Encouraging informed participation in cervical screening

Understanding the barriers to screening participation

Understanding who is not attending screening and the barriers preventing them from participating is important when looking at ways to support engagement with the programme. The reasons for non-attendance may be complex and several factors may be at play. It is important to address these different barriers to enable everyone who’s eligible to attend screening if they want to. 

Barriers to screening participation¹

Judah G, et al. A population survey on beliefs around cervical cancer screening: determining the barriers and facilitators associated with attendance. BMC Cancer. 2022  

²

Wilding, S., et al. What factors are most influential in increasing cervical cancer screening attendance? An online study of UK-based women. Health Psychology and Behavioral Medicine, 2020. 

³

Waller J, et al. Barriers to cervical cancer screening attendance in England: a population-based survey. J Med Screen. 2009 

⁴

Cancer Awareness Measure. September 2023   (PDF)

⁵

Chorley, A. J., et al. Experiences of cervical screening and barriers to participation in the context of an organised programme: a systematic review and thematic synthesis. Psycho-Oncology. 2017 

⁶

Wearn, A. & Shepherd, L. Determinants of routine cervical screening participation in underserved women: a qualitative systematic review. Psychology & Health, 39:2, 145-170, DOI: 10.1080/08870446.2022.2050230. 2024 

:

Personal perception of screening 

• Feeling embarrassed 

• Worry that the procedure will be painful (especially for post-menopausal women) 

• Concern for sexual connotations and being perceived as promiscuous 

• Fear of what the test may find 

• Lack of awareness of the purpose of screening  

• Perceived low risk of cervical cancer (eg not currently sexually active or in a lesbian relationship) 

• Religious beliefs (eg trust in God or outcomes being “God’s will”) 

Personal experience which impacts decision to attend 

• Lack of trust with the health system 

• Previous negative screening experience (eg past painful procedure) 

• Previous sexual assault or abuse 

• Negative body image issues 

• Gender dysphoria 

Practical or access barriers such as: 

• Difficulty arranging an appointment at a convenient time 

• Intending to go but forgetting or not getting round to it 

• Inaccessible information due to language or mode of delivery

Groups with lower participation:

• people aged 25–29 and those above 50⁷

  NHS digital. Cervical Screening Programme, England - 2022-2023. 

   

• people living in areas of high deprivation⁸

  Douglas, E., et al. Socioeconomic inequalities in breast and cervical screening coverage in England: are we closing the gap? Journal of Medical Screening. 2016

• people with a learning or physical disability⁹

  NHS Digital. Health and Care of People with Learning Disabilities , Experimental Statistics: 2019 to 2020.

• ethnic minority communities – note disparity varies by ethnic minority group¹⁰

  Urwin, S. et al., Factors associated with cervical screening coverage: a longitudinal analysis of English general practices from 2013 to 2022, Journal of Public Health. 2023. 

• people who are lesbian or bisexual¹¹

  Saunders CL, et al. Cervical screening attendance and cervical cancer risk among women who have sex with women. J Med Screen. 2021. 

• the transgender community¹²

  Berner, A. M., et al. Attitudes of Trans Men and Non-binary People to UK Cervical Screening. British Journal of General Practice. 2021. 

• people with severe mental illness¹³

  Kerrison, R. S. et al., Inequalities in cancer screening participation between adults with and without severe mental illness: results from a cross-sectional analysis of primary care data on English Screening Programme. Nature. 2023. 

There may also be other groups in your practice population that face barriers to participating in screening. Use your practice data to identify people who are not attending screening to consider strategies to support their informed participation.  

Supporting people to access screening

Discuss cervical screening with your patients

Although cervical screening is a familiar procedure for primary care staff, for most people it is not a routine process. When you have the opportunity, talk about screening with your patients, making sure to discuss potential concerns and address barriers. 

Impersonal patient-provider relationships have been found to be a barrier to participation in some underscreened populations. Ensure your patients feel safe, supported and able to participate, through a good rapport and ensure people feel listened to during appointments⁶

. 

Send tailored reminders

In addition to screening invitations, consider different options for reminding patients of their cervical screening appointment:  

Consider how your target population would want to be communicated with and try to tailor communication methods to different groups. For example, younger people have been found to prefer digital information¹⁵

Templates and top tips can be found in our cervical good practice guide(PDF, 1.78 MB).  

The Independent Review of Adult Screening Programmes (England),(PDF) written by Professor Sir Mike Richards recommended widespread implementation of initiatives which have been shown to improve uptake. Some that can be actioned within primary care include: 

• sending GP endorsements in screening reminders 

• providing easy read information and versions in other languages 

• offering screening appointments in the evening or on weekends 

• ensuring eligible trans and non-binary people are considered within screening invitation lists  

Case study

One practice focused on ways to improve uptake of cervical screening after practice data showed cervical screening rates had decreased over the previous 2 years. Rates for younger women and people whose first language wasn’t English were particularly low.   Interventions included educating staff on the importance of screening and the role of HPV, increasing access to screening, encouraging women to bring a friend along and placing leaflets in different languages in waiting rooms.   A year later, the percentage of women attending cervical screening increased by 10% compared to the previous year.

For full details, see case study 5 here

Primary care training and development 

Practice staff should undertake training to ensure they’re aware of potential barriers, support they can offer to address them and how to discuss this appropriately with people.

Share learning 

Check your local screening data to identify whether there are any particular areas requiring improvement. You can find out what other practices in your area may be doing in case there is an opportunity to work together, or to share good practice.  

To find out about system-wide recommendations which could improve screening coverage, check out our Future optimisation of cervical screening page. 

Safety netting

Let patients know when they should expect to receive their screening results, and who to contact if they do not receive their results in the expected timeframe.  

Patients and health professionals should be aware that a previous normal cervical screening test result does not rule out cancer. 

Remind your patients, regardless of whether they participate in screening, their HPV status or HPV vaccination status, that they should contact a health professional if they have any symptoms or changes that are not normal for them. You could share our public information on cervical cancer symptoms. 

Read more about safety netting on our webpage for healthcare professionals. 

Colposcopy attendance 

Primary care can support colposcopy attendance following primary cervical screening, by understanding patient barriers. Anxiety, work or childcare commitments, transport and forgetting the appointment have all been identified as barriers to colposcopy attendance. In addition, non-attendance is higher in more deprived areas and among younger people¹⁶

.  

Consider how you can contact people invited for colposcopy with a text or phone call to encourage them to attend.  

Resources 

• Cervical Screening Primary Care Good Practice Guide(PDF, 1.78 MB)

• Reducing inequalities in cancer screening(PDF)

• ‘Should I go for cervical screening?' video for the public 

• GOV.UK Cervical screening: Support people who find it hard to attend 

Read more about cervical screening