Socio-economic and demographic determinants affecting participation in the Swedish cervical screening program: A population-based case-control study.

BACKGROUND: Cervical screening programs are highly protective for cervical cancer, but only for women attending screening procedure. OBJECTIVE: Identify socio-economic and demographic determinants for non-attendance in cervical screening. METHODS: Design: Population-based case-control study. Setting: Sweden. Population: Source population was all women eligible for screening. Based on complete screening records, two groups of women aged 30-60 were compared. The case group, non-attending women, (N = 314,302) had no smear registered for 6-8 years. The control group (N = 266,706) attended within 90 days of invitation. Main outcome measures: Risk of non-attendance by 9 groups of socioeconomic and demographic variables. Analysis: Unadjusted odds ratios (OR) and OR after adjustment for all variables in logistic regression models were calculated. RESULTS: Women with low disposable family income (adjOR 2.06; 95% confidence interval (CI) 2.01-2.11), with low education (adjOR 1.77; CI 1.73-1.81) and not cohabiting (adjOR 1.47; CI 1.45-1.50) were more likely to not attend cervical screening. Other important factors for non-attendance were being outside the labour force and receiving welfare benefits. Swedish counties are responsible for running screening programs; adjusted OR for non-participation in counties ranged from OR 4.21 (CI 4.06-4.35) to OR 0.54 (CI 0.52-0.57), compared to the reference county. Being born outside Sweden was a risk factor for non-attendance in the unadjusted analysis but this disappeared in certain large groups after adjustment for socioeconomic factors. CONCLUSION: County of residence and socio-economic factors were strongly associated with lower attendance in cervical screening, while being born in another country was of less importance. This indicates considerable potential for improvement of cervical screening attendance in several areas if best practice of routines is adopted.

Attending cervical cancer screening, opportunities and obstacles: a qualitative study on midwives' experiences telephoning non-attendees in Sweden.

AIM: As part of a research project aimed at increasing participation in the cervical cancer screening program (CCS), we explored midwives' unique experiences of telephoning non-attendees and offering Pap smear appointments. METHODS: Twenty midwives, in four focus groups, discussed their experiences of a study investigating ways to increase participation in the CCS. The group discussions were tape-recorded and transcribed verbatim and underwent qualitative content analysis. RESULTS: Speaking with more than 1000 non-attendees provided the midwives with new perspective on the CCS and they realised that improving it might address a number of reasons for not participating. These reasons were often related to logistics, such as scheduling flexibility and appointment booking. The telephone conversations revealed that some women required more individual attention, while it was discovered that others did not require screening. The midwives considered the CCS to be life-saving; participating in this screening activity gave them a sense of satisfaction and pride. CONCLUSIONS: This study shows that midwives can improve access and prevent non-attendance at the cervical cancer screening program when they are aware of women's varying requirements for attending screening.

Increasing participation in cervical cancer screening: offering a HPV self-test to long-term non-attendees as part of RACOMIP, a Swedish randomized controlled trial.

RACOMIP is a population-based, randomized trial of the effectiveness and cost-effectiveness of different interventions aimed at increasing participation in a well-run cervical cancer screening program in western Sweden. In this article, we report results from one intervention, offering non-attendees a high-risk human papillomavirus (HPV) self-test. Comparison was made with standard screening invitation routine or standard routine plus a telephone call. Women (8,800), aged 30-62, were randomly selected among women without a registered Pap smear in the two latest screening rounds. These women were randomized 1:5:5 to one of three arms: 800 were offered a high-risk HPV self-test, 4,000 were randomized to a telephone call (reported previously) and 4,000 constituted a control group (standard screening invitation routine). Results were based on intention to treat analysis and cost-effectiveness was calculated as marginal cost per cancer case prevented. The endpoint was the frequency of testing. The total response rate in the self-testing arm was 24.5%, significantly higher than in the telephone arm (18%, RR 1.36, 95% CI 1.19-1.57) and the control group (10.6%, RR 2.33, 95% CI 2.00-2.71). All nine women who tested positive for high-risk HPV attended for a cervical smear and colposcopy. From the health-care sector perspective, the intervention will most likely lead to no additional cost. Offering a self-test for HPV as an alternative to Pap smears increases participation among long-term non-attendees. Offering various screening options can be a successful method for increasing participation in this group.

Increasing participation in cervical cancer screening: telephone contact with long-term non-attendees in Sweden. Results from RACOMIP, a randomized controlled trial.

Non-participation is the foremost screening-related risk factor for cervical cancer. We studied the effectiveness and cost-effectiveness of an intervention to increase participation in the context of a well-run screening program. Telephone contact with non-attendees, offering an appointment to take a smear, was compared with a control group in a population-based randomized trial in western Sweden. Of 8,800 randomly selected women aged 30-62, without a registered Pap smear in the two latest screening rounds, 4,000 were randomized to a telephone arm, another 800 were offered a high-risk human papillomavirus (HPV) self-test by mail (not reported in this article) and 4,000 constituted a control group. Endpoints were frequency of testing, frequency of abnormal smears and further assessment of abnormal tests. Participation during the following 12 months was significantly higher in the telephone arm than in the control group, 718 (18.0%) versus 422 (10.6%) [RR: 1.70, 95% confidence interval (CI): 1.52-1.90]. The number of detected abnormal smears was 39 and 19, respectively (RR: 2.05, 95% CI: 1.19-3.55). The respective numbers of further assessed abnormalities were 34 and 18 (RR: 1.89, 95% CI: 1.07-3.34). Twice as many high-grade intraepithelial neoplasia (CIN2+) were detected and treated in the telephone arm: 14 and 7, respectively. Telephone contact with women who have abstained from cervical cancer screening for long time increases participation and leads to a significant increase in detection of atypical smears. Cost calculations indicate that this intervention is unlikely to be cost-generating and this strategy is feasible in the context of a screening program.