HPV Case Report - examining attendance rates for cervical screening appointments.

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Case Report

‘It would be easy to give the public information and hope they change behaviour but we know that doesn’t work very satisfactorily. Otherwise, none of us would be obese, smoke or drive like lunatics’.

- Ian Potter. Director of New Zealand Health Sponsorship Council. NZ


Cervical screening identifies abnormal cells in the cervix. Early detection and treatment prevents ¾ of cancers developing. According to Cancer Research UK, this is the second most common cancer in women under 35. Regular cervical screening is the best way to identify abnormal cell changes in the cervix. Following the introduction of the national HPV vaccination programme in 2008, the NHS cervical screening programme continues to play an important role in checking women between the ages of 25 and 64 for early-stage cell changes.

Screening for cervical cancer, or HPV, has consistently shown to be effective in reducing the mortality rate due to cervical cancer. However, cervical screening attendance rates are still far from satisfactory in many countries. Following a period of consultation and information-gathering, the team have identified factors which influence attendance rates for cervical cancer screening.

Factors identified included knowledge of the disease itself and the importance of screening; emotions such as fear/confidence/denial; access and availability; ignorance and embarrassment; and clerical errors.

Image 1 – Reasons for low attendance. (NHS)

According to the British Medical Journal, until recently, one of the main obstacles for women participating in the cervical screening programme was administrative errors, mainly, incorrect contact details. This has been tackled by the payment incentive for GP’s. GP’s pay depends on the proportion of women aged 20-64 screened. The more women that are screened, the better the payment to the GP. This incentive suggests that the main reason women miss screening is due to the Doctors, however this may not be entirely the case.

In November 2011, a charity called Jo’s Trust produced new figures showing that one in five women don’t take up their invitations to have smear tests and looking more closely, one in three don’t turn up in under 35’s. Reasons that Jo’s Trust found for this are a lack of flexibility with employers, embarrassment of having to explain the absence from work, and lack of appointment choices. 

The theory of reasoned action was developed by M. Fishbein and I. Ajzen, with it's key application being to predict behaviour, attitude and behavioural intention, through their attitude toward said behaviour, and how they believe others would perceive them if they exhibited that behaviour. Relating this theory to the current situation, we must take into account the women's attitude, subjective norms and their behavioural intention. Their attitude depends on the individual themselves and how important they consider cancer screening to be. Their attitude may also be one of ignorance, not wanting to know the outcome for fear of being told they have a life threatening disease. With subjective norms, these can highly influence decision making. If their mother recently had a screening and it was negative, they may feel there is no point them being tested, and vice versa with a positive result. Behavioural intention relates to attitude and social norm, to influence intention levels. It is basically the weight you place on the previous aspects, which in turn lead to a decision to attend or not attend screening (Fishbein et al, 1975). Ajzen (1975) continued to revise the theory of reasoned action, and introduced the theory of planned behaviour. This theory originated from the self-efficiency by Bandura (1997). Bandura (1997) considered this the most important precondition for changes in behaviour du8e to the fact that it determines the initiation of copying behaviour. He defined self-efficiency as the conviction that one can successfully execute the behaviour required to produce the outcomes. This led to outcome expectancy, which was an estimation of the behaviour leading to outcomes. Applying this theory to the current case, it may aid us when explaining why there is a decrease in attendance. Self-efficiency is responsible for the attendance excuse of lack of transport. Attendance relies on the individual’s execution of the behaviour of planning to attend, which would in turn lead to the attendance. Rutter (2010) discovered a 10% increase in attendance rates if women planned their attendance. Another explanation relates to outcome expectancy - the woman's perceived belief that the reasons to attend outweigh reasons not to attend, in other words, the effectiveness of the preventative behaviour will effectively reduce the vulnerability to a negative outcome. Finally, social influence - the individuals consideration of expectance from friends and family, may explain an increase of attendance in 2009. This was the time that Jade Goody was in the media every day, up until her untimely death due to cervical cancer. The fear associated with this media panic affected peoples decision, having seen the consequences of not catching a problem quick enough. However, the attendance rates decreased since, suggesting that maybe the fear turned opinions from wanting to check themselves out, to ignoring the problem as it's not a priority now.

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Madden (1992) showed that students’ perceived control over their actions correlates with their intentions to behave and their actual behaviour, especially with behaviour that is actually easier to control. Terry (1993) applied the theory of planned behaviour to the issue of safe sex, and found that the degree of control that people believe they have substantially improves the prediction of behaviour from attitudes in this real world context. These theories could help to explain why women miss the appointments. If they have the intention of going, they will make the effort to go. If they book an appointment with no ...

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