Uptake for cervical screening by ethnicity and place-of-birth: a population-based cross-sectional study

Use of SARC services by victims of sexual violence: Auditing the ethnicity of Saint Mary's Sexual Assault Referral Centre's clients

INTRODUCTION

Saint Mary's Sexual Assault Referral Centre (SARC) in Manchester provides services to adults and children who have suffered sexual assault. The ethnic composition of those who attended the centre was audited in 2001 and 2003 to measure how well it serves different ethnic groups. This paper provides an updated audit using 2019 data.

METHODOLOGY

Census data for Greater Manchester, and data from the Crime Survey of England and Wales (CSEW) showing rates of sexual assault for different ethnic groups, were used to predict the ethnic composition of sexual assault victims in Greater Manchester. These predicted figures were then compared with the ethnic composition of Saint Mary's SARC 2019 client base to measure how well the SARC is serving different groups. This comparison was repeated using data from the 2001 SARC client base to explore change over time.

RESULTS

The analysis shows that South Asians and Chinese individuals are underrepresented in the SARC client base, and that this issue has become more pronounced over time. Every other group is overrepresented.

CONCLUSION

The underrepresentation of South Asian and Chinese clients at Saint Mary's SARC is concerning. Making the service more accessible to those from these ethnic groups should be a priority for the centre.

A systematic review of the cost-effectiveness of interventions to increase cervical cancer screening among underserved women in Europe

BACKGROUND

This study aimed to conduct a systematic review of the cost-effectiveness studies of interventions to increase cervical cancer screening uptake rates in underserved women in Europe.

METHODS

A search of Embase, Medline, Global Health, PsychINFO, and NHS Economic Evaluation Database was conducted for studies published between January 2000 and September 2022. Studies were eligible if they analysed the cost-effectiveness of any interventions to improve participation in cervical cancer screening among underserved women of any age eligible to participate in cervical cancer screening in European countries, in any language. Study characteristics and cost-effectiveness results were summarised. Study quality was assessed using the Drummond Checklist, and methodological choices were further compared.

RESULTS

The searches yielded 962 unique studies, with 17 of these (from twelve European countries) meeting the eligibility criteria for data extraction. All studies focused on underscreened women as an overarching group, with no identified studies focusing on specific subgroups of underserved women. Generally, self-HPV testing and reminder interventions were shown to be cost-effective to increase the uptake rates. There was also research showing that addressing access issues and adopting different screening modalities could be economically attractive in some settings, but the current evidence is insufficient due to the limited number of studies.

CONCLUSION

This systematic review has revealed a gap in the literature on the cost-effectiveness of interventions to improve uptake rates of cervical cancer screening through tailored provision for specific groups of underserved women.

Adherence to Cervical Cancer Screening Programs in Migrant Populations: A Systematic Review and Meta-Analysis

Organized cervical cancer screening programs to promote the early identification of precancerous lesions have proven to be effective in decreasing the burden associated with cervical cancer, but knowledge regarding screening adherence among migrant women compared to that of native women has not been summarized. A systematic search of the literature on PubMed, Scopus and Embase led to the identification of 772 papers that were published up to July 2022 and reported population-based data regarding adherence to cervical screening. The screening participation rates among migrant women, compared to native women, were pooled using a random-effects meta-analysis. A total of 18 papers were included in the review, with most of them being conducted in Europe (83.3%). Overall, migrants showed a significantly lower participation rate compared to native women (OR for screening adherence: 0.54, 95% CI = 0.42-0.70). This discrepancy was especially evident for migrant women from North Africa and Sub-Saharan Africa (OR = 0.47, 95% CI = 0.35-0.63, and OR = 0.35, 95% CI = 0.24-0.49, respectively). The results of this systematic review emphasize the importance of increasing cervical cancer screening adherence among migrant women. A significant heterogeneity in screening adherence was observed based on the country of origin. Interventions aimed at reducing the disparities in screening participation should specifically consider how to improve the recruitment of migrant women.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology.

MAIN RESULTS

Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

Ethnic disparities in the uptake of colorectal cancer screening: An analysis of the West London population

AIM

Colorectal cancer (CRC) screening reduces mortality but variation exists in uptake, with poorer uptake in ethnic minority groups. The aim of this work was to evaluate the relationship between ethnicity and uptake of CRC screening in West London.

METHOD

Results of CRC screening from the Central London, West London, Hammersmith and Fulham, Hounslow and Ealing Clinical commissioning group collaborative between 2012 and 2017 were retrospectively analysed. These five clinical commissioning groups (CCGs) are located in West London. Compliance with screening according to ethnic group was evaluated compared with White British as the control.

RESULTS

A total of 155 038 individuals were screened. White British individuals had the highest compliance (52.6%). A maximum difference in compliance of 8.2% was seen between CCGs. The odds of being less likely to participate were significant (p < 0.05) in all ethnic minorities except for Asian Chinese on univariate and multivariate analysis (adjusted OR 1.091, p = 0.88).

CONCLUSION

This is the largest retrospective study focusing on the role of ethnicity in the uptake of CRC screening in England. Poor uptake of screening in all ethnic minorities in West London, with the exception of Asian Chinese individuals in particular, is a novel finding. A mandate to routinely collect ethnicity data, the use of a single more diverse census and further intervention are needed to understand this disparity and reduce health inequity.

Prevalence of Neisseria gonorrhoeae and Trichomonas vaginalis in Portuguese women of childbearing age

The purpose of this study was to evaluate the prevalence of Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) in Portuguese women of childbearing age. Cervicovaginal self-collected samples of 680 childbearing-age women (15-44 years) were tested for NG and TV by polymerase chain reaction. Sociodemographic, clinical and behavioural data were assessed through an anonymous self-administered questionnaire. NG and TV prevalence was 1.3% (95% confidence interval (CI) 0.7-2.5%) and 1.0% (95% CI 0.5-2.1%), respectively. The prevalence of TV was significantly higher in women aged >22 years (p = .003), with >6 years after sexual intercourse (p = .003), and who reported previous pregnancy (p = .004). Our study suggests that NG and TV are rare in Portuguese women of childbearing age. However, larger epidemiological studies with a nationally representative sample of female subjects are warranted, to clarify the need for screening of these microorganisms in Portuguese women, since its prevalence is probably underestimated.IMPACT STATEMENTWhat is already known on this subject? Studies on the prevalence of NG and TV have been performed in several developed and developing countries. However, limited data is available in Portuguese women. The detection of NG and TV is necessary because, beside the risk of transmission to sex partners, these STIs may be associated with an increased risk of HIV acquisition and transmission, and ultimately with reproductive, pregnancy and perinatal complications.What do the results of this study add? Our study adds new findings to the body of knowledge on NG and TV prevalence in Portuguese women of reproductive age. As so, we found a low prevalence of both NG (1.3%) and TV (1.0%) in the studied population.What are the implications of these findings for clinical practice and/or further research? Our results may be a step ahead to encourage future nationally representative studies evaluating the prevalence of NG and TV genital infection and, consequently, to clarify the need for screening of these microorganisms. In clinical practice, it should be highlighted the appropriate management of NG and TV infection in specific situations, such as pregnancy. Also, sexual partners must be treated to prevent the recurrences in the index cases and reduce transmission to other partners.

Human papillomavirus immunization uptake among girls with a refugee background compared with Danish-born girls: a national register-based cohort study

Refugee children and their families may experience impaired access to healthcare; therefore, we aimed to uncover human papillomavirus (HPV) immunization patterns among a large group of refugee girls compared with Danish-born girls. We also examined possible predictors of uptake among refugee girls. We used a register-based cohort design where refugee girls (n=3264) who, between 1 January 1994 and 31 December 2010, obtained residency permits in Denmark, were included and matched on age and sex with Danish-born girls (n=19 584). Personal identification numbers were cross-linked to the National Danish Health Service Register, identifying all contacts for HPV-immunization in both the ordinary HPV-immunization program and in a catch-up program. We applied logistic regression to estimate the odds ratios (OR) of uptake. We found that refugee girls had significantly lower HPV immunization uptake compared with Danish-born girls in the ordinary immunization program (OR=0.44; 95% confidence interval: 0.37-0.51) and the catch-up program (OR=0.61; 95% confidence interval: 0.54-0.69). The difference in odds decreased after adjusting by family income, but remained significant for the ordinary immunization program. We also identified that region of origin, duration of residence, and income were predictors of uptake among refugee girls. The lower uptake of HPV immunization among refugee girls raises questions about the coverage of this immunization program across increasingly ethnic diverse societies. More efforts to secure equal uptake are needed.

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.

A systematic review of barriers and enablers to South Asian women's attendance for asymptomatic screening of breast and cervical cancers in emigrant countries

OBJECTIVES

The aim of this review was to identify the cultural, social, structural and behavioural factors that influence asymptomatic breast and cervical cancer screening attendance in South Asian populations, in order to improve uptake and propose priorities for further research.

DESIGN

A systematic review of the literature for inductive, comparative, prospective and intervention studies. We searched the following databases: MEDLINE/In-Process, Web of Science, EMBASE, SCOPUS, CENTRAL, CDSR, CINAHL, PsycINFO and PsycARTICLES from database inception to 23 January 2018. The review included studies on the cultural, social, structural and behavioural factors that influence asymptomatic breast and cervical cancer screening attendance and cervical smear testing (Papanicolaou test) in South Asian populations and those published in the English language. The framework analysis method was used and themes were drawn out following the thematic analysis method.

SETTINGS

Asymptomatic breast or cervical screening.

PARTICIPANTS

South Asian women, including Bangladeshi, Indian, Pakistani, Sri Lankan, Bhutanese, Maldivian and Nepali populations.

RESULTS

51 included studies were published between 1991 and 2018. Sample sizes ranged from 25 to 38 733 and participants had a mean age of 18 to 83 years. Our review showed that South Asian women generally had lower screening rates than host country women. South Asian women had poorer knowledge of cancer and cancer prevention and experienced more barriers to screening. Cultural practices and assumptions influenced understandings of cancer and prevention, emphasising the importance of host country cultures and healthcare systems.

CONCLUSIONS

High-quality research on screening attendance is required using prospective designs, where objectively validated attendance is predicted from cultural understandings, beliefs, norms and practices, thus informing policy on targeting relevant public health messages to the South Asian communities about screening for cancer.

PROSPERO REGISTRATION NUMBER

CSD 42015025284.

Effect of HPV vaccination and cervical cancer screening in England by ethnicity: a modelling study

BACKGROUND

Health equality is increasingly being considered alongside overall health gain when assessing public health interventions. However, the trade-off between the direct effects of vaccination and herd immunity could lead to unintuitive consequences for the distribution of disease burden within a population. We used a transmission dynamic model of human papillomavirus (HPV) to investigate the effect of ethnic disparities in vaccine and cervical screening uptake on inequality in disease incidence in England.

METHODS

We developed an individual-based model of HPV transmission and disease, parameterising it with the latest data for sexual behaviour (from National Survey of Sexual Attitudes and Lifestyles [Natsal-3]) and vaccine and screening uptake by ethnicity (from Public Health England [PHE]) and fitting it to data for HPV prevalence (from ARTISTIC, PHE, Natsal-3) and HPV-related disease incidence (from National Cancer Registry [ONS]). The outcome of interest was the age-adjusted incidence of HPV-related cancer (both cervical and non-cervical) in all women in England in view of differences and changes in vaccination and screening uptake by ethnicity in England, over time. We also studied three potential public health interventions aimed at reducing inequality in HPV-related disease incidence: increasing uptake in black and Asian females to match that in whites for vaccination; cervical screening in women who turn 25 in 2018 or later; and cervical screening in all ages.

FINDINGS

In the pre-vaccination era, before 2008, women from ethnic minorities in England reported a disproportionate share of cervical disease. Our model suggests that Asian women were 1·7 times (95% credibility interval [CI] 1·1-2·7) more likely to be diagnosed with cervical cancer than white women (22·8 vs 13·4 cases per 100 000 women). Because HPV vaccination uptake is lower in ethnic minorities, we predict an initial widening of this gap, with cervical cancer incidence in Asian women up to 2·5 times higher (95% CI 1·3-4·8) than in white women 20 years after vaccine introduction (corresponding to an additional 10·8 [95% CI 10·1-11·5] cases every year). In time, we predict that herd immunity benefits will diffuse from the larger white sub-population and the disparity will narrow. Increased cervical screening uptake in vaccinated women from ethnic minorities would lead to rapid improvement in equality with parity in incidence after 20 years of HPV vaccination.

INTERPRETATION

Our study suggests that the introduction of HPV vaccination in England will initially widen a pre-existing disparity in the incidence of HPV-related cancer by ethnicity, partly due to herd immunity disproportionately benefiting subgroups with high vaccination rates. Although in time this induced disparity will narrow, increasing cervical screening uptake in girls from ethnic minorities should be encouraged to eliminate the inequality in cervical cancer incidence in the medium term. We recommend that dynamic effects should be considered when estimating the effect of public health programmes on equality.

FUNDING

Cancer Research UK.

Do Cervical Cancer Patients Diagnosed with Opportunistic Screening Live Longer? An Arkhangelsk Cancer Registry Study

The aim of the current study was to compare cervical cancer (СС) patients diagnosed with and without screening in terms of: (i) sociodemographic and clinical characteristics; (ii) factors associated with survival; and (iii), and levels of risk. A registry-based study was conducted using data from the Arkhangelsk Cancer Registry. It included women with newly diagnosed malignant neoplasm of the uterine cervix during the period of 1 January 2005 to 11 November 2016 (N = 1548). The Kaplan-Meier method, the log-rank test, and Cox regression were applied. Most participants who were diagnosed by screening were at stage I and died less frequently from CC than those diagnosed without screening. The latter group was also diagnosed with СС at a younger age and died younger. Younger individuals and urban residents diagnosed with stage I and II, squamous cell carcinoma had longer survival times. Cox regression modeling indicated that the hazard ratio for death among women with CC diagnosed without screening was 1.61 (unadjusted) and 1.37 (adjusted). CC diagnosed by screening, cancer stage, patient residence, histological tumor type, and age at diagnosis were independent prognostic variables of longer survival time with CC. Diagnosis of CC made within a screening program improved survival.

Migrant's access to preventive health services in five EU countries

Background

Preventive health services (PHSs) form part of primary healthcare with the aim of screening to prevent disease. Migrants show significant differences in lifestyle, health beliefs and risk factors compared with the native populations. This can have a significant impact on migrants’ access to health systems and participation in prevention programmes. Even in countries with widely accessible healthcare systems, migrants’ access to PHSs may be difficult. The aim of the study was to compare access to preventive health services between migrants and native populations in five European Union (EU) countries.

Methods

Information from Health Interview Surveys of Belgium, Italy, Malta, Portugal and Spain were used to analyse access to mammography, Pap smear tests, colorectal cancer screening and flu vaccination among migrants. The comparative risk of not accessing PHSs was calculated using a mixed-effects multilevel model, adjusting for potential confounding factors (sex, education and the presence of disability). Migrant status was defined according to citizenship, with a distinction made between EU and non-EU countries.

Results

Migrants, in particular those from non-EU countries, were found to have poorer access to PHSs. The overall risk of not reporting a screening test or a flu vaccination ranged from a minimum of 1.8 times (colorectal cancer screening), to a high of 4.4 times (flu vaccination) for migrants. The comparison among the five EU countries included in the study showed similarities, with particularly limited access recorded in Italy and in Belgium for non-EU migrants.

Conclusions

The findings of this study are in accordance with evidence from the scientific literature. Poor organization of health services, in Italy, and lack of targeted health policies in Belgium may explain these findings. PHSs should be responsive to patient diversity, probably more so than other health services. There is a need for diversity-oriented, migrant-sensitive prevention. Policies oriented to removing impediments to migrants’ access to preventive interventions are crucial, to encourage more positive action for those facing the risk of intersectional discrimination.

Testing innovative strategies to reduce the social gradient in the uptake of bowel cancer screening: a programme of four qualitatively enhanced randomised controlled trials

Background

Bowel cancer screening reduces cancer-specific mortality. There is a socioeconomic gradient in the uptake of the English NHS Bowel Cancer Screening Programme (BCSP), which may lead to inequalities in cancer outcomes.

Objective

To reduce socioeconomic inequalities in uptake of the NHS BCSP’s guaiac faecal occult blood test (gFOBt) without compromising uptake in any socioeconomic group.

Design

Workstream 1 explored psychosocial determinants of non-uptake of gFOBt in focus groups and interviews. Workstream 2 developed and tested four theoretically based interventions: (1) ‘gist’ information, (2) a ‘narrative’ leaflet, (3) ‘general practice endorsement’ (GPE) and (4) an ‘enhanced reminder’ (ER). Workstream 3 comprised four national cluster randomised controlled trials (RCTs) of the cost-effectiveness of each intervention.

Methods

Interventions were co-designed with user panels, user tested using interviews and focus groups, and piloted with postal questionnaires. RCTs compared ‘usual care’ (existing NHS BCSP invitations) with usual care plus each intervention. The four trials tested: (1) ‘gist’ leaflet (n = 163,525), (2) ‘narrative’ leaflet (n = 150,417), (3) GPE on the invitation letter (n = 265,434) and (4) ER (n = 168,480). Randomisation was based on day of mailing of the screening invitation. The Index of Multiple Deprivation (IMD) score associated with each individual’s home address was used as the marker of socioeconomic circumstances (SECs). Change in the socioeconomic gradient in uptake (interaction between treatment group and IMD quintile) was the primary outcome. Screening uptake was defined as the return of a gFOBt kit within 18 weeks of the invitation that led to a ‘definitive’ test result of either ‘normal’ (i.e. no further investigation required) or ‘abnormal’ (i.e. requiring referral for further testing). Difference in overall uptake was the secondary outcome.

Results

The gist and narrative trials showed no effect on the SECs gradient or overall uptake (57.6% and 56.7%, respectively, compared with 57.3% and 58.5%, respectively, for usual care; allp-values > 0.05). GPE showed no effect on the gradient (p = 0.5) but increased overall uptake [58.2% vs. 57.5% in usual care, odds ratio (OR) = 1.07, 95% confidence interval (CI) 1.04 to 1.10;p < 0.0001]. ER showed a significant interaction with SECs (p = 0.005), with a stronger effect in the most deprived IMD quintile (14.1% vs. 13.3% in usual care, OR = 1.11, 95% CI 1.04 to 1.20;p = 0.003) than the least deprived (34.7% vs. 34.9% in usual care OR = 1.00, 95% CI 0.94 to 1.06;p = 0.98), and higher overall uptake (25.8% vs. 25.1% in usual care, OR = 1.07, 95% CI 1.03 to 1.11;p = 0.001). All interventions were inexpensive to provide.

Limitations

In line with NHS policy, the gist and narrative leaflets supplemented rather than replaced existing NHS BCSP information. This may have undermined their effect.

Conclusions

Enhanced reminder reduced the gradient and modestly increased overall uptake, whereas GPE increased overall uptake but did not reduce the gradient. Therefore, given their effectiveness and very low cost, the findings suggest that implementation of both by the NHS BCSP would be beneficial. The gist and narrative results highlight the challenge of achieving equitable delivery of the screening offer when all communication is written; the format is universal and informed decision-making mandates extensive medical information.

Future work

Socioculturally tailored research to promote communication about screening with family and friends should be developed and evaluated.

Trial registration

Current Controlled Trials ISRCTN74121020.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information.

Increasing attendance in a cervical cancer screening programme by personal invitation: experience of a Lithuanian primary health care centre

BACKGROUND

High participation rates are an essential component of an effective screening programme and many approaches were introduced as being successful for enhancing compliance to screening guidelines. The aim of this study was to evaluate to which extent a personal invitation by mail increases the rate of attendance in a cervical cancer screening programme in a primary health care centre.

MATERIALS AND METHODS

The study was carried out as a pilot project to gain insight into feasibility of applying a well-known compliance increasing measure in Lithuanian population. The study included a sample of women registered at the primary health care centre in Panevėžys who had not participated in the cervical cancer screening programme for six and more years. Personal registered invitation letters to attend the primary health care centre for a Pap smear were sent out to 1789 women by mail.

RESULTS

In total, 2195 women were tested during 2011 at the primary health care centre. 487 (22.2%) of them attended the screening programme after receiving a personal invitation letter. Response rate for attending screening after receiving a personal invitation letter was 27.3%.

CONCLUSIONS

Our study demonstrated that personal invitation letters addressed to long-term non-attendees could markedly increase participation in cervical cancer screening in Lithuania.

Acceptability of unsupervised HPV self-sampling using written instructions

Objectives

The study measured the acceptability of self-sampling for human papillomavirus (HPV) testing in the context of cervical cancer screening. Women carried out self-sampling unsupervised, using a written instruction sheet.

Setting

Participants were women attending either a family planning clinic or a primary care trust for routine cervical screening.

Methods

Women (n = 902) carried out self-sampling for HPV testing and then a clinician did a routine cervical smear and HPV test. Immediately after having the two tests, participants completed a measure of acceptability for both tests, and answered questions about ease of using the instruction sheet and willingness to use self-sampling in the future.

Results

The majority of women found self-sampling more acceptable than the clinician-administered test, but there was a lack of confidence that the test had been done correctly. Significant demographic differences in attitudes were found, with married women having more favourable attitudes towards self-sampling than single women, and Asian women having more negative attitudes than women in other ethnic groups. Intention to use self-sampling in the future was very high across all demographic groups.

Conclusion

Self-sampling for HPV testing was highly acceptable in this large and demographically diverse sample, and women were able to carry out the test alone, using simple written instructions. Consistent with previous studies, women were concerned about doing the test properly and this issue will need to be addressed if self-sampling is introduced. More work is needed to see whether the demographic differences we found are robust and to identify reasons for lower acceptability among single women and those from Asian background.

Barriers and facilitators to uptake of the school-based HPV vaccination programme in an ethnically diverse group of young women

BACKGROUND

To identify the barriers and facilitators to uptake of the HPV vaccine in an ethnically diverse group of young women in the south west of England.

METHODS

Three school-based vaccination sessions were observed. Twenty-three young women aged 12 to 13 years, and six key informants, were interviewed between October 2012 and July 2013. Data were analysed using thematic analysis and the Framework method for data management.

RESULTS

The priority given to preventing cervical cancer in this age group influenced whether young women received the HPV vaccine. Access could be affected by differing levels of commitment by school staff, school nurses, parents and young women to ensure parental consent forms were returned. Beliefs and values, particularly relevant to minority ethnic groups, in relation to adolescent sexual activity may affect uptake. Literacy and language difficulties undermine informed consent and may prevent vaccination.

CONCLUSIONS

The school-based HPV vaccination programme successfully reaches the majority of young women. However, responsibility for key aspects remain unresolved which can affect delivery and prevent uptake for some groups. A multi-faceted approach, targeting appropriate levels of the socio-ecological model, is required to address procedures for consent and cultural and literacy barriers faced by minority ethnic groups, increase uptake and reduce inequalities.

Cancer screening behaviours among South Asian immigrants in the UK, US and Canada: a scoping study

South Asian (SA) immigrants settled in the United Kingdom (UK) and North America [United States (US) and Canada] have low screening rates for breast, cervical and colorectal cancers. Incidence rates of these cancers increase among SA immigrants after migration, becoming similar to rates in non-Asian native populations. However, there are disparities in cancer screening, with low cancer screening uptake in this population. We conducted a scoping study using Arksey & O'Malley's framework to examine cancer screening literature on SA immigrants residing in the UK, US and Canada. Eight electronic databases, key journals and reference lists were searched for English language studies and reports. Of 1465 identified references, 70 studies from 1994 to November 2014 were included: 63% on breast or cervical cancer screening or both; 10% examined colorectal cancer screening only; 16% explored health promotion/service provision; 8% studied breast, cervical and colorectal cancer screening; and 3% examined breast and colorectal cancer screening. A thematic analysis uncovered four dominant themes: (i) beliefs and attitudes towards cancer and screening included centrality of family, holistic healthcare, fatalism, screening as unnecessary and emotion-laden perceptions; (ii) lack of knowledge of cancer and screening related to not having heard about cancer and its causes, or lack of awareness of screening, its rationale and/or how to access services; (iii) barriers to access including individual and structural barriers; and (iv) gender differences in screening uptake and their associated factors. Findings offer insights that can be used to develop culturally sensitive interventions to minimise barriers and increase cancer screening uptake in these communities, while recognising the diversity within the SA culture. Further research is required to address the gap in colorectal cancer screening literature to more fully understand SA immigrants' perspectives, as well as research to better understand gender-specific factors that influence screening uptake.

Barriers to cervical cancer screening among ethnic minority women: a qualitative study

BACKGROUND

Ethnic minority women are less likely to attend cervical screening.

AIM

To explore self-perceived barriers to cervical screening attendance among ethnic minority women compared to white British women.

DESIGN

Qualitative interview study.

SETTING

Community groups in ethnically diverse London boroughs.

METHODS

Interviews were carried out with 43 women from a range of ethnic minority backgrounds (Indian, Pakistani, Bangladeshi, Caribbean, African, Black British, Black other, White other) and 11 White British women. Interviews were recorded, transcribed verbatim and analysed using Framework analysis.

RESULTS

Fifteen women had delayed screening/had never been screened. Ethnic minority women felt that there was a lack of awareness about cervical cancer in their community, and several did not recognise the terms 'cervical screening' or 'smear test'. Barriers to cervical screening raised by all women were emotional (fear, embarrassment, shame), practical (lack of time) and cognitive (low perceived risk, absence of symptoms). Emotional barriers seemed to be more prominent among Asian women. Low perceived risk of cervical cancer was influenced by beliefs about having sex outside of marriage and some women felt a diagnosis of cervical cancer might be considered shameful. Negative experiences were well remembered by all women and could be a barrier to repeat attendance.

CONCLUSIONS

Emotional barriers (fear, embarrassment and anticipated shame) and low perceived risk might contribute to explaining lower cervical screening coverage for some ethnic groups. Interventions to improve knowledge and understanding of cervical cancer are needed in ethnic minority communities, and investment in training for health professionals may improve experiences and encourage repeat attendance for all women.

Understanding cervical screening non-attendance among ethnic minority women in England

BACKGROUND

Women from Black, Asian and Minority Ethnic (BAME) backgrounds are less likely to attend cervical screening than White British women. This study explored sociodemographic and attitudinal correlates of cervical screening non-attendance among BAME women.

METHODS

Women (30-60 years) were recruited from Indian, Pakistani, Bangladeshi, Caribbean, African and White British backgrounds (n=720). Participants completed structured interviews.

RESULTS

BAME women were more likely to be non-attenders than white British women (44-71% vs 12%) and fell into two groups: the disengaged and the overdue. Migrating to the United Kingdom, speaking a language other than English and low education level were associated with being disengaged. Being overdue was associated with older age. Three attitudinal barriers were associated with being overdue for screening among BAME women: low perceived risk of cervical cancer due to sexual inactivity, belief that screening is unnecessary without symptoms and difficulty finding an appointment that fits in with other commitments.

CONCLUSIONS

BAME non-attenders appear to fall into two groups, and interventions for these groups may need to be targeted and tailored accordingly. It is important to ensure that BAME women understand cancer screening is intended for asymptomatic women and those who have ceased sexual activity may still be at risk.

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.

Barriers to uptake among high-risk individuals declining participation in lung cancer screening: a mixed methods analysis of the UK Lung Cancer Screening (UKLS) trial

OBJECTIVE

The current study aimed to identify the barriers to participation among high-risk individuals in the UK Lung Cancer Screening (UKLS) pilot trial.

SETTING

The UKLS pilot trial is a randomised controlled trial of low-dose CT (LDCT) screening that has recruited high-risk people using a population approach in the Cambridge and Liverpool areas.

PARTICIPANTS

High-risk individuals aged 50-75 years were invited to participate in UKLS. Individuals were excluded if a LDCT scan was performed within the last year, if they were unable to provide consent, or if LDCT screening was unable to be carried out due to coexisting comorbidities.

OUTCOME MEASURES

Statistical associations between individual characteristics and UKLS uptake were examined using multivariable regression modelling. In those who completed a non-participation questionnaire (NPQ), thematic analysis of free-text data was undertaken to identify reasons for not taking part, with subsequent exploratory linkage of key themes to risk factors for non-uptake.

RESULTS

Comparative data were available from 4061 high-risk individuals who consented to participate in the trial and 2756 who declined participation. Of those declining participation, 748 (27.1%) completed a NPQ. Factors associated with non-uptake included: female gender (OR=0.64, p<0.001), older age (OR=0.73, p<0.001), current smoking (OR=0.70, p<0.001), lower socioeconomic group (OR=0.56, p<0.001) and higher affective risk perception (OR=0.52, p<0.001). Among non-participants who provided a reason, two main themes emerged reflecting practical and emotional barriers. Smokers were more likely to report emotional barriers to participation.

CONCLUSIONS

A profile of risk factors for non-participation in lung screening has emerged, with underlying reasons largely relating to practical and emotional barriers. Strategies for engaging high-risk, hard-to-reach groups are critical for the equitable uptake of a potential future lung cancer screening programme.

TRIAL REGISTRATION NUMBER

The UKLS trial was registered with the International Standard Randomised Controlled Trial Register under the reference 78513845.

Consultation rates in cervical screening non-attenders: opportunities to increase screening uptake in GP primary care

OBJECTIVE

To estimate the proportion of cervical screening non-attenders presenting to general practice (GP) primary care over one year.

SETTING

137 practices in East London, UK.

METHODS

Anonymous primary care records were downloaded using EMIS web (clinical software). Cervical screening nonattendance was defined as no recorded smear in the last 3.5 years (women aged 25-49) or 5.5 years (women aged 50-64). The last three consultation entries were used to estimate the proportion of non-attenders who consulted in GP over 3 months and 1 year using the Kaplan-Meier method. Newly registered women were assessed separately. Results were calculated for each practice and the median and interquartile range (IQR) across practices are presented. Heterogeneity was assessed using funnel plots.

RESULTS

Of 261,810 women, 224,313 (86%) had been registered for >1 year. The proportion classified as non-attenders differed between those registered for >1 year (30%, IQR 27%--35%) and within the last year (49%, IQR 40%--57%), suggesting that screening records were less up-to-date in newly registered women. A median of 32% (IQR: 27%--37%) of non-attenders presented over 3 months, and 60% (IQR: 52%--67%) over 1 year. Funnel plots of the proportion of non-attenders presenting by the number of non-attenders showed substantial variation between practices.

CONCLUSIONS

Over half of cervical screening non-attenders present to their GP at least once a year, in over 75% of practices. This represents a good opportunity for improving coverage by offering an alternative form of screening, such as self-sampling for human papillomavirus testing.

A randomized controlled trial in non-responders from Newcastle upon Tyne invited to return a self-sample for Human Papillomavirus testing versus repeat invitation for cervical screening

BACKGROUND

Non-attenders for cervical screening are at increased risk of cervical cancer. Studies offering self-sampling for high-risk Human Papillomavirus (HrHPV) testing have shown greater uptake than sending another invitation for cytology.

OBJECTIVES

To explore whether uptake would increase in a less diverse, more stable population than the previous English study, which demonstrated a lower response rate than other studies. The primary objective was whether non-attenders were more likely to respond to a postal invitation, including kit, to collect a self-sample compared with a further invitation for cytology screening. The secondary objective was whether women with an abnormal result would attend for follow-up.

METHODS

6000 non-attenders for screening in this pragmatic, randomized (1:1) controlled trial in Newcastle-upon-Tyne were sent an HPV self-sample kit (intervention) or a further invitation for cytology screening (comparator).

RESULTS

411(13%) responded to the intervention, returning a self-sample (247(8%)) or attending for cytology (164(5%)), compared with 183(6%) attending for cytology, relative risk 2.25 (95% CI 1.90-2.65) (comparator arm). Of those testing hrHPV positive (32(13%)), 19(59%) subsequently attended cytology screening. Of those in the intervention group who attended for cytology screening without returning an hrHPV self-sample (n = 164), 5% (n = 8) were referred for colposcopy - all attended. In the comparator group eight of the nine referred for colposcopy attended.

CONCLUSION

Persistent non-responders to invitations for cervical screening are significantly more likely to respond to a postal invitation to return a self-collected sample for HPV testing than a further invitation for cytology screening. However, just over half followed up on this positive HPV result.

Barriers and facilitators to HPV vaccination of young women in high-income countries: a qualitative systematic review and evidence synthesis

BACKGROUND

Vaccination against Human Papillomavirus (HPV) is recommended for adolescent young women prior to sexual debut to reduce cervical cancer related mortality and morbidity. Understanding factors affecting decision-making of HPV vaccination of young women is important so that effective interventions can be developed which address barriers to uptake in population groups less likely to receive the HPV vaccine.

METHODS

We undertook a qualitative systematic review and evidence synthesis to examine decision-making relating to the HPV vaccination of young women in high-income countries. A comprehensive search of databases from inception to March 2012 was undertaken to identify eligible studies reporting the perspectives of key stakeholders including policy makers, professionals involved in programme, parents, and young women. Factors affecting uptake of the vaccine were examined at different levels of the socio-ecological model (policy, community, organisational, interpersonal and intrapersonal).

RESULTS

Forty-one studies were included. Whether young women receive the HPV vaccine is strongly governed by the decisions of policy makers, healthcare professionals, and parents. These decisions are shaped by: financial considerations; social norms and values relating to sexual activity, and; trust in vaccination programmes and healthcare providers. Financial constraints may be overcome through universal healthcare systems offering the HPV vaccine free at the point of delivery. In the healthcare setting, judgements by healthcare professionals about whether to recommend the vaccine may restrict a young woman's access to the vaccine irrespective of her own beliefs and preferences. Parents may decide not to allow their daughters to be vaccinated, based on cultural or religious perceptions about sexual activity.

CONCLUSIONS

Barriers to the uptake of the HPV vaccine have implications for young women's future sexual, physical and reproductive health. Interventions to address barriers to uptake of the vaccine should target appropriate, and multiple, levels of the socio-ecological model. Issues of trust require clear, accessible, and sometimes culturally appropriate, information about the HPV vaccination programme. Although young women are central to the HPV vaccination programme, their views are underrepresented in the qualitative literature. Future research should consider young women's perceptions of, and involvement in, consent and decision-making.

Sociodemographic factors predicting mother's cervical screening and daughter's HPV vaccination uptake

BACKGROUND

Achieving high human papillomavirus (HPV) vaccine coverage may reduce inequalities in cervical cancer prevention by mitigating the inequalities seen in the cervical screening programme. This paper assesses whether the same sociodemographic factors are associated with both cervical screening and HPV vaccination.

METHODS

Girls' HPV vaccination records were linked by address to cervical screening records for their mothers in the North West of England. Index of Multiple Deprivation scores (2010) and census ethnicity data (2001) were used to investigate the association between deprivation and ethnic composition of area of residence with HPV vaccination and cervical screening uptake, along with potential differences between Primary Care Trusts (PCTs), which were responsible for vaccine delivery.

RESULTS

Deprivation was not associated with routine (12-13-year-olds) vaccination initiation, but girls living in the most deprived quintile were significantly less likely to complete the three vaccine doses (OR 0.75; 95% CI 0.63 to 0.88). Mother-daughter pairs failing to engage in either screening or vaccination were also more likely to live in deprived areas (routine vaccination OR for most deprived quintile: 2.35; 95% CI 2.00 to 2.77). There were differences between PCTs after controlling for demographic effects (OR 1.35; 95% CI 1.23 to 1.52).

CONCLUSIONS

Ensuring completion of the vaccine schedule is critical for organisations responsible for vaccine delivery in order to reduce cancer risk among girls living in deprived areas. There remains a small minority of mothers and daughters from disadvantaged backgrounds who do not participate in either cervical screening or HPV vaccination.

Attitudes towards cytology and human papillomavirus self-sample collection for cervical screening among Hindu women in London, UK: a mixed methods study

Objectives

To explore the attitudes, views and understanding of women attending a Hindu temple in London, UK towards cervical screening, human papillomavirus (HPV) testing and two HPV self-sample collection devices: the Dacron swab and Evalyn^® brush.

Methods

A mixed methods design comprising a survey and four focus groups was adopted. Focus group discussions were recorded and transcribed verbatim and explored using thematic framework analysis.

Results

A total of 185 Hindu women completed surveys and 23 attended focus groups. Of the respondents 75% aged 25–64 years reported having cervical screening within the last 5 years; 85% had attended college or university. Familiar barriers to attendance for screening were identified: fear of pain and the test result, embarrassment, screener's attitude, inconvenient appointment times and difficulty with child care. Additional barriers cited included age and country of birth, with older and Indian-born women thought to be less likely to attend for screening. Self-collected sampling had a mixed reception. Women were not confident that their sample would be as good as a clinician sample and expressed concern about the impact that a positive HPV result might have on their relationships.

Conclusions

Screening attendance in this highly educated group of Hindu women was slightly lower than in the general population (75% of women aged 25–64 years had been screened in the last 5 years compared with 79% in England as a whole). Familiar barriers to screening were identified. Women felt able to collect their own sample for HPV testing with a Dacron swab but lacked confidence that it would be as good as that obtained by a clinician.

Accessing cancer services in North West England: the Chinese population

Relatively few Chinese patients access tertiary cancer services in North West England. We investigated the reasons behind this using a culturally sensitive questionnaire. The questionnaire, completed by 214 Chinese people in English, Cantonese or Mandarin, evaluated the Chinese population's access and satisfaction with primary care, understanding of cancer and awareness of local cancer services. Ninety-five per cent of respondents were registered with a general practitioner (GP) and 75% had accessed primary care in the last year. Satisfaction with GP consultations was high but a third of respondents reported a lack of confidence in local National Health Service (NHS) services. Only 57% of eligible women had attended cervical screening programmes. The overall understanding of the causes and treatment of cancer and cancer services in the North West was poor. Despite registration with primary healthcare, the Chinese population under-utilise cancer prevention programmes and tertiary cancer services because of a lack of awareness and understanding of cancer services in the North West. A significant proportion of the population is dissatisfied with the perceived slow service and lack confidence in services, with 41% considering using healthcare abroad. These data highlight the critical need to engage with, educate and support the Chinese population if they are to access NHS cancer services.

Towards equitable commissioning for our multiethnic society: a mixed-methods qualitative investigation of evidence utilisation by strategic commissioners and public health managers

Background

The health-care commissioning cycle is an increasingly powerful determinant of the health services on offer and the care that patients receive. This study focuses on the mobilisation and use of evidence relating to ethnic diversity and inequality.

Objective

To describe the patterns and determinants of evidence use relating to ethnic diversity and inequality by managers within commissioning work and to identify promising routes for improvement.

Methods

In-depth semistructured interviews with 19 national key informants and documentation of good practice across England. Detailed case studies of three primary care trusts involving 70+ interviews with key strategic and operational actors, extensive observational work and detailed analysis of related documentation. A suite of commissioning resources based on findings across all elements were tested and refined through three national workshops of key stakeholders.

Results

Commissioners often lack clarity on how to access, appraise, weight or synthesise diverse sources of evidence and can limit the transformational shaping of services by a narrow conceptualisation of their role. Attention to evidence on ethnic diversity and inequality is frequently omitted at both national and local levels. Understanding of its importance is problematic and there are gaps in this evidence that create further barriers to its use within the commissioning cycle. Commissioning models provide no reward or sanction for inclusion or omission of evidence on ethnicity and commissioning teams or partners are not representative of minority ethnic populations. Neglect of this dimension within national drivers results in low demand for evidence. This organisational context can promote risk-averse attitudes that maintain the status quo. Pockets of good practice exist but they are largely dependent on individual expertise and commitment and are often not shared. Study findings suggested the need for action at three levels: creating an enabling environment; equipping health-care commissioners; and empowering wider stakeholders. Key enabling factors would be attention to ethnicity within policy drivers; senior-level commitment and resource; a diverse workforce; collaborative partnerships with relevant stakeholders; and the creation of local, regional and national infrastructure.

Limitations

It was harder to identify enablers of effective use of evidence in this area than barriers. Including a case study of an organisation that had achieved greater mainstreaming of the ethnic diversity agenda might have added to our understanding of enabling factors. The study was conducted during a period of fundamental restructuring of NHS commissioning structures. This caused some difficulties in gathering data and it is possible that widespread change and uncertainty may have produced more negative narratives from participants than would otherwise have been the case.

Conclusions

Knowledge mobilisation and utilisation within the commissioning cycle occurs in the context of dynamic interactions between individual agency, organisational context and the wider health-care setting, situated within the UK sociopolitical milieu. Our findings highlight isolated pockets of good practice amidst a general picture of limited organisational engagement, low priority and inadequate skills. Findings indicate the need for specific guidance alongside incentives and resources to support commissioning for a multiethnic population. A more comprehensive infrastructure and, most importantly, greater political will is needed to promote practice that focuses on reducing ethnic health inequalities at all stages of the commissioning cycle.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Cervical cancer screening adherence among Somali immigrants and refugees to the United States

Somali women have lower cervical cancer screening (CCS) rates than non-Somali women in the United States. We examined clinical and administrative data associated with CCS adherence among Somali women seen at a large primary care practice over 2 years. Fifty-one percent of 310 women were adherent to CCS, and adherence was associated with more overall health care system visits. Patients saw male providers 65.8% of the time; however, only 20.4% of the CCS tests were performed by male providers. Future interventions that enhance cancer prevention, health literacy, and patient-provider gender concordance may improve rates of CCS among Somali women.

Major ethnic group differences in breast cancer screening uptake in Scotland are not extinguished by adjustment for indices of geographical residence, area deprivation, long-term illness and education

Background:

Breast cancer screening data generally show lower uptake in minority ethnic groups. We investigated whether such variations occur in Scotland.

Methods:

Using non-disclosive computerised linkage we combined Scottish breast screening and Census 2001 data. Non-attendance at first breast-screening invitation (2002–2008) was compared between 11 ethnic groups using age-adjusted risk ratios (RR) with 95% confidence intervals (CI), multiplied by 100, using Poisson regression.

Results:

Compared with the White Scottish (RR=100), non-attendance was similar for Other White British (99.5, 95% CI 96.1–103.2) and Chinese (112.8, 95% CI 96.3–132.2) and higher for Pakistani (181.7, 95% CI 164.9–200.2), African (162.2, 95% CI 130.8–201.1), Other South Asian (151.7, 95% CI 118.9–193.7) and Indian (141.7, 95% CI 121.1–165.7) groups. Adjustment for rural vs urban residence, long-term illness, area deprivation and education, associated with risk of non-attendance, increased the RR for non-attendance except for Pakistani women where it was modestly attenuated (RR=164.9, 149.4–182.1).

Conclusion:

Our data show important inequality in breast cancer screening uptake, not attenuated by potential confounding factors. Ethnic inequalities in breast screening attendance are of concern especially given evidence that the traditionally lower breast cancer rates in South Asian groups are converging towards the risks in the White UK population. Notwithstanding the forthcoming review of breast cancer screening, these data call for urgent action.

HPV vaccination among ethnic minorities in the UK: knowledge, acceptability and attitudes

BACKGROUND

Human papillomavirus (HPV) vaccination offers a unique opportunity for the primary prevention of cervical cancer. Studies suggest that knowledge and attitudes about the vaccine are likely to influence uptake. One limitation of most studies assessing HPV vaccine knowledge, attitudes and acceptability is their under representation of ethnic minorities. It is important to ensure that our understanding of HPV knowledge and attitudes include all ethnic groups in the UK. This article reviews research that has considered knowledge, acceptability and attitudes about HPV and the HPV vaccine among ethnic minorities in the UK.

METHODS

Articles in Medline, CINAHL and PsycINFO (January 2000-March 2010) were searched.

RESULTS

A total of 17 UK-based papers examined knowledge, attitudes or acceptability related to HPV vaccination in the 'lay' population (parents, adolescents or the general population as opposed to health professionals) and reported findings by ethnicity.

CONCLUSION

Findings seem to suggest lower awareness of HPV and lower acceptability of the vaccination, which could be important if they are reflected in uptake. More research is needed with ethnic minority groups, particularly in the context of the vaccination programme.

The association between socio-demographic characteristics and adherence to breast and colorectal cancer screening: analysis of large sub populations

BACKGROUND

Populations having lower socioeconomic status, as well as ethnic minorities, have demonstrated lower utilization of preventive screening, including tests for early detection of breast and colorectal cancer.

THE OBJECTIVE

To explore socio-demographic disparities in adherence to screening recommendations for early detection of cancer.

METHODS

The study was conducted by Maccabi Healthcare Services, an Israeli HMO (health plan) providing healthcare services to 1.9 million members. Utilization of breast cancer (BC) and colorectal cancer (CC) screening were analyzed by socio-economic ranks (SERs), ethnicity (Arab vs non-Arab), immigration status and ownership of voluntarily supplemental health insurance (VSHI).

RESULTS

Data on 157,928 and 303,330 adults, eligible for BC and CC screening, respectively, were analyzed. Those having lower SER, Arabs, immigrants from Former Soviet Union countries and non-owners of VSHI performed fewer cancer screening examinations compared with those having higher SER, non-Arabs, veterans and owners of VSHI (p < 0.001). Logistic regression model for BC Screening revealed a positive association with age and ownership of VSHI and a negative association with being an Arab and having a lower SER. The model for CC screening revealed a positive association with age and ownership of VSHI and a negative association with being an Arab, having a lower SER and being an immigrant. The model estimated for BC and CC screening among females revealed a positive association with age and ownership of VSHI and a negative association with being an Arab, having a lower SER and being an immigrant.

CONCLUSION

Patients from low socio-economic backgrounds, Arabs, immigrants and those who do not own supplemental insurance do fewer tests for early detection of cancer. These sub-populations should be considered priority populations for targeted intervention programs and improved resource allocation.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

World-wide, cervical cancer is the second most common cancer in women. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical cancer screening.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2009. MEDLINE, EMBASE and LILACS databases up to March 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible the data were synthesised in a meta-analysis.

MAIN RESULTS

Thirty-eight trials met our inclusion criteria. These trials assessed the effectiveness of invitational and educational interventions, counselling, risk factor assessment and procedural interventions. Heterogeneity between trials limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. Secondary outcomes including cost data were incompletely documented so evidence was limited. Most trials were at moderate risk of bias. Informed uptake of cervical screening was not reported in any trials.

AUTHORS' CONCLUSIONS

There is evidence to support the use of invitation letters to increase the uptake of cervical screening. There is limited evidence to support educational interventions but it is unclear what format is most effective. The majority of the studies are from developed countries and so the relevance to developing countries is unclear.

Factors associated with non-attendance, opportunistic attendance and reminded attendance to cervical screening in an organized screening program: a cross-sectional study of 12,058 Norwegian women

BACKGROUND

Cervical cancer incidence and mortality may be reduced by organized screening. Participant compliance with the attendance recommendations of the screening program is necessary to achieve this. Knowledge about the predictors of compliance is needed in order to enhance screening attendance.

METHODS

The Norwegian Co-ordinated Cervical Cancer Screening Program (NCCSP) registers all cervix cytology diagnoses in Norway and individually reminds women who have no registered smear for the past three years to make an appointment for screening. In the present study, a questionnaire on lifestyle and health was administered to a random sample of Norwegian women. The response rate was 68%. To address the predictors of screening attendance for the 12,058 women aged 25-45 who were eligible for this study, individual questionnaire data was linked to the cytology registry of the NCCSP. We distinguished between non-attendees, opportunistic attendees and reminded attendees to screening for a period of four years. Predictors of non-attendance versus attendance and reminded versus opportunistic attendance were established by multivariate logistic regression.

RESULTS

Women who attended screening were more likely than non-attendees to report that they were aware of the recommended screening interval, a history of sexually transmitted infections and a history of hormonal contraceptive and condom use. Attendance was also positively associated with being married/cohabiting, being a non-smoker and giving birth. Women who attended after being reminded were more likely than opportunistic attendees to be aware of cervical cancer and the recommended screening interval, but less likely to report a history of sexually transmitted infections and hormonal contraceptive use. Moreover, the likelihood of reminded attendance increased with age. Educational level did not significantly affect the women's attendance status in the fully adjusted models.

CONCLUSIONS

The likelihood of attendance in an organized screening program was higher among women who were aware of cervical screening, which suggests a potential for a higher attendance rate through improving the public knowledge of screening. Further, the lower awareness among opportunistic than reminded attendees suggests that physicians may inform their patients better when smears are taken at the physician's initiative.

Explaining variation in the uptake of HPV vaccination in England

BACKGROUND

In England, two national programmes of HPV vaccination for girls have been instituted, a routine programme for 12- and 13-year-olds and a catch-up programme for 17- and 18-year-olds. Uptake rates across the country have been far from uniform, and this research sought to identify factors explaining the variation in uptake by locality.

METHODS

An association between uptake, deprivation and ethnic background had been established in pilot research. The present analysis was conducted at an aggregate, Primary Care Trust (PCT), level for the first year of the programmes. Published measures of HPV vaccination uptake, material deprivation, ethnic composition of PCT populations, primary care quality, and uptake of cervical screening and of other childhood immunisations were collated. Strong evidence of collinearity amongst the explanatory variables required a factor analysis to be undertaken. This provided four independent factors, used thereafter in regression models to explain uptake by PCT.

RESULTS

The factor analysis revealed that ethnic composition was associated with attitudes towards cervical screening and other childhood vaccinations, whilst material deprivation and quality of primary care were orthogonal. Ethnic composition, early childhood vaccination, cervical screening and primary care quality were found to be influential in predicting uptake in both the routine and the catch-up cohorts, although with a lower degree of confidence in the case of the last two independent variables. Lower primary care quality was significant in explaining a greater fall in vaccination uptake between the first two doses in the catch-up cohort. Greater deprivation was a significant explanatory factor for both uptake and the fall in uptake between doses for the catch-up cohort but not for uptake in the routine cohort.

CONCLUSION

These results for uptake of the first year of the national programme using aggregate data corroborate findings from intentions surveys and pilot studies. Deprivation, the ethnic composition of the population, the effectiveness of primary care and the acceptability of childhood vaccinations are salient factors in explaining local HPV vaccine uptake in England.

HPV self-sampling as an alternative strategy in non-attenders for cervical screening - a randomised controlled trial

Background:

A randomised trial to ascertain whether women who do not attend for cervical screening are more likely to respond to the opportunity to collect a self-sample for human papillomavirus (HPV) testing, or to a further invitation to attend for cervical screening.

Methods:

The study was carried out in a Primary Care Trust (PCT) in London between June 2009 and December 2009. In total, 3000 women were randomly selected from persistent non-responders (i.e., who had not responded to at least two invitations to attend for screening). The women were randomised on a 1 : 1 basis to either receive an HPV self-sampling kit or a further invitation to attend for cervical cytology. The main outcome measures were (1) percentage of women attending for cervical cytology compared with those returning a self-sample HPV test or attending for cytology subsequent to receiving the kit and (2) percentage of those testing positive for HPV who attended further investigation.

Results:

The total response in the self-sampling group for screening was 10.2%. Of the 1500 women in the control group sent a further invitation for cervical screening, 4.5% attended for cytology screening. This difference is highly statistically significant (P<0.0001). Of the 8 women who tested positive for HPV, 7 attended for a cervical smear and had a concurrent colposcopy. Three of these (43%) had high-grade disease (defined as CIN 2+), with one found to have an invasive cancer (stage 1b) and one CIN 3.

Conclusions:

The value of this intervention relies on the detection of high-grade CIN and early stage cancer with a good prognosis. The relatively high yield of abnormalities found is consistent with that expected among a hard to reach and relatively high-risk group of women. Our study suggests that self-sampling could increase participation among non-responders in England, but further work is needed to ascertain whether the low response rate seen here is likely to be representative of the rest of the country. Other studies are needed to investigate the response to self-sampling in different demographic and geographic settings.

How can young women be encouraged to attend cervical cancer screening? Suggestions from face-to-face and internet focus group discussions with 30-year-old women in Stockholm, Sweden

BACKGROUND

cervical cancer screening (CCS) using Pap-smears has been carried out for decades and is still an essential tool for secondary cancer prevention. Focus has traditionally been on what hinders women's attendance, instead of researching this issue from a positive standpoint, i.e. what factors encourage women to take a Pap-smear? In this article, we therefore explore issues that 30-year-old women have addressed as encouraging CCS attendance, with particular focus on aspects susceptible to intervention.

MATERIAL AND METHODS

through the population-based cervical cancer screening (PCCSP) registry in Stockholm, Sweden, a stratified random sampling technique was used to recruit women from the same birth cohort with varied CCS histories and results. Nine face-to-face focus groups discussions (FGDs) and 30 internet-based FGDs were conducted with a total of 138 women aged 30. Qualitative analysis was inspired by interpretative description, to generate clinically relevant and useful data.

RESULTS

in general, these women expressed positive views about the PCCSP as an existing service, regardless of screening history. They described a wide range of factors encompassing the entire screening trajectory from invitation through follow-up which could motivate young women to CCS participation, including social marketing. Many of the suggestions related to individualization of the PCCSP, as well as a need to understand the relationship between human papilloma virus (HPV) and cervical cancer.

DISCUSSION

[corrected these results are discussed in terms of the inherent tension between population-based public health initiatives and individually-oriented health care provision. Many suggestions given are already incorporated into the existing Stockholm-Gotland screening program, although this information may not reach women who need it. New research should test whether systematic information on HPV may provide a missing link in motivating young women to attend CCS, and which of their suggestions can serve to increase CCS participation.

Human papillomavirus vaccination and social inequality: results from a prospective cohort study

We investigated the effect of social inequalities on the uptake of human papillomavirus (HPV) vaccination, combining data from a feasibility study conducted in 2007–2008 in 2817 secondary schoolgirls in two UK primary-care trusts, with census and child health records. Uptake was significantly lower in more deprived areas (P<0·001) and in ethnic minority girls (P=0·013). The relatively small proportion of parents who actively refused vaccination by returning a negative consent form were more likely to come from more advantaged areas (P<0·001). Non-responding parents were from more deprived (P<0·001) and ethnic minority (P=0·001) backgrounds. Girls who did not receive HPV vaccination were less likely to have received all their childhood immunizations particularly measles, mumps and rubella (MMR). Different approaches may be needed to maximize HPV vaccine uptake in engaged and non-responding parents, including ethnic-specific approaches for non-responders.

Perceived barriers to flexible sigmoidoscopy screening for colorectal cancer among UK ethnic minority groups: a qualitative study

OBJECTIVES

Evidence from existing UK screening programmes indicates disparities in uptake rates between UK ethnic minorities and the white majority population. The aim of this study was to explore barriers to the uptake of flexible sigmoidoscopy (FS) screening among UK ethnic minority populations. Specifically, beliefs about bowel cancer, perceived barriers to the test and ideas about ways to increase uptake were investigated.

METHODS

Nine focus groups were conducted with a total of 53 participants from African-Caribbean, Gujarati Indian, Pakistani and white British communities. The topic guide was based on the Health Belief Model. Discussions were subject to framework analysis.

RESULTS

Most participants expressed limited awareness of bowel cancer and cited this as a barrier to screening attendance. Anxiety regarding the invasiveness of the test, the bowel preparation and fear of a cancer diagnosis were common barriers across all ethnic groups. Language difficulties, failure to meet religious sensitivities and the expression of culturally influenced health beliefs were all discussed as specific barriers to uptake. Ethnically tailored health promotion and general practitioner involvement were recommended as ways of overcoming such barriers.

CONCLUSIONS

The study was the first attempt to qualitatively explore barriers to FS bowel cancer screening in UK ethnic minorities. Most barriers were shared by all ethnic groups but health educators should supplement approaches designed for the majority to incorporate the specific needs of individual minority groups to ensure equitable access.

Inequalities in colorectal cancer screening participation in the first round of the national screening programme in England

BACKGROUND

Introduction of organised, population-based, colorectal cancer screening in the United Kingdom using the faecal occult blood test (FOBT) has the potential to reduce overall colorectal cancer mortality. However, socio-economic variation in screening participation could exacerbate existing inequalities in mortality.

METHODS

This study examined FOBT uptake rates in London, England in relation to area-level socio-economic deprivation over the first 30 months of the programme during which 401 197 individuals were sent an FOBT kit. Uptake was defined as return of a completed test kit within 3 months. Area-level deprivation in each postcode sector was indexed with the Townsend Material Deprivation Index. Analyses controlled for area-level household mobility, ethnic diversity and poor health, each of which was associated with lower return rates.

RESULTS

The results showed a strong socio-economic gradient in FOBT uptake, which declined from 49% in the least deprived quintile of postcodes to 38% in the middle quintile and 32% in the most deprived quintile. Variation in socio-economic deprivation between sectors accounted for 62% of the variance in return rates, with little attenuation as a result of controlling for ethnic diversity, household mobility or health status.

CONCLUSION

These results highlight the need to understand the causes of socio-economic gradients in screening participation and address barriers that could otherwise increase disparities in colorectal cancer survival.

Awareness of cancer symptoms and anticipated help seeking among ethnic minority groups in England

OBJECTIVE

Little is known about ethnic differences in awareness of cancer-warning signs or help-seeking behaviour in Britain. As part of the National Awareness and Early Diagnosis Initiative (NAEDI), this study aimed to explore these factors as possible contributors to delay in cancer diagnosis.

METHODS

We used quota sampling to recruit 1500 men and women from the six largest minority ethnic groups in England (Indian, Pakistani, Bangladeshi, Caribbean, African and Chinese). In face-to-face interviews, participants completed the newly developed cancer awareness measure (CAM), which includes questions about warning signs for cancer, speed of consultation for possible cancer symptoms and barriers to help seeking.

RESULTS

Awareness of warning signs was low across all ethnic groups, especially using the open-ended (recall) question format, with lowest awareness in the African group. Women identified more emotional barriers and men more practical barriers to help seeking, with considerable ethnic variation. Anticipated delay in help seeking was higher in individuals who identified fewer warning signs and more barriers.

CONCLUSIONS

The study suggests the need for culturally sensitive, community-based interventions to raise awareness and encourage early presentation.

Uptake in cancer screening programmes: a priority in cancer control

Achieving adequate levels of uptake in cancer screening requires a variety of approaches that need to be shaped by the characteristics of both the screening programme and the target population. Strategies to improve uptake typically produce only incremental increases. Accordingly, approaches that combine behavioural, organisational and other strategies are most likely to succeed. In conjunction with a focus on uptake, providers of screening services need to promote informed decision making among invitees. Addressing inequalities in uptake must remain a priority for screening programmes. Evidence informing strategies targeting low-uptake groups is scarce, and more research is needed in this area. Cancer screening has the potential to make a major contribution to early diagnosis initiatives in the United Kingdom, and will best be achieved through uptake strategies that emphasise wide coverage, informed choice and equitable distribution of cancer screening services.

Migrants' utilization of somatic healthcare services in Europe--a systematic review

BACKGROUND

Utilization of services is an important aspect of migrants' access to healthcare. The aim was to review the European literature on utilization of somatic healthcare services related to screening, general practitioner, specialist, emergency room and hospital by adult first-generation migrants. Our study question was: 'Are there differences in migrants' utilization of somatic healthcare services compared to non-migrants?'

METHODS

Publications were identified by a systematic search of PUBMED and EMBASE. Appropriateness of the studies was judged independently by two researchers based on the abstracts. Additional searches were conducted via the references of the selected articles. The final number of studies included was 21.

RESULTS

The results suggested a diverging picture regarding utilization of somatic healthcare services by migrants compared to non-migrants in Europe. Overall, migrants tended to have lower attendance and referral rates to mammography and cervical cancer screening, more contacts per patient to general practitioner but less use of consultation by telephone, and same or higher level of use of specialist care as compared to non-migrants. Emergency room utilization showed both higher, equal and lower levels of utilization for migrants compared to non-migrants, whereas hospitalization rates were higher than or equal to non-migrants.

CONCLUSION

Our review illustrates lack of appropriate epidemiological data and diversity in the categorization of migrants between studies, which makes valid cross-country comparisons most challenging. After adjusting for socio-economic factors and health status, the existing studies still show systematic variations in somatic healthcare utilization between migrants and non-migrants.

Exploring the acceptability of two self-sampling devices for human papillomavirus testing in the cervical screening context: a qualitative study of Muslim women in London

Objectives

We explored Muslim women's attitudes to self-sampling for human papillomavirus (HPV) in the context of cervical cancer screening and their responses to two self-sampling devices.

Setting

A Muslim community centre in north-east London.

Methods

Following a talk given on the subject of cervical cancer and HPV at the community centre, 28 women were recruited to take part in three focus group discussions. The discussion covered cervical screening, self-sampling and HPV testing. Women were also asked for their responses to a swab self-sampling kit and a cervico-vaginal lavage device. Discussions were recorded and transcribed verbatim and the qualitative data were analysed using Framework Analysis.

Results

Participants were generally positive about cervical screening but acknowledged that some women in their community were reluctant to attend because of embarrassment, language difficulties, fear or because they were unmarried and did not want to communicate implicit messages about being sexually active. Self-sampling met a mixed response – women were concerned about not doing the test correctly, but thought that it might overcome barriers to screening for some women. HPV testing itself was thought to raise potentially difficult issues relating to trust and fidelity within marriages. Although most women said they would prefer to continue to have screening by a health professional, if they were to perform self-sampling, there was overwhelming preference for the swab over the lavage kit.

Conclusions

There was limited enthusiasm for self-sampling in this group of Muslim women who had mostly attended for cervical screening, but a clear preference for a swab rather than a cervico-vaginal lavage.

Cervical screening: Perceptions and barriers to uptake among Somali women in Camden

OBJECTIVES

To explore barriers to, and ways to improve, uptake of cervical screening among Somali women in Camden, London.

STUDY DESIGN

A qualitative research study using focus group discussions and in-depth interviews.

METHODS

A qualitative study (comprising seven focus groups and eight in-depth interviews) was conducted with 50 first-generation Somali women aged 25-64 years. Both the groups and the interviews explored participants' understanding of the purpose of cervical screening, and the various risk factors for cervical cancer, as well as their opinions on barriers to screening and suggestions for overcoming those barriers.

RESULTS

Knowledge about the purpose of cervical screening was limited among Somali women. There was also a lack of understanding of risk factors for cervical cancer, and many of the women held fatalistic attitudes, associated with the idea of 'God's will', about this cancer and other aspects of health. Another culturally specific barrier was embarrassment associated with female circumcision, i.e. female genital mutilation. Other barriers suggested by the participants were: lack of knowledge about the need for cervical screening, practical problems such as appointment times and childcare needs, language difficulties, fear of the test and negative past experiences. Possible solutions suggested by the participants included the provision of education and information about cervical screening in the Somali language by Somali community workers. They also suggested that healthcare staff should be trained about Somali culture, particularly regarding female circumcision, and that general practitioners should more proactively encourage Somali women to attend screening.

CONCLUSIONS

Language difficulties and specific cultural issues are key barriers to first-generation Somali women attending cervical screening. Providing education and information orally, as well as improving access to a more culturally appropriate screening service, could lead to improved uptake among this group.