odds ratio = 5.80, 95% CI = 4.34-7.75).

CONCLUSION

Population-based screening initiatives have successfully reduced participation differences between women with medium and high educational attainment in some countries; however, persistent disparities still exist between women with low and high levels of education. There is an urgent need to increase participation rates of CCS, especially among lower-educated women.

Women's country of birth and failure to catch up an overdue cervical cancer cytological screening participation during pregnancy in France, an observational study based on survey sources

BACKGROUND

Cervical cancer is the fourth most common cancer among women worldwide, both for incidence and mortality. Prevention relies on screening with a Pap test to detect precancerous lesions, which can then be treated. Access to this screening is currently both improvable and inequitable. Pregnancy may be an ideal moment for women to catch up on their overdue cervical cancer screening. In the general population, women's risk of not being screened is associated with their place of birth and other social factors; this may be true as well among pregnant women. Our objective was to study the association between women's place of birth and their failure to catch up with this screening during pregnancy.

METHODS

The 2016 French National Perinatal Survey included 13,147 women who gave birth after 21 weeks of gestation. The association between their place of birth and failure to catch up on this screening (defined by the absence of a Pap test during pregnancy for women overdue for it) was adjusted for age, parity, education level, health insurance, and when they began prenatal care with logistic regression models.

RESULTS

Among the women for whom screening was then recommended, 49% were not up to date at the start of pregnancy, and of these, 53% were not caught up before delivery. After adjustment for other risk factors, maternal place of birth was not associated with a higher risk of failure to catch up with this screening during pregnancy. However, factors identified as associated with this risk included a low education level and late start of prenatal care.

CONCLUSION

About half of women overdue for cervical cancer screening did not catch up with it during their pregnancy. Professionals should pay special attention to women with lower education levels and late initiation of prenatal care, who constitute a group at high risk of not catching up on this screening during pregnancy.

"Well, that Was Pretty Clever!"-Ethnic Minority Women's Views on HPV Self-Sampling Devices for Cervical Cancer Screening: Attitudes to Brushes, First-Void Urine, and Menstrual Blood Devices

BACKGROUND

Ethnic minority women are less likely to participate in cervical cancer uteri (CCU) screening compared to native women. Human Papillomavirus (HPV) self-sampling kits for CCU screening may be a potential strategy to increase participation. This study aimed to explore views and attitudes on four different types of self-sampling kits (two brushes, a first-void urine device, and a menstrual blood device) among non-Western ethnic minority women living in Denmark.

METHODS

The study was a social science single case study based on focus group interviews with 30 women aged 32-54 with non-Western background from a deprived area. A phenomenological approach was applied to describe the phenomenon "self-sampling" as seen from the women's lifeworlds. The interviews were transcribed verbatim and analysed using systematic text condensation.

RESULTS

The women expressed significant interest in the possibility of using HPV self-sampling kits as an alternative to being screened by their general practitioner. They were particularly motivated to use the non-invasive self-sampling kits for CCU screening as they were deemed suitable for addressing cultural beliefs related to their bodies and virginity. The women expressed interest in the use of the invasive self-sampling kits but were cautious, primarily due to lack of confidence in correctly performing self-sampling with a brush and due to cultural beliefs.

CONCLUSION

The use of non-invasive self-sampling kits, such as a first-void urine collection device and menstrual blood pad, represents a promising solution to overcome cultural barriers and promote greater equality in CCU screening participation among non-Western ethnic minority women.

Social factors and age play a significant role in cervical cancer and advanced-stage disease among Danish women

BACKGROUND

For cervical cancer (CC), the implementation of preventive strategies has the potential to make cervical cancer occurrence and death largely avoidable. To better understand the factors possibly responsible for cervical cancer, we aimed to examine possible differences in age and social parameters as well as screening status between women with low- or high-stage cervical cancer and matched controls.

METHODS

Through the Danish Cancer Registry (DCR), women diagnosed with cervical cancer in Denmark between 1987 and 2016 were included. These were age- and residence-matched in a 1:5 ratio with controls from the general female population. The study population was sub grouped into a low-stage subpopulation with women with early-stage cervical cancer and matched controls and a high-stage subpopulation with women with late-stage cervical cancer and matched controls. Age and social parameters were compared within the subpopulations as well as between low- and high-stage cases. For part of the study population, screening attendance was examined to compare differences in adherence.

RESULTS

Overall, we found that the risk of cervical cancer is significantly increased in socially disadvantaged women and not least non-attenders in screening. Interestingly, the high-stage subpopulation was significantly older than the low-stage subpopulation (p < 0.001), and when examining the impact of age further, we found that for cervical cancer cases, the risk of having low-stage disease decreases significantly with increasing age, whereas the risk of having high-stage disease increases significantly with increasing age. In the screening cohort, significantly less cases than controls were attenders in screening with the most pronounced differences seen in the old subpopulation (women aged 50-64 years) and in the high-stage subpopulation (p-values all < 0.001). Interestingly, when examining the risk of CC for attenders and non-attenders, we demonstrated that many social parameters continue to influence the risk of cervical cancer, even in women attending screening.

CONCLUSIONS

Older women, socially disadvantaged women, and non-attenders in screening are particularly vulnerable in terms of developing cervical cancer, especially high-stage disease. Therefore, improvements in the participating rate in screening as well as a revision of the current screening guidelines are needed.

Untreated cervical intraepithelial neoplasia grade 2 and subsequent risk of cervical cancer: population based cohort study

OBJECTIVE

To describe the long term risk of cervical cancer in women with untreated (that is, undergoing active surveillance) or immediately treated cervical intraepithelial neoplasia grade 2 (CIN2).

DESIGN

Nationwide population based historical cohort study.

SETTING

Danish healthcare registries.

PARTICIPANTS

Women with CIN2 diagnosed in 1998-2020 and aged 18-40 years at diagnosis, who had either active surveillance or immediate treatment with large loop excision of the transformation zone (LLETZ). Women with a previous record of CIN2 or worse or LLETZ were excluded.

MAIN OUTCOME MEASURE

A Weibull survival model for interval censored time-to-event data was used to estimate the cumulative risk of cervical cancer. Inverse probability treatment weighting was used to adjust estimates for age, index cytology, calendar year, and region of residence.

RESULTS

The cohort included 27 524 women with CIN2, of whom 12 483 (45%) had active surveillance and 15 041 (55%) had immediate LLETZ. During follow-up, 104 cases of cervical cancer were identified-56 (54%) in the active surveillance group and 48 (46%) in the LLETZ group. The cumulative risk of cervical cancer was comparable across the two groups during the active surveillance period of two years. Thereafter, the risk increased in the active surveillance group, reaching 2.65% (95% confidence interval 2.07% to 3.23%) after 20 years, whereas it remained stable in the LLETZ group at 0.76% (0.58% to 0.95%).

CONCLUSIONS

Undergoing active surveillance for CIN2, thereby leaving the lesion untreated, was associated with increased long term risk of cervical cancer compared with immediate LLETZ. These findings show the importance of continued follow-up of women having active surveillance.

Effect of Test History at Ages 50-64 on Later Cervical Cancer Risk: A Population-based Case-control Study

As life expectancy increases, the effectiveness of cervical cancer screening programs needs to be reassessed for the older population. We addressed the effect of test history in and outside organized screening at age 50-64 years on later cervical cancer risk. A case-control study was conducted by deriving 229 cases of 65-79 years old women with invasive cervical cancer in 2010-2019 from the Finnish Cancer Registry. Ten controls were matched for each case by birth year and hospital district. The effect of test uptake and abnormal results in 50-64 year olds on cancer risk was investigated using conditional logistic regression and adjusted for self-selection. Test uptake within the 50-64 years age group showed 75% lower odds of cervical cancer [adjusted OR (aOR) = 0.25; 95% confidence interval (95% CI), 0.18-0.35]. Untested women had 4.9 times higher odds than those tested with normal results (aOR = 4.86; 95% CI, 3.42-6.92). Having at least one abnormal test result increased the odds by 2.5 when compared with only normal results but showed lower odds when compared with untested women. The importance of testing is exhibited by the result showing a reduction of odds of cancer to one-fourth for those tested compared with untested. Similarly, receiving abnormal results was protective of cancer compared with having no tests highlighting the importance of proper follow-up. Therefore, screening history should be considered when further developing cervical cancer screening programs with special interest in non-attenders and those receiving abnormal results at older ages.

Significance

To our knowledge, this is the first study from Finnish data describing the effect of test history on later cervical cancer at older ages. Focusing on the cervical tests taken within the Finnish national screening program and outside it highlights the overall importance of having cervical tests and adds this study into the slowly increasing number of studies considering all cervical testing in Finland.

Socioeconomic, lifestyle and biological determinants of cervical screening coverage: Lolland-Falster Health Study, Denmark

BACKGROUND

Cervical cancer is preventable. Screening is important for early detection. However, even in high-income countries, coverage is sub-optimal. We identified socioeconomic, lifestyle and biological determinants of cervical screening coverage.

METHODS

In Denmark, women aged 23-64 are free of charge personally invited to screening. All cervical cell samples are registered centrally in the Patobank. We linked data from the Lolland-Falster Health Study (LOFUS) with Patobank data. LOFUS was a population-based health survey undertaken in 2016-2020. With logistic regression, coverage defined as ≥1 cervical sample registered within a 6-year period from 2015 to 2020 was compared across levels of risk factors expressed as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

Among 13 406 women of screening aged 23-64 and invited to LOFUS, 72% had ≥1 cervical sample registered. Non-participation in LOFUS was a strong predictor of low coverage; aOR 0.32; 95% CI 0.31-0.36. Among LOFUS participants, education was a strong predictor of coverage in univariate analysis, OR 0.58; 95% CI 0.48-0.71, but this association disappeared in multi-variate analysis, aOR 0.86; 95% CI 0.66-1.10. In multi-variate analysis, predictors of low coverage were high age, living without a partner, retired, current smoker, poor self-rated health, elevated blood pressure and elevated glycated haemoglobin.

CONCLUSIONS

Women with low cervical screening coverage had limited contact to healthcare, exemplified by non-participation in LOFUS, and pertinent health and social problems, exemplified by elevated blood pressure and glycated haemoglobin, poor self-rated health, and retirement already in screening age. Structural changes in screening are needed to reach non-screened women.

Barriers to adherence to cytology exam: a case study in low-income Colombian women

BACKGROUND

Cervical cytology is essential for the early detection of cervical cancer. However, in Colombia, only 50% of women with subsidized health insurance were screened in 2019, compared to 100% of women with contributory insurance. This disparity highlights significant barriers that must be addressed. This study aimed to identify the factors that contribute to or hinder adherence to cervical cytology screening among low-income women with subsidized health insurance in a public primary care network in Cali, Colombia, from 2014 to 2018.

METHODS

In a qualitative case study, the experience of women and health care and administrative personnel was recovered. Forty-seven women participated in seven focus group discussions. Five other women using the program participated in in-depth interviews. Finally, we interviewed eight people from the healthcare area and the health services administration. The qualitative data collected underwent content analysis, guided by the theoretical framework of Social Determinants of Health. Within this framework, five interconnected dimensions that influence adherence were incorporated.

RESULTS

Adherence is a multifactorial phenomenon, and in relation to attendance at cervical cytology, the analysis delved into the mechanisms that affect it in a low-income context. Barriers to adherence were identified across multiple dimensions, including social and economic factors, health conditions, and patient-related factors, among both adherent and non-adherent women. Among adherent women, barriers and facilitators related to the healthcare team and system, as well as patient-related factors, were identified.

CONCLUSIONS

The findings of this research can be useful in developing personalized interventions and strategies to improve adherence and screening outcomes in low-income settings. It is necessary to increase the resources of health insurance entities to establish effective communication channels with women who attend the cervical cancer prevention program.

Participation in Population Health Interventions by Older Adults in Poland: Barriers and Enablers

BACKGROUND

The participation of older adults in population health interventions constitutes a key factor in their physical, mental and social health. The aim of this study was to determine variables considered as enablers and barriers to participation in health programmes.

METHODS

The conceptual framework of the study was developed and population health interventions were operationalised as health programmes. A total of 805 older adults participated in a questionnaire survey. The questionnaire included questions about socio-demographic, health and social connectedness-related factors as well as participation in population health interventions/programmes. Multiple logistic regression was used to examine the relationship between respondents' characteristics and participation in the intervention.

RESULTS

Participation in health programmes was declared by 316 respondents. The enablers of participation were general practitioner's affability (OR = 2.638 [1.453-4.791], p = 0.001), three or more social activities (OR = 3.415 [1.477-7.894], p = 0.004), taking part in support groups (OR = 4.743 [1.255-17.929], p = 0.022) and involvement in Universities of the Third Age (OR = 2.829 [1.093-7.327], p = 0.032). The barriers were primary education (OR = 0.385 [0.215-0.690], p = 0.001), infrequent general practitioner's appointments (OR = 0.500 [0.281-0.888], p = 0.018) and lack of social activity (OR = 0.455 [0.299-0.632], p < 0.001).

CONCLUSION

The enablers of participation appeared to solely include variables regarding health service utilisation, patient experience and social activity, i.e., interpersonal and community relationships, not intrapersonal factors.

Inequalities in reported use of cervical screening in Estonia: results from cross-sectional studies in 2004-2020

BACKGROUND

Despite the national cervical cancer (CC) screening program established in 2006, the CC incidence in Estonia in 2020 was still one of the highest in Europe. To better understand the possible barriers among women, the aim of this study was to describe the inequalities in the Pap smear uptake trend in 2004-2020 and to analyse the associations between different factors in Estonia.

METHODS

Weighted data of 25-64-year-old women (N = 6685) from population-based cross-sectional studies of Health Behaviour among Estonian Adult Population in 2004-2020 was used. Linear trends in uptake of Pap smear over time were tested using the Cochrane-Armitage test. Binary logistic regression with interactions was performed to analyse associations between the uptake of Pap smear and sociodemographic, socioeconomic, health-related and lifestyle factors. Crude and adjusted odds ratios with 95% confidence intervals were calculated.

RESULTS

Prevalence of lifetime uptake of Pap smear increased in 2004-2020 from 50.6 to 86.7% (P < 0.001). From 2004 to 2020, uptake of Pap smear increased significantly among women aged 25-34, 35-44, 45-54 and 55-64, in both ethnicity groups and among women with basic, secondary and higher education (P < 0.001). The gap in Pap smear uptake increased between Estonians and non-Estonians but decreased between education levels over time. Lower lifetime uptake of Pap smear was associated from sociodemographic factors with younger age, being non-Estonian and single, from socioeconomic factors with lower educational level and unemployment, from health indicators with higher body mass index indicating overweight and obesity, presence of chronic disease and depressiveness, and from lifestyle factors with non-smoking.

CONCLUSIONS

Although Pap smear uptake among 25-64 year old women increased significantly in Estonia in 2004-2020, inequalities were found indicating an opportunity for development of targeted CC prevention strategies.

Supporting the implementation of new healthcare technologies by investigating generalisability of pilot studies using area-level statistics

BACKGROUND

Implementation of new technologies into national health care systems requires careful capacity planning. This is sometimes informed by data from pilot studies that implement the technology on a small scale in selected areas. A critical consideration when using implementation pilot studies for capacity planning in the wider system is generalisability. We studied the feasibility of using publicly available national statistics to determine the degree to which results from a pilot might generalise for non-pilot areas, using the English human papillomavirus (HPV) cervical screening pilot as an exemplar.

METHODS

From a publicly available source on population indicators in England ("Public Health Profiles"), we selected seven area-level indicators associated with cervical cancer incidence, to produce a framework for post-hoc pilot generalisability analysis. We supplemented these data by those from publicly available English Office for National Statistics modules. We compared pilot to non-pilot areas, and pilot regimens (pilot areas using the previous standard of care (cytology) vs. the new screening test (HPV)). For typical process indicators that inform real-world capacity planning in cancer screening, we used standardisation to re-weight the values directly observed in the pilot, to better reflect the wider population. A non-parametric quantile bootstrap was used to calculate 95% confidence intervals (CI) for differences in area-weighted means for indicators.

RESULTS

The range of area-level statistics in pilot areas covered most of the spectrum observed in the wider population. Pilot areas were on average more deprived than non-pilot areas (average index of multiple deprivation 24.8 vs. 21.3; difference: 3.4, 95% CI: 0.2-6.6). Participants in HPV pilot areas were less deprived than those in cytology pilot areas, matching area-level statistics. Differences in average values of the other six indicators were less pronounced. The observed screening process indicators showed minimal change after standardisation for deprivation.

CONCLUSIONS

National statistical sources can be helpful in establishing the degree to which the types of areas outside pilot studies are represented, and the extent to which they match selected characteristics of the rest of the health care system ex-post. Our analysis lends support to extrapolation of process indicators from the HPV screening pilot across England.

Changes in rate and socioeconomic inequality of cervical cancer screening in northeastern China from 2013 to 2018

Objective

Cervical cancer, the fourth leading cancer diagnosed in women, has brought great attention to cervical cancer screening to eliminate cervical cancer. In this study, we analyzed two waves of provincially representative data from northeastern China's National Health Services Survey (NHSS) in 2013 and 2018, to investigate the temporal changes and socioeconomic inequalities in the cervical cancer screening rate in northeastern China.

Methods

Data from two waves (2013 and 2018) of the NHSS deployed in Jilin Province were analyzed. We included women aged 15-64 years old and considered the occurrence of any cervical screening in the past 12 months to measure the cervical cancer screening rate in correlation with the annual per-capita household income, educational attainment, health insurance, and other socioeconomic characteristics.

Results

A total of 11,616 women aged 15-64 years were eligible for inclusion. Among all participants, 7,069 participants (61.11%) were from rural areas. The rate of cervical cancer screening increased from 2013 to 2018 [odds ratio (OR): 1.06; 95% confidence interval (CI): 1.04-1.09, p < 0.001]. In total, the cervical cancer screening rate was higher among participants who lived in urban areas than rural areas (OR: 1.20; 95% CI: 1.03-1.39, p = 0.020). The rate was also higher among those with the highest household income per capita (OR: 1.30; 95% CI: 1.07-1.56, p = 0.007), with higher educational attainment (p < 0.001), and with health insurance (p < 0.05), respectively. The rate of cervical cancer screening was also significantly associated with parity (OR: 1.62; 95% CI: 1.23-2.41, p = 0.001) and marital status (OR: 1.45; 95% CI: 1.15-1.81, p = 0.001) but not ethnicity (OR: 1.41; 95% CI: 0.95-1.36, p = 0.164).

Conclusion

Cervical cancer screening coverage improved from 2013 to 2018 in northeastern China but remains far below the target 70% screening rate proposed by the World Health Organization. Although rural-urban inequality disappeared over time, other socioeconomic inequalities remained.

Lessons Learnt From Pilot Cervical Cancer Screening and Treatment Programmes Integrated to Routine Primary Health Care Services in Benin, Cote d'Ivoire, and Senegal

PURPOSE

The project aimed to implement pilot screening and treatment services for cervical cancer integrated with existing primary health centers (PHCs) in Benin, Cote d'Ivoire, and Senegal and evaluate these services using implementation research outcomes such as reach, effectiveness, adoption, and acceptability.

MATERIALS AND METHODS

The Ministry of Health in each country took the lead in setting up a stakeholder's group that designed a protocol tailored to the local context. The target age was 25-49 years in Benin and Cote d'Ivoire and 30-49 years in Senegal. Visual inspection with acetic acid (VIA) was the screening test, and thermal ablation (TA) was the ablative treatment of choice in all. The Ministry in each country identified 4-5 PHCs to set up screening and ablation services and one higher-level center for colposcopy referral. After a master-trainer led training program, nurses, midwives, or general practitioners screened opportunistically the eligible women attending the clinics. The VIA-positive women eligible for ablation were offered immediate treatment.

RESULTS

Between May 2018 and January 2021, 16,530 women were screened opportunistically. VIA positivity was 8.1% with huge variability within and between countries. Sixty-one percent of all VIA-positive cases were eligible for immediate TA, and 88% of them accepted same-day treatment. Compliance to TA at PHCs was 99%. Majority of women treated with TA complained of minor side effects. Significant dropouts occurred as the women were referred to colposcopy clinics.

CONCLUSION

Opportunistic screening provided as part of routine PHC service can screen many women and treat a significant proportion of screen-positive women with TA with minimal side effects. Primary concerns are the hard-to-reach women who remain out of opportunistic screening coverage and noncompliance of the screen-positive women referred to higher-level centers.

Assessing how routes to diagnosis vary by the age of patients with cancer: a nationwide register-based cohort study in Denmark

BACKGROUND

Older patients with cancer have poorer prognosis compared to younger patients. Moreover, prognosis is related to how cancer is identified, and where in the healthcare system patients present, i.e. routes to diagnosis (RtD). We investigated whether RtD varied by patients' age.

METHODS

This population-based national cohort study used Danish registry data. Patients were categorized into age groups and eight mutually exclusive RtD. We employed multinomial logistic regressions adjusted for sex, region, diagnosis year, cohabitation, education, income, immigration status and comorbidities. Screened and non-screened patients were analysed separately.

RESULTS

The study included 137,876 patients. Both younger and older patients with cancer were less likely to get diagnosed after a cancer patient pathways referral from primary care physician compared to middle-aged patients. Older patients were more likely to get diagnosed via unplanned admission, death certificate only, and outpatient admission compared to younger patients. The patterns were similar across comorbidity levels.

CONCLUSIONS

RtD varied by age groups, and middle-aged patients were the most likely to get diagnosed after cancer patient pathways with referral from primary care. Emphasis should be put on raising clinicians' awareness of cancer being the underlying cause of symptoms in both younger patients and in older patients.

A walk-in clinic as an alternative approach to reaching non-attenders of the cervical cancer screening program in the North Denmark region-a pilot study

INTRODUCTION

Up to 39% of women in Denmark do not participate regularly in the cervical cancer screening program and initiatives to increase participation are called upon. The primary aim of this study was to describe previous screening history and characteristics of women attending screening in a walk-in clinic. Furthermore, we wanted to investigate barriers to cervical cancer screening.

MATERIAL AND METHODS

We designed a walk-in clinic that was open 2 days a week from 16.00 to 19.00 h, located in the Departments of Gynecology in the two main hospitals of the North Denmark Region. The main purpose of the clinic was cervical cancer screening and the study period was 5 months. Women who were not eligible for screening or had other health complaints were referred to their general practitioner. The women included in the study, filled out a questionnaire regarding educational and occupational status; their screening history was registered using data from the Danish Pathology Register.

RESULTS

During the study period, 255 women visited the walk-in clinic. The final study population consisted of 249 women who met the inclusion criteria. Age range of participants was 23-77 years, with a median age of 45 years. The majority of the participants were currently employed (81%) or students (10%), the remaining being retired (5%) or unemployed (4%). Screening history showed that 138 (55.4%) of the women were on time for the screening or delayed less than 6 months compared to their recommended screening interval. Sixty-one women (24.5%) were delayed >6 months but <2 years. Fifty women (20.1%) were classified as non-attenders, with more than a 2-year delay in their screening. In the group of non-attenders, eight women had never been screened. Of the remaining 42 women, the median time since last screening was 8.2 years (range 5.0-25.3 years).

CONCLUSIONS

Women attending the walk-in clinic tended to be primarily actively working or students (91%). All age groups in the screening population were represented. Screening history showed that 44.6% had not followed the recommended screening program.

Association of Late Marriage and Low Childbirth with Cervical Cancer Screening among Korean Women: Results from a Nationwide Survey

Simple Summary

Marriage and childbirth may affect adherence to cervical cancer screening. We have examined whether marriage and childbirth were associated with the adherence to cervical cancer screening among young adult women in Korea. Among 3925 women aged 20–39 years, 39.1% undertook cervical cancer screening within two years of eligibility. Compared with unmarried women, married women were more likely to adhere cervical cancer screening (adjusted odds ratio = 2.80, 95% CI: 2.99–3.44). And, as the number of births in married women increased, the adherence to cervical cancer screening increased.

Abstract

This study aimed to identify the association of marriage and childbirth with the adherence to cervical cancer screening among young adult women. Data across four years (2017–2020) of the cross-sectional Korean National Cancer Screening Survey were used. For measuring the adherence to cervical cancer screening, we used the cervical cancer screening rate with recommendation, which was defined as the percentage of women in the population eligible for screening who have had a cervical cancer screening within the past two years. Multiple logistic regression analysis was conducted to identify the association between marriage and adherence to cervical cancer screening. Overall, 3925 women aged 20–39 years were analyzed. Of these, 39.1% were screened for cervical cancer (26.6% unmarried and 57.1% married women). The married women had significantly higher adherence to cervical cancer screening than unmarried women (adjusted odds ratio = 2.80, 95% CI: 2.99–3.44). Compared with unmarried women, adherence to cervical cancer screening was significantly more likely to increase (p for trend, <0.001) in married women with an increased number of births. Our study confirmed that marriage and childbirth influence adherence to cervical cancer screening, suggesting that unmarried women may be vulnerable to cervical cancer.

[Factors associated with access barriers to cervical cancer screening in Yaoundé]

INTRODUCTION

Several studies report that only 10% of Cameroonian women at risk have ever been screened for this disease.

OBJECTIVE

This study aims to analyze the factors explaining the difficulties in accessing screening for cervical cancer in Yaoundé, Cameroon.

METHODOLOGY

This was an analytical cross-sectional study (participed/not participated), conducted from May 1 to August 10, 2020. The study population was made up of two groups (i.e. women without a history of screening; women who benefited from at least one screening session). Data collection was carried out at the gynecology-obstetrics department in two hospitals in Yaoundé (University hospital center and the obstetrics-gynecology and pediatric hospital). Variables were collected using a pre-tested and validated questionnaire. Data were analyzed using SPSS version 20 software. Simple and multiple logistic regression analysis was performed to assess the influence of different variables on the risk of not participating in screening. A difference was considered significant if P &lt; 5%.

RESULTS

Out of 300 women interviewed, 150 had never participated in screening (50%). In multivariate analysis, the factors associated with difficulties in accessing cervical cancer screening were, level of primary education (58,33% vs. 41,67%, [AOR: 5.12 (3.42-7.65)]), lack of employment (69,74% vs. 30,26%, [AOR: 5.44 (3.32-8.92)]), insufficient knowledge (78,64% vs. 21,36%; [AOR: 7.11(5.70-8.88)]) and unfavourable attitude (85,71% vs. 14,29%, [AOR: 5.58 (4.41-7.06)]).

CONCLUSION

There are many factors associated with not being screened. It is therefore necessary to develop strategies to improve access to cervical cancer screening services in Cameroon.

Health outcomes in women attending with clinical guideline PROGYNE to a primary care center for cervical cancer prevention

AIM

The objective of the current study was to analyze the health outcomes of women attending with a clinical guideline to consultations for cervical cancer (CC) prevention in a primary care center.

METHODS

A cross-sectional design was used, and data were collected from March to July 2016 with a sample of 87 women in Fortaleza, Brazil.

RESULTS

The following correlations were found: previous history of sexually transmitted infection (p = 0.025), women who used oral contraceptives (p = 0.035), and undergo the Papanicolaou test annually; having black skin color (p = 0.031) and attending to the first gynecological consultation; being single (p = 0.031), family history of cancer (p < 0.001), and undergoing the first Papanicolaou test within the first 3 years of sexual activity; age up to 30 years and positive colposcopy (p = 0.027); and being single and positive colposcopy (p = 0.021). CC was characterized by the presence of intraepithelial lesion detected on colposcopy (gold standard). Receiver operating characteristic curves were used to evaluate the diagnostic accuracy of visual inspection with Lugol's iodine, digital cervicography, and Papanicolaou test. The area under the curve values were as follows: digital cervicography: 0.558, p = 0.509; Lugol's iodine: 0.491, p = 0.919; and Papanicolaou test: 0.697, p = 0.024.

CONCLUSION

Colposcopy in primary care provided a faster diagnosis of pre-cancerous lesions. Understanding the health outcomes of women who underwent consultations for CC prevention, as well as the screening and diagnosis methods used, is essential to the service and national health system of the less developed countries.

Human Papillomavirus Testing in the Last Cervical Screening Round at Age 60-64 Years

OBJECTIVE

To compare the real-life screening outcomes after cytology was replaced by human papillomavirus (HPV) testing for women aged 60-64 years.

METHODS

Using the Danish national pathology register, we compared screening outcomes during two consecutive calendar periods, one where women were screened with cytology and one where most women were screened with HPV testing. Our primary outcomes were the proportions of women with positive test results, high-grade cervical intraepithelial neoplasia (CIN 2 or worse), and cervical cancer.

RESULTS

Women screened during the HPV testing period were more likely to have a positive screening test result than were women screened during the cytology period (relative proportion 2.80, 95% CI 2.65-2.96). The detection of CIN 2 or worse was also increased (relative proportion 1.54, 95% CI 1.31-1.80), whereas there was no increase in screen-detected cervical cancer diagnoses (relative proportion 1.27, 95% CI 0.76-2.12). Within the first 4 years after a negative screening test result, including 168,477 woman-years at risk after a negative screen result in the HPV period and 451,421 woman-years after a negative screen result in the cytology period, the risk of a cervical cancer diagnosis was approximately 4 per 100,000 woman-years and was similar for both screening tests (relative risk 0.99, 95% CI 0.41-2.35).

CONCLUSION

Human papillomavirus testing led to more positive screening test results and diagnoses of high-grade CIN lesions. Few women were diagnosed with cervical cancer after a negative screening test result.

Cervical testing beyond the screening target age - A register-based cohort study from Finland

OBJECTIVE

It has been proposed that cervical cancer screening should be continued in women with previous abnormal results or irregular attendance. We examined the coverage and factors that might influence cervical testing beyond the age range of the organized cervical screening programme in Finland. The national programme invites women in every five years least until the age of 60. After the stopping age, only opportunistic service is available.

METHODS

Data on cervical testing were collected from the Mass Screening Registry and providers of opportunistic Pap/HPV-testing and were linked with information on socio-economic variables. The study included 373,353 women who had at least one invitation to the national screening programme between ages 50-60 years, and who were aged 65-74 years in the follow-up period 2006-2016. Multivariable binomial regression models were conducted to determine associations.

RESULTS

Altogether 33% of the study population had been tested at least once at ages 65-74 years. Previous regular screening attendance (adjRR 1.70; 95% CI 1.67-1.73) and earlier abnormal results (adjRR 2.08; 95% CI 2.04-2.12) were most clearly related to higher testing adherence at older age. Other factors related to higher testing adherence were urban area of residence, domestic mother tongue, high education level, and high socio-economic status.

CONCLUSION

Testing at older age was frequent with normal results, whereas only a small proportion of women with earlier abnormal results or irregular attendance were tested. The upper age limit of the national programme should be raised to 65 years, and the invitations thereafter should be targeted to selected high-risk groups.

Cervical Cancer Screening Among Immigrant Women Residing in Australia: A Systematic Review

Since the introduction of systematic population-based cervical cancer screening in Australia in 1991, age-standardized incidence of cervical cancer has halved. Given recent advances in human papillomavirus (HPV) vaccination and screening, cervical cancer may be eliminated nationally within 20 years. However, immigrant women are not equitably reached by screening efforts. This study systematically reviewed evidence on cervical cancer screening practices among immigrant women in Australia. A systematic search of MEDLINE, Embase, PubMed, CINAHL, and PsycINFO and gray literature for English language studies published till March 1, 2019, was conducted. Observational and qualitative studies evaluating cervical cancer screening awareness and participation of immigrant women were screened. Of 125 potentially relevant studies, 25 were eligible: 16 quantitative (4 cohort, 12 cross-sectional), 6 qualitative, and 3 mixed-methods studies. Quantitative studies indicated 1% to 16% lower screening rates among migrant women compared with Australian-born women, with participation of South Asian women being significantly lower (odds ratio = 0.54, 95% confidence interval = 0.48-0.61). Qualitative studies illustrated factors affecting women's willingness to participate in screening, including insufficient knowledge, low-risk perception, and unavailability of a female health professionals being key barriers. Future studies should focus on South Asian women, due to recent increase in their immigration.

Investigating the decrease in participation in the Dutch cervical cancer screening programme: The role of personal and organisational characteristics

Declining attendance in the Dutch cervical cancer screening programme was recently observed, coinciding with preparations for implementing primary hrHPV-based screening, which was implemented in January 2017. We aimed to investigate which factors were related to decreased attendance. We conducted a population-based cohort study including all women aged 30 to 60 years who were eligible for screening between 2014 and 2018. Attendance was defined as participation in the screening programme within 15 months of the start of the invitation-eligible year. We used data from the Dutch pathology archive (PALGA) linked with data from Statistics Netherlands to investigate population characteristics (position in the household, household income, socio-economic status, number of people in the household, migration background, age) and data from the five Dutch screening organisations (SO) to investigate the effect of cessing self-inviting GP's ('inviting organisation'). SO's were termed SO 1 to 5. Higher attendance rates were observed in women who were employed (60.8%), married (62.9%), Dutch (61.2%), in the highest income bracket (63.4%), living in households with four persons (65.3%) and women who were invited by their GP (69.8%). Differences in personal characteristics did not explain the decline in attendance rates. By adjusting for whether the GP or the SO sent the invitation, the differences in attendance rates between 2014 and 2015 and 2016 and between 2014 and 2015 and 2017-2018 were explained in some screening organisations. Removing the possibility for GPs to send invitations explains some of the decline in participation, although this did not account for the total change in attendance.

Medication-Induced Oral Hyperpigmentation: A Systematic Review

BACKGROUND

Medication-induced oral hyperpigmentation is an oral condition that impacts patients' quality of life and has been linked to many systemic therapeutic agents. The exact pathogenesis of tissue pigmentation varies greatly and is not completely known. This systematic review aimed to present data on the causal association between medications and the development of oral/mucosal pigmentation as an adverse drug reaction.

METHODS

A systematic review and analysis of literature were conducted using the following databases: PubMed, Science Direct, ProQuest, Web of Science, and Scopus. The systematic review included original articles written in English and published between January 1982 and June 2020. Following the PRISMA statement, eligible articles were systematically reviewed, and data were extracted from eligible studies and analyzed.

RESULTS

A total of 235 articles were identified, of which 57 met the inclusion criteria and were included in this review. The mean age of included patients was 46.2±16.38 years (range: 10-90 years) with a male to female ratio of 1:1.45. Oral mucosal hyperpigmentation was reported following the use of several classes of medications such as antiviral (eg, zidovudine), antibiotic (eg, minocycline), antimalarial (eg, chloroquine), anti-fungal (eg, ketoconazole), antileprotic (eg, clofazimine), antihypertensive (eg, amlodipine), chemotherapeutic, and antineoplastic drugs. The risk of developing oral pigmentation was significantly higher with antimalarial medications, antibiotics, antineoplastic and chemotherapeutic agents. Medication-induced oral hyperpigmentation was most frequent among women and in the hard palate.

CONCLUSION

Future research is warranted to better understand the pathogenesis and risk factors for medication-induced oral hyperpigmentation in order to reassure patients during prescription and management.

Screening participation after a false positive result in organized cervical cancer screening: a nationwide register-based cohort study

Our aim was to investigate whether receiving a false positive (FP) cervical cytology result affected subsequent cervical cancer screening participation. This Danish nationwide register-based cohort study included 502,380 women aged 22.5–45 attending cervical cancer screening in 2012–2014 with a normal (n = 501,003) or FP (n = 1,377) cytology screening result. A FP result was defined as a cervical cytology showing high grade cytological abnormalities followed by a normal or ‘Cervical Intraepithelial Neoplasia grade 1’ biopsy result. Women were categorized as subsequent participants if they had a cervical cytology within 24–42 months after their last screening or surveillance test. We compared subsequent participation among women with a normal versus a FP result, using odds ratios including 95% confidence intervals. Participation was slightly higher among women with FP results than among women with normal results (71.5% vs. 69.2%, p = 0.058). After adjustment for age and screening history, women with FP results participated significantly more than women with normal results (OR: 1.19, 95% CI 1.06–1.35). Women receiving a FP result did not participate less in subsequent cervical cancer screening than women receiving a normal result. In fact, the use of opportunistic screening seemed to be increased among women receiving a FP result.

National organization of uterine cervical cancer screening and social inequality in France

Some of the inequality in uterine cervical cancer (UCC) screening uptake are due to the socioeconomic deprivation of women. A national organized screening programme has proven to be effective in increasing the uptake, but may increase socioeconomic inequality. Therefore, we compared inequality in uptake of UCC screening between two French departments, one of which is experimenting an organized screening programme. We used reimbursement data from the main French health insurance scheme to compare screening rates in the municipalities of the two departments over a three-year period. The experimental department had higher screening rates, but the increase in deprivation in municipalities had a greater effect on the decrease in participation in this department. Moreover, while screening rates were higher in urban areas, the negative effect of deprivation on participation was greater in rural areas. Although these departments were compared at the same time under different conditions, socioeconomic inequality between them may have been greater before the experimentation started. However, screening may have led to an increase in socioeconomic inequality between women screened. Special attention must be paid to changes in socioeconomic and geographic inequality in the uptake of UCC screening when the programme is rolled out nationally.

Non-participation in cervical cancer screening according to health, lifestyle and sexual behavior: A population-based study of nearly 15,000 Danish women aged 23-45 years

High participation in cervical cancer screening is essential for an effective screening program. In this population-based study, we investigated associations between general health, lifestyle and sexual behavior, and non-participation in cervical cancer screening in Denmark. During 2011-2012, a random sample of women aged 18-45 years from the general female population were invited to participate in a survey regarding health, lifestyle and sexual habits. Altogether 18,631 women responded (response rate: 75.1%), of whom 14,271 women aged 23-45 years were included in this analysis. Information on screening participation within four years after response, and data on sociodemographic characteristics, was obtained from nationwide registers. Logistic regression was used to calculate odds ratios (ORs) for non-participation, crude and adjusted for sociodemographic characteristics. Overall, 13.9% of the women were not screened during follow-up. The odds of non-participation was increased in women who were overweight (OR_adj. = 1.20; 95% CI, 1.06-1.35), obese (OR_adj. = 1.46; 95% CI, 1.27-1.67), perceived themselves as much too fat (OR_adj. = 1.50; 95% CI, 1.29-1.74), had poor self-perceived health (OR_adj. = 1.22; 95% CI, 1.03-1.45) or smoked daily (OR_adj. = 1.81; 95% CI, 1.61-2.03). Conversely, women with previous genital warts or other sexually transmitted infections, and young women with ≥10 lifetime sexual partners or ≥2 new recent partners, had decreased odds of non-participation. In conclusion, obesity, poor self-perceived health and daily smoking were associated with lower participation in cervical cancer screening. Interventions targeting these groups are needed.

Social inequalities in cervical cancer screening: a discrete choice experiment among French general practitioners and gynaecologists

BACKGROUND

Cervical cancer screening is effective in reducing mortality due to uterine cervical cancer (UCC). However, inequalities in participation in UCC screening exist, especially according to age and social status. Considering the current situation in France regarding the ongoing organized UCC screening campaign, we aimed to assess general practitioners' (GPs) and gynaecologists' preferences for actions designed to reduce screening inequalities.

METHODS

French physicians' preferences to UCC screening modalities was assessed using a discrete choice experiment. A national cross-sectional questionnaire was sent between September and October 2014 to 500 randomly selected physicians, and numerically to all targeted physicians working in the French region Midi-Pyrénées. Practitioners were offered 11 binary choices of organized screening scenarios in order to reduce inequalities in UCC screening participation. Each scenario was based on five attributes corresponding to five ways to enhance participation in UCC screening while reducing screening inequalities.

RESULTS

Among the 123 respondents included, practitioners voted for additional interventions targeting non-screened women overall (p <  0.05), including centralized invitations sent from a central authority and involving the mentioned attending physician, or providing attending physicians with the lists of unscreened women among their patients. However, they rejected the specific targeting of women over 50 years old (p <  0.01) or living in deprived areas (p <  0.05). Only GPs were in favour of allowing nurses to perform Pap smears, but both GPs and gynaecologists rejected self-collected oncogenic papillomavirus testing.

CONCLUSIONS

French practitioners tended to value the traditional principle of universalism. As well as rejecting self-collected oncogenic papillomavirus testing, their reluctance to support the principle of proportionate universalism relying on additional interventions addressing differences in socioeconomic status needs further evaluation. As these two concepts have already been recommended as secondary development leads for the French national organized screening campaign currently being implemented, the adherence of practitioners and the adaptation of these concepts are necessary conditions for reducing inequalities in health care.

Concurrent participation in screening for cervical, breast, and bowel cancer in England

Objectives

To determine how many women participate in all three recommended cancer screening programmes (breast, cervical, and bowel). During their early 60s, English women receive an invitation from all the three programmes.

Methods

For 3060 women aged 60–65 included in an England-wide breast screening case–control study, we investigated the number of screening programmes they participated in during the last invitation round. Additionally, using the Fingertips database curated by Public Health England, we explored area-level correlations between participation in the three cancer screening programmes and various population characteristics for all 7014 English general practices with complete data.

Results

Of the 3060 women, 1086 (35%) participated in all three programmes, 1142 (37%) in two, 526 (17%) in one, and 306 (10%) in none. Participation in all three did not appear to be a random event (p < 0.001). General practices from areas with less deprivation, with more patients who are carers or have chronic illnesses themselves, and with more patients satisfied with the provided service were significantly more likely to attain high coverage rates in all programmes.

Conclusions

Only a minority of English women is concurrently protected through all recommended cancer screening programmes. Future studies should consider why most women participate in some but not all recommended screening.

Utilization of cervical cancer screening among migrants and non-migrants in Germany: results from a large-scale population survey

BACKGROUND

Studies from European and non-European countries have shown that migrants utilize cervical cancer screening less often than non-migrants. Findings from Germany are inconsistent. This can be explained by several limitations of existing investigations, comprising residual confounding and data which is restricted to only some regions of the country. Using data from a large-scale and nationwide population survey and applying the Andersen Model of Health Services Use as the theoretical framework, the aim of the present study was to examine the role that different predisposing, enabling and need factors have for the participation of migrant and non-migrant women in cervical cancer screening in Germany.

METHODS

We used data from the 'German Health Update 2014/2015' survey on n = 12,064 women ≥20 years of age. The outcome of interest was the participation in cancer screening (at least once in lifetime vs. no participation). The outcome was compared between the three population groups of non-migrants, migrants from EU countries and migrants from non-EU countries. We employed multivariable logistic regression to examine the role of predisposing, enabling and need factors.

RESULTS

Non-EU and EU migrant women reported a lower utilization of cervical cancer screening (50.1 and 52.7%, respectively) than non-migrant women (57.2%). The differences also remained evident after adjustment for predisposing, enabling and need factors. The respective adjusted odds ratios (OR) for non-EU and EU migrants were OR = 0.67 (95%-CI = 0.55-0.81) and OR = 0.80 (95%-CI = 0.66-0.97), respectively. Differences between migrants and non-migrants were particularly pronounced for younger age groups. Self-rated health was associated with participation in screening only in non-migrants, with a poorer health being indicative of a low participation in cancer screening.

CONCLUSIONS

The disparities identified are in line with findings from studies conducted in other countries and are indicative of different obstacles this population group encounters in the health system. Implementing patient-oriented health care through diversity-sensitive health services is necessary to support informed decision-making.

Screening history and FIGO-stages among Danish women with cervical cancer in 2012-2014: a register-based study

The objective was to examine whether attendance in the mass cervical screening programme has implications for the prognosis when cervical cancer is diagnosed. We performed a retrospective analysis of all cases of cervical cancer between 1st of January 2012 and 31st of December 2014 in the Region of Southern Denmark. The cases were retrieved from the Danish National Pathology Registry, PatoBank. Odds ratios (OR) with confidence intervals (95% CI) were calculated for attendees versus non-attendees of the screening programme by using χ2-test. 216 patients were included in the study. 61.6% of the study population had not attended the screening programme. Patients who had attended the programme were characterised by disease in low stage (OR = 3.14, 95% CI; 1.66 to 5.92), treatment with surgery alone (OR = 2.63, 95% CI; 1.49 to 4.64) and a lower risk of death (OR = 0.36, 95% CI; 0.15 to 0.87). Adenocarcinomas were more often detected among attendees of the programme compared to squamous cell carcinomas (OR = 4.06, 95% CI; 2.03 to 8.14). Statistically significant results regarding relapse of cancer (OR = 0.62, 95% CI; 0.23 to 1.68, p = 0.47) and lymph node metastases (OR = 0.62, 95% CI; 0.32 to 1.21, p = 0.19) were not found. Cervical cancer detected in women who had attended the mass cervical screening programme prior to the diagnosis, was shown to have a statistically significant lower FIGO stage (p = 0.0004) and was therefore linked to less extensive treatment options. Continued focus on increasing the participation rate of the programme is of importance, as the nonattendance rate continues to be high.

Non-Adherence To Childhood HPV Vaccination Is Associated With Non-Participation In Cervical Cancer Screening - A Nationwide Danish Register-Based Cohort Study

Background

The combination of organized cervical cancer screening and childhood HPV vaccination programs has the potential to eliminate cervical cancer in the future. However, only women participating in both programs gain the full protection, and combined non-attenders remain at high risk of developing cervical cancer. Our aim was to analyze the association between non-adherence to HPV vaccination and non-participation in cervical cancer screening for the total population and stratified by native background and parental education.

Participants

Women born in 1993 eligible for both childhood HPV vaccination and first cervical cancer screening.

Analysis

Logistic regression models were used to estimate the odds ratio (OR) of non-participation in cervical cancer screening with 95% confidence intervals (CI). Stratified and adjusted logistic regression models were used along with the Wald test in order to test for interaction.

Results

24,828 women were included in the study. Among vaccinated women, 61.4% participated in cervical cancer screening; only 39.0% of unvaccinated women participated in cervical cancer screening. Unvaccinated and unscreened women were often non-native and had the lowest socio-economic status, whereas vaccinated and screened women were often native and had the highest socio-economic status. The adjusted OR for non-participation in cervical cancer screening was 2.07 [95% CI: 1.88–2.28] for unvaccinated compared to vaccinated women. After stratifying by country of origin, unvaccinated natives had the highest adjusted OR of not participating in cervical cancer screening compared to non-native women from both western and non-western countries (adjusted ORs of 2.2 [95% CI: 2.0–2.4], 1.3 [95% CI: 0.6–2.8], and 1.5 [95% CI: 1.1–2.0], respectively) (Wald test p=0.019).

Conclusion

Among natives, non-adherence to HPV vaccination and non-participation in screening seem to be signs of generally poor health-preventive behavior, whereas among non-natives from non-western countries, non-attendance in HPV vaccination and cervical cancer screening seem to be influenced by unrelated factors. Therefore, a differentiated and culturally sensitive approach is needed to enhance overall cervical cancer preventive behavior across different nativities.

Participation in cervical cancer screening among immigrants and Danish-born women in Denmark

In this nationwide register-based cohort study, we examined cervical cancer screening participation among immigrants in Denmark by country and region of origin. Furthermore, we assessed whether differences in screening participation between immigrants and Danish-born women were explained by sociodemographic or health-related characteristics, and examined predictors of participation among immigrants. Using high-quality registries, we identified women invited for cervical cancer screening during 2008-2009 and retrieved individual-level data on sociodemographic-, health- and immigration-related characteristics. A total of 610,907 women were followed for up to 2.9 years after screening invitation. We estimated the probability of participation using the Aalen-Johansen estimator and the hazard ratios (HRs) of participation using Cox regression. The probability of participation within follow-up was 74.5% (95% CI, 74.4%-74.6%) in Danish-born women; 61.2% (95% CI, 60.4%-62.1%) in Western immigrants; and 61.3% (95% CI, 60.9%-61.8%) in non-Western immigrants. Participation in immigrants varied by region of origin from 44.3% (95% CI, 41.4%-47.4%) in immigrants from North America, New Zealand and Australia to 67.8% (95% CI, 65.4%-70.3%) in immigrants from South- and Central America. Substantial variation was seen between specific countries of origin. Differences in participation between immigrants and Danish-born women were not explained by sociodemographic or health-related characteristics. Predictors of low participation in immigrants included lower income, unemployment, being unmarried, having a history of schizophrenia or other psychoses, and ≤5 years' stay in Denmark. In conclusion, cervical cancer screening participation in immigrants varied by region and country of origin, but all immigrant groups had lower participation than Danish-born women.

Differential Impact of Education Level, Occupation and Marital Status on Performance of the Papanicolaou Test among Women from Various Regions in Brazil

Background:

In Brazil, little is known regarding the underlying causes of differences among populations regarding socio-economic variables that affect women’s cervical cancer screening behavior. The present study focused on socio-economic variables that affect women’s performance of the Papanicolaou test, comparing two distinct Brazilian populations.

Methods:

We collected data regarding performance of the Papanicolaou test and socio-economic variables from 559 women in Mato Grosso do Sul (MS), in the Central East region, and 338 women in Paraíba (PB), in the Northeast region of Brazil. Nominal logistic regression modeling was performed to identify independent variables for both groups of data.

Results:

Of the women interviewed from MS and PB, 116 out of 599 (19.37%) and 94 out of 338 (27.81%), respectively, had not performed the Papanicolaou test within the last three years (p = 0.025). Low educational level characterized 570 (95.16%) and 203 (60.06%) of women from MS and PB, respectively (p = 0.000). Women in PB who had a low educational level and were unemployed had a 2.96-fold (OR = 0.338; 95% CI: 0.121 - 0.939) and 2.40-fold (OR = 0.416; 95% CI: 0.199 - 0.869) lower chance, respectively, to have performed the Papanicolaou test ≥ three times, or once within the last three years (p = 0.029; p = 0.014). The chance of women in MS who did not live in a stable relationship to have performed the test ≥ three times was 1.79-fold (OR = 0.560; 95% CI: 0.348 – 0.901) lower compared to women who reported a stable relationship (p = 0.039).

Conclusions:

High educational level, employment, and having a stable interpersonal relationship positively associated with performance of the Papanicolaou test among women in PB and MS. Despite having predominantly a low educational level, women in MS performed the Papanicolaou test more frequently than those in PB.

Cervical cancer screening history prior to a diagnosis of cervical cancer in Danish women aged 60 years and older-A national cohort study

The incidence and mortality of cervical cancer are high in Danish women aged 60 years and older who are about to exit the cervical cancer screening program. The present study aimed to describe the screening history in women ≥60 years old, diagnosed with cervical cancer in Denmark, 2009‐2013. We retrieved information on cases of cervical cancer and previous cervical cancer screening from national registries. During the study period, a total of 1907 women were diagnosed with cervical cancer, 574 (30.1%) of which were ≥60 years old. The majority of women were diagnosed with squamous cell carcinoma (73.7%) and advanced‐stage disease (ASD, ie, ≥FIGO IIB; 63.1%). The proportion of ASD increased with age, from 51.9% in women aged 60‐64% to 76.7% in women aged 75‐79. Among screened women (n = 377), 22.8% had a cervical cytology within 5 years of diagnosis, 73.3% of which were normal, and 45.1% were diagnosed with ASD. Women who had been sufficiently screened prior to screening exit (≥2 normal cytology test in the age interval 50‐59) accounted for 18.1%. Of note, 53.8% of the sufficiently screened women were diagnosed with ASD. Sufficiently screened women were less likely to be diagnosed with ASD compared to never‐screened women (53.8% vs 67.5%, P < 0.020), but no difference was observed between sufficiently and insufficiently screened women (53.8% vs 63.4%, P = 0.091). Our findings suggest that cancer in older women may occur due to insufficient screening prior to screening exit, a low sensitivity of screening, and premature screening exit.

Impact of HPV vaccination on outcome of cervical cytology screening in Denmark-A register-based cohort study

4vHPV vaccination has been tested in randomized controlled trials under almost ideal conditions, and studies of real-life use have compared outcome between vaccinated and unvaccinated women from the same birth cohort and mostly before screening age. Here we present the first-to our knowledge-evaluation of the impact of the 4vHPV vaccination in real life without selection bias in the reported data. The study has been carried out by comparing the results after first cervical screening between an HPV-vaccinated and an unvaccinated birth cohort, consisting of women born in Denmark in 1993 and 1983, respectively. Cytology data covering an 8-year period, from the age of 15 (age of HPV-vaccination) to age 23 (age of invitation to first cervical screening), were retrieved from the Danish National Pathology Register. Abnormal cytology, defined as atypical squamous cell of undetermined significance and worse (ASCUS+) was detected in 9.4% of women born in 1993 as compared with 9.0% of women born in 1983; RR = 1.04 (95% CI 0.96-1.12), p = .29. Detection of high-grade squamous intraepithelial lesion (HSIL) was statistically significantly lower in the 1993 than in the 1983 cohort, RR = 0.6 (95% CI 0.5-0.7), p < .0001, while the opposite pattern was seen for ASCUS RR = 1.4 (95% CI 1.2-1.6), p < .0001. The decrease in HSIL means that more women can be spared referral for colposcopy and biopsy. The increase of ASCUS could be explained by transition from conventional to liquid-based cytology, but this observation requires further monitoring.

HPV self-sampling in cervical cancer screening: the effect of different invitation strategies in various socioeconomic groups - a randomized controlled trial

Background

Participation in cervical cancer screening varies by socioeconomic status. The aims were to assess if offering human papilloma virus (HPV) self-sampling kits has an effect on screening participation among various socioeconomic groups and to determine if two invitation strategies for offering self-sampling influence the participation rate equally.

Methods

The study was based on registry data that were applied to data from a randomized controlled trial (n=9,791) measuring how offering HPV self-sampling affected screening participation. The women received either 1) a self-sampling kit mailed directly to their homes (directly mailed group); 2) an invitation to order the kit (opt-in group); or 3) a standard second reminder to attend regular cytology screening (control group). The participation data were linked to registries containing socioeconomic information.

Results

Women in the directly mailed group participated significantly more than women in the control group, regardless of their socioeconomic status, but the largest effects were observed in Western immigrants (participation difference [PD]=18.1%, 95% CI=10.2%–26.0%) and social welfare recipients (PD=15.2%, 95% CI=9.7%–20.6%). Compared with the control group, opt-in self-sampling only had an insignificant effect on participation among women who were immigrants, retired, or less educated. Western immigrants had a significantly higher increase in participation than native Danish women when kits were mailed directly compared with the opt-in strategy (PD=18.1%, 95% CI=10.2%–26.2% and PD=5.5%, 95% CI=2.9%–8.1%, respectively, P=0.01).

Conclusion

All socioeconomic groups benefited from the directly mailed strategy in terms of higher screening participation, but Western immigrants and lower socioeconomic groups seemed to benefit the most. Immigrants and some lower socioeconomic groups only had insignificant benefits of opt-in self-sampling. The directly mailed strategy might be preferable to opt-in self-sampling because it ensures that ethnic minority groups obtain benefits of introducing HPV self-sampling in an organized cervical cancer screening program.

Trial registration

Current Controlled Trials NCT02680262. Registered February 10, 2016.

Factors associated with non-participation in cervical cancer screening - A nationwide study of nearly half a million women in Denmark

Cervical cancer occurs most often in under-screened women. In this nationwide register study, we described differences in sociodemographic characteristics between passive and active non-participants and examined socio-demographic characteristics, reproductive history, and mental and physical health as potential determinants for passive non-participation compared with participation in the Danish cervical cancer screening program. Screening history in women aged 23-49 years invited for cervical cancer screening in 2008-2009 was retrieved from the Danish Pathology Databank with information about dates of invitation and unsubscription. We identified participants (n = 402,984), active non-participants (n = 10,251) and passive non-participants (n = 63,435) within four years following baseline invitation and retrieved data about the study population from high-quality registries. We examined differences in socio-demographic characteristics of passive and active non-participants, and used multiple logistic regression analyses to identify potential determinants of passive non-participation. We found that active and passive non-participants differed in relation to socio-demography. When compared with screening participants, the odds of passive non-participation was increased in women who originated from less developed countries; were unmarried; had basic education or low income; had four or more children; smoked during pregnancy; had multiple induced abortions; or had a history of obesity, intoxicant abuse or schizophrenia or other psychoses. In conclusion, in this nationwide, prospective, population-based study, differences in socio-demographic characteristics between passive and active non-participants were found. Furthermore, sociodemography, reproductive history, and mental and physical health were determinants for passive non-participation. Addressing inequalities in screening attendance may help to further decrease the incidence of and mortality from cervical cancer.

Preventing cervical cancer using HPV self-sampling: direct mailing of test-kits increases screening participation more than timely opt-in procedures - a randomized controlled trial

Background

Cervical cancer screening participation remains insufficient in most countries. Our aim was to evaluate whether offering a HPV self-sampling kit, either mailed directly to the woman’s home or using timely opt-in procedures for ordering the kit, increased screening participation compared with a standard second reminder.

Methods

In this randomized, controlled effectiveness trial, 9791 Danish women aged 30–64 who were due to receive the second reminder were equally randomized to either: 1) direct mailing of a second reminder and a self-sampling kit (directly mailed group); 2) mailing of a second reminder that offered a self-sampling kit to be ordered by e-mail, text message, phone, or webpage (opt-in group); or 3) mailing of a second reminder to attend regular cytology screening (control group). In an intention-to-treat analysis, we estimated the participation rate at 180 days post intervention, by returning a self-sample or attending regular cytology screening. We calculated the proportion of women with a positive HPV self-sample who attended for cervical cytology triage at the general practitioner within 90 days.

Results

Participation was significantly higher in the directly mailed group (38.0%) and in the opt-in group (30.9%) than in the control group (25.2%) (participation difference (PD): 12.8%, 95% CI: 10.6–15.0% and PD: 5.7%, 95% CI: 3.5–7.9%, respectively). Within 90 days, 107 women (90.7%, 95% CI: 83.9–95.3%) with a HPV-positive self-sample attended follow-up.

Conclusions

Offering the opportunity of HPV self-sampling as an alternative to regular cytology screening increased participation; the direct mailing strategy was the most effective invitation strategy. A high compliance with follow-up was seen.

Trial registration

Current Controlled Trials NCT02680262. Registered 10 February 2016.

Socio-economic and demographic determinants affecting participation in the Swedish cervical screening program: A population-based case-control study

Background

Cervical screening programs are highly protective for cervical cancer, but only for women attending screening procedure.

Objective

Identify socio-economic and demographic determinants for non-attendance in cervical screening.

Methods

Design: Population-based case-control study.

Setting: Sweden.

Population: Source population was all women eligible for screening. Based on complete screening records, two groups of women aged 30–60 were compared. The case group, non-attending women, (N = 314,302) had no smear registered for 6–8 years. The control group (N = 266,706) attended within 90 days of invitation.

Main outcome measures: Risk of non-attendance by 9 groups of socioeconomic and demographic variables.

Analysis: Unadjusted odds ratios (OR) and OR after adjustment for all variables in logistic regression models were calculated.

Results

Women with low disposable family income (adjOR 2.06; 95% confidence interval (CI) 2.01–2.11), with low education (adjOR 1.77; CI 1.73–1.81) and not cohabiting (adjOR 1.47; CI 1.45–1.50) were more likely to not attend cervical screening. Other important factors for non-attendance were being outside the labour force and receiving welfare benefits. Swedish counties are responsible for running screening programs; adjusted OR for non-participation in counties ranged from OR 4.21 (CI 4.06–4.35) to OR 0.54 (CI 0.52–0.57), compared to the reference county. Being born outside Sweden was a risk factor for non-attendance in the unadjusted analysis but this disappeared in certain large groups after adjustment for socioeconomic factors.

Conclusion

County of residence and socio-economic factors were strongly associated with lower attendance in cervical screening, while being born in another country was of less importance. This indicates considerable potential for improvement of cervical screening attendance in several areas if best practice of routines is adopted.

Temporal trend in socioeconomic inequalities in the uptake of cancer screening programmes in France between 2005 and 2010: results from the Cancer Barometer surveys

OBJECTIVES

Cancer screening is a form of secondary prevention for a disease which is now the leading cause of death in France. Various socioeconomic indicators have been identified as potential factors for disparities in breast, cervical and colorectal cancer screening uptake. We aimed to identify the socioeconomic inequalities, which persisted in screening uptake for these cancers, and to quantify these disparities over a 5-year period.

SETTING

The Cancer Barometer was a population-based-survey carried out in 2005 and 2010 in France.

PARTICIPANTS

A randomly selected sample of participants aged 15-85 years (n=3820 in 2005 and n=3727 in 2010) were interviewed on their participation in breast, cervical and colorectal cancer screening-programmes and their socioeconomic profile.

PRIMARY AND SECONDARY OUTCOME MEASURES

For each type of screening programme, we calculated participation rates, OR and relative inequality indices (RII) for participation, derived from logistic regression of the following socioeconomic variables: income, education, occupation, employment and health insurance. Changes in participation between 2005 and 2010 were then analysed.

RESULTS

Participation rates for breast and colorectal screening increased significantly among the majority of socioeconomic categories, whereas for cervical cancer screening there were no significant changes between 2005 and 2010. RIIs for income remained significant for cervical smear in 2005 (RII=0.25, 95% CI 0.13 to 0.48) and in 2010 (RII=0.31, 95% CI 0.15 to 0.64). RIIs for education in mammography (RII=0.43, 95% CI 0.19 to 0.98) and cervical smear (RII=0.36, 95% CI 0.21 to 0.64) were significant in 2005 and remained significant for cervical smear (RII=0.40, 95% CI 0.22 to 0.74) in 2010.

CONCLUSIONS

There was a persistence of socioeconomic inequalities in the uptake of opportunistic cervical cancer screening. Conversely, organised screening programmes for breast and colorectal cancer saw a reduction in relative socioeconomic inequalities, even though the results were not statistically significant. The findings suggest that organised cancer screening programmes may have the potential to reduce socioeconomic disparities in participation.

The influence of total hysterectomy in a cervical cancer screening population: a register-based cross-sectional study

BACKGROUND

High coverage of a screening program is essential to program success. Many European screening programs cover only 10-80% of their target population. A possible explanation for the low coverage may be that some women in the screening population have had a total hysterectomy, thus they are not at risk of cervical cancer. The aim of this study was to identify the prevalence of hysterectomy in the target population of the Danish National Cervical Cancer Screening Program (NCCSP) and to recalculate coverage after excluding women with total hysterectomy. Furthermore, to analyze the association between hysterectomy and sociodemographic factors within the screening population.

METHODS

A population-based cross-sectional study using register data on all women in the target population of the NCCSP on January 12, 2012 (women born January 12, 1947, to January 12, 1986). The total coverage included women with hysterectomy in the target population whereas the recalculated coverage was calculated excluding women with total hysterectomy. To test the differences between the total coverage and the recalculated coverage, a two-sample z-test between the proportion of covered hysterectomized women and the proportion of covered non-hysterectomised women were used. A logistic regression model adjusted for age and sociodemographic characteristics was used to analyze the association between sociodemographic factors and total hysterectomy.

RESULTS

The coverage among women aged 26-49 years and 55-64 years were 77.4% and 72.7%, respectively. The recalculated coverage was 78.2% (26-49 years) and 79.4% (55-64 years). Recalculating the coverage did not result in coverage higher than 82.7% at any age. The effect of excluding women with total hysterectomy increased with age, reaching its maximum of 8 % points for the oldest women. Women with higher socioeconomic status (higher education and higher disposable income) had lower odds of being hysterectomized compared to other women. Also, immigrants and descendants had lower odds of being hysterectomized compared to ethnic Danes.

CONCLUSIONS

Excluding women with total hysterectomy only partly explained the low coverage of the NCCSP. Thus, initiatives must be made to improve acceptability of and accessibility to the NCCSP, especially in the youngest and the oldest women.

Personal and provider level factors influence participation to cervical cancer screening: A retrospective register-based study of 1.3 million women in Norway

High coverage is essential for an effective screening programme. Here we present screening barriers and facilitators among 1.3 million women aged 25-69years eligible for screening within the Norwegian Cervical Cancer Screening Program (NCCSP). We defined non-adherence as no screening test in 2008-2012. We divided adherent women into those screened spontaneously, and those who had a smear after receiving a reminder from the NCCSP. Explanatory variables were extracted from several nationwide registers, and modelled by modified Poisson regression. In total, 34% of women were non-adherent. 31% of native Norwegians were non-adherent, compared to 50% of immigrants. Immigrant status was a strong predictor of non-adherence, but the vast majority of non-adherent women were still native Norwegians. Higher non-adherence rates were associated with having a male general practitioner (GP), a foreign GP, a young GP, and distance to the screening site. Being unmarried, having no children, having lower socioeconomic position and region of residence predicted non-adherence and, to a smaller extent, reminded adherence to screening. In contrast, previous experience with cervical abnormalities substantially increased adherence to screening. The population-based screening programme promotes equity by recruiting women who are less likely to participate spontaneously. However, socioeconomic disparities were evident in a country with a nationwide programme and a policy of equal access to health care. Initiatives aimed at removing practical and financial barriers to equitable screening delivery and at reducing the effect of sociodemographic attributes on screening participation are needed.

Study protocol of the CHOiCE trial: a three-armed, randomized, controlled trial of home-based HPV self-sampling for non-participants in an organized cervical cancer screening program

BACKGROUND

The effectiveness of cervical cancer screening programs is challenged by suboptimal participation and coverage. Offering cervico-vaginal self-sampling for human papillomavirus testing (HPV self-sampling) to non-participants can increase screening participation. However, the effect varies substantially among studies, especially depending on the approach used to offer HPV self-sampling. The present trial evaluates the effect on participation in an organized screening program of a HPV self-sampling kit mailed directly to the home of the woman or mailed to the woman's home on demand only, compared with the standard second reminder for regular screening.

METHODS/DESIGN

The CHOiCE trial is a parallel, randomized, controlled, open-label trial. It will include 9327 women aged 30-64 years who are living in the Central Denmark Region and who have not participated in cervical cancer screening after an invitation and one reminder. The women will be equally randomized into three arms: 1) Directly mailed a second reminder including a HPV self-sampling kit; 2) Mailed a second reminder offering a HPV self-sampling kit, to be ordered by e-mail, text message, phone, or through a webpage; and 3) Mailed a second reminder for a practitioner-collected sample (control group). The primary outcome will be the proportion of women in the intervention groups who participate by returning their HPV self-sampling kit or have a practitioner-collected sample compared with the proportion of women who have a practitioner-collected sample in the control group at 90 and 180 days after mail out of the second reminders. Per-protocol and intention-to-treat analyses will be performed. The secondary outcome will be the proportion of women with a positive HPV self-collected sample who attend follow-up testing at 30, 60, or 90 days after mail out of the results.

DISCUSSION

The CHOiCE trial will provide strong and important evidence allowing us to determine if and how HPV self-sampling can be used to increase participation in cervical cancer screening. This trial therefore has the potential to improve prevention and reduce the number of deaths caused by cervical cancer.

TRIAL REGISTRATION

Current Controlled Trials NCT02680262 . Registered 10 February 2016.

How does HPV vaccination status relate to risk perceptions and intention to participate in cervical screening? a survey study

BACKGROUND

Women in several countries will soon be covered by two preventive programmes targeting cervical cancer: HPV vaccination and cervical screening. The HPV vaccines are expected to prevent approximately 70 % of cervical cancers. It has been speculated, that HPV vaccinated women will not attend screening because they falsely think that the vaccine has eliminated their cervical cancer risk. The aim of this study was to investigate the association between HPV vaccination status and perceptions of cervical cancer risk; perceptions of vaccine effect; and intention to participate in cervical screening. Furthermore, to investigate associations between perceptions of cervical cancer risk and intention to participate in cervical screening.

METHODS

A random sample of Danish women from the birth cohorts 1993-1995 was invited to complete a web-based questionnaire concerning risk perceptions and intentions to participate in cervical screening. Main outcomes were: perceived lifetime-risk of cervical cancer; perceived HPV vaccine effect; and intention to participate in cervical screening.

RESULTS

HPV vaccinated women more often than unvaccinated women intended to participate in screening: adjusted odds ratio (OR) for being HPV vaccinated when intending to participate in screening of 3.89 (95 % CI: 2.50-6.06). HPV vaccinated women perceived cervical cancer risk to be higher than unvaccinated women did: adjusted OR of 0.11 (95 % CI: 0.03-0.39) and 0.51 (95 % CI: 0.33-0.78) for being HPV vaccinated while having the lowest perception of risk (in two different pre-specified dichotomisations). HPV vaccinated women perceived the vaccine effect to be larger than unvaccinated women did: adjusted OR of 0.31 (95 % CI: 0.18-0.51) and 0.37 (95 % CI: 0.25-0.53) for being HPV vaccinated while having the lowest perception of vaccine effect (in two different pre-specified dichotomisations). There were no associations between perceived cervical cancer risk and intention to participate in screening.

CONCLUSIONS

HPV vaccinated women more often than unvaccinated women intended to participate in screening and they perceived cervical cancer risk to be higher and the vaccine effect to be larger than unvaccinated women did. However, in our analyses, risk perceptions could not explain screening intentions neither among vaccinated nor among unvaccinated women.

Burden and incidence of human papillomavirus-associated cancers and precancerous lesions in Denmark

Aim: The aim of the study was to investigate the incidence of human papillomavirus (HPV)-associated cancers in Denmark between 1978 and 2011, estimate the current absolute annual number (burden) of HPV-associated cancers (HPVaCa) and their precancerous lesions, and assess whether there is socioeconomic inequality in the risk of HPV-associated cancers. Methods: From four nationwide population-based registries, information was collected on HPVaCa diagnosed during 1978–2011 and age-standardised incidence rate for each site by calendar year and birth cohort was calculated. Furthermore, the current annual burden of HPVaCa and severe precancerous lesions was estimated. Incidence rate ratios and corresponding 95% confidence intervals for HPVaCa were calculated according to socioeconomic status. Results: The age-standardised incidence rate of HPV-associated cancers for the two sexes converged during the study period, and almost identical incidence rates were seen for women and men in the youngest birth cohorts. The current burden of HPV-associated lesions amounted to more than 5000 cases, the vast majority (85%) being severe precancerous lesions. The highest risk for HPV-associated cancers was associated with lower socioeconomic status. Conclusions: The burden of HPV-associated cancers among men will likely surpass that among women in the near future if the incidence trends continue. As many of these cancers and their precancerous lesions are associated with HPV type 16, a substantial proportion of cases are, in theory, preventable by the currently available vaccines.

Impact of opportunistic testing in a systematic cervical cancer screening program: a nationwide registry study

BACKGROUND

Systematic screening for precancerous cervical lesions has resulted in decreased incidence and mortality of cervical cancer. However, even in systematic screening programs, many women are still tested opportunistically. This study aimed to determine the spread of opportunistic testing in a systematic cervical cancer screening program, the impact of opportunistic testing in terms of detecting cytological abnormalities and examine the associations between sociodemography and opportunistic testing.

METHODS

A nationwide registry study was undertaken including women aged 23-49 years (n = 807,624) with a cervical cytology between 2010 and 2013. The women were categorised into: 1) screening after invitation; 2) routine opportunistic testing, if they were either tested more than 9 months after the latest invitation or between 2.5 years and 3 years after the latest cervical cytology and 3) sporadic opportunistic testing, if they were tested less than 2.5 years after the latest cervical cytology. Cytological diagnoses of women in each of the categories were identified and prevalence proportion differences (PPD) and 95% confidence intervals (CIs) were used to explore group differences. Associations between sociodemography and undergoing opportunistic testing were established by multinomial logistic regression.

RESULTS

In total, 28.8% of the cervical cytologies were due to either routine (20.7%) or sporadic (8.1%) opportunistic testing. Among women undergoing routine opportunistic testing, a larger proportion had high-grade squamous intraepithelial abnormalities than invited women (PPD: 0.6%, 95 % CI: 0.03-1.17%). A similar proportion of cytological abnormalities among women undergoing sporadic opportunistic testing and invited women was found. In multivariate analyses, younger age, being single or a social welfare recipient and residence region (North Denmark) were especially associated with opportunistic testing (routine or sporadic).

CONCLUSIONS

One fourth of cervical cytologies in this study were collected opportunistically. Compared to invited women, women undergoing routine opportunistic testing were more likely to be diagnosed with abnormal cytologies. Hence, routine opportunistic testing might serve as an important supplement to the systematic screening program by covering non-participating women who may otherwise be tested with a delay or not tested at all. Among women tested more often than recommended (sporadic testing), no benefits in terms of detecting more cytological abnormalities were identified.

Socioeconomic predictors of human papillomavirus vaccination among girls in the Danish childhood immunization program

PURPOSE

In 2009, human papillomavirus (HPV) vaccination was introduced in the Danish national childhood immunization program targeting all 12-year-old girls. Previous findings suggest that 10%-13% of girls born in 1996-1997 have not initiated vaccination despite free access. This study aims to identify socioeconomic predictors of initiation and completion of HPV vaccination.

METHODS

Girls born in 1996-1997 and their guardians were identified through the Danish Civil Registration System. Information on socioeconomic variables and HPV vaccination status was obtained by linkage to Statistics Denmark and the Danish National Health Insurance Service Register. Through logistic regression, we examined associations between socioeconomic variables and HPV vaccine initiation (N = 65,926) and completion (N = 61,162).

RESULTS

Girls with immigrant ethnicity (odds ratio [OR] = .49; 95% confidence interval [CI], .42-.57) had lower HPV vaccine initiation than Danish girls. Girls of mothers with basic education (OR = .75; 95% CI, .69-.82) or low disposable income (OR = .67; 95% CI, .61-.73) had decreased initiation compared with girls of mothers with higher education/income. Girls of unemployed mothers (OR = .75; 95% CI, .69-.82) or mothers being unmarried (OR = .70; 95% CI, .65-.76) had lower initiation than girls of employed or married mothers. Finally, vaccine initiation varied depending on place of residence. The predictors of HPV vaccine completion were similar to those of initiation.

CONCLUSIONS

We found social inequality in the initiation and completion of HPV vaccination despite free access. As socioeconomic risk factors identified for cervical cancer also are associated with decreased HPV vaccination, social inequalities in cervical cancer have the potential to increase.

Mothers’ and their daughters’ use of preventive measures against cervical cancer

Aims: Vaccination against human papillomavirus (HPV) and screening are complementary preventive measures against cervical cancer. In Denmark, screening and vaccination are free of charge for the women. In total, 75% of women are screened and about 90% of girls are vaccinated with at least one dose. Our aim was to determine whether, in Denmark, daughters of unscreened mothers are less likely to be vaccinated against HPV than are daughters of screened mothers. Methods: We used population-based data from the Danish Patient Register, Health Service Registration, Pathology Data Bank, and Civil Registration System. Individual-level data on screening, vaccination, and vital status until 31 December 2010 were retrieved. Daughters were linked to their mothers through the link provided in the Civil Registration System. The study population included 149,147 girls born in 1993–1997 and their mothers. We calculated birth cohort-specific relative risks (RRs) of non-initiation of HPV vaccination in daughters depending on their mothers’ screening status. Results: In total, 8% of girls did not receive any vaccination, and 35% of their mothers were unscreened. Among the 92% of girls receiving at least one vaccine dose, 14% of mothers were unscreened. The birth cohort-specific RRs of non-initiation of vaccination given an unscreened mother varied between 2.16 (95% CI: 2.00–2.33) and 2.83 (95% CI: 2.63–3.05). Conclusions: The observed association between screening and vaccination suggest that it will be difficult to increase the vaccination coverage by, for example, counselling at the mother’s cervical screening appointment. Other measures to increase the coverage with vaccination will be important.