General practitioners can increase participation in cervical cancer screening – a model program in Hungary

The mortality rate for cervical cancer is very high in Hungary compared with the average in western European countries (Fig. 1) [1]. More than 400 women die of this disease each year in a country with a total female population of 5.28 million [2]. Opportunistic complex gynecological screening (including colposcopic screenings) and cytological examination with Papanicolaou smears have a long tradition in Hungary [3]. However, this tradition has not translated into a decrease in cervical cancer mortality rates. Therefore, national-level call-and-recall-based organized cervical cancer screening began in 2003 in Hungary [4]. Women between 25 and 65 years of age are called for a screening every 3 years by the National Public Health Service [5, 6]. Traditionally, the great majority of eligible women visit their gynecologists, at least within every 3 year, who perform a complete gynecological examination along with smear-taking for cytological examination. In this way, a large number of cervical screening examinations take place outside organized screening settings [7]. Unfortunately, the national cervical cancer screening program increased the proportion of those who received a screening by only a few percentage points [8, 9]. In 2011 Eurostat reported that cervical cancer screening participation rate was low in Hungary. The percentage of women who underwent at least 1 Pap test in a 3-year period was 35.94%. [10]. Participation in a screening program is known to be closely related to socioeconomic factors, cultural factors and attitudes [11, 12]. According to surveys, the majority of women not attending screenings have low socioeconomic status, and see a gynecologist only if they have serious complaints. Other reasons are lack of time and ignorance of the importance of screening [13].

As general practitioners provide health service closest to the population, they are respected, trustworthy members of the local community and can have a key role in health communication, including mobilization of the population to participate in screening programs [14].

Cervical cancer is a preventable cancer; evidence of the success of cytological screening is indicated by the low incidence of invasive cervical cancer in well-screened populations and by the high incidence and mortality in populations without screening [17]. In 2013, the mortality rate was 6.02 per 100,000 women in Hungary. Based on the most recently available data, morbidity rates have declined over the past decades, with the mortality rate essentially remaining constant (5–6/100,000 women/year) since 2005 [1]. Although the organized screenings began in 2003, the number of sample tests performed outside the program is still 20 times higher than the number performed within the screening program [7, 18]. According to our survey, the overall screening rate in Hungary (74%) is not low. The real frequency, however, is likely to be lower because of selection bias associated with a relatively low response rate of 47%. It is reasonable to assume that, on average, the level of health consciousness was higher among the respondents than that among the target population [13]. GPs’ frequent contact with the public and their credibility offer a great potential for cancer prevention [19]. Effective communication is a key success factor for an organized screening program [20]. Our results showed that the majority of the target population did not receive any information about the screening program. Effective communication should be an inherent part of the screening program in order to enable the target population to make informed decisions about participation [20‐22]. According to the results of our investigation, women asked for and received relevant information mainly from their gynecologists and characteristically not before screening but rather in the framework of the gynecological examination.

General practitioners had a very limited role in the cancer screening program in Hungary. The results obtained from the Zala county model project showed that the involvement of general practitioners in the cervical cancer screening program process could increase the participation of women who generally refuse these services. In the model program, a quarter of the women who typically did not take part in cervical cancer screening underwent the screening after advice from their general practitioner. Some recent developments in the Hungarian health care system have facilitated the participation of general practitioners in preventive activities. General practitioners gained online access to the records of their patients in the information system of the National Health Fund, and thus, they could obtain information about the type of outpatient and in-patient services their patients received, including screenings. Furthermore, the financing system for general practice, which still largely depends on capitation, was extended to performance-based financing [23, 24]. A small proportion of general practice fees currently depend on performance indicators. Participation of the target population in mammographic screening is already included in the list of indicators, but this is not yet the case for cervical cancer screening.

In developing a screening program, it is important to increase its accessibility, especially for low-income families and Romani people [25, 26]. Locally driven strategies that take into account the sociocultural beliefs and values of families can minimize barriers to cervical cancer prevention and control [27, 28]. If smears were taken in primary health care settings by GPs or nurses (as is standard practice in several Western European countries [29]), then participation rates in Hungary would probably increase. Primary health care services are more accessible to the general population. Staff are familiar with the cultural and socioeconomic background of the local population and could also be involved in local communication efforts regarding the program. It is important that the service utilization information is integrated with the screening information system. This is organized in Hungary in the framework of the cooperation between the National Health Insurance Fund and of the National Public Health Service. The recent development of the Hungarian e-health program, especially the establishment of the National Electronic Health Records, which centrally stores all medical records of every patient provides an opportunity for GPs themselves to follow-up their patients. To increase the accessibility of the cervical cancer screening program, the National Public Health Service has recently expanded the number of service providers. Health visitors were trained to take the smear and to provide the service locally, even in small villages. Smear taking has been integrated into the graduate training of health visitors, who traditionally provided only maternal and child care [30].

Pilot Health Visitor’s Cervical Screening Programs were introduced in 2009, and 15.8% (2009), 11.1% (2010) and 14.9% (2011) of the invited women appeared in each year for the request of the health visitors [31]. The Health Visitor’s Cervical Screening Program was later institutionalized, and currently it operates as part of the national public health service. Its effectiveness can further be enhanced by the involvement of the GPs in health communication and motivation of the target population. Developing a community-based intervention that is evidence based and theoretically grounded is challenging and time intensive [32]. It requires collaboration of different professionals, including medical and health professionals, psychologists, and sociologists.

Limitations of our study were the low response rate in the survey and the relatively small sample size in the intervention study. The main strength of our study was that it resulted in collaboration between primary care, the public health service and the cytology labs in one research project which served as a proof of concept to improve the screening program.

Our results reaffirm that the capacity of primary health services could be more efficiently utilized in preventive care in Hungary.

Community-oriented health services need to be reorganized. A new framework of cooperation is needed from the National Public Health Services, screening coordinators, general practitioners, nurses, health visitors and patients.