Mass mailing campaigns to promote screening for cervical cancer: do they work,and do they continue to work?

Abstract: Campaigns involving sending personally addressed letters to encourage women to have Pap smears increase Pap smear rates. The aim of this study was to assess whether this effect is maintained when campaigns are repeated regularly. In October 1992, a letter reminding women of the importance of screening was mailed to all women in three New South Wales postcode regions where a similar letter had been sent three years previously. The response was compared to the response in three regions receiving no earlier letter. The number of women attending for cervical screening during the three months after distribution of the letters was assessed from Health Insurance Commission claims for cervical cytology. These attendances were compared with expected attendances based on the attendance patterns over 28 pre-intervention quarters. Significant postintervention increases in attendance were observed in all three regions receiving an initial letter. However, in one region, the increase in attendances, around 1 per cent of eligible women, was not significandy greater than the increase in the control region ( z = 0.15, P = 0.88). The second letter campaign had no measurable effect on attendances. No significant increase in screenings was observed in two of the towns. A significant increase was observed in one region, but this was not significandy greater than the increase in the control region ( z = -0.05, P = 0.96). These results suggest that repeated direct-mail campaigns to promote screening for cervical cancer may be of no benefit. A one-off campaign may result in an increase in screenings in the short term.     

Evaluation of a mass-media-led campaign to increase Pap smear screening

A health education campaign designed to encourage women between the ages of 18 and 70, especially 'older' women (defined as those 50 and over), to have a Pap smear took place in New South Wales (NSW), Australia in early 1988. The campaign involved the mass media, some related community activities and mailing of an educational package to all General Practitioners. According to a sample survey the media campaign was recalled by just over 40% of its target audience. Outcome evaluation was based on the analysis of Pap smear records for a representative 10% sample (N = 338 000) of women registered with the Australian universal health insurance scheme in NSW and three control States. From logistic regression models we estimate that, for women over 50 years and older in NSW, there was a 30% increase overall in Pap smears during the 4 months following the campaign and a 50% increase amongst those who had not had a smear in the previous 2 years. Smaller increases were observed in some other States. Increases of 13-20% were observed among the younger age groups in NSW. Although the campaign appears to have prompted short-term increases in screening rates, the effect is too small to make a substantial impact on the size of the under-screened population.     

Cervical cancer screening for hospital inpatients: report of an intervention study

A pilot study of a cervical cancer screening service was carried out at a major teaching hospital in Perth. The service, for women inpatients aged 20 to 69 years, was staffed by a women's health nurse. The effect of providing the service (service) was compared with giving a leaflet on Pap smears to eligible women (education) and with no intervention (control). Of 517 women in the service group, 184 (36 per cent) needed a Pap smear and were well enough to be offered screening; only 29 of 184 (16 per cent) refused and 132 of 184 (72 per cent) were screened. Of those screened, 29 per cent had never had a Pap smear. Information on women in the education and control groups was obtained by mailed questionnaire. Of the eligible women in the service group, 72 per cent accepted screening in hospital, but only 24 per cent of eligible women in the education group and 20 per cent in the control group reported having a Pap smear in the four months since leaving hospital. The service group showed a very large effect relative to the control group (odds ratio (OR) 17.71, 95 per cent confidence interval (CI) 10.05 to 31.22), but there was no significant difference between the education and control groups. Other significant variables in the logistic regression model were age, marital status, and sex of the woman's general practitioner. The effect of offering the service was greater for women over 50 (OR 51.51, CI 19.01 to 139.60) A hospital-based cervical screening service provides an important opportunity for screening women who are not being reached by other services. (Aust J Public Health 1995; 19: 288–93)     

Knowledge of cancer risk reduction practices in rural towns of New South Wales

Abstract: The Australian Cancer Society has published guidelines for recommended risk reduction strategies for breast, cervical, smoking-related and skin cancer. While knowledge may not be sufficient for change, it is argued to be necessary for change to occur. A measure of the level of health knowledge in the community can be useful for health promotion practitioners, identifying where health messages are not reaching their proposed targets. Our aims were to examine the level of knowledge about risk reduction practices for breast, cervical, smoking-related and skin cancers, for a rural New South Wales sample, and to examine sex and age effects on knowledge levels. A survey of 2846 women and 1732 men from rural New South Wales, which used an unprompted recall strategy, revealed some notable deficits in recall of cancer risk reduction practices: only 26 per cent of women identified mammograms as a risk reduction strategy for breast cancer; only 5 per cent of women knew at which ages mammograms should start and stop; only 6 per cent of women could identify when Pap tests should be discontinued; less than half of the sample could identify common solar protection strategies; and less than one-third of people identified passive smoking as a lung cancer risk.     

Who has Pap smears in New South Wales? Patterns of screening across sociodemographic groups

Abstract: The aim of this study was to determine whether Pap smear screening at adequate intervals is associated with area of residence, frequency of consultations with a general practitioner, socioeconomic status and non-English-speaking background. A representative 10 per cent sample of women from New South Wales and the Australian Capital Territory, aged 25 to 69 years and registered with the Health Insurance Commission (Medicare) (N = 155 281) was used to obtain age, postcode, frequency of Pap smears and frequency of consultations with general practitioners in the three-year period from February 1985 to January 1988. Census data for each postcode area were used as an indicator of other sociodemographic characteristics. Age-specific screening rates did not vary between Sydney, Newcastle/Wollongong, Canberra, and nonmetropolitan areas. In all age groups, having had a smear was most strongly associated with the frequency with which a woman consulted a general practitioner. Women who visited a general practitioner at least four times a year on average were about twice as likely to have had a recent Pap smear as those who averaged less than one visit per year. Screening rates were lowest among women living in areas with the most non-English-speakers and the lowest socioeconomic status. Sociodemographic factors and health service usage patterns influence the proportion of women who are currently being screened. Evaluation of interventions to improve Pap smear screening rates should consider whether the percentage of women screened increases overall, and also whether the imbalances in screening rates between different groups are diminishing.     

A community-based cervical screening program in a remote Aboriginal community in the Northern Territory

Abstract: We established a culturally appropriate, community-based women's health service in Yuendumu, Northern Territory, to improve women's health and to remedy the low rate of cervical screening. During the 16 months of the program 419 cervical smears were taken, increasing coverage of the women eligible from 51 to 78 per cent Acceptance of the program was excellent, with only 2 per cent of the women approached refusing to have a smear. Over 70 per cent of the Pap smears were done by the nursing staff in the clinic; quality control was good, with 9 per cent of smears reported as having no endocervical cells. Sixty-four per cent of screened women had normal smears and 0.9 per cent showed evidence of cervical intraepithelial neoplasia (CIN). Three women were referred for treatment of CIN, two for CIN I and one for CIN III. The program illustrates how a combination of community involvement, staff stability, teamwork, and cross cultural understanding can achieve a comprehensive and successful cervical screening service in a remote Aboriginal community.     

Effects and sustainability of a cervical screening program in remote Aboriginal Australia

Abstract: We assessed the effects of an organised cervical screening program, using a population–based cervical cytology register, for Aboriginal women in the Fitzroy Valley, a remote part of the Kimberley region of Western Australia. Comparison of age–specific screening rates in the area during 1987–88, 1990–92 and 1993–94 showed that establishing the program in late 1989 was accompanied by dramatic increases in cervical screening rates, ranging from two– to over fourfold, with the largest increases in women aged 50 years and over. Following the departure of the coordinator in early 1993, screening rates decreased to between 76 per cent and 29 per cent of their 1990–92 levels, with the largest decreases occurring in the 40–49 and 60–69 years age groups. Rates were still above 1987–88 levels for most age groups. Of 545 women screened during 1991–92, 65 per cent had undergone a second Pap smear within the follow–up period of two to four years. Among women recommended for a repeat smear in two years, the probability of having a second smear was negatively associated with age (log–rank statistic = 35.58, 4 df, P < 0.0001). Follow–up of smears recommended for repeat in 12 months or earlier was less adequate in 1993–94 (46 per cent) than in 1991–92 (75 per cent). The program was successful in recruiting a large proportion of eligible women within a relatively short time, but coverage, especially of older women, was not sustained after a decline in the functioning of the recall system owing to staffing and organisational changes.     

Limited Pap screening associated with reduced risk of cervical cancer in South Africa

BACKGROUND: We investigated the effect of Pap smear screening on the incidence of invasive cancer of the cervix in the Western Cape, South Africa where screening is limited. METHODS: Data were derived from a case-control study of the association of hormonal contraceptives and invasive cervical cancer. Incident cases (n = 524) of invasive cervical cancer who presented at two tertiary hospitals and controls (n = 1540) series matched for age, race, and place of residence were interviewed. Information on a wide range of variables was collected including whether the women had previously had a Pap smear taken and the number and timing of smears. Odds ratios (OR) and 95% CI were calculated using multiple logistic regression. RESULTS: The OR of cervical cancer was reduced among women who had ever had a smear (OR = 0.3, 95% CI: 0.3-0.4). The OR declined with increasing number of smears to 0.2 for >/=>3 smears (trend P = 0.0003). Among women who had a smear <5 years previously the OR was 0.3, but even if the smear was taken >/=15 years previously the women remained at reduced risk (OR = 0.5). CONCLUSION: The data suggest that even limited Pap smear screening reduces the risk of cervical cancer. Should a screening programme be successfully implemented, the incidence of cervical cancer might be reduced by as much as 70%.     

Pap smear use in California: are we closing the racial/ethnic gap?

BACKGROUND: Minority women continue to be disproportionately affected by cervical cancer. Minority population groups at high risk for cervical cancer may be failing to fully comply with screening recommendations. The use of Pap smears among women in California was evaluated to identify ethnic groups at higher risk for noncompliance with cervical cancer screening. METHODS: Cross-sectional analysis of 2001 California Health Interview Survey data. Logistic regression was used to assess the independent contribution of race/ethnicity to the use of Pap smears. RESULTS: Hispanic (aPR = 1.03, 95% CI 1.02-1.05) and Black (aPR = 1.03, 95% CI 1.001-1.06) women are more likely to report a Pap smear in the past 3 years as compared to White women. Asians were the least likely to report cervical cancer screening despite a more favorable sociodemographic profile. Screening rates varied among Hispanic or Asian subgroups; Mexicans, Vietnamese, Chinese, and South Asians are particularly underserved. CONCLUSIONS: In contrast to the country as a whole, Hispanic women in California are more likely to report a recent Pap smear as compared to White women. However, racial/ethnic disparities in Pap smear use persist; Asian women are the least likely to report cervical cancer screening as compared to any other group.     

Evaluation of the New South Wales Cancer Council Pap Test Reminder Service

Abstract: This study aimed to assess the effect of reminder letters on Pap test rates for women enrolled on the New South Wales Cancer Council Pap Test Reminder Service and to identify predictors of response to the letter. Ten weeks after they had received their reminder letter a questionnaire was sent to 3086 women. It was completed by 1525 (49 percent) women, of whom 1393 (91 percent) said they had received their reminder letter. Of these 1393, 48 per cent (95 per cent confidence interval 46 per cent to 51 per cent) reported having had a Pap test within 10 weeks of the reminder letter arriving. The proportion of women having a Pap test in response to the reminder letter did not differ by age, region of residence or language spoken at home. Women were less likely to have had a Pap test if they did not know how they were enrolled, were of low socioeconomic status or had some tertiary education. Women on the reminder service have 15-month rescreening rates at least 9 per cent higher than other women in New South Wales; for women aged 50 to 69 in nonmetropolitan areas the increase is estimated at 19 per cent. Reminder services may be a cost-effective way to increase Pap test rescreening rates. Reminder services need accurate records and to follow up changes in address and date of next test.     

Community-based cholesterol screening and education to prevent heart disease: five-year results of the North Coast Cholesterol Check Campaign

Abstract: A cardiovascular disease screening and education campaign was conducted throughout the North Coast Region of New South Wales from 1987 to 1991. Objectives were: to screen 20 per cent of the adult population for blood cholesterol and other heart disease risk factors; to raise awareness of the risks associated with a high-fat diet; to provide nutrition counselling and referral advice for those with elevated cholesterol; and to monitor these participants' cholesterol levels with a follow-up test at three months. During the five years, 42 869 individuals or 18 per cent of North Coast adults participated, with some overrepresentation of women aged 40 to 60 years. Initially, 65 per cent of participants had elevated cholesterol levels (≥5.5 mmol/L) and 46 per cent were overweight (body mass index over 25). A three-month retest was offered to all participants with elevated cholesterol, of whom 53 per cent attended. Participants who received nutrition counselling generally reported dietary changes which were reflected in significant cholesterol and weight reductions. Of participants who attended retest, 63 to 87 per cent had reduced cholesterol levels and 57 to 71 per cent reduced weight. A stratified random sample of participants was retested at one and three years. Reductions in cholesterol were well maintained for one year but showed signs of relapse after three years. There was a tendency for initially lower cholesterol levels to increase over a three-year period. Contributing factors included aging, regression to the mean and complacency. Maintenance may be enhanced by regular reinforcement of nutrition changes and development of more supportive environments.     

Incidence of cervical cancer following negative smear. A cohort study from Maribo County, Denmark

In order to estimate the risk of developing cervical cancer among women who originally had cytologically normal Papanicolaou (Pap) smears, information has been collected on all Pap smears taken in Maribo County, Denmark in 1966-1982 among women born 1918-1952. A total of 27,811 women are included in the study, and cases of invasive cervical cancer developed in the study population have been identified from the local department of pathology and from the Danish Cancer Registry. The incidence of cervical cancer has been tabulated by number of previous negative smears and by time elapsed since last negative smear. Women with one previous negative smear have a zero risk of developing cervical cancer during the first year following the negative smear. The incidence among these women increases with length of time since the negative smear and reaches the level of unscreened women during the fifth year of follow-up. Women with 2-4 previous negative smears also have a negligible risk of developing cervical cancer during the first two years following the last negative smear. The incidence among these women increases less over time than the incidence for women with one previous negative smear. No cases of cervical cancer were observed among 7,716 women with 5+ previous negative smears. The study indicates that the 5-year risk of developing cervical cancer is 48% lower in women with one previous negative smear than in an unselected population of unscreened women. The 5-year risk for women with 2-4 previous negative smears is 69% lower than that for unscreened women.     

Low knowledge of cervical cancer and cervical pap smears among women in Peru, and their ideas of how this could be improved

Estimates of the percentage of women who have had Pap smears in Peru vary between 7% and 43%. This study explores what women know about cervical cancer and Pap smears, as well as their barriers to obtaining Pap smears. Focus group discussions (FGD) were conducted with a total of 177 women in four Peruvian cities. Discussions reveal that most women did not know what causes cervical cancer. Most women did not know the purpose of Pap smears, although knowledge about Pap smears was higher than knowledge about cervical cancer. Fear, embarrassment, and lack of knowledge were the main barriers identified for not getting Pap smears. Programs and policies aiming to increase Pap smear coverage must start by educating women on cervical cancer and its prevention in order to improve women's perceptions about the screening test and increase Pap smear seeking behaviors in the long term.     

Pap smears in general practice: a secondary analysis of the Australian Morbidity and Treatment Survey 1990 to 1991

Abstract: We investigated the characteristics of Australian general practice that predict performance of Pap smears by secondary analysis of the Australian Morbidity and Treatment Survey 1990 to 1991. Chi–squared analysis identified potential associations between Pap smear rate and patient, doctor and practice variables. Significant associations were examined using logistic regression and generalised estimating equations. Participants were 495 general practitioners who collected information on 113 468 doctor–patient encounters, of which 43 211 encounters involved females aged 18 to 70 years. Pap smear encounters (2449) were identified and classified as patient–requested (62 per cent), diagnostic (5 per cent) or opportunistic (33 per cent). The large difference in the unadjusted Pap smear rates per 100 female encounters for female general practitioners (11.7) and male general practitioners (4.2) required separate analysis by sex of the general practitioner. For male general practitioners, a Pap smear was less likely: as patient age increased; for new patients; for general practitioners with less general practice experience; for general practitioners with no postgraduate qualifications; with metropolitan practice location; and if the practice had more than 25 per cent of patients with English as a second language. For female general practitioners, a Pap smear was less likely: for older known patients; as the age of the general practitioners increased; and for management of fewer problems per 100 encounters. A Pap smear was less likely to be opportunistic: as patient age increased; for general practitioners who were Australian graduates; and for general practitioners with no postgraduate qualifications. Consideration of patient, doctor, and general practice characteristics may facilitate the design of interventions to improve cervical cancer screening.     

CERVICAL CANCER SCREENING AMONG SOUTH ASIAN WOMEN IN CANADA: THE ROLE OF EDUCATION AND ACCULTURATION

Cervical cancer screening by Papanicolaou (Pap) smear lowers the incidence and provides early detection of cervical cancer and is a preventative health care measure that should be available on a regular basis to all women at risk. As the population of ethnic women increases, it is important to assess whether these women are aware of and are utilizing this health service. A self-administered questionnaire was completed by 124 South Asian women, aged 18 to 60 years. Sixty-two South Asian students were selected from a university setting and 62 Tamil women were selected from a community center for South Asian women. This study examined the knowledge and use of Pap smears in South Asian women in Canada, and whether their level of acculturation or formal education influenced whether they know about and receive Pap smears. Low level of knowledge about the Pap test and a low prevalence of Pap testing behaviour was significantly correlated ( p < 0.001) with a low level of formal education, education taking place outside of Canada, and a low index of acculturation. South Asian students were significantly more acculturated than Tamil women ( p < 0.001). In conclusion, there was a low level of knowledge and prevalence of cervical cancer screening among South Asian women. This study highlights the need for educational interventions in Canada directed to ethnic women especially from South Asia.     

Promoting screening for cervical cancer: realising the potential for recruitment by general practitioners

This paper explores the potential for general practitionersto promote screening for cervical cancer and describes one exampleof an effective general practitioner-based (GP-based) programmeto improve community screening rates. The GP-based programmewas designed to improve general practitioners' involvement inrecruiting women in their communities to have Pap smears. Theaim was to raise doctors' awareness of the fact that many womenare not adequately screened, to encourage them to consider whythese women are not being recruited, to assist them to developstrategies to overcome these problems, and to support them inthe use of these strategies by providing information and resources,feedback on performance, and peer support. The effectivenessof the GP-based programme was assessed as part of a multi-centretrial to compare the differential effectiveness of three community-basedstrategies to promote screening for cervical cancer: a televisioncampaign, a television campaign combined with personally addressedletters sent to all women in the community, and a televisioncampaign combined with the GP-based programme. Each interventionwas delivered to three postal regions in New South Wales, Australia,and time-series data on Pap smear rates were obtained. Threecontrol regions were included for comparison. Of all three strategies,the combined television campaign and GP-based programme hadthe most potential, with up to an additional 8% of previouslyunscreened women being screened during each quarter of the combinedtelevision campaign and GP-based programme. This compares withscreening of 2–4% of previously unscreened women in associationwith television combined with letters, and only 1–3% ofpreviously unscreened women when television was used alone.However, the impact of the GP-based programme was highly variable.This variation in effectiveness points to a need for furtherresearch to determine the general practitioner, community andprogramme factors associated with programme success.     

Cervical cancer screening among South Asian women in Canada: the role of education and acculturation

Cervical cancer screening by Papanicolaou (Pap) smear lowers the incidence and provides early detection of cervical cancer and is a preventative health care measure that should be available on a regular basis to all women at risk. As the population of ethnic women increases, it is important to assess whether these women are aware of and are utilizing this health service. A self-administered questionnaire was completed by 124 South Asian women, aged 18 to 60 years. Sixty-two South Asian students were selected from a university setting and 62 Tamil women were selected from a community center for South Asian women. This study examined the knowledge and use of Pap smears in South Asian women in Canada, and whether their level of acculturation or formal education influenced whether they know about and receive Pap smears. Low level of knowledge about the Pap test and a low prevalence of Pap testing behaviour was significantly correlated (p < 0.001) with a low level of formal education, education taking place outside of Canada, and a low index of acculturation. South Asian students were significantly more acculturated than Tamil women (p < 0.001). In conclusion, there was a low level of knowledge and prevalence of cervical cancer screening among South Asian women. This study highlights the need for educational interventions in Canada directed to ethnic women especially from South Asia.     

A mobile unit: an effective service for cervical cancer screening among rural Thai women

BACKGROUND: We carried out a systematic screening programme using a mobile unit with the purpose of increasing use of Papanicolaou (Pap) smear screening among rural Thai women. The mobile unit campaign was carried out initially between January and February 1993 and then in 1996 in all the 54 rural villages in Mae Sot District, Tak Province, northern Thailand. METHODS: To evaluate the effect of the programme on changes in knowledge and use of screening, we compared the results of three interview surveys of women, 18-65 years old, in villages selected by systematic sampling for each survey; first in 1991 (before the operation of the programme), secondly in 1994 (one year after the first screening campaign), and last in 1997 (one year after the second campaign). This report also compares data on Pap smears taken by the mobile unit with other existing screening services in the study area. RESULTS: A total of 1603, 1369, and 1576 women respectively, participated in each survey. The proportion of women reported knowing of the Pap smear test increased from 20.8% in 1991 to 57.3% in 1994 and to 75.5% in 1997. The proportion of women who had ever had a Pap smear increased from 19.9% in 1991 to 58.1% in 1994 and to 70.1% by 1997. Screening by the mobile unit accounted for 85.2% of all cervical intraepithelial neoplasia (CIN) III and all invasive cancers identified among the Pap smears taken by screening services in the area between 1992 and 1996. The rate of CIN III was 3.5/1000 smears in this screening programme, which was 5.2 and 2.0 times higher than the rates in the maternal and child health/family planning clinic and the annual one-week mass screening campaign respectively. CONCLUSIONS: The use of a mobile unit may be an effective screening programme in rural areas where existing screening activities cannot effectively reach the female population at risk.     

Repeated Pap smear screening among Mexican-American women

The factors that influence repeated cervical cancer screening among Latina women are not well understood. Studies of compliance in this population over-emphasize initial or recent screening and under-emphasize how this practice is repeated over time. The purpose of this study was to identify the demographic and psychosocial factors associated with repeated Pap smear screening among low-income Mexican-American women living in two urban communities in Texas. A total of 1804 Mexican-American women were interviewed as part of a community survey. Multiple regression results indicate that demographic characteristics such as age, marital status, level of acculturation and health insurance were associated with the total number of Pap smears reported for the 5 years prior to the interview. Pap smear beliefs were the strongest predictor of repeated screening, while global beliefs about cancer did not significantly explain the results. Health promotion interventions should take into consideration the cultural and psychosocial needs of Mexican-American women, placing emphasis on their specific screening-related beliefs, if they are to succeed in promoting repeated compliance with Pap smear screening guidelines.     

Cervical papillomavirus infection and cervical dysplasia in Hispanic, Native American, and non-Hispanic white women in New Mexico.

BACKGROUND: Human papillomavirus infections of the cervix are found with varying frequencies in different populations worldwide, and have been associated with cervical cytologic abnormalities. METHODS: We studied 1,603 randomly selected Hispanic, Native American, and non-Hispanic White women in New Mexico to determine the prevalence of cervical HPV infection in these ethnic groups, and its association with Pap smear abnormalities, using a new commercial dot-blot hybridization assay. RESULTS: Nine percent of all women screened had evidence of cervical HPV infection (13.7% of non-Hispanic White women, 9.7% of Hispanics, and 6.6% of Native American women). Prevalence was higher in younger women ages 14-19 years than in older age groups. Over half of women with cervical HPV infection (n = 145) had normal Pap smears. The proportion of infected women increased among those with more advanced cytopathologic abnormalities; 5.6 percent with normal Pap smears had cervical HPV vs 66.7 percent with moderate-severe dysplasia. CONCLUSIONS: Cervical HPV infection is common among New Mexico clinic attendees, varies in prevalence among the three major ethnic groups, and is strongly associated with cervical cytopathologic abnormalities.