Australian women's cervical cancer screening attendance as a function of screening barriers and facilitators
Introduction
Cervical cancer is the fourth most common cancer and a leading cause of cancer death in women (International Agency for Research on Cancer [IARC], 2014). It is a largely preventable cancer inasmuch as the routine screening of asymptomatic women is effective in preventing its' occurrence and cancer-related mortality (World Health Organization, 2014). However, 43% of eligible Australian women failed to screen in the most recent published reporting period (2014–2015) (Australian Institute of Health & Welfare [AIHW], 2017). Few prior studies have elucidated the screening barriers and facilitators predicting women's screening attendance, upon which tailored health promotion strategies could be based (Sadler et al., 2013).
Australia's National Cervical Screening Program operates as a part of a woman's routine primary health care. Most screening (80%) is performed by general practitioners (GP), but nurses and gynecologists can conduct the procedure; and it is subsidized by the Australian Medicare Benefits Schedule. If a woman is three months overdue for human papillomavirus (HPV) testing, she is sent a letter from the national screening reminder system to remind her to have the test; which is first performed at 25-years of age and repeated every five years (Australian Department of Health, 2018). However, prior to May 2017, Australian women received a Pap test every two years (AIHW, 2017), as did the female participants in this study. In this study, women were deemed overdue for screening if they had not screened in the past 27 months (i.e., overdue by more than three months).
Only a small literature has previously examined cervical cancer screening barriers and facilitators experienced by women. A distinction has been made between emotional and practical factors (Eaker et al., 2001; Waller et al., 2009). Emotional (or psychological) barriers are factors that are related to emotional state (e.g., anxiety, embarrassment), personal attitudes/perceptions (e.g., test is ineffective), and knowledge about the procedure, which make a person less likely to screen; whereas emotional facilitators include emotional state and attitudes/perceptions (e.g., perceived cancer risk) that increase the likelihood of screening. In contrast, practical barriers are external to a person or logistical in nature (e.g., lack of time, expense of test), whereas practical facilitators are factors external to a person (e.g., nearby GP clinic) that increase the likelihood of screening (Waller et al., 2009).
Practical facilitators have been examined in regards to screening attendance in intervention studies. A Cochrane review of 38 randomized controlled trials shows that invitations to screen were more effective than educational interventions (e.g., media education campaign) (Everett et al., 2011), especially individualized reminder prompts and physician recommendations (Marcus and Crane, 1998; Yabroff et al., 2003). GP status (i.e., regular GP vs. no regular GP) is another practical facilitator linked to screening history. For example, engagement with health services can facilitate screening behavior in women (Australian Bureau of Statistics [ABS], 2017; Henderson and Weisman, 2005), and GP-related factors are reported to increase screening attendance, including access to health care (Black et al., 2011), flexible appointment times (Logan and McIlfatrick, 2011; Waller et al., 2009) and opportunistic screening (e.g., test done when person attends clinic for another reason). Thus, GP status will be examined as a specific screening facilitator in this study, along with the facilitators identified by female study participants.
In the psychological literature, the most commonly reported psychological barrier is emotional response to the test including embarrassment (Armstrong et al., 2012; Lovell et al., 2015), anxiety (e.g., fear of abnormal test result) (Eaker et al., 2001; Waller et al., 2009), and distress related to pain or discomfort during the procedure (Armstrong et al., 2012; Waller et al., 2009). Poor knowledge is also nominated as a key psychological barrier (Islam et al., 2017; McFarland et al., 2016). Several studies have shown that women often have poor knowledge about the purpose and efficacy of screening (Neilson and Jones, 1998; Philips et al., 2003) and the cervical screening guidelines (e.g., correct age to start testing) (Mather et al., 2012), but awareness of cervical cancer screening does not necessarily lead to timely screening (Viens et al., 2016).
However, few prior studies have examined the screening barriers and facilitators in regards to women's screening status (i.e., up-to-date vs. overdue for screening). Waller et al. (2009) showed that women endorsed emotional screening barriers more often than practical barriers, especially older women, but younger women were more likely to endorse practical barriers and only the latter predicted women's screening status. Similarly, Eaker et al. (2001) showed that women who reported a lack of time as a practical barrier were less likely to have screened; and Catarino et al. (2016) found that practical barriers were the main reason for not screening, especially in women who were young, working, sexually inactive or without insurance. Results suggest that practical barriers will tend to interfere the most with women's screening behavior, but it is unclear if this is the same or different for women who have not screened before. In this study, women were deemed overdue for screening if they had not screened in the past 27 months (i.e., overdue by at least three months).
Thus, no prior studies have examined whether prior screening varies with regard to the experience of screening barriers and facilitators (Chorley et al., 2016). Only two studies show that the key screening barriers reported by women who had mostly not screened included the cost of the test, perceived cervical cancer risk (Were et al., 2011), knowledge gaps, and worry (Al-Naggar et al., 2010). Thus, the relationship between screening barriers and facilitators and prior screening was examined in this study. Prior screening was operationalized as: never screened (0) vs. prior screen (1). Women who had prior screening were asked to provide the year and month of their most recent test. They were provided with a definition of the Pap test prior to the screening questions.
In summary, few studies have examined the cervical cancer screening barriers and facilitators nominated by women in regards to their screening status. Three studies showed that practical barriers were more likely to interfere with women's screening behavior than psychological barriers, but few studies have concurrently examined cervical cancer screening barriers and facilitators in a single study. Furthermore, no studies have examined the barriers and facilitators in regards to prior screening. Thus, we examined if the number of screening barriers and facilitators, and individual barriers and facilitators listed by women, were related to their screening status and prior screening. Women in two age groups (25–35 years and 45–55 years) were recruited for the study as they have the lowest and highest reported screening rates of all Australian women, respectively (AIHW, 2017).
Finally, regarding potential confounders, several studies have shown that young women are more likely than older women to have never screened (Catarino et al., 2016; Were et al., 2011); with the lowest screening rates reported by women aged 20–29 years (42–51%), relative to those aged 45–54 years, who have the highest screening rate (63%; AIHW, 2017). Thus, age group will be controlled in the planned study analyses in this study. Consistent with the prior relevant literature, the number of psychological and practical screening barriers and facilitators, and individual screening barriers and facilitators were examined in regards to women's screening status and prior screening. Specifically, it was hypothesized that:
- 1.
The numbers of practical barriers and facilitators listed by women will more strongly relate to screening status than the number of psychological barriers.
- 2.
Specifically, a lack of time (practical barrier) and GP status (practical facilitator) will be most strongly related to women's screening status.
Finally, as a research question, the relationship between prior screening and numbers of barriers and facilitators and individual barriers and facilitators will be explored making no a priori assertions.
Section snippets
Power analysis
An a priori power analysis showed that 256 women were required to detect a small effect size (f2 = 0.10), with power set at 0.95, alpha of .005, and using up to five predictors in the logistic regression analyses. Conservative power and p-values were applied in the analyses to accommodate the larger number of young vs. older women in the sample.
Statistical analysis
Routine statistical analyses were conducted using the Statistical Package for the Social Sciences (Version 24) (IBM, 2015). Logistic regression analyses
Results
There were no missing data. Several univariate outliers were detected on the continuous variables (number of screening barriers & facilitators), but they were retained as they represented clinically significant responses. No differences were found between the 5% trimmed means and the untrimmed variable means. Continuous variables were all positively skewed. Shapiro-Wilk and Kolmogorov-Smirnov normality tests were all significant (p < .001) showing that none of the factors was normally
Discussion
Few studies have examined women's cervical cancer screening behavior, including screening status (i.e., overdue vs. up-to-date with screening) (Catarino et al., 2016; Eaker et al., 2001; Waller et al., 2009) in regards to the experience of screening barriers and facilitators. No prior studies have explored the factors in relation to women's prior screening (i.e., screened vs. never screened). Thus, this study examined screening barriers and facilitators listed by women with regards to screening
Conclusions
In conclusion, the screening barrier most often identified by women was a lack of time (practical barrier) and the screening facilitator most often listed was the low cost of the test. In logistic regression analyses, the number of psychological barriers was related to women's screening status (i.e., overdue vs. up-to-date), whereas the numbers of practical and psychological screening barriers were related to prior screening (i.e., screened vs. never screened), along with the number of
Declarations of interest
None.
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