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.
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).
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?
3. Do women believe action (e.g. attending cervical screening) can reduce the threat of this disease? And do the benefits of screening outweigh the costs (e.g. embarrassment, feeling uncomfortable)?
4. Do women feel confident to participate in a screening appointment? What about future HPV home-testing kits? Would women feel confident to test themselves?
Psychological theories of health-related behaviours can also help to inform public health campaigns to increase cervical screening attendance. In March 2019, Public Health England (PHE) launched the ‘Cervical Screening Saves Lives’ national campaign in an attempt to increase cervical screening attendance.
The campaign includes a television advert, targeted at women of all ages, to increase awareness and understanding of cervical screening. In line with the Health Belief Model, the campaign flags up women’s potential susceptibility and the severity of cervical cancer. The advert and posters distributed in GP surgeries and pharmacies also attempt to increase their perceived risk of cervical by stating – “Two women die every day from cervical cancer”. Such information is alarming and might create a pressure to act.
However, paradoxically, some women are mistakenly associating cervical screening with being diagnosed with cancer, rather than cancer prevention. This misconception triggers anxiety, which was found to stop women from attending regular cervical screening (Were, Nyaberi & Buziba, 2011). Hence, the PHE campaign has also focused on eliminating common misconceptions about cervical screening procedure and highlighting the preventative benefits – “Cervical screening can stop cancer before it starts”.
As predicted by the HBM, for the action to occur, the perceived benefits of screening need to outweigh the perceived costs. The PHE campaign therefore also attempts to tackle specific barriers to screening, including concerns over pain and discomfort, embarrassment, cultural attitudes and misunderstandings. For example, the advert takes a diverse approach by featuring women of different ethnic backgrounds, age and sexual orientation.
Finally, in accordance with HBM, the are numerous ‘cues to action’ or resources available to support the national campaign. Apart from an advert, which has been broadcast on TV, radio and online, there are posters, leaflets, social media posts, badge stickers etc. available for download from the PHE website.
In contrast, there may be some psychological components that were not incorporated by the PHE campaign. For example, self-efficacy, or feeling competent and confident to attend cervical screening, may depend on factors such as demographic, socio-cultural and psychological factors, such as negative past experiences with cervical screening or sexual trauma. Furthermore, research suggests that particular cultural or ethnic subgroups may actively decline cervical screening due to religious beliefs and language difficulties (Abdullahi et al, 2009). These variables may influence one’s perceptions, beliefs, confidence and thus, indirectly affect cervical screening attendance. The PHE campaign could go further to improve by finding ways to encourage and enable women of diverse backgrounds to respond to their screening invitation.
I hope that my describing the Health Belief Model has shed some light on the possible psychological processes behind the decision to attend cervical screening, the benefits of which definitely outweigh the costs of participation!
Edited by Dr Rebecca Richards
Abdullahi, A., Copping, J., Kessel, A., Luck, M.Bonell, C. (2009) Cervical screening: Perceptions and barriers to uptake among Somali women in Camden. Public Health, 123 (10), 680-685.
Glanz, K., Marcus Lewis, F. & Rimer, B.K. (1997). Theory at a Glance: A Guide for Health Promotion Practice. National Institute of Health.
Janz, N. K., & Becker, M. H. (1984). The Health Belief Model: A Decade Later. Health Education Quarterly, 11(1), 1–47.
Rosenstock, I. M. (1974). Historical Origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335.
Public Health England (2018). PHE launches 'Cervical Screening Saves Lives' campaign. Retrieved from:
Richards, R. (2018). Cervical cancer in the UK news: A look back over 2018, by Dr Rebecca Richards. Retrieved from:
Screening & Immunisations Team, NHS Digital. (2018). Cervical screening programme 2017-18 [NS]. Retrieved from: https://digital.nhs.uk/data-and-information/publications/statistical/cervical-screening-programme/england---2017-18
Were, E. Nyaberi, Z. Buziba, N. (2011) Perceptions of risk and barriers to cervical cancer screening at Moi Teaching and Referral Hospital (MTRH), Eldoret, Kenya. African Health Sciences, 11 (1), 58-64 .