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Healthy women or risk patients?: Non-attendance in a cervical cancer screening program
Linköping University, Department of Molecular and Clinical Medicine. Linköping University, Faculty of Health Sciences.
2007 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Women afflicted with cervical cancer who have the highest morbidity and mortality rates have been the least likely to be screened. The overall aim of this research project was to investigate non-attendance in a cervical cancer screening (CCS) program among women with no registered cervical smear during the previous five years. Both quantitative (I,III) and qualitative methods (II) as well as costeffectiveness analysis (IV) were used in this research project. In Kalmar County women (aged 23-65 years) are invited to CCS every third year. All cervical smears taken both in opportunistic and organised CCS are coordinated in a register called Sympathy. The coverage is 88.4 %. From Sympathy, a random sample of 400 women served as a study group and another 400 women as a control group (III,IV). From the study group, 133 women participated in study I and 14 women in study II. Data was collected by telephone interviews based on a questionnaire (I), qualitative face-to-face interviews (II), questionnaire, promotive efforts and outcome (III), costs and effectiveness (IV). Quantitative data was analysed by descriptive and analytic statistics (I,III), qualitative data was analysed by content analysis. In study IV, cost-effectiveness analysis was used.

The women believed that CCS was a good idea for all other women, but tended to refer to various circumstances resulting in their own non-attendance. One of the most common reasons for non-attendance was the feeling of being healthy. The women prioritized family and work commitments, and the invitation to attend CCS was sometimes experienced as a stressful disturbance. The feeling of discomfort was related to the gynaecologic examination, or to health care visits in general (I,II). Of 133 women, 120 could consider having a cervical smear taken and their two most common requirements for doing so were to be assured they would be treated in a friendly way (19%) and to find a suitable time (18%) for having the cervical smear. Fifty women wanted to be helped to have a cervical smear taken. Promotive efforts ranged from making a simple telephone call to arranging an appointment time to a combination of promotive efforts including repeated encounters in order to create a trusting relationship with respect to taking the smear. In the study group, 29.5% (n=118) had a registered cervical smear at follow-up compared to 18.5% (n=74) in the control group, (p<0.001) (III). In the study group, the cost per cervical smear taken was 66.87 €, and in the control group it was 16.62 €. The incremental cost per additional cervical smear taken was 151.36 € (IV). In conclusion, women’s reasons for not attending CCS are complex and are influenced by both present and earlier circumstances. In settings with high coverage, further contact in order to promote women’s attendance at CCS seems to be associated with high costs in relation to the number of additional cervical smears taken.

Place, publisher, year, edition, pages
Institutionen för klinisk och experimentell medicin , 2007. , 63 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1021
Keyword [en]
Non-attendance, screening, cervical cancer, health promotion, improverment, informed consent
National Category
Clinical Science
Identifiers
URN: urn:nbn:se:liu:diva-10092ISBN: 978-91-85895-71-7 (print)OAI: oai:DiVA.org:liu-10092DiVA: diva2:16834
Public defence
2007-11-09, Aulan, Hälsans hus, Campus US, Linköpings universitet, Linköping, 09:00 (English)
Opponent
Supervisors
Note
On the day of the defence data the status of article I was: In press; article II: Submitted; article II: Accepted and artile IV: In press.Available from: 2007-10-24 Created: 2007-10-24 Last updated: 2009-08-22
List of papers
1. Reasons for non-attendance at cervical screening as described by non-attendees in Sweden
Open this publication in new window or tab >>Reasons for non-attendance at cervical screening as described by non-attendees in Sweden
2008 (English)In: Journal of Psychosomatic Obstetrics and Gynecology, ISSN 0167-482X, Vol. 29, no 11, 23-31 p.Article in journal (Refereed) Published
Abstract [en]

Purpose. To describe reasons for non-attendance at cervical screening, as reported by non-attendees, in Sweden. Methods. Four hundred women were randomized from a population-based register, of which 133 non-attendees answered the Cervical Screening Questionnaire (CSQ) in telephone interviews. Pearson's Chi2 and Mann-Whitney U-test were used to analyze differences between groups. Logistic regression was used to study the relationship between explanatory variables and a binary response variable. Results. The most common reasons for non-attendance were: feeling healthy, lack of time, and feelings of discomfort with the gynecologic examination. Non-attendees, who reported non-attendance due to experiences of discomfort associated with the gynecologic examination, estimated great discomfort at their latest examination. A history of sexual abuse was reported by 16.5%, but there were no differences regarding non-attendance due to experiences of discomfort associated with the gynecologic examination, between non-attendees who had no history of sexual abuse and those who had. Conclusion. It seems as though non-attendees did not attend cervical screening as they felt healthy, and thereby did not give time to preventive efforts. Earlier negative experiences such as discomfort during earlier gynecologic examinations seem to guide their decision not to attend.

Keyword
Cervical screening; non-attendance; gynecologic examination; sexual abuse; questionnaire
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-12674 (URN)10.1080/01674820701504619 (DOI)
Available from: 2007-10-24 Created: 2007-10-24 Last updated: 2012-04-06
2. “I do not need to… I do not want to… I do not give it priority …”: why women choose not to attend cervical cancer screening.
Open this publication in new window or tab >>“I do not need to… I do not want to… I do not give it priority …”: why women choose not to attend cervical cancer screening.
2008 (English)In: Health Expectations, Vol. 11, no 1, 26-34 p.Article in journal (Refereed) Published
Abstract [en]

Objective To describe and interpret why women with no cervical smear taken during the previous 5 years choose not to attend a cervical cancer screening (CCS) programme.

Background CCS programme is a service for early detection of cervical cancer. Today, some women choose not to attend the programme.

Design Data were collected by tape-recorded interviews and analysed by qualitative inductive content analysis.

Setting and participants Purposive sample of 14 women in southeast Sweden, who had chosen not to attend CCS during the previous 5 years.

Findings The following themes were revealed: I do not need to…, I do not want to… and I do not give it priority…. The women had a positive attitude to CCS but as long as they felt healthy, they chose not to attend. A negative body image, low self-esteem, feelings of discomfort when confronted with the gynaecological examination and fear of the results also influenced their non-attendance. The women prioritized more important things in life and reported various degrees of lack of trust in health-care.

Conclusion Women's choice not to attend CCS were complex and influenced by present and earlier intra- and inter-personal circumstances. They had a positive attitude to CCS, but other things in life were more important. Health-care professionals have to facilitate a co-operative discussion with the women in order to contribute to a mutual understanding for the perspectives of the women and the professionals.

Keyword
cervical cancer screening • cervical smear • content analysis • interviews • non-attendance
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-12675 (URN)10.1111/j.1369-7625.2007.00478.x (DOI)
Available from: 2007-10-24 Created: 2007-10-24 Last updated: 2012-04-06
3. Non-attendance in a cervical cancer screening program: What happens if women’s requirements are met?
Open this publication in new window or tab >>Non-attendance in a cervical cancer screening program: What happens if women’s requirements are met?
2008 (English)In: Health Care for Women International, Vol. 29, no 2, 183-197 p.Article in journal (Refereed) Published
Abstract [en]

In this study we focus on women who have no registered cervical smear during the previous 5 years, their requirements for attendance, and promotive efforts performed. Of the 400 women randomly selected to answer a telephone-based questionnaire about future attendance at cervical cancer screening (CCS), 120 would consider having a cervical smear taken, and 50 of them wanted help to accomplish that. When meeting the women's requirements, such as being assured friendly treatment and a suitable appointment time, the numbers of registered cervical smears were higher for the study group compared with a control group. Still, the most highly resistant women did not attend.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-12676 (URN)10.1080/07399330701738242 (DOI)
Available from: 2007-10-24 Created: 2007-10-24 Last updated: 2013-10-18
4. Promotion of cervical screening among non-attendees: A partial cost-effectiveness analysis
Open this publication in new window or tab >>Promotion of cervical screening among non-attendees: A partial cost-effectiveness analysis
2007 (English)In: European Journal of Cancer Prevention, ISSN 0959-8278, E-ISSN 1473-5709, Vol. 16, no 6, 559-563 p.Article in journal (Refereed) Published
Abstract [en]

Measures to increase attendance rate in cervical screening programmes have been suggested, but few have been evaluated in terms of value for money. The aim of this study was to describe the cost-effectiveness of a resource-intensive intervention to promote attendance at cervical screening among women with no registered cervical smear during the last 5 years. Among all 56 644 women (28-65 years) in Kalmar County, January 2004, a total of 6565 women had no registered cervical smear during the last 5 years. From this population, 400 women were randomly selected to a study group and another 400 women to a control group. The intervention was composed of a variety of efforts intended to promote attendance at cervical screening. We included, for example, all costs for identifying the women, sending out invitation letters, making phone calls and helping to make arrangements. Data on registered cervical smears at follow-up were collected from a data register within 1 year. In the study group, 118 women had a registered cervical smear compared with 74 in the control group (P=0.000). In the study group, the cost per cervical smear taken was 66.87 € compared with 16.63 € in the ordinary screening programme. The incremental cost per additional registered cervical smear was calculated at 151.36 € in an area with high coverage, efforts to promote attendance at cervical screening were related to high costs per extra cervical smear gained and is not considered as reasonable from a cost-effectiveness perspective.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-12677 (URN)
Available from: 2007-10-24 Created: 2007-10-24 Last updated: 2012-04-09

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