How to increase the uptake of cervical screening: A profile of success

Cervical cancer screening needs a boost

There has been much work done in recent years to improve cervical screening rates in New Zealand. Screening rates for the total population reached 75% in 2011 (as measured by the PHO Performance Programme indicator for cervical cancer).¹ However, it is important to keep cervical screening “on the agenda” because the number of women who have been screened can still be improved.

In 2012, the percentage of women up to date with their cervical screening dropped from 74.8% to 73.9%.¹ Of the 35 PHOs in New Zealand, 28 had fewer women up to date than in the previous year, for the total population group.¹ In the high need group the uptake of screening was 66%, also dropping from the previous year’s level.¹ The high need group for the PHO Performance Programme comprises Māori and Pacific peoples and people living in the lowest (NZDep 9 and 10) socioeconomic areas.¹ The National Cervical Screening Programme (NCSP) also identifies Asian women as having consistently lower screening rates than the total population group and includes them in their high need group.

Increasing the rate of uptake of cervical screening is essential. Cervical cancer has a ten to 20 year latency, and regular smear tests* can effectively identify the majority of pre-cancerous lesions.² The incidence of invasive cervical cancer and subsequent mortality rate has dropped by 50% in New Zealand since the implementation of the national screening programme.² An inadequate screening history is associated with increased rates of cervical cancer and cervical cancer mortality. This is particularly apparent among the high need group; Māori women are more than twice as likely to die from cervical cancer as European women.³

Although cervical screening rates have decreased overall, there are individual practices and clinicians around New Zealand who continue to achieve high rates of screening. The following article profiles three such groups, asking them why they have been successful and what other practices can do to increase uptake of cervical screening in their populations.

* A cervical screening test may be done by the conventional Papanicolaou smear method or by using liquid-based cytology. For brevity, we refer to both tests as a “cervical smear” in this article.

Why is the high need group falling behind?

Women who are eligible for screening, particularly those in the high need group, face many potential barriers to receiving regular smears, such as:⁵

• Embarrassment/shyness/whakamā
• Cost
• Lack of transport
• Inability to take time off from work/family commitments preventing attendance
• Fear of the results
• Pain or discomfort from the smear
• Not knowing what to expect
• Not understanding the need to receive a smear

Health can be viewed differently by different groups of people and traditional attitudes toward medicine are often more prevalent among people of Māori, Pacific and Asian ethnicity. This is also true of sexuality, and the association between sexual activity, cervical screening and cervical cancer prevents some women from being comfortable presenting for a smear. Because of these differences, as well as a higher level of socioeconomic barriers, such as lack of transport and the cost of screening, levels are well below the desired level.

“[The barriers we see are] outstanding debt with a practice, lack of transport, shyness, inability to attend during normal working hours due to work, home and personal commitments.” Hawke’s Bay DHB and PHO

“The same barriers are seen in each PHO – lack of awareness, lack of transport, lack of willingness to attend the medical centre.” KMC

“We have an evaluation form that women fill out... the top barrier for women is cost.” CDHB

However, it is important to acknowledge that these barriers are not limited to the high need groups. Explaining to women that they do not qualify for free screening can be difficult. It is important to phrase the issue as one of reducing disparities within the New Zealand population, but to also approach the way the practice funds smears on a case by case basis.

“Sometimes [the issue of funding] can cause quite a bit of a discussion. Imagine you’re a woman and you’re not part of that priority group; there can be discussion around ‘how come these women are funded for smears but I’m not.’... In addition, it can be difficult as there is no standard price for a smear [between practices in New Zealand].” CDHB

While many of these barriers are common to all types of health care, cervical screening faces an additional hurdle in that it is a “wellness” programme, performed in women who are asymptomatic, rather than a “sickness” programme where symptoms or reduced health are a strong motivating factor for women attending the practice. Preventative medicine is often low in the list of priorities for people in lower socioeconomic groups.³

“It’s a case of stretching that family budget. So it’s food, it’s a roof over their head, all those things they might need, and women will always put their smear test last.”CDHB

On a more technical level, accurate coding of ethnicity data was also identified as being important for ensuring that eligible women are able to access all of the available services. By correctly coding ethnicity, women in the high need group can access lower-cost or free smears from certain providers. In addition, funding for the clinic, through the PHO Performance Programme and other sources, better represents the make-up of the practice population if ethnicity coding is accurate. Women should be asked what ethnicity they identify with, when they present for a smear, and this can be checked for consistency with their coded ethnicity. In addition, accurate coding of other data, such as phone numbers and current address are important at a practice level to ensure that women are able to be contacted in the future.

“Improving the quality of ethnicity data has positively impacted on screening coverage for Māori. Smear takers are encouraged to verify a woman’s ethnicity and ensure it is recorded on the laboratory form.” Hawke’s Bay DHB and PHO

“At the regional service level, we receive hundreds of return-to-sender letters every week, for result letters, recall letters, contact letters, which are going out to women that no longer live at that address.” CDHB

How can general practice reach the high need groups?

Being proactive in contacting and making appointments for women in the high need group is likely to increase screening in the women at higher risk of poor cervical cancer outcomes. Each of the interviewed groups have implemented an active approach to reaching out to high need women, and attributed this as important to the relative success of their programmes. General practice should implement a systematic approach to find and contact women who have not received a smear within the last three years. The following method may be used:

• Search patient records to identify the women aged 20 – 69 years in the practice population who have never had a smear or who have not had one within the last three years
• If the woman is not up to date, use the PMS to place an alert on her medical record so that a smear can be offered the next time they attend the general practice
• All women who are overdue for a smear should be contacted by text message, letter or telephone and encouraged to make an appointment for a smear
• If the woman cannot be contacted, contact the NCSP (0800 729 729) to verify their contact information and to check if a smear has been performed by another provider, such as Family Planning
• Those women who decline to have a smear in General Practice or are unable to, to should be offered referral to another provider based on their reason for declining, e.g. to a regional provider if they feel uncomfortable being screened by someone they know or wish to be screened by a culturally specific provider, or to a free provider if cost is an issue (if available)
• Women who still decline or wish to withdraw from the national register should have their details forwarded to the NCSP, so that they can be removed from the register. In addition, they should be regularly asked whether they wish to begin screening again, and any barriers to testing discussed.

Such an approach has proven successful for Karori Medical Centre:

“We have designed the cervical screening programme to contact women for their three-yearly cervical smear by sending a recall letter just before they are due, followed up with a text or phone call (or second letter if no mobile phone number [has been recorded]) about two to three months later. If the patient still does not present, another letter is then sent and the recall moved on to start the process over again. The same process happens for women needing annual cervical smears but within a tighter timeframe.” KMC

Despite these measures, some women will still be missed. Taking the opportunity to offer a smear to women when they attend general practice for another reason can help to “capture” those women who are unable to be contacted or are unable to present for a smear.

“Our high needs women can also have a cervical smear free of charge if they come in for another reason, e.g. with a child or for some other health reason. An alert/dashboard [on their medical record] will show they are overdue so they can be identified while at the practice.” KMC

To complement these approaches, regional providers (available in most regions through either the DHB or PHO and occasionally through non-government organisations) are able to help general practices maintain and stay current with their database of women requiring or overdue for a smear.

“We also work alongside [Primary Care] practices to help with data matching of their register, if a practice needs to, they can provide us a complete list of their population, their overdue women, and we will take that back to the [National] register and update the information for them.” CDHB

What strategies can help general practice make screening more accessible and comfortable?

The major theme from the comments of each respondent was to encourage practices to make the screening process as simple and accessible as possible. Strategies to make screening easier generally focus on directly addressing barriers, and include:

• Normalise the procedure as routine, and explain that this is recommended for all women as part of maintaining their health
• Give women a choice of smear-taker (gender, ethnicity, anonymity)
• Make sure that low cost screening options are in place for women who cannot afford a full consultation, or that referral to a free screening provider (if one is available within the region) is offered for women who cannot meet the cost of being screened in general practice
• Consider running a nurse-led smear clinic after hours or at weekends, as this may increase uptake among patients with work and other commitments
• Provide advice and educational material about cervical cancer, the smear test and about what the results mean, i.e. an abnormal cervical smear result rarely indicates cancer

Such an approach was encouraged and used by all three respondents:

“Give women a variety of service options – evening and weekend clinics, kaupapa Māori service providers, outreach smear clinics, female nurse smear-takers.” Hawke’s Bay DHB and PHO

“By having the clinics in the evening and on a Saturday, women who work could access the service… An extra project is then implemented six monthly to capture our remaining high need patients by offering open and booked clinics at no charge…The results were seen almost immediately with a strong uptake within two to three weeks of sending out texts or phone calls.” KMC

“We [understand] that family member’s and extended families’ children might need to come, because mum might not have someone to babysit the children, and while mum is in with the nurse our team are there to support the family members. Family support is really important as well, especially for Māori, so when women attend a clinic it’s really encouraged that the practitioner knows to invite a support person, and that this person will be different for different groups.” CDHB

Financial barriers of the clinic, as well as staffing requirements, will mean that not all practices are able to provide services on week-nights and weekends or to provide smear-takers to suit all ethnic groups. However, there are other ways to reduce the barriers that many people face in attending screening, such as referring to clinics that provide free screening (see: ”Free or low cost smears”).

Many women are not aware that screening is important, that it is necessary from an age as young as 20 years (if they have ever been sexually active) or that it remains important for older women. The respondents indicated that increasing awareness increased screening rates. This can be done in the practice by taking the opportunity to briefly mention to women just prior to their twentieth birthday that they will now need regular screening, using alerts to mention screening to women with incomplete screening histories and reiterating the need to continue screening up until age 70 years in older women.

“What would be ideal is if something goes out to young women [in a practice population] at the age of 19 years... to say ‘when you turn 20, we encourage you, as your practice, to talk to your Practice Nurse or talk to the team about your first cervical smear test.” CDHB

How can General Practice use regional-level screening programmes and community groups to increase screening?

The primary focus of cervical cancer screening should be to ensure that all New Zealand women have access to preventative health care, regardless of where they choose to receive this care. As one of the respondents put it:

“Be it that you’re at a practice, you’re a provider providing free clinics, you’re a family planning clinic or you’re a [regional level] screening programme... We want the focus to be on preventing cervical cancer.” CDHB

Several of the respondents expressed that regional-level cervical screening programmes were not “in competition” with General Practice. The Christchurch DHB group pointed out that many women are uncomfortable being screened by their usual General Practitioner or Nurse and that the anonymity of a regional screening provider (where available) or family planning clinic was seen as a positive for some. In addition, the cost of a General Practice consultation for a smear was too expensive for some patients. This means that General Practice must either have a lower cost screening option for certain high need women, or, alternatively, make use of their regional provider and refer some groups of women to the free screening services that are offered over much of the country.

Support for general practice is widely available, from both the NSU and local groups. Practices may be able to access resources for organising “screening days” or hosting after hours/weekend clinics, or to help train Practice Nurses to become smear takers, reducing the cost to the practice of administering a smear test. In addition to support available from regional screening groups, grants to cover the cost of nurse training are available from the NSU.

Contact your local PHO and DHB to find out what funding is available

“General Practice Facilitators are assigned to General Practices to provide support. The Facilitators support best practice and arrange for independent nurses to work in practices that do not have nurses.” Hawke’s Bay DHB and PHO

“We also [provide] training, our contract is to provide two smear-taker updates a year, and clinical updates to smear-takers. As well as [training] new nurse smear-takers... we also provide education and presentations for training every quarter.” CDHB

Linked to this was the idea that making use of allied care providers and other public health initiatives could increase the screening rate, while still being cost effective.

“In the future, we will be looking very closely at a cervical smear outreach service to work in conjunction with our already established immunisation outreach service. This would ensure we reached women who, for many reasons, do not want to come into the medical centre directly.” KMC

“We are aiming to have Māori health providers affiliated with general practices” Hawke’s Bay DHB and PHO

The National Screening Unit provides support and resources to General Practice, as well as helping to organise CME and training for smear takers. They can be reached on 0800 729 729 or by visiting: www.nsu.govt.nz

“We all want to ensure a family is not robbed of a woman because she’s dying of cervical cancer, which we can prevent. We want women to have their choices…We want women to have their health.”