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• To recognise that health inequalities can act as barriers to cervical screening
• To read about a general practice project that aims to increase uptake of cervical screening through addressing health inequalities
• To acknowledge the importance of co-production in interventions that aim to reduce health inequalities
Cervical screening is a crucial intervention to detect cervical cancer at an early stage and reduce mortality rates. Early detection through regular screening can significantly improve treatment outcomes and survival rates. However, health inequalities can obstruct access to cervical screening services, which leads to disparities in outcomes among different population groups.
This article discusses barriers to cervical screening and describes a general practice project in Suffolk that aims to address health inequalities related to uptake of cervical screening through various interventions, including training for clinical and non-clinical staff and provision of patient information and education.
Primary Health Care. doi: 10.7748/phc.2024.e1815Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated software
Ainsley LE, Dunningham ML (2024) Reducing health inequalities in cervical screening: a general practice project. Primary Health Care. doi: 10.7748/phc.2024.e1815
Published online: 07 February 2024
Cervical cancer is a preventable disease and is curable if detected early and treated adequately, however it is the fourth most common cancer among women globally. If issues that affect early detection are not addressed, the annual global number of new cases of cervical cancer is predicted to increase from 570,000 to 700,000, between 2018 and 2030, while the annual number of deaths is predicted to increase from 311,000 to 400,000 in the same period (World Health Organization 2020). In England, women and people with a cervix are invited to attend cervical screening every three years from age 25 to 49 years and every five years between the ages of 50-64 years; however, approximately one third of those invited do not attend cervical screening. Figures indicate that screening prevents 70% of deaths, but that 83% of deaths could be prevented by regular attendance (Department of Health and Social Care et al 2022).
Suffolk GP Federation, a community interest company, is funded by the NHS Suffolk and North East Essex Integrated Care Board (SNEE ICB) to run the Very Important Invitation project (referred to as ‘the project’ throughout the article) (suffolkfed.org.uk/healthcare-services/cervical-screening). The project focuses on addressing health inequalities related to cervical screening in Suffolk. Its main goal is to increase uptake of and participation in cervical screening, in line with the NHS (2019) Long Term Plan objective to diagnose 75% of cancers at stage one or two by 2028.
The project assists 56 GP practices throughout Suffolk to offer training sessions to clinical and non-clinical staff on best cervical screening practices and in addressing health inequalities that may pose barriers to screening. The project covers a diverse locality, including urban, rural and coastal regions, some of which experience significant poverty levels. The 2021 census (Office for National Statistics 2024) indicates that Suffolk has a population of 760,600, approximately 10% of whom live in the 20% most deprived lower layer super output areas (LSOAs) in England – LSOAs are a geographic hierarchy designed to improve the reporting of small area statistics in England and Wales. Ipswich is the most deprived local authority in Suffolk and has 28 LSOAs that are in the 20% most deprived nationally (Suffolk County Council and Public Health Communities 2022). Disparities in deprivation levels across Suffolk have contributed to significant health inequalities.
The NHS People Plan (NHS England 2020) emphasised the importance of collaboration between ICBs and integrated care systems (ICSs). By providing the necessary framework and support, ICSs enable ICBs to lead and deliver integrated care effectively in their respective regions, and this has been an integral aspect of the project (SNEE ICS 2022). The NHS People Plan (NHS England 2020) highlighted the principles of compassion, inclusivity and valuing individual voices and the SNEE ICS is committed to upholding these by prioritising equality, diversity and inclusion. For example, the SNEE ICS actively seeks feedback and opinions from people in Suffolk who have expressed a desire for a personalised approach that will lead to improved health outcomes and reduced health inequalities. The project has developed a strategic plan and objectives that align with these principles and the SNEE ICS’s five-year plan.
• There are health inequalities in cervical screening rates, with some population groups less likely to attend screening
• To address health inequalities, interventions should be tailored to the specific needs and circumstances of different population groups
• Healthcare providers have an important role in addressing health inequalities and promoting cervical screening
• Health education, including raising awareness, providing accurate information and addressing misconceptions about cervical screening, has a vital role in promoting this intervention
In the UK, cervical screening uptake rates are falling yearly (Jo’s Cervical Cancer Trust 2019). Women and people with a cervix may find cervical screening challenging for various reasons including, for example, that the procedure will be embarrassing, painful or uncomfortable, fear of judgement and fear of the results (Jo’s Cervical Cancer Trust 2019, Dsouza et al 2020). Identifying modifiable factors that may influence attendance can help healthcare services to develop effective interventions to increase screening uptake (Judah et al 2022), although barriers to screening are subjective and can differ significantly among different groups and communities (Marlow et al 2017).
Psychology is an important factor in cervical screening attendance. Many people feel vulnerable and exposed when undergoing a gynaecological examination, while others find it too embarrassing even to discuss (Butler et al 2020). This vulnerability does not appear to be exclusive to any specific group. Fear and embarrassment about others seeing one’s genitalia may stem from stigma and a historical view of women. Sex education in schools is inconsistent in quality (Sex Education Forum 2022). Lack of understanding and resources for learning about women’s bodies and health means that some people turn to the media or the porn industry to learn (Placik and Arkins 2014). The media also reinforces the idea that women should look a certain way (Sharp et al 2015, YouGov 2021, de Souza 2022, Mental Health Foundation 2023).
Formby and Donovan (2020) identified that formal sex and relationships education may not equip young people with ‘sexual literacy’ or with the skills to understand sexual feelings, sexual anatomy, family planning and consent. This is heightened for LGBTQ+ young people due to the broader heteronormative context in which their identities and relationships are formed and negotiated (Formby and Donovan 2020).
Fear of test results can influence cervical screening participation. For some, the perceived severity of cancer motivates their lack of attendance (Hamdiui et al 2022). In extreme cases, some people have suggested they would prefer to die without knowing they had cancer rather than attend cervical screening (Anaman-Torgbor et al 2017). Perceptions about the risk of cervical cancer can also affect screening uptake. For example, researchers have reported that some women felt falsely reassured that screening was unnecessary as they only had one sexual partner or were in a monogamous long-term relationship (Azerkan et al 2015, Marlow et al 2019, Hamdiui et al 2022). Others have felt falsely reassured that women from Somali or Pakistani communities do not develop cervical cancer due to the perception that their religious background was a protective factor (Gele et al 2017).
In England, invitations for cervical screening are sent by mail directly from NHS England. At the time of writing, these letters are sent in one language (English) and do not include easy-read formats. This potentially excludes people who cannot speak English, as they will be unable to appreciate the importance of attendance (Addawe et al 2018, Idehen et al 2020, Patel et al 2020).
Cervical screening patient information leaflets translated into various languages are available on a government website at: www.gov.uk/government/publications/cervical-screening-description-in-brief (Public Health England 2022). In Suffolk, the main languages spoken, other than English, are Portuguese, Romanian, Polish, Bengali, Kurdish, Lithuanian and Arabic (Suffolk County Council 2024). However, leaflets in only four of these languages – Arabic, Bengali, Polish and Portuguese – are available on the government website (Public Health England 2022).
People must know where to access information to be able to use it, so the project encourages GP practices that serve communities whose first language is not English to ensure that translated leaflets are accessible. In addition, the project has worked closely with an organisation in Suffolk that provides courses in English for speakers of other languages, to translate information resources into Ukrainian, Russian, Bengali, Bulgarian, Portuguese, Romanian, Urdu, Punjabi, Polish, Gujarati and Arabic.
There is evidence to suggest that people living in rural areas are 5% less likely to survive cancer compared with urban residents (Carriere et al 2018). As previously mentioned, Suffolk is a largely rural county, therefore some people’s access to healthcare may be affected by large distances between their homes and health centres and lack of transport. In addition, those registered with a small rural practice may perceive a lack of anonymity due to the close-knit nature of such communities (Davis et al 2017).
Women with learning disabilities have a lower life expectancy and lower rates of routine cancer screening uptake than those without learning disabilities. Figures from NHS Digital (2019) show that 31% of people with learning disabilities attend cervical screening compared with 73% of those without learning disabilities.
Incidence and mortality rates of cervical cancer are unequally distributed among different socioeconomic groups (Murfin et al 2020). Women and people with a cervix living in the most deprived areas in England are more likely to die from cervical cancer compared with those living in the least deprived areas (Payne et al 2020).
Socioeconomic status and education level have a significant association with knowledge of cervical cancer. For example, in England, 16% of adults have been described as having ‘very poor literacy skills’, meaning they can understand short, straightforward texts on familiar topics and obtain information from everyday sources, but reading information from unfamiliar sources or on unfamiliar topics can be problematic (Kerr 2021, National Literacy Trust 2024). In a study in Pakistan (Riaz et al 2020), 388 women were interviewed to determine their level of knowledge, general attitudes, perceptions and prevention practices relating to cervical cancer. Although around 64% of participants had suboptimal knowledge, 79% were willing to know more about screening and preventive practices regarding cervical cancer (Riaz et al 2020). These findings emphasise the need for more diverse health information formats, such as an easy-read document that presents information in an accessible style with accompanying images. People with limited literacy skills may still require further support, as they may find some information unfamiliar even if it is presented in an accessible format.
People experiencing homelessness may have difficulty registering with a GP due to their lack of a permanent address, which can mean they do not receive screening invitation letters. One solution is for practices to register people using the practice’s address, which the project encourages during clinician training. In addition, GP practices could implement strategies to inform people who are homeless about available services and support during a new patient appointment.
Women globally bear a disproportionate burden of unpaid work, regardless of their income level, and are responsible for undertaking three-quarters of the world’s unpaid care work (Langer et al 2015, Oxfam International 2024). This gender disparity is more pronounced in low- and middle-income countries compared with high-income countries (UN Women 2019, Milner et al 2021). According to the Office for National Statistics (2018), men in the UK have five more hours of leisure time per week than women, while an Australian study found that women’s limited leisure time is often fragmented and combined with other tasks (Spotswood et al 2021). It is not unreasonable to suggest, therefore, that this gender disparity creates another barrier to screening.
The project recognises the barriers to cervical screening described above and works with primary and secondary care services, community-based organisations and charities to address these barriers and to reach as many under-served groups as possible. The project also uses social media platforms to gain a wide audience.
Suffolk GP Federation provides an extended access service called GP+. All patients registered with a GP practice in Suffolk have access to GP+ appointments which include evenings, weekends and bank holidays and which operate from nine different sites across the county. Patients can access these appointments through their general practice. The project also uses an appointment booking request system via Suffolk GP Federation’s website. People who request a screening appointment in this way are contacted by the project staff, who will then support them to make a booking for a GP+ clinic.
Evidence suggests that intervention is required for those with no previous cervical screening experience (Jo’s Cervical Cancer Trust 2020, Nelson et al 2021). To address this, the project works closely with the education sector in the county to provide teaching on the topic in secondary schools.
A central aspect of the project’s ethos is co-production. People with lived experience of a condition are often best placed to determine which services will positively affect their lives (NHS England 2024a); therefore, the project’s co-production approach includes working with service users as well as primary and secondary care services, the Suffolk and North East Essex Cancer Programme and the voluntary, community and social enterprise sectors.
Co-production is crucial to support people’s autonomy, empowerment and trust in organisations, particularly in such intimate healthcare services as cervical screening. A co-production approach can support diverse communities and align local service provision with cultural beliefs (Filipe et al 2017). The aim of co-production should be to increase service user satisfaction and ‘meet the societal objectives or contribute to social cohesion or well-being’ (Osborne et al 2016).
Through a co-production approach, the project has made significant progress with many under-served groups in Suffolk. For example, the project has made effective connections with a trans man, who works for the local health authority, who has created social media content highlighting representation and visibility of the LGBTQ+ community in the project’s work. In addition, by attending local LGBTQ+ Pride events and engaging in ad hoc conversations during community events, the project staff can dispel myths around cervical screening and offer tailored support to those within the community who want it.
The project has also co-produced with local charities and organisations supporting people with learning disabilities by attending peer support events. This has enabled the development of relationships with individual service users, resulting in the provision of tailored, one-to-one screening support.
With regards to working with multicultural communities and people whose first language is not English, one of the project’s initiatives involved producing translated health information and promotion materials and making these available on its health promotion stands at community events. This provides people with the information they need to make an informed decision about cervical screening and gives them time and space to do so. The project recognises the need to approach the topic of cervical screening sensitively with people from different cultures and is working closely with Suffolk County Council to develop positive relationships with local Traveller families through regular visits to Traveller sites across the county.
The project has adopted a health education model, recognising that simply expecting people to attend screening appointments without providing effective education is insufficient and that it is crucial to equip people with the knowledge and understanding they require to make informed decisions about their healthcare. The project focuses on engaging appropriately with under-served communities, attempting to understand their concerns and anxieties about accessing healthcare services and providing relevant, trustworthy information and education about cervical screening. Additionally, the project acknowledges that it is important to support people who choose to defer or opt out of the national screening programme.
The project employs registered nurse health educators with extensive knowledge and experience of cervical screening who work collaboratively with stakeholders, such as GP Practices and voluntary, community and social enterprise organisations, to set and achieve targets that support the increased uptake of cervical screening in the county. The health educators also offer GP practices bespoke education sessions on health inequalities in cervical screening for clinical and non-clinical staff, which are updated regularly to ensure the information is current, insightful and evidence based. Practice staff can contact the health educators in between education sessions if they require further advice or support.
The UK hosts two national events dedicated to raising awareness about cervical screening and cervical cancer – Cervical Cancer Prevention Week (usually held in January) and Cervical Screening Awareness Week (usually held in June). The project ensures it is present at community outreach events, charity events and/or in primary or secondary care facilities throughout both awareness weeks. This emphasises the importance of these campaigns and enables the project to provide health promotion and education material to those who need or want it.
The effectiveness of the project is evaluated in various ways. It can be challenging to source quantitative data, due in part to the three- and five-year routine cervical screening recall intervals, however the project attempts to collect all available qualitative data on screening uptake. A person may accept a screening invitation after receiving education and support from the project, even if the figures do not reflect this outcome. The project refers to this as ‘intent to action’ but recognises the importance of supporting the person to progress from intent to attending a cervical screening appointment. Therefore, patient reviews and follow-up are undertaken in collaboration with primary care services and are supported by prior notification lists that identify people who are due to be invited for cervical screening.
Formal feedback is received during or after every event the project participates in. For example, a survey will be given to members of the public with whom cervical screening has been discussed, to pupils and teachers following a school teaching session and to healthcare professionals following a training session. Such feedback has a vital role in shaping the project and providing evidence of its effect on the community, including aspects that are functioning effectively and those that require improvement. Feedback highlights the project’s successes to commissioners and supports discussions about recommissioning and funding.
The cervical screening Power BI dashboard (NHS England and Jo’s Cervical Cancer Trust 2023) is an interactive resource that details cervical screening coverage in local ICBs. Data sourced from the dashboard and from the Quality and Outcomes Framework (NHS England 2024b) enable the project to support GP practices to identify patient groups who are not accessing cervical screening. The project also uses the Eclipse digital data platform (www.eclipselive.org) to continuously assess screening uptake rates and identify non responders most at risk of developing cancer, for example smokers or people with a raised body mass index. Analysis of Eclipse data enables the project to provide GP practices with information about specific cohorts of patients who are not attending cervical screening.
The project aims to continue to deliver a high-quality, effective service to those most in need, and recognises that the population continues to evolve and that progress is sometimes linear. Therefore, it will continue to identify communities and populations that experience challenges in accessing cervical screening and develop tailored services that aim to improve health outcomes. The project also plans to expand into other localities that may adapt the model to provide similar sustainable projects, ultimately improving health education, access and outcomes for under-served communities.
In the UK, cervical cancer screening uptake rates are falling. There are various barriers to accessing cervical screening for different population groups and communities. It is important to identify those barriers and implement interventions that align with the needs of local communities to increase screening uptake and improve health outcomes. The project described in this article provides bespoke training for clinical and non-clinical staff and has adopted a co-production approach to the provision of health promotion and information for under-served communities across the county of Suffolk.
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