Encouraging informed participation in cervical screening

Understanding the barriers to screening participation

Understanding who is not attending screening and the barriers preventing them from participating is important when finding ways to support engagement with the programme. The reasons for non-attendance may be complex and several factors may be at play. It is important to address these different barriers to enable everyone who’s eligible to attend screening if they want to. 

Barriers to screening participation:¹²³⁴⁵⁶

Personal perception of screening:

• Feeling embarrassed

• Worry that the procedure will be painful (especially for post-menopausal women)

• Concern for sexual connotations and being perceived as promiscuous

• Fear of what the test may find

• Lack of awareness of the purpose of screening

• Perceived low risk of cervical cancer (e.g. not currently sexually active or in a lesbian relationship)

• Religious beliefs (e.g. trust in God or outcomes being “God’s will”)

Personal experience which impacts decision to attend:

• Lack of trust with the health system

• Previous negative screening experience (e.g. past painful procedure)

• Previous sexual assault or abuse

• Negative body image issues

• Gender dysphoria

• Women who have experienced Female Genital Mutilation (FGM)

Practical or access barriers such as: 

• Difficulty arranging an appointment at a convenient time 

• Intending to go but forgetting or not getting round to it 

• Inaccessible information due to language or mode of delivery

Groups with lower participation:

• people aged 25–29 and those above 50⁷ 

• people living in areas of high deprivation⁸

• people with a learning or physical disability⁹

• ethnic minority communities (note disparity varies by ethnic minority group)¹⁰

• people who are lesbian or bisexual¹¹

• the transgender community¹²

• people with severe mental illness¹³

There may also be other groups in your practice population that face barriers to participating in screening. Use your practice data to identify people who are not attending screening to consider strategies to support their informed participation.  

Supporting people to access screening

Discuss cervical screening with your patients

Although cervical screening is a familiar procedure for primary care staff, for most people it is not a routine process. When you have the opportunity, talk about screening with your patients, making sure to discuss potential concerns and address barriers. 

Impersonal patient-provider relationships have been found to be a barrier to participation in some under-screened populations. Ensure your patients feel safe, supported and able to participate, through a good rapport and ensure people feel listened to during appointments⁶. 

Encourage people to keep contact details updated

Encourage people to keep their contact details up to date so that invitations reach your patients.

In England, eligible women receive a notification on the NHS app first, followed by a text message if the app notification isn't opened. Invitation letters will remain in place for those who need them.

In Wales, Scotland and Northern Ireland, people are sent a letter in the post inviting them to book a cervical screening appointment.

Send tailored reminders

People receive a letter when they’re invited for cervical screening. In England, people who use the NHS App will be notified digitally first. Encourage people to keep their contact details up to date so that invitations reach your patients. 

In addition to screening invitations, consider different options for reminding patients of their cervical screening appointment:  

Consider how your target population would want to be communicated with and try to tailor communication methods to different groups. For example, younger people have been found to prefer digital information¹⁶

Templates and top tips can be found in our cervical good practice guide(PDF, 1.57 MB).

You may also wish to supplement email and SMS communications with additional content, such as educational videos and leaflets¹⁷.

Primary care training and development

Practice staff should undertake training to ensure they’re aware of potential barriers, support they can offer to address them and how to discuss this appropriately with people.

Share learning

Check your local screening data to identify whether there are any particular areas requiring improvement. You can find out what other practices in your area may be doing in case there is an opportunity to work together, or to share good practice.  

To find out about system-wide recommendations which could improve screening coverage, check out our Future optimisation of cervical screening page. 

Invitations for trans men and non-binary people with a cervix

The call and recall systems used in cervical screening programmes invite people based on their gender as recorded in their primary healthcare record.  GP practices should manage cervical screening administration for eligible people with a cervix registered as male or “indeterminate” with their GP practice who want to opt into screening.   

In England, trans men and non-binary people assigned female at birth, who are registered with a GP as female, will be routinely invited to cervical screening. Trans men and non-binary people assigned female at birth, who are registered with a GP as male, can opt in to receive routine cervical screening invitations by contacting their GP practice, sexual health clinic or transgender health clinic.

In Wales, people with a cervix who are registered with their GP as female in the 25-64 age group will receive cervical screening invites automatically. People with a cervix who are registered as male with their GP in the 25-64 age group will not be sent an invitation automatically. They will need to inform their doctor or Cervical Screening Wales so that they can receive invitations.

In Scotland, anyone who is eligible for screening and has changed their gender in their primary healthcare record since June 2015 should receive automatic invitations to cervical screening. People who changed their gender in their primary healthcare record prior to June 2015 will not receive automatic invitations to screening.

In Northern Ireland, transgender patients who are aged 25 to 64 and have a cervix are eligible for cervical screening. However, if they are registered with their GP as male, they will not be routinely invited for screening and will need to arrange it directly with their GP practice.

GP practices still have a key role in proactively identifying and opportunistically consulting people about whether they’d like to be invited to cervical screening.  

Safety netting

Let patients know when they should expect to receive their screening results, and who to contact if they do not receive their results in the expected timeframe.  

Patients and health professionals should be aware that a previous normal cervical screening test result does not rule out cancer. 

Remind your patients, regardless of whether they participate in screening, their HPV status or HPV vaccination status, that they should contact a health professional if they have any symptoms or changes that are not normal for them. You could share our public information on cervical cancer symptoms. 

Read more about safety netting on our webpage for healthcare professionals. 

Colposcopy attendance

Primary care can support colposcopy attendance following primary cervical screening, by understanding the patient barriers and proactively following up with patients.

Barriers to colposcopy attendance include:

• Anxiety

• Work or childcare commitments

• Transport difficulties

• Forgetting the appointment

A pilot found that proactively contacting patients before colposcopy appointments and addressing practical barriers may help improve attendance, particularly among younger people and those living in more deprived areas¹⁸. Non-attendance is higher in these groups¹⁹.

Resources

• Cervical Screening Primary Care Good Practice Guide(PDF, 1.57 MB)

• Reducing inequalities in cancer screening(PDF, 306 KB)

• ‘Should I go for cervical screening?' video for the public 

• GOV.UK Cervical screening: Support people who find it hard to attend 

• GOV.UK Information for trans and non-binary people 

• Public Health Scotland Cervical screening hub

Read more about cervical screening

Cervical screening homepage

Get resources to support uptake, including information on safety netting and barriers to participation.

Cervical cancer prevention: HPV vaccination and screening

Read about primary human papillomavirus (HPV) testing and cervical screening coverage.

Optimisation of cervical screening

Covers extending screening intervals, self-sampling and wider quality improvements.

Contact us

You can contact our Strategic Evidence team if you have any questions.