Knowledge of cervical cancer and screening among women in east-central England

Effects of numerical information on intention to participate in cervical screening among women offered HPV vaccination: a randomised study

OBJECTIVES

To investigate the effects of different types of information about benefits and harms of cervical screening on intention to participate in screening among women in the first cohorts offered human papilloma virus (HPV) vaccination.

DESIGN

Randomised survey study.

SETTING

Denmark.

SUBJECTS

A random sample of women from the birth cohorts 1993, 1994 and 1995 drawn from the general population.

INTERVENTIONS

A web-based questionnaire and information intervention. We randomised potential respondents to one of the following four different information modules about benefits and harms of cervical screening: no information; non-numerical information; and two numerical information modules. Moreover, we provided HPV-vaccinated women in one of the arms with numerical information about benefits and harms in two steps: firstly, information without consideration of HPV vaccination and subsequently information conditional on HPV vaccination.

MAIN OUTCOME MEASURE

Self-reported intention to participate in cervical screening.

RESULTS

A significantly lower proportion intended to participate in screening in the two groups of women receiving numerical information compared to controls with absolute differences of 10.5 (95% CI: 3.3-17.6) and 7.7 (95% CI: 0.4-14.9) percentage points, respectively. Among HPV-vaccinated women, we found a significantly lower intention to participate in screening after numerical information specific to vaccinated women (OR of 0.38).

CONCLUSIONS

Women are sensitive to numerical information about the benefits and harms of cervical screening. Specifically, our results suggest that HPV-vaccinated women are sensitive to information about the expected changes in benefits and harms of cervical screening after implementation of HPV vaccination. KEY POINTS Women were less likely to participate in cervical screening when they received numerical information about benefits and harms compared to non-numerical or no information. Specifically, numerical information about the potential impact of the reduced risk of cervical cancer among HPV-vaccinated women reduced the intention to participate among vaccinated women.

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.

Development of a pre-notification leaflet to encourage uptake of cervical screening at first invitation: a qualitative study

Cervical screening attendance among women aged 25-29 years in England is lower than at older ages. There is some evidence that pre-notification leaflets motivate women who have not yet considered their response to a health intervention. We aimed to identify key information to motivate young women at their first cervical screening invitation. Six focus groups were conducted, five with young women aged 17-25 registered with a General Practice in Manchester, UK, and one with Practice nurses. Some women took part in two further groups to discuss leaflet design. There was low awareness of the purpose or procedures of cervical screening, and most women were de-motivated by reports of bad experiences. Some intended to be screened, but not immediately after invitation. Screening was viewed as a test for a cancer that affected older women. Since none of the participants believed that they had cervical cancer, screening seemed unnecessary. We conclude that the perception that screening is unimportant when you are young needs to be challenged. Women also need to be better informed of screening procedures. A pre-notification leaflet incorporating key information was designed and will be tested in a randomized trial of complex interventions within the routine cervical screening programme.

Informed decision-making in colorectal cancer screening using colonoscopy or CT-colonography

OBJECTIVE

To evaluate the level of informed decision making in a randomized controlled trial comparing colonoscopy and CT-colonography for colorectal cancer screening.

METHODS

8844 citizens aged 50-75 were randomly invited to colonoscopy (n=5924) or CT-colonography (n=2920) screening. All invitees received an information leaflet. Screenees received a questionnaire within 4 weeks before the planned examination, non-screenees 4 weeks after the invitation. A decision was categorized as informed when characterized by sufficient decision-relevant knowledge and consistent with personal attitudes toward participation in screening.

RESULTS

Knowledge and attitude items were completed by 1032/1276 colonoscopy screenees (81%), by 698/4648 colonoscopy non-screenees (15%), by 824/982 CT-colonography screenees (84%) and by 192/1938 CT-colonography non-screenees (10%). 1027 colonoscopy screenees (>99%) and 815 CT-colonography screenees (99%) had adequate knowledge; 915 (89%) and 742 (90%) had a positive attitude. 675 non-screenees invited to colonoscopy (97%) and 182 invited to CT-colonography (95%) had adequate knowledge; 344 (49%) and 94 (49%) expressed a negative attitude.

CONCLUSION

A large majority of screenees made an informed decision on participation. Almost half of responding non-screenees, made an uninformed decision, suggesting additional barriers to participation.

PRACTICE IMPLICATIONS

Efforts to understand the additional barriers will create opportunities to facilitate informed participation to colorectal cancer screening.

Assessing knowledge and attitudes towards screening among users of Faecal Immunochemical Test (FIT)

BACKGROUND

Informed decision making is recognized as important in screening. Invitees should be provided with relevant information, enabling them to make an informed decision. This may be more difficult in ethnic minority and low socio-economic status groups. We aimed to assess the proportion of informed decisions to participate in a faecal immunochemical test (FIT)-based colorectal cancer (CRC) screening pilot and to explore differences in knowledge and attitude across various subgroups.

METHODS

Asymptomatic persons aged 50-74 were invited to a second round of a Dutch FIT-based pilot screening programme for CRC. An information leaflet containing all information relevant to enable informed decision making accompanied the invitation. Informed choice was assessed by a mailed questionnaire. Knowledge was elicited through 18 items and attitude towards screening through four items. Main outcome measure was the proportion of informed decision makers among participants. Differences between subgroups were evaluated using logistic regression.

RESULTS

Of 5367 screening participants, 2774 (52%) completed the questionnaire. Knowledge was adequate in 2554 (92%); 2736 (99%) showed a positive attitude towards screening. A total of 2525 persons had made an informed choice (91%); male gender, low education level, non-Dutch ethnicity and not speaking Dutch at home were negatively associated with having adequate knowledge in multivariable analysis.

CONCLUSION

In FIT-based screening for CRC, the majority of responders made an informed decision to participate. However, we did not succeed in equally providing all population subgroups with sufficient information. Future initiatives should be aimed at reaching these groups to further enable informed decision making.

Assessment of knowledge about cervical cancer and its prevention among female students aged 17-26 years

OBJECTIVE

To assess knowledge about cervical cancer and its primary and secondary prevention, and identify the sources of information about the disease among female high school and university students in Krakow, Poland.

STUDY DESIGN

This study was based on a questionnaire consisting of 64 questions, divided into six parts: personal data, general knowledge about cervical cancer, estimation of risk factors, knowledge about primary prevention, knowledge about secondary prevention, and information sources. Data were collected from students aged 17-26 years over a 3-month period in 2011 and 2012.

RESULTS

Four hundred women living in Krakow or its vicinity were included in the study. Nearly all respondents (98.5%) had heard of cervical cancer, 89.4% were aware of the risk of death associated with cervical cancer, and 44.8% believed that the disease could affect them in the future. The interviewees considered genetics and family history to be the most important risk factors, followed by infection with human papillomavirus (HPV) and having multiple sex partners. Most (91.5%) respondents had not been vaccinated against HPV, 47.9% did not know where to go to get vaccinated, and 30.1% were unaware of vaccination as a prevention method. Most (91.5%) respondents were aware of cytological screening, and 86.5% thought that they should have it done in the future. Women who had not heard of cytological screening were more likely to be unaware of cervical cancer than women who had heard about cytological screening (odds ratio 0.24, 95% confidence interval 0.11-0.49, p=0.0001). The Internet, television and newspapers were reported to be the main sources of information about the disease.

CONCLUSIONS

General awareness of cervical cancer among young women in Poland is insufficient. HPV infection is not considered to be the major aetiological factor. A relatively high percentage of women in this study had never heard of the HPV vaccine as a way of preventing cervical cancer. Knowledge about cytological screening, however, appears to be much better.

Cervical screening among migrant women: a qualitative study of Polish, Slovak and Romanian women in London, UK

OBJECTIVE

To explore awareness of and participation in cervical screening services in women from Poland, Slovakia and Romania living in London, UK.

METHODS

Three qualitative studies were carried out in London in 2008-2009: an interview study of professionals working with Central and Eastern European migrants (n=11); a focus group study including three Polish, one Slovak and one Romanian focus group; and an interview study of Polish (n=11), Slovak (n=7) and Romanian (n=2) women.

RESULTS

Awareness of the cervical screening programme was good, but understanding of the purpose of screening was sometimes limited. Some women were fully engaged with the UK screening programme; others used screening both in the UK and their countries of origin; and a third group only had screening in their home countries. Women welcomed the fact that screening is free and that reminders are sent, but some were concerned about the screening interval and the age of the first invitation.

CONCLUSIONS

Migrant women from Poland, Slovakia and Romania living in London vary in their level of participation in the National Health Service Cervical Screening Programme. More needs to be done to address concerns regarding screening services, and to ensure that language is not a barrier to participation.

Knowledge of human papillomavirus (HPV) and the HPV vaccine in a national sample of Australian men and women

BACKGROUND

Human papillomavirus (HPV) knowledge has rarely been investigated in the context of a national vaccination program. The present study investigated HPV knowledge after the introduction of a national HPV vaccination program in Australia using a national sample of men and women.

METHODS

Questions assessing HPV knowledge were part of a broader national study of health and relationships administered via a computer-assisted telephone interview. These findings are from wave four of the study, conducted between 2007 and 2008. Knowledge questions about HPV included its association with cervical cancer, genital warts and abnormal Pap tests.

RESULTS

A total of 2634 women and 2556 men between the ages of 18 and 70 were interviewed. Overall, 62.8% (95% confidence interval (CI): 60.8-64.7%) of women and 38.3% (95% CI: 36.3-40.4%) of men had heard of HPV. Of these, 66.0% (95% CI: 64.1-67.9%) correctly answered that HPV is associated with cervical cancer, 50.2% (95% CI: 48.2-52.1%) answered that HPV is associated with abnormal Pap tests and 44.5% (95% CI: 42.5-46.5%) answered that HPV causes warts. Predictors of good knowledge included being female, aged between 26 and 45, holding higher education levels and older age at first sex. Ever having a Pap test was also associated with awareness about HPV.

CONCLUSION

One of the highest levels of knowledge about HPV in Australia to date is reported in the present study. Knowledge about the association between HPV and cervical cancer was particularly high, especially when compared with knowledge of the association with genital warts. This appears to be a consequence of the marketing of the HPV vaccine as a vaccination against cervical cancer.

Men and women: beliefs about cancer and about screening

Background

Cancer screening programmes in England are publicly-funded. Professionals' beliefs in the public health benefits of screening can conflict with individuals' entitlements to exercise informed judgement over whether or not to participate. The recognition of the importance of individual autonomy in decision making requires greater understanding of the knowledge, attitudes and beliefs upon which people's screening choices are founded. Until recently, the technology available required that cancer screening be confined to women. This study aimed to discover whether male and female perceptions of cancer and of screening differed.

Methods

Data on the public's cancer beliefs were collected by means of a postal survey (anonymous questionnaire). Two general practices based in Nottingham and in Mansfield, in east-central England, sent questionnaires to registered patients aged 30 to 70 years. 1,808 completed questionnaires were returned for analysis, 56.5 per cent from women.

Results

Women were less likely to underestimate overall cancer incidence, although each sex was more likely to cite a sex-specific cancer as being amongst the most common cancer site. In terms of risk factors, men were most uncertain about the role of stress and sexually-transmitted diseases, whereas women were more likely to rate excessive alcohol and family history as major risk factors. The majority of respondents believed the public health care system should provide cancer screening, but significantly more women than men reported having benefiting from the nationally-provided screening services. Those who were older, in better health or had longer periods of formal education were less worried about cancer than those who had illness experiences, lower incomes, or who were smokers. Actual or potential participation in bowel screening was higher amongst those who believed bowel cancer to be common and amongst men, despite women having more substantial worries about cancer than men.

Conclusion

Our results suggest that men's and women's differential knowledge of cancer correlates with women's closer involvement with screening. Even so, men were neither less positive about screening nor less likely to express a willingness to participate in relevant screening in the future. It is important to understand gender-related differences in knowledge and perceptions of cancer, if health promotion resources are to be allocated efficiently.

Knowledge, awareness, and attitudes of female sex workers toward HPV infection, cervical cancer, and cervical smears in Thailand

OBJECTIVE

To determine the knowledge, attitudes, and awareness of female sex workers (FSWs) regarding cervical cancer and its prevention in Thailand.

METHOD

From August through November 2008, 402 consecutive FSWs were recruited for interviews.

RESULTS

The mean knowledge score was 4.9 (maximum possible, 15; range, 0-14). Approximately 60% of the FSWs had knowledge scores less than 5. Low education and a lack of health insurance were significant independent predictors of low knowledge scores (adjusted odds ratios, 3.17 and 1.97, respectively). More than half of the FSWs were unaware of being at higher risk for HPV infection or of the possible consequences of HPV infection. The negative attitude regarding cervical screening was caused by the fear of abnormal results (27.9%), experiencing pain (18.4%), and embarrassment (14.7%).

CONCLUSION

The knowledge and awareness of HPV infection, cervical cancer, and utility of cervical smears is low among FSWs in Thailand. Designing and implementing effective interventions is crucial and merits attention in future research.

Cancer screening in a middle-aged general population: factors associated with practices and attitudes

BACKGROUND

The aim of this study was to identify factors associated with cancer screening practices and with general attitudes toward cancer screening in a general population.

METHODS

Mailed survey of 30-60 year old residents of Geneva, Switzerland, that included questions about screening for five cancers (breast, cervix uteri, prostate, colon, skin) in the past 3 years, attitudes toward screening, health care use, preventive behaviours and socio-demographic characteristics. Cancer screening practice was dichotomised as having done at least one screening test in the past 3 years versus none.

RESULTS

The survey response rate was 49.3% (2301/4670). More women than men had had at least one cancer screening test in the past 3 years (83.2% vs 34.5%, p < 0.001). A majority of women had had a cervical smear (76.6%) and a mammography (age 30-49: 35.0%; age 50 and older: 90.3%); and 55.1% of men 50-60 years old had been screened for prostate cancer. Other factors associated with screening included older age, higher income, a doctor visit in the past 6 months, reporting a greater number of preventive behaviours and a positive attitude toward screening. Factors linked with positive attitudes included female gender, higher level of education, gainful employment, higher income, a doctor visit in the past 6 months and a personal history of cancer.

CONCLUSION

Attitudes play an important role in cancer screening practices among middle-aged adults in the general population, independent of demographic variables (age and sex) that determine in part screening recommendations. Negative attitudes were the most frequent among men and the most socio-economically disadvantaged. The moderate participation rate raises the possibility of selection bias.

Weaving meaning? An exploration of the interplay between lay and professional understandings of cervical cancer risk

In line with the increasing emphasis on informed choice, women invited for cervical cancer screening in England receive a leaflet containing information on the risk factors and causation of the condition. However, data from a qualitative interview study with 35 women suggest that the ways in which women make sense of this information can vary and frequently do not correspond to the causal pathways and explanations which characterise contemporary professional medical explanations. This paper examines the complex interplay between lay and professional understandings that takes place as women attempt to weave the information they receive, their prior understandings and contextual factors together into some kind of coherent framework, in which each piece of information makes sense in relation to everything else. We conclude by arguing that, while presenting full and accurate information about orthodox medical understandings of cervical cancer causation in an accessible way maybe challenging, partial presentation of 'the facts' is likely to be ineffective.

Reasons for non-attendance at cervical screening as reported by non-attendees in Sweden

PURPOSE

To describe reasons for non-attendance at cervical screening, as reported by non-attendees, in Sweden.

METHODS

Four hundred women were randomized from a population-based register, of which 133 non-attendees answered the Cervical Screening Questionnaire (CSQ) in telephone interviews. Pearson's Chi2 and Mann-Whitney U-test were used to analyze differences between groups. Logistic regression was used to study the relationship between explanatory variables and a binary response variable.

RESULTS

The most common reasons for non-attendance were: feeling healthy, lack of time, and feelings of discomfort with the gynecologic examination. Non-attendees, who reported non-attendance due to experiences of discomfort associated with the gynecologic examination, estimated great discomfort at their latest examination. A history of sexual abuse was reported by 16.5%, but there were no differences regarding non-attendance due to experiences of discomfort associated with the gynecologic examination, between non-attendees who had no history of sexual abuse and those who had.

CONCLUSION

It seems as though non-attendees did not attend cervical screening as they felt healthy, and thereby did not give time to preventive efforts. Earlier negative experiences such as discomfort during earlier gynecologic examinations seem to guide their decision not to attend.

Knowledge about infection with human papillomavirus: a systematic review

OBJECTIVE

Human papillomavirus (HPV) is a necessary cause of cervical cancer and genital warts. The aim of this systematic literature review was to provide an overview of knowledge about HPV infection among the public, students, patients and health professionals.

METHOD

PubMed searches were performed and the results of studies were reported by age, gender, study population, country, recruitment score and year of study conduct. The recruitment score covered the mode of recruitment, study size and response rate.

RESULTS

We included 39 studies published between 1992 and 2006 covering a total of 19,986 participants. The proportion of participants who had heard of HPV varied from 13% to 93%. Understanding that HPV is a risk factor for cervical cancer depended on whether the question was closed (8-68%) or open (0.6-11%). Between 5% and 83% knew about the association of HPV and (genital) warts. HPV was often mistaken with other sexually transmitted viruses. Health professionals and women had better knowledge about HPV than other participants.

CONCLUSION

Overall, the knowledge of the general public about HPV infection is poor. Efforts should be increased to give sufficient and unbiased information on HPV infection to the general public.

Patient perspectives on information and choice in cancer screening: a qualitative study in the UK

The principle of informed choice has been recently incorporated into cancer screening policy. However, there is limited empirical or theoretical work on informed choice in this particular context. The main aim of the study reported here was to explore the information needs of people invited for screening, and to gain insights into the relationship between the information they wanted and the choices they made. A qualitative study (nine focus groups and 15 individual interviews) was undertaken with people who had contrasting experiences (and outcomes) of either breast, cervical, or colorectal cancer screening at two locations in Scotland, UK. Findings suggest that lay people define and conceptualise informed choice differently from policy makers. The study also found that information about the disease was as important to people as information on the risks and limitations of screening. However, information may have little part to play in the choices people make. Rather, it may have more impact on outcomes such as satisfaction and anxiety. An explicit policy aim in promoting informed choice is to enhance patient autonomy and to prevent people from being deceived or coerced. However, this research shows that the provision of evidence-based information alone does not necessarily mean that an informed choice is made. People may not read, want, or understand the information, and, additionally, they may not be able to carry out their intended choice. There may be personal barriers, such as physical or mental health problems and language, or organisational barriers, such as the availability of the service/intervention and access. Therefore, the term 'informed choice' might not be useful in this context.

Why do women participate in the English cervical cancer screening programme?

The vast majority of women in England attend for cervical cancer screening. Conventional economic theorising fails to explain why and its predictions are inconsistent with the evidence. Using questionnaire data, we analyse directly motivations for screening attendance. We conclude that regular attendance at screening is driven primarily by a search for reassurance, a sense of duty and herd signalling. It is evident that recognisable sub-groups of attenders exist, in which the configurations of motivational factors differ. Being motivated to attend by physicians is less significant that is widely supposed and is more frequently associated with irregular attendance.

An approach to measuring the quality of breast cancer decisions

OBJECTIVE

To explore an approach to measuring the quality of decisions made in the treatment of early stage breast cancer, focusing on patients' decision-specific knowledge and the concordance between patients' stated preferences for treatment outcomes and treatment received.

METHODS

Candidate knowledge and value items were identified after an extensive review of the published literature as well as reports on 27 focus groups and 46 individual interviews with breast cancer survivors. Items were subjected to cognitive interviews with six additional patients. A preliminary decision quality measure consisting of five knowledge items and four value items was pilot tested with 35 breast cancer survivors who also completed the control preferences scale and the decisional conflict scale (DCS).

RESULTS

Preference for control and knowledge did not vary by treatment. The mean of the participants' knowledge scores was 54%. There was no correlation between the knowledge scores and the informed subscale of the DCS (Pearson r = .152, n = 32, p = 0.408). Patients who preferred to keep their breast were over five times as likely to have breast-conserving surgery than those who did not (OR 5.33, 95% CI (1.2, 24.5), p = 0.06). Patients who wanted to avoid radiation were six times as likely to choose mastectomy than those who did not (OR 6.4, 95% CI (1.34, 30.61), p = 0.04).

CONCLUSION

Measuring decision quality by assessing patients' decision-specific knowledge and concordance between their values and treatment received, is feasible and important. Further work is necessary to overcome the methodological challenges identified in this pilot work.

PRACTICE IMPLICATIONS

Guidelines for early stage breast cancer emphasize the importance of including patients' preferences in decisions about treatment. The ability of doctors and patients to make decisions that reflect the considered preferences of well-informed patients can and should be measured.