Rachael H Dodd

Women’s experiences of the renewed National Cervical Screening Program in Australia 12 months following implementation: a qualitative study

Objective To explore women’s experiences of the renewed National Cervical Screening Program in Australia from the perspective of women who have received different human papillomavirus (HPV) test results. Women aged 25 to 74 are now screened every 5 years with primary HPV screening. Design Qualitative interview study. Setting Australia. Participants Women in Australia aged 25 to 74 who reported participating in cervical screening since December 2017, purposively sampled by test result (HPV positive, HPV negative and HPV status unknown). Methods 26 interviews with women aged 25 to 74 were conducted and analysed thematically. Results Three main themes emerged: knowledge and attitudes about the programme changes, information dissemination, the meaning and responses to test results and the new cervical screening test (CST). Some women showed little awareness of the changes, but others understood that HPV is detected earlier than abnormal cells. Some expressed positive attitudes towards the CST and were not anxious about less frequent screening. Most women envisaged the changes would have minimal impact on their screening behaviour. Women mainly wanted more information about the changes and the possible results from the new CST. Overall women could recall their HPV results and understand the implications for future cervical screening. Anxiety about being at ‘increased risk’ was more apparent in women who were HPV positive without history of abnormal results. Conclusions Women show some understanding of HPV and the new CST, but more written and public communication about the changes and possible results are warranted. Efforts are needed to ensure that women who are HPV positive without history of abnormal results receive the information needed to alleviate anxiety.

Implementing changes to cervical screening: A qualitative study with health professionals

BackgroundProfound changes were made to the Australian National Cervical Screening Program in December 2017, which included a reduction in the frequency of screening and a new cervical screening test.AimTo explore the attitudes and experiences of health professionals practising in Australia since implementation of these changes.Materials and MethodsThirty‐one semi‐structured interviews were conducted with general practitioners, obstetricians and gynaecologists, pathologists and nurses involved in cervical screening Australia‐wide. Data were analysed using Framework Analysis.ResultsOverall, health professionals had positive attitudes toward the changes but described many challenges associated with their implementation. Participants discussed practical system challenges, communication and education, finding ways around the guidelines and other perceived ‘collateral’. Practical system challenges included increased colposcopy referrals, limited access to the National Cancer Screening Register, a complex primary screening approach, and issues with self‐collection. In terms of communication and education, limited public education was recognised, in addition to challenges with particular age groups of women. Finding ways around the guidelines were described, for example over‐referring women for co‐testing by stating symptoms, which could lead to overtreatment. Other perceived collateral were demonstrated through reduced opportunistic screening opportunities due to less frequent primary care presentations, and concern over the potential for further underscreening in already under‐screened populations.ConclusionsThese findings provide insight into the challenges health professionals face with renewing programs, in terms of practical issues and unexpected downstream effects which need to be addressed to ensure future implementation of the program is streamlined.

Web-Based Health Information Following the Renewal of the Cervical Screening Program in Australia: Evaluation of Readability, Understandability, and Credibility

Background Three main changes were implemented in the Australian National Cervical Screening Program (NCSP) in December 2017: an increase in the recommended age to start screening, extended screening intervals, and change from the Papanicolaou (Pap) test to primary human papillomavirus screening (cervical screening test). The internet is a readily accessible source of information to explain the reasons for these changes to the public. It is important that web-based health information about changes to national screening programs is accessible and understandable for the general population. Objective This study aimed to evaluate Australian web-based resources that provide information about the changes to the cervical screening program. Methods The term cervical screening was searched in 3 search engines. The first 10 relevant results across the first 3 pages of each search engine were selected. Overall, 2 authors independently evaluated each website for readability (Flesch Reading Ease [FRE], Flesch-Kincaid Grade Level, and Simple Measure of Gobbledygook [SMOG] index), quality of information (Patient Education Materials Assessment Tool [PEMAT] for printable materials), credibility (Journal of the American Medical Association [JAMA] benchmark criteria and presence of Health on the Net Foundation code of conduct [HONcode] certification), website design, and usability with 5 simulation questions to assess the relevance of information. A descriptive analysis was conducted for the readability measures, PEMAT, and the JAMA benchmark criteria. Results Of the 49 websites identified in the search, 15 were eligible for inclusion. The consumer-focused websites were classed as fairly difficult to read (mean FRE score 51.8, SD 13.3). The highest FRE score (easiest to read) was 70.4 (Cancer Council Australia Cervical Screening Consumer Site), and the lowest FRE score (most difficult to read) was 33.0 (NCSP Clinical Guidelines). A total of 9 consumer-focused websites and 4 health care provider–focused websites met the recommended threshold (sixth to eighth grade; SMOG index) for readability. The mean PEMAT understandability scores were 87.7% (SD 6.0%) for consumer-focused websites and 64.9% (SD 13.8%) for health care provider–focused websites. The mean actionability scores were 58.1% (SD 19.1%) for consumer-focused websites and 36.7% (SD 11.0%) for health care provider–focused websites. Moreover, 9 consumer-focused and 3 health care provider–focused websites scored above 70% for understandability, and 2 consumer-focused websites had an actionability score above 70%. A total of 3 websites met all 4 of the JAMA benchmark criteria, and 2 websites displayed the HONcode. Conclusions It is important for women to have access to information that is at an appropriate reading level to better understand the implications of the changes to the cervical screening program. These findings can help health care providers direct their patients toward websites that provide information on cervical screening that is written at accessible reading levels and has high understandability.

“A Pap smear saved my life”: Personal experiences of cervical abnormalities shape attitudes to cervical screening renewal

Objective In 2017, the Australian National Cervical Screening Program changed from two-yearly Pap smears between ages 18 and 69, to five-yearly human papillomavirus screening between ages 25 and 74 (the “Renewal”). This study investigated attitudes towards the changes, among individuals previously affected by cervical abnormalities/cervical cancer, personally or through a friend/relative. Methods We conducted a thematic analysis of comments expressing personal history or a family/friend history of cervical abnormalities/cervical cancer as a reason for opposing changes to the cervical screening program. The comments were taken from a 20% random sample of 19,633 comments posted on the “Change.org” petition “Stop May 1st Changes to Pap Smears – Save Women's Lives” in February–March 2017. Results There were 831 (20.8%) commenters who reported that they were concerned about a change in screening due to: feelings of increased personal vulnerability to cervical cancer due to their own personal history of cervical abnormalities; comparison of extended screening intervals and later age of first screening to their own experiences; and a perception of increased personal risk due to family history. Conclusion Women previously affected by cervical abnormalities or cervical cancer, personally or through a friend/relative, expressed concern about changes to cervical screening due to perceived increased risk and feeling vulnerable due to personal history.

Understanding women’s choices for management of cervical intraepithelial neoplasia 2 (CIN2): Qualitative analysis of a randomised experimental study

BackgroundActive surveillance for cervical intraepithelial neoplasia 2 (CIN2) would allow time for most cases to regress naturally and in turn avoid potentially unnecessary and harmful treatment.AimTo determine reasons for choosing active surveillance over surgery among women given a hypothetical diagnosis of CIN2.Materials and MethodsWomen residing in Australia aged 25–40 years with no prior diagnosis of cervical cancer, cervical abnormality CIN2 or above, and/or previous hysterectomy, were randomised to one of four identical hypothetical scenarios of testing human papillomavirus (HPV)‐positive: high‐grade cytology and a diagnosis of CIN2 that used alternate terminology to describe resolution of abnormal cells and/or inclusion of an overtreatment statement. Participants selected active surveillance or surgery after viewing the scenario and free‐text reason/s for their choice were thematically analysed.ResultsOf the 1638 women randomised, 79% (n = 1293) opted for active surveillance. The most common reasons for choosing active surveillance included concerns about surgery and associated risks, preferring to ‘wait and see’, trusting the doctor’s recommendations and having an emotional response toward surgery. For women who chose surgery, being risk‐averse, addressing the issue straight away and perceiving surgery to be the better option for them were the most common themes identified.ConclusionWhen presented with balanced information on the benefits and harms of different management options for CIN2 and given a choice, most women in this hypothetical situation chose active surveillance over surgery. Addressing women’s concerns about active surveillance may open up the possibility that if deemed safe, it could be an acceptable alternative for women.

No longer recommended for cervical screening: How women aged 18–24 feel about the renewed National Cervical Screening Program

BackgroundSince December 2017, the Australian National Cervical Screening Program no longer recommends screening for women under 25 years of age.AimTo explore the attitudes of women under 25 years toward the changes.MethodsIn December 2019, women aged 18–24, residing in Australia, were recruited via the social media platform Instagram and Facebook. Descriptive analysis, t‐tests, χ2 tests and multivariable regressions were used to analyse the data.ResultsFive hundred and twelve women completed a cross‐sectional web‐based survey. Women who were older (22–24: 3.1 vs 18–21: 2.8, P < 0.001), sexually active (3.1 vs 2.7, P = 0.003), vaccinated against human papillomavirus (mean = 3.2 vs 2.7, P = 0.005) or who had screened previously (mean = 3.5 vs 2.8, P < 0.001) had significantly greater knowledge about the current cervical screening practices. Older women (odds ratio (OR) = 0.85, 95% CI 0.80–0.95) or those who had screened previously (OR = 0.51, 95% CI 0.31–0.83) were less positive about the delayed start age of screening and five‐yearly screening (OR = 0.54, 95% CI 0.35–0.85). A significant association was determined between being sexually active (χ2(4) = 32.71, P < 0.001) and women who had screened previously (χ2(4) = 34.43, P < 0.001), with a greater intention to screen in the future. Regarding health information, 64.6% of women had never heard of the ‘National Cervical Screening Program’ website and 38.9% of the sample (n = 199/512) reported they had ‘rarely’ noticed any health information regarding cervical screening in the past 12 months.ConclusionFurther work is required to rectify women’s knowledge of cervical screening to ensure women under 25 are aware of the screening guidelines and reduce the potential for over‐testing and overtreatment in this age group.

Australian National Cervical Screening Program renewal: Attitudes and experiences of general practitioners, and obstetricians and gynaecologists

BackgroundIn 2017, the Australian National Cervical Screening Program (NCSP) implemented five‐yearly primary human papillomavirus (HPV) screening for women aged 25–74. It is important that clinicians are able to explain the NCSP changes to women and confidently address concerns.AimsThis study examined Australian clinicians’ attitudes toward and experiences of the NCSP renewal since its implementation.Materials and MethodsCross‐sectional survey of clinicians (general practitioners, obstetricians and gynaecologists) involved in cervical screening, distributed two years after implementation of the renewed NCSP. Responses were analysed using descriptive statistics and thematic analysis.ResultsSix hundred and seven participants completed the survey. More than 80% of clinicians were comfortable with the main NCSP changes: extended screening intervals, increased age of first screening, and screening test used. However, only 47% of clinicians reported having utilised the National Cancer Screening Register, and a third of clinicians did not believe that self‐collection was a reasonable alternative to practitioner‐collected screening for under‐screened women. Increased demands for colposcopy were reported. All clinicians identified at least one area of educational need, including the management of women with a history of screen‐detected abnormalities in the previous program (34.9%), post‐colposcopy management for women with no abnormalities detected (25.5%), and screening in complex scenarios (eg immunocompromise) (26.5%).ConclusionsOverall, Australian clinicians are comfortable with the main changes to the cervical screening program. Certain areas may require further policy review, such as screening in complex clinical scenarios, colposcopy availability, accessibility of the Register and self‐collection. These issues could be meaningful for other countries switching to HPV‐based screening.

Psychosocial impact of testing human papillomavirus positive in Australia's human papillomavirus‐based cervical screening program: A cross‐sectional survey

AbstractObjectiveTo examine the impact of self‐reported human papillomavirus (HPV) test result (HPV negative, HPV positive, HPV result unknown) on a range of psychosocial outcomes.MethodsWomen and other people with a cervix in Australia aged 25–74 years who reported having participated in cervical screening since December 2017 were recruited through Facebook and Instagram to complete an online survey. The primary outcome measures were anxiety, emotional distress, and general distress.ResultsNine hundred fifteen participants completed the online survey; 73.2% reported testing HPV negative (‘HPV−’), 15% reported testing HPV positive (‘HPV+’) and 11.8% reported that they did not know/remember their test result (‘HPV unknown’). Compared to participants testing HPV−, participants testing HPV+ had higher mean anxiety (41.67 vs. 37.08, p < 0.001) and emotional distress scores (11.88 vs. 7.71, p < 0.001). Concern about test result (34.3% vs. 1.3%, p < 0.001), perceived risk compared to average women (55.4% vs. 14.1%, p < 0.001), and cancer worry (27.8% vs. 5.9%, p < 0.001) were also greater among HPV+ participants than participants testing HPV−. Participants testing HPV+ felt less reassured about their screening result than participants testing HPV− (16% vs. 75.1%, p < 0.001). Participants testing HPV+ had greater knowledge of HPV (11.96 vs. 10.36 out of 16, p < 0.001) and HPV testing (3.94 vs 3.28 out of 5, p < 0.001) than participants who reported testing HPV−.ConclusionsElevated levels of anxiety and emotional distress were found in those testing HPV+ compared with those testing HPV−. Future research should examine what strategies should be used to deliver test results and what additional information is provided, in order to alleviate anxiety among individuals testing HPV+.