Evidence on increasing cervical screening uptake

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We pull together resources and information that can help you increase uptake of cervical screening in your area while promoting informed consent.

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Cervical screening rates are declining across all UK nations. This decline is greater among under 50s, and in particular young women aged 25-29.

Cancer Research UK would like to see a concerted commitment to increasing uptake of cervical screening across the UK. 

The evidence base for interventions designed to increase screening uptake is small, but growing. We have summarised the findings of UK projects that have been able to publish robust evaluations, but there is activity underway locally besides the projects covered here. Let us know if you are aware of or are involved in projects that could provide further evidence of good practice.

A study targeting women who had not been screened for more than 15 years, found that sending a letter from a Health Authority District Cervical Screening Commissioner on behalf of the National Cervical Screening Programme, was more effective than a letter from a celebrity (Claire Rayner) or a call from a nurse.[1] However overall response was very low.

Another study looked at how providing different information in letters affected uptake. It found that inclusion of the line ‘Every year over 700 women die from cervical cancer’ was marginally more effective than the standard letter; 32 weeks after the letters were sent 34% of women in the group with the negative line had attended screening, vs. 33% of women who had been sent the regular invitation letter. However, in women under 27 receiving their first invitation including the line ‘Cervical screening saves 4,500 lives in England every year’ had more impact than the standard letter[2]; 32 weeks after the letters were sent 70% who were sent the letter with the positive line had attended screening, vs. 61% of women who had been sent the regular invitation letter. 

Practical tips

Letters with fixed appointments are more effective than open appointments.[3]

Although it might be useful to think about the wording of invitation letters it is important to be careful about including negative facts, like the number of women who die yearly from cervical cancer, these should not be used in an overly persuasive manner. Communications need to provide factual information, impartially to women so they can make an informed-choice.

 

References

[1] Stein K, Lewendon G, Jenkins R, et al. Improving uptake of cervical cancer screening in women with prolonged history of non-attendance for screening: a randomized trial of enhanced invitation methods. J Med Screen 2005:12(4), 185–18.

[2] Honeywell S and Huf S. A no cost way to increase the uptake of cervical screening: Results from a randomised controlled trial. Department of Health, Behavioural Insights & Imperial College 2016: as yet unpublished.

[3] Everett T, Bryan A., Griffin MF, et al. Interventions targeted at women to encourage the uptake of cervical screening. Europe PMC Funders Group 2014.

Evidence for the effectiveness of telephone interventions is weak; a Cochrane review (the gold standard in reviewing) concluded that there is some evidence for effectiveness, but it is unclear if telephone interventions are any more effective than letters.[1]. In another study phone calls were no more effective than the control group.[2]

 

References

[1] Everett T, Bryan A., Griffin MF, et al. Interventions targeted at women to encourage the uptake of cervical screening. Europe PMC Funders Group 2014.

 [2] Stein K, Lewendon G, Jenkins R, et al. Improving uptake of cervical cancer screening in women with prolonged history of non-attendance for screening: a randomized trial of enhanced invitation methods. J Med Screen 2005:12(4), 185–18.

There is insufficient evidence to support any particular educational intervention. A ‘pre-leaflet’ sent out to inform and prepare women who were due to receive their first invitation for screening had no impact on uptake.[1]. However the Cochrane review concluded that good quality materials are important for increasing informed uptake.[2].

Practical tip

It is important to ensure that as well as being well-evidenced and accurate that information about screening addresses both the harms and the benefits of taking part. The information that people are provided with should also be written in understandable, lay terms.

 

References

[1] Kitchener, HC, Gittins M, Rivero-Arias O, et al. A cluster randomised trial of strategies to increase cervical screening uptake at first invitation (STRATEGIC). Health Technol Assess. 2016 Sep;20(68):1-138

[2] Everett T, Bryan A., Griffin MF, et al. Interventions targeted at women to encourage the uptake of cervical screening. Europe PMC Funders Group 2014.

Self-sampling usually involves women taking a vaginal swab at home, which is sent off and tested for HPV (although there are other methods). Those women who test positive then need to go for cytology screening (cervical smear). Evidence suggests this could be an effective way of increasing uptake, probably because it reduces some of the barriers that currently stop women from being screened.[1-3]

Three trials in the UK reported a higher uptake of screening in the group that were sent a self-sampling kit,[1-3] but overall response in two of these studies (which both targeted women who hadn’t responded to the standard letter) was low.[1,3]. In one trial 8% of the women who were sent kits returned them, and of those women who were invited to screening, as per normal, 6% attended.[1] This suggests that although self-sampling kits may be more effective than just the standard letter for hard-to-reach women, neither approach has a big impact.  

Self-sampling might be effective and efficient if introduced nationwide, for all eligible women, but it is expensive, and involves a longer process for the women who test positive, who may still choose not to attend the smear test.[1] 

Practical tip

Self-sampling is unlikely to be a cost-efficient way of increasing uptake if implemented by individual healthcare services.  

 

References

[1] Cadman L, Wilkes S, Mansour D, et al. 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. J Med Screen 2015:22(1), 28–37.

[2] Kitchener, HC, Gittins M, Rivero-Arias O, et al. A cluster randomised trial of strategies to increase cervical screening uptake at first invitation (STRATEGIC). Health Technol Assess. 2016:20(68):1-138

[3] Szarewski A, Cadman L, Mesher D, et al. HPV self-sampling as an alternative strategy in non-attenders for cervical screening – a randomised controlled trial. BJC 2011:104(6), 915–920.

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