Challenges and opportunities for cervical screening in women over the age of 50 years: a qualitative study.

BACKGROUND: Cervical cancer is a preventable disease. Cases in women age >50 years are predicted to rise by 60% in the next two decades, yet this group are less likely to attend for screening than younger women. AIM: To seek novel solutions to the challenges of cervical screening in women >50 years of age by examining practitioner and service-user experiences. DESIGN AND SETTING: Semi-structured interviews were conducted with 28 practitioners and 24 service users >50 years of age, recruited via UK primary care networks in Northern England in 2016-2017, to explore experiences related to cervical screening. METHOD: An inductive thematic analysis was conducted to explore the data. RESULTS: Findings are presented under three key themes. The first, exploring the barriers to successful cervical screening, examines the influences of sexuality and early experiences of screening on attendance, and how preventive health care becomes a low priority as women age. The second, the role of relationships, explores how peer talk shapes attitudes towards cervical screening, how teamwork between practitioners engenders investment in cervical screening, and how interactions between service users and primary care over time can significantly affect intentions to screen. The third, what constitutes good practice, describes practical and sensitive approaches to screening tailored to women aged >50 years. CONCLUSION: Good practice involves attention to structural and practical challenges, and an understanding of the role of relationships in shaping screening intentions. Experienced practitioners adapt procedures to increase sensitivity, and balance time invested in problem solving against the benefits of reaching practice targets for attendance. Building networks of expertise across multiple practices can increase practitioner skill in screening this age group.

Translating qualitative data into intervention content using the Theoretical Domains Framework and stakeholder co-design: a worked example from a study of cervical screening attendance in older women.

BACKGROUND: Previous screening interventions have demonstrated a series of features related to social determinants which have increased uptake in targeted populations, including the assessment of health beliefs and barriers to screening attendance as part of intervention development. Many studies cite the use of theory to identify methods of behaviour change, but fail to describe in detail how theoretical constructs are transformed into intervention content. The aim of this study was to use data from a qualitative exploration of cervical screening in women over 50 in the UK as the basis of intervention co-design with stakeholders using behavioural change frameworks. We describe the identification of behavioural mechanisms from qualitative data, and how these were used to develop content for a service-user leaflet and a video animation for practitioner training. The interventions aimed to encourage sustained commitment to cervical screening among women over 50, and to increase sensitivity to age-related problems in screening among primary care practitioners. METHODS: Secondary coding of a qualitative data set to extract barriers and facilitators of cervical screening attendance. Barrier and facilitator statements were categorised using the Theoretical Domains Framework (TDF) to identify relevant behaviour change techniques (BCTs). Key TDF domains and associated BCTs were presented in stakeholder focus groups to guide the design of intervention content and mode of delivery. RESULTS: Behavioural determinants relating to attendance clustered under three domains: beliefs about consequences, emotion and social influences, which mapped to three BCTs respectively: (1) persuasive communication/information provision; (2) stress management; (3) role modelling and encouragement. Service-user stakeholders translated these into three pragmatic intervention components: (i) addressing unanswered questions, (ii) problem-solving practitioner challenges and (iii) peer group communication. Based on (ii), practitioner stakeholders developed a call to action in three areas - clinical networking, history-taking, and flexibility in screening processes. APEASE informed modes of delivery (a service-user leaflet and a cartoon animation for practitioners). CONCLUSION: The application of the TDF to qualitative data can provide an auditable protocol for the translation of qualitative data into intervention content.