Elsevier

Gynecologic Oncology

Volume 135, Issue 3, December 2014, Pages 487-494
Gynecologic Oncology

Self-sampling experiences among non-attendees to cervical screening

https://doi.org/10.1016/j.ygyno.2014.09.019Get rights and content

Highlights

  • Non-attendees to screening had mainly good experiences with self-sampled HPV-tests

  • Insecurity, fear or anxiety during self-sampling were more common among immigrants

  • Both practical and emotional barriers to screening can be overcome with self-sampling

Abstract

Objective

High coverage and attendance is essential to positive cervical cancer screening results. Offering self-sampling for HPV-testing to the non-attendees of the program may improve attendance rates. Information on women's perceptions and experiences with self-sampling (acceptability) is needed to further optimize attendance by this method.

Methods

A questionnaire study focusing on women's experiences on the screening method was embedded in a trial investigating the effects and feasibility of self-sampling among non-attendees of cervical screening in 31 Finnish municipalities in 2011–2012 (n = 4688). Reasons for non-attendance in routine screening were also surveyed.

Results

Response rate to the questionnaire was 98.8% (909/920) among women who performed self-sampling. Self-sampling participants reported mainly good experiences. Negative experiences (difficulties in sample taking, pain, fear, anxiety, insecurity) were reported rarely, but more commonly among women with a mother tongue other than Finnish or Swedish (immigrants). Most common reason for non-attendance in routine screening was a recent Pap-smear elsewhere (opportunistic screening). Practical reasons (pregnancy, scheduling difficulties) were reported by 42%, emotional or attitudinal reasons by 17%, and 16% forgot to take part. Response yield to questionnaire was unsatisfactory among those women who declined the self-sampling option.

Conclusions

Optimizing the practical aspects of screening and offering a self-sampling option to non-attendees can help to overcome a large variety of both practical and emotional barriers to traditional screening. More research is needed among the non-attendees to routine screening who decline also the self-sampling option.

Introduction

High coverage and attendance is essential for effective cervical cancer screening. Personal invitations to screening, pre-booked appointments in invitation letters and reminders sent to non-attendees increase screening attendance [1], [2], [3], [4], [5], [6], [7], [8], [9], [10]. Self-sampling for high risk human papillomavirus (hrHPV) DNA testing helps to further increase attendance among women who are not reached by the routine screening program [9], [10], [11], [12], [13], [14], [15], [16]. Information on self-sampling experiences is needed to further optimize attendance by this method.

Acceptability of self-sampling, in the meaning of women's experience of the procedure, not solely response rate, has been previously studied by focus group discussions and questionnaires with self-sampling being introduced but not necessarily used by the participants [17], [18], [19], [20], [21], [22], [23], [24], and in comparison to a Pap-smear among screening participants or patients at a clinic [25], [26], [27], [28]. In countries with existing and functional screening programs, however, the current role of self-sampling would be to provide an alternative for women reluctant to participate in clinic-based screening. For this purpose, acceptability should be studied in the actual target group, i.e. among non-attendees to the current program. Some studies have gathered information on non-attending women's preferences for self-collection or clinician-collection and the reasons for their preference [15], [29], [30]. Only previous one study thus far has explored the aspects of user-friendliness of a self-sampling procedure in a population-based setting among non-attendees [31].

We studied women's experiences and perceptions on self-sampling based screening among non-attendees to cervical screening in a diverse set of Finnish municipalities. We further studied how demographic factors such as age, mother tongue and education level affect the self-sampling experience. In order to explore what kind of barriers to traditional screening can be overcome with the self-sampling option, women's reasons for non-attendance to routine screening were also studied.

Section snippets

Material and methods

In the Finnish program, all women aged 30–60 years are invited to screening by their home municipalities with personal invitations in 5-year intervals. The study population consisted of women who received two invitations to screening (primary invitation and a reminder letter) in 31 municipalities in years 2011 or 2012 and did not attend. These non-attendees were included in a clinical trial on the effects and feasibility of self-sampling described in detail elsewhere [32]. The women were offered

Response rate and characteristics of the responders

In total, 1326 originally non-attending women returned the questionnaire, 28% of all recipients of the questionnaire. 909 (68.6%) of the responders took part in screening with a self-taken sample. The demographic characteristics of the whole study population and of the questionnaire responders are shown in Table 1.

Among the self-sampling participants, response rate to the questionnaire was 98.8% (909/920) and no significant demographic differences were seen among responders and non-responders

Discussion

Cervical cancer screening in Finland has been effective in reducing incidence and mortality rates; in 2012 the incidence was 4.3/100,000 and mortality 0.9/100,000 woman-years [34]. A current challenge in Finland is the somewhat low participation rate to the organized program, at less than 70%, and extensive opportunistic screening that results in higher overall coverage but also costs with significant overscreening among some women. Reducing the number of opportunistic smears and increasing

In conclusion

What is the acceptability of self-sampling for HPV-testing among non-attendees to cervical screening in Finland? In terms of willingness to use, approximately 21% participated when offered the self-sampling option [9], [32]. In general, the participants had a good sampling experience, and negative experiences were reported rarely. However, response rate to the questionnaire among those non-attendees that declined also the self-sampling option was small and most likely affected by selection

Conflicts of interest statement

PN was a member of the GSK HPV-vaccine Endpoint Committee for HPV-vaccine trials. Other authors have no potential conflicts of interest.

Acknowledgments

The study received funding from the Academy of Finland (139622) and Finnish Cancer Society. AV received a personal grant from the Orion-Farmos Research Foundation.

The authors thank the staff of the Mass Screening Registry and in the laboratory of the Cancer Society of Finland for their valuable contribution.

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