Cervical screening: Do the benefits outweigh the costs? by Tatjana Doronda

Despite the efforts towards the elimination cervical cancer in the last year, summarised by Dr Rebecca Richards in a previous blog (‘Cervical cancer in the UK news: A look back over 2018’), recent data on cervical screening attendance, reported in March 2018 by NHS England, is worrying.

Key Facts

  • The national target for cervical screening coverage* is 80%. In March 2018, the percentage of eligible women who were screened adequately** had reduced to 71.4% compared to 72% in March 2017. This means that coverage is below the national target, has declined since last year and reached the lowest screening rates in two decades.

* Coverage – the percentage of women in a population eligible for screening at a given point in time who were screened adequately.

** Screened adequately – meaning that the pathology laboratory was able to assess the cells to give a result, as opposed to a small proportion of cases when a test is considered inadequate.

  • In contrast, the number of women invited for screening in 2017-18 period had increased 0.3% since the 2016-2017 period to 4.46 million.

  • Furthermore, the number of women who were tested in the 2017-18 period is the same as 2016-17, when 3.18 million women were tested (Image 3 below).

Source: NHS Digital

So there has been no improvement in cervical screening attendance or increase in testing, despite more women being invited to attend screening.

Today, I’d like to share with you one of the psychological theories of health-related behaviour that could help us to start to make sense of this data.

The Health Belief Model

The Health Belief Model (HBM) (Rosenstock, 1974) was originally developed in the 1950’s by a group of social psychologists working in the U.S. public services, as a response to the failure of free tuberculosis screening services. Psychologists aimed to explain and predict screening behavior among the population by finding out what encourages and discourages people from participating in screening programmes. Since then, the HBM has been expanded and widely used to predict a variety of health-related behaviours, such as vaccinations, practice of breast self-examination, seat-belt use, smoking and following nutrition, exercise and medication regimens (Janz & Becker, 1984).

According to the model, health-related action (such as attending a cervical screening appointment) can be influenced by several things:

1) Perceived susceptibility to the illness (e.g. mistakenly assuming no risk of cervical cancer due to being sexually inactive)

2) Perceived severity (seriousness) of the illness (e.g. being unaware that getting cervical cancer could have serious health, social and financial consequences)

3) Perceived barriers to a health-related action (e.g. perceiving cervical screening as painful or embarrassing)

4) Perceived benefits of a health-related action (e.g. identifying abnormal cells and preventing them developing in cancer in the future)

However, holding beliefs about severity (of cervical cancer) and susceptibility (to the disease) does not guarantee that women will attend a screening appointment. The likelihood of engaging in a health-related behaviour (i.e. screening) also depends on their subjective perception that the benefits of attending screening will outweigh the costs of participation (costs can include things like embarrassment, being slightly uncomfortable, travelling to the appointment, taking time off work etc). Further components include: cues to action ("prompts" to engage in screening, such as alarming symptoms, the social influence of peers or news reports in the media) and self-efficacy (confidence in one's ability to successfully engage in a screening appointment).

Figure 1. The core components of the HBM. © Tatjana Doronda

With respect to cervical cancer, this model prompts several questions which we can use to explore the recent data for screening attendance:

1. How susceptible do women feel to cervical cancer?

2. Do women believe that cervical cancer is a ‘serious’ health issue?