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Screening for cervical cancer: An evaluation of three different methods of recruitment among women between the ages of 40 and 64

Thornton, J. S. (1994). Screening for cervical cancer: An evaluation of three different methods of recruitment among women between the ages of 40 and 64. (Unpublished Doctoral thesis, City, University of London)



To evaluate the effectiveness of three different methods of recruitment for routine cervical cytology among women aged, primarily, 40-64 years. The recruitment drives took place between 1985 and 1987 across three separate Health Districts within the South West Thames Regional Health Authority.


During the year of the evaluation 8221 letters were issued to healthy women in the target age-range. While 38% of these invitations resulted in screening taking place, over half of the cervical smears done were unwarranted as they were performed on asymptomatic, adequately screened women. It was estimated that only 13% of invitations resulted in necessary screenings.


Leaflets were delivered to 110,000 homes, and almost 400 posters were sited in prominent areas. But in 25 out of the 26 Wards which comprised the Health District no significant increase in attendance for cervical cytology was registered at the local clinics. Furthermore the advertising appeared to have no appreciable effect on the knowledge & attitudes of interviewees towards the subject. However, one probable consequence of the publicity campaign was that more women in the post-advertising sample were aware of the location of their nearest screening clinic.


When screening facilities were provided within the workplace, 91 % of the workforce attended, more than half of whom required cytology. The detection of abnormal cytology was high, and over 50% of women with aberrant results were inadequately screened for cervical cancer. BUT;-
(a) It was possible to accurately estimate the population of women at risk for only 54% of the companies visited.
(b) Only 48% of companies approached agreed to allow a mobile caravan to visit.
(c) This method of recruitment was the most expensive, averaging £15 per head
(d) At best workplace screening could reach between only 20-25% of eligible women, & probably less in other, not so industrialised, Health Districts.
(e) To ensure future compliance this type of service would need to be repeated at regular intervals - a cost that could not be met solely from the Health District budget.


While the poster won four major awards and was highly acclaimed within the media world, it was impossible to tell how many of the target population read, or even saw, the advertising material. Just over 1 in 3 women interviewed subsequent to the publicity campaign could recall the leaflet &/or poster, and only 1 in 10 could cor-rectly recall any information contained therein.
However, the biggest omission was the failure to assess, by means of pilot studies, the winning design for (1) visual effectiveness; (2) its potential to recruit women for cervical cytology; and (3) the understanding of the target group with regard to message content.
This latter point is especially valid since it is believed that the degree of illiteracy within the target age-range was greatly underestimated. These factors may well have resulted in a poster that was inappropriate for the women it was intended to recruit.
If all professional involvement had been paid for, the advertising campaign would have cost in excess of £25,000. While this is not a frugal use of funds for one Health District in isolation, a country-wide campaign would be more economically viable, and could well prove to be a useful adjunct to the computerised call and recall.


This method of recruitment would, within five years, have achieved almost entire adult female population coverage. But across all the 18574 invitations issued to all women aged 20+: -
(a) 59% were issued to women whose previous screening history was unknown & indeterminable. It is not unreasonable to assume that some of this group would be adequately screened and would, therefore, ignore an invitation as inappro-priate.
(b) 29% went to women who were found to have received cervical cytology within the preceding five years.
(c) A further 12% were issued with an invitation against the advice of their family doctor.
These problems resulted primarily from poor record keeping. The family doctors’ failed to include relevant information on the Prior Notification Lists (only 47% were returned to Family Health Service Authorities with relevant details included), and their case-note records of cervical smears were often poorly maintained when compared to those held by the cytopathology laboratories. The computerised details of screening & medical status held by the Family Health Service Authorities were often wrong and, despite extensive upgrading prior to computerisation, demographic inaccuracies (particularly name & address but also age & sex) were common.
It is also possible that the aforementioned subject of illiteracy could have contributed to the low response rate since the choice of the letter of invitation was decided by ’ Health Experts’, and the missive selected was not piloted for effect or comprehension on the target population.
The computerised call and recall has now been implemented across the country. However, its true effectiveness can only be judged when the population registers of the Family Health Service Authorities are adequately maintained.


In order to determine whether any of the three aforementioned projects caused a significant increase in the overall screening coverage within each Health District, two separate case note reviews were undertaken. The first of these occurred in the year preceding the interventions and the second upon completion of the projects. A fourth Health District with no organised screening policy was used as a control.
85% of eligible General Practitioners agreed to be involved and over 4500 women aged 40-64 years were selected from their lists held by the Family Health Service
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Authorities. The screening histories of 3756 women were cross-checked with the records held by the 15 cytopathology laboratories supplying the four Health Districts. Information was obtained from this source for over 40% of the women investigated.
No significant alterations in screening patterns were noted across any of the Districts as a consequence of the interventions. But, due to sampling error and various other factors, the case-note review cannot be seen as an adequate reflection of the success or failure of the recruitment drives.


Although this work is unable to champion one single method of recruitment for cervical cytology, it has nevertheless highlighted other relevant considerations. Foremost among these is a credible estimation of screening history. Across all Health Districts and interventions it was consistently shown that between 30% to 40% of women in the age-range 40-64 years were inadequately screened for cancer of the cervix uteri.
Secondly, this study has gone some way to validate the use of housing tenure as an indicator of deprivation and poor screening attendances. At the time under scrutiny, only 1 in 5 women residing in council housing were regularly seeking cervical cytology compared to 1 in 3 who were either living in their own homes or renting in the private sector. Furthermore it must be emphasised that the social conditions reflected in this treatise were not common to the rest of the country. Indeed, this work took place in areas that were, on average, among the most affluent in the United Kingdom & where council housing formed just 15% of the total housing market. The concurrent national percentage of local authority tenants was around 30%. Although home ownership has subsequently increased, in 1990 the number of people resident in local authority housing was still significant and roughly equivalent in size to Social Classes IV and V combined. Thus it remains an important area where specific interventions can be targeted.


There is always going to be a hardcore of women who will never be persuaded to seek screening and no one method of recruitment will work for all women. The work showed that the age-group 50+ years is the most intangible and their right to remain unscreened must be respected - provided their decision is an informed one. Thus, the role of education in this subject must not be neglected although advertising in isolation is not seen as a viable educator for women from the least advantaged social classes.
The problem with the older women being reluctant to undergo screening should become less acute with time. Younger women are more familiar with cytology examinations and should be called regularly through the GP call/recall scheme, although errors and omissions will continue to occur. As a consequence other methods of recruitment should not be ignored but more studies involving psycho-logical factors are necessary to determine which of these are the most effective.

Publication Type: Thesis (Doctoral)
Subjects: H Social Sciences > HA Statistics
R Medicine > RZ Other systems of medicine
Departments: Bayes Business School > Actuarial Science & Insurance > Statistical Research Reports
Bayes Business School > Bayes Business School Doctoral Theses
Doctoral Theses
[thumbnail of Thornton thesis 1994 PDF-A.pdf]
Text - Accepted Version
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