Women's Behaviors Toward Mammogram and Pap Test: Opportunities to Increase Cervical Cancer Screening Participation Rates among Older Women

Increasing coverage in cervical and colorectal cancer screening by leveraging attendance at breast cancer screening: A cluster-randomised, crossover trial

BACKGROUND

Screening participation remains suboptimal in cervical cancer (CC) and colorectal cancer (CRC) screening despite their effectiveness in reducing cancer-related morbidity and mortality. We investigated the effectiveness of an intervention by leveraging the high participation rate in breast cancer (BC) screening as an opportunity to offer self-sampling kits to nonparticipants in CC and CRC screening.

METHODS AND FINDINGS

A pragmatic, unblinded, cluster-randomised, multiple period, crossover trial was conducted in 5 BC screening units in the Central Denmark Region (CDR) between September 1, 2021 and May 25, 2022. On each of 100 selected weekdays, 1 BC screening unit was randomly allocated as the intervention unit while the remaining units served as controls. Women aged 50 to 69 years attending BC screening at the intervention unit were offered administrative check-up on their CC screening status (ages 50 to 64 years) and CRC screening status (aged 50 to 69), and women with overdue screening were offered self-sampling. Women in the control group received only standard screening offers according to the organised programmes. The primary outcomes were differences between the intervention group and the control group in the total screening coverage for the 2 programmes and in screening participation among women with overdue screening, measured 6 months after the intervention. These were assessed using intention-to-treat analysis, reporting risk differences with 95% confidence intervals (CIs). A total of 27,116 women were included in the trial, with 5,618 (20.7%) in the intervention group and 21,498 (79.3%) in the control group. Six months after the intervention, total coverage was higher in the intervention group as compared with the control group in CC screening (88.3 versus 83.5, difference 4.8 percentage points, 95% CI [3.6, 6.0]; p < 0.001) and in CRC screening (79.8 versus 76.0, difference 3.8 percentage points, 95% CI [2.6, 5.1]; p < 0.001). Among women overdue with CC screening, participation in the intervention group was 32.0% compared with 6.1% in the control group (difference 25.8 percentage points, 95% CI [22.0, 29.6]; p < 0.001). In CRC screening, participation among women overdue with screening in the intervention group was 23.8% compared with 8.9% in the control group (difference 14.9 percentage points, 95% CI [12.3, 17.5]; p < 0.001). Women who did not participate in BC screening were not included in this study.

CONCLUSIONS

Offering self-sampling to women overdue with CC and CRC screening when they attend BC screening was a feasible intervention, resulting in an increase in participation and total coverage. Other interventions are required to reach women who are not participating in BC screening.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05022511. The record of processing activities for research projects in the Central Denmark Region (R. No.: 1-16-02-217-21).

A qualitative study of ethnic Korean women and men's experiences of HPV and HPV vaccination in the United States

INTRODUCTION

Approximately 42.5% of adults aged 18-59 in the United States is estimated to be affected by human papillomavirus (HPV) infection. However, Asian Americans have the lowest HPV vaccination initiation rate compared to other racial groups. This study aims to explore the experiences of HPV and the HPV vaccination among ethnic Korean women and men in the United States.

METHODS

A total of 33 ethnic Korean and Korean Americans aged 27-45 years living in the U.S. were recruited via word-of-mouth and social media using a purposive sampling strategy. They participated in an online survey. Of the 33 participants, 29 (14 females and 15 males) participated in in-depth interviews via password-protected Zoom. A content analysis approach was used to analyze the interviews.

RESULTS

Only 32% of participants had received the HPV vaccine at least once (female: 35.3%, male: 12.5%). Six major themes emerged from data analysis: (1) awareness of HPV, HPV vaccine, and HPV-associated cancers; (2) attitudes toward the HPV vaccine; (3) barriers to HPV vaccination; (4) women's experiences and preferences for pap smear testing; (5) experiences with HPV diagnosis; and (6) HPV and HPV vaccination education preferences.

CONCLUSION

The findings highlight cultural factors that may impede the discussion about and uptake of HPV vaccination and HPV-associated cancer screening, which emphasize the need for culturally appropriate interventions to overcome stigma around HPV and enhance vaccination rates. Healthcare providers should consider ethnic and cross-cultural differences perceptions to effectively HPV-related health information. This study provides insight into the experiences and understanding of HPV and vaccination among ethnic Korean men and women, laying the groundwork for developing culturally-tailored programs that sim to increase HPV vaccination rates and mitigate the stigma and impact of HPV-related disease in this community.

Non-adherence to cervical cancer screening recommendations among women in Eswatini: a cross-sectional study

BACKGROUND

In 2018, Eswatini had the world's highest age-standardised cervical cancer incidence rate. Cervical cancer screening reduces women's risk of invasive cervical cancer. Data on adherence to cervical cancer screening recommendations in Eswatini are scarce. The purpose of the current study was to determine Eswatini women's self-reported adherence to cervical cancer screening recommendations, attitudes toward screening, and factors associated with non-adherence.

METHODS

A cross-sectional survey of women (n = 377) aged 25 to 59 accessing primary healthcare clinics (n = 4) in Eswatini assessed screening participation, attitudes and knowledge regarding cervical cancer screening, and socio-demographic variables. Adjusted logistic regression was used to assess factors associated with non-adherence to Eswatini cervical cancer screening recommendations.

RESULTS

One hundred and sixty-six (44%) women were classified as adherent to cervical cancer screening recommendations. Attitudinal barriers endorsed by over one-third of participants included a perceived low risk of cervical cancer (n = 161, 43%) and a view that screening is likely to be painful (n = 146, 38%). Participants had higher odds of being classified as non-adherent if they: were single compared with married (OR = 1.78, 95% CI: 1.05, 3.01, p = 0.03), perceived screening as likely painful (OR = 4.43, 95% CI: 2.62, 7.46, p < 0.001); and had not been advised by a doctor/ nurse to screen (OR = 2.82, 95% CI: 1.71, 4.64, p < 0.001). Also, a 1-year increase in age was associated with an increase in the odds of being classified as non-adherent (OR = 1.42, 95% CI: 1.39, 1.45, p = 0.01).

CONCLUSIONS

Self-reported adherence was moderate among this group of women. Tailored interventions are needed to increase participation in cervical cancer screening, especially for those women with characteristics associated with being classified as non-adherent. Primary healthcare clinic nurses (and other health providers) may contribute toward improving participation in cervical cancer screening by advising eligible women to screen and providing health education addressing negative attitudes toward screening.

Determinants of Protective Healthcare Services Awareness among Female Syrian Refugees in Turkey

War-related migration may deprive people of access to a regular healthcare system and cause new diseases to be battled. Since refugee women are more vulnerable to diseases during this period, protective healthcare services awareness is critical for early disease diagnosis. Following the civil war that triggered the migration of millions of Syrians, an extensive survey was undertaken in coordination with the World Health Organization Country Office in Turkey to explore the health status of Syrian refugees in Turkey. Employing the survey data, we aimed to investigate the determinants of the awareness of protective health services (Pap smear test, mammogram, HIV test) among female Syrian refugees. Logit regression analysis was applied in order to investigate the determinants of the awareness of protective health services among the female refugee population. The results revealed a notably low rate of awareness of protective health services among female Syrian refugees. Furthermore, the association of explanatory variables, including socioeconomic factors, healthcare use, and health literacy with the protective health services awareness, was found to be significant.

Trends and Determinants in Uptake of Cervical Cancer Screening in Spain: An Analysis of National Surveys from 2017 and 2020

Cervical cancer rates have declined in industrialized nations as a result of cytology screening programs. However, there are still sizeable differences in screening adherence in Spain. This study aimed to identify the prevalence of cervical cancer screening among women in Spain, to analyze trends in that prevalence from 2017 and 2020 and to identify socio-demographic, health, and lifestyle factors related with adherence to this screening test. We conducted a cross-sectional study of 13,619 women aged 25−65 who participated in the 2017 Spanish National Health Survey and the 2020 European Health Survey for Spain. We used logistic regression to examine the relationship between socio-demographic, health and lifestyle factors and cervical cancer adherence. The prevalence of adherence was 73.18%. Additionally, there was a significant decrease in cervical cancer screening uptake from 2017 and 2020 among women aged 25−44 years (2017: 77.80%, 2020: 75.20%, p = 0.02), but an increase in the age group of 45−65 years (2017: 68.93%, 2020: 72.39%, p < 0.01) and in foreigners (2017: 64.29%, 2020: 72.29%, p < 0.01). Screening for cervical cancer is related with age, educational level, social class, insurance status, visits to the family doctor, alcohol consumption and free time physical exercise.

Determinants of Non-Participation in Population-Based Breast Cancer Screening: A Systematic Review and Meta-Analysis

Background

Breast cancer (BC) screening can be performed in a screening program (BCSP) or in opportunistic screening. The existing reviews on the determinants of non-participation depend on self-reported data which may be biased. Furthermore, no distinction was made between the probably different determinants of both screening strategies.

Objective

To find the determinants of non-participation in BCSP by means of a meta-analysis.

Methods

PubMed, Embase, and Web of Science were searched for observational studies which quantified factors associated with non-participation in BCSP in a general population. Studies on opportunistic screening and studies using self-reported data were excluded. A random-effect model was used to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). Potential sources of heterogeneity were explored by stratification of the results.

Results

Twenty-nine studies with in a total of 20,361,756 women were included. Low income (OR: 1.20, 95% CI: 1.10–1.30), low education (OR: 1.18, 95% CI: 1.05–1.32), living far from an assigned screening unit (OR: 1.15, 95% CI: 1.07–1.24), being immigrant (OR: 2.64, 95% CI: 2.48–2.82), and having a male family doctor (OR: 1.43, 95% CI: 1.20–1.61) was associated with higher non-participation in screening. Reminders sent to non-attenders and estimations of ORs (adjusted or not) partly explained substantial heterogeneity.

Conclusion

In this meta-analysis excluding studies on the non-participation in opportunistic screening, or with self-reported data on non-participation, the well-known determinants for non-participation are still significant, but less strong. This analysis only supports the relevance of meta-analysis of studies with registered non-participation in a BCSP.

Systematic Review Registration

PROSPERO, CRD42020154016.

Barriers and facilitators to participation in breast, bowel and cervical cancer screening in rural Victoria: A qualitative study

ISSUE ADDRESSED

Population cancer screening rates are around 50% for the general population and even lower in rural areas. This study aimed to explore knowledge, attitudes, behaviours, motivators and barriers to breast, bowel and cervical screening participation in under-screened men and women.

METHODS

We used a qualitative research design. Focus groups were segmented by age, sex and screening participation. Participants were under-screened in at least one of the cancer screening programs, with separate groups for each of the programs. The discussion guides were designed around the Health Belief Model and group discussions were coded using a thematic content analysis approach.

RESULTS

Fourteen focus groups were held with 80 participants. Key themes were that the concept of cancer screening was not well understood, a low priority for preventive health behaviours, issues relating to local general practitioners (GP) and screening was unpleasant, embarrassing and/or inconvenient. A key determinant of participation in cancer screening was exposure to prompts to action, and it was evident that participants often required multiple prompts before they took action.

CONCLUSIONS

Opportunities that develop attitudes to health that place disease prevention as a high priority; improve understanding of the benefit of screening in terms of early detection and treatment; improve GP availability and the patient-practitioner relationship; and the development of messages for each of the screening programs should be further explored as factors that may influence rural population screening rates. SO WHAT?: Addressing health attitudes, beliefs, knowledge, health practitioner and test-related barriers and improving messaging may increase cancer screening participation in under-screened rural populations.

Adherence to Mammography and Pap Screening Guidelines Among Medically Underserved Women: the Role of Family Structures and Network-Level Behaviors

Poor adherence to screening recommendations is an important contributing factor to disparities in breast and cervical cancer outcomes among women in the USA. Screening behaviors are multifactorial, but there has been limited focus on how family network beliefs and behaviors influence individual's likelihood to complete screening. This research aims to fill this gap by evaluating the role of family network composition and screening behaviors on women's likelihood to adhere to mammogram and pap screening recommendations. We used an ego network approach to analyze data from 137 families and their networks. Primary outcomes were whether an individual had received a mammogram in the past year and whether she had received a pap screening in the past 3 years. Network-level predictors included network composition (size of network, average age of network members, satisfaction with family communication) and network screening behaviors. We conducted multivariable logistic regressions to assess the influence of network-level variables on both mammogram and pap smears, adjusting for potential individual-level confounders. Each network had an average age of 47.9 years, and an average size of 3.05 women, with the majority of members being sisters (57.7%). We found differences in network screening behaviors by race, with Arab networks being less likely to have completed self-breast exams (OR = 0.21, 95%CI = 0.05-0.76, p = 0.02), ever a gotten pap screen (OR = 0.11, 95%CI = 0.01-0.85, p = 0.04), and gotten pap screening in the last 3 years (OR = 0.31, 95%CI = 0.10-0.99, p = 0.04) compared with African American networks. Network screening behaviors also strongly influenced the likelihood of an individual completing a similar screening behavior. This analysis sheds light on family network characteristics that influence screening behaviors among medically underserved women. These findings support the development and dissemination of screening interventions among female's family networks.

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.

Survival of Older Women With Cervical Cancer Based on Screening History

OBJECTIVE

A population-level retrospective cohort study was conducted to determine the influence of cervical screening history on the survival from cervical cancer in women 50 years or older.

METHODS

The study included women diagnosed with invasive cervical cancer in Ontario, Canada, between 2005 and 2012, who were followed for at least 4 years. Screening history was observed for the 5 years before diagnosis. Health care administrative databases were linked to determine demographic, affiliation with primary care physicians, stage (available 2010-2012), treatment, and survival data. Kaplan-Meier and multivariate analyses were carried out to evaluate the impact of cervical screening on overall survival (OS).

RESULTS

There were eligible 1,422 women diagnosed with invasive cervical cancer between 2005 and 2012 of whom 566 had been screened within the 5 years before diagnosis. There were 856 women who did not undergo screening within the 5 years before diagnosis. Unscreened women were more likely to present with locally advanced disease (69.3%) compared with the screened women (42.9%). Four-year OS was significantly greater in the screened group (79.9% vs 58.2%). In our univariate analysis, screening was significantly related to survival (hazard ratio = 2.1, p < .01). In our multivariate analysis after adjusting for age, treatment, affiliation with a primary care physician, and income, screening was still significantly associated with improved survival (hazard ratio = 1.5, p < .01).

CONCLUSIONS

Our results demonstrate a survival benefit to screening in women 50 years or older who are diagnosed with cervical cancer. Screening participation must be encouraged in women older than 50 years as rates decline in this age group.

Predictors and Trend in Attendance for Breast Cancer Screening in Lithuania, 2006-2014

In Lithuania, a Nationwide Breast Cancer (BC) Screening Program was launched in 2005, offering mammography for women aged 50 to 69 years, every other year. This study aimed to determine the trend in the attendance for mammography screening during 2006–2014 and to identify the factors that are predictive for participation in it. The study sample consisted of 1941 women aged 50–64 years, who participated in five cross-sectional biennial postal surveys of Lithuanian Health Behavior Monitoring, carried out in independent national random samples. The attendance for screening was identified if women reported having had a mammogram within the last two years. The proportion of women attending the screening was continuously increasing from 20.0% in 2006 up to 65.8% in 2014. The attendance for BC screening was associated with the participation in cervical cancer screening. A higher level of education, living in a city, frequent contact with a doctor, and healthy behaviors (fresh-vegetable consumption, physical activity, and absence of alcohol abuse) were associated with higher participation rates in BC screening. To increase BC screening uptake and to reduce inequalities in attendance, new strategies of organized BC screening program using systematic personal invitations are required in Lithuania.