English summary: Reasons for not participating in cervical cancer screening

Background

The Finnish cervical cancer screening programme has successfully reduced the number of cervical cancer cases since it was established in the 1960s. However, recently only less than 70% of the women identified as eligible for screening have been participating each year. Previous studies have shown that the most common reasons for non-attendance are Pap smears taken outside the screening programme, recently performed gynaecological examinations, practical reasons and forgetting the appointment. The aim of this study was to find out why Finnish women do not participate in cervical cancer screening. This information can be used in developing the programme and thus improving the attendance rate.

Methods

The study cohort consisted of 31,053 women who were identified as eligible for cervical cancer screening in 31 Finnish municipalities in 2011 and 2012. A questionnaire on the reasons for non-attendance was sent to 5,328 non-attendees after the initial and reminder invitations. These women were also offered the opportunity to participate in the screening by means of self-sampling at home.

Results

The attendance rate at organized screening was 79.2%. Low attendance rates were associated with young age, a lower level of education and belonging to a language minority (other than the Swedish-speaking one). The return rate for the questionnaire was 29%. The most common reasons for non-attendance were Pap smears taken outside the organized screening programme, practical reasons, preferring to have the Pap smear taken at a doctor’s office and forgetting the appointment. Some 60% of those who returned the questionnaire had had a Pap smear outside the programme sometime during the last 5 years. On the other hand, 24% were under-screened (no Pap smear in the last 5 years). In this group practical reasons for not participating, e.g. trouble finding a suitable time for the appointment, work and health related obstacles, and traveling, were even more common. Reluctance to undergo a gynaecological examination was also a more common reason among the under-screened. Some 75% of the under- screened women in our study chose to participate with a self-sampling test.

Conclusions

In order to optimize the attendance rate, some improvements should be made to screening practices. Having more available appointments and also having them on weekday evenings and weekends would make it easier for women to choose a suitable time. Reminder letters for non-attendees should be routine in every municipality. Information about the screening programme should also be available in other languages to ensure a better attendance rate among immigrants. Self-sampling could be used as a way to encourage participation in those women who are reluctant to take part in routine clinic-based screening. Finally, a joint effort among all health-care providers in Finland is needed to make the shift from the currently widespread opportunistic screening activities to the more cost-effective organized screening.