Social Science & Medicine

Combating vaccine hesitancy: The case of HPV vaccination

Cervical cancer, primarily caused by persistent Human Papillomavirus (HPV) infection, remains one of the leading causes of cancer-related deaths among women in low- and middle-income countries. Although HPV vaccines are widely available in these regions, vaccine uptake remains persistently low. To address behavioral barriers contributing to this low demand, we employed a mixed-method design combining qualitative analysis with a large-scale randomized evaluation of a behaviorally informed SMS campaign targeting parents in Cali, Colombia. Our study included 15,231 parents, who were randomized into six groups: control, placebo, and four behaviorally informed treatment groups, forming a large-scale study of text-based nudges. Participants received tailored messages over eight weeks. The intervention yielded significant increases in vaccination rates, with improvements ranging from 34% to 55%. Furthermore, the economic analysis demonstrated that the intervention generated between USD 3.6 and USD 5.75 in economic benefits for every dollar spent, primarily due to prevented deaths. These findings underscore the potential of behavioral interventions in enhancing HPV vaccination rates among parents and emphasize the cost-effectiveness and relative success of each intervention strategy. This study provides actionable insights for public health officials to design targeted strategies that address vaccination disparities and promote preventive healthcare practices.

Barriers to breast and cervical cancer screening among adolescent girls and young women in Kenya: A nationwide cross-sectional survey

Promoting regular screening remains one of the primary preventive measures for breast and cervical cancer. The study aimed to assess the prevalence and barriers to breast and cervical cancer screening among adolescent girls and young women (AGYW) in Kenya. The study used data from the 2022 Kenya Demographic and Health Survey (KDHS), with 12,026 AGYW who were selected by multistage sampling. The outcomes of interest were breast and cervical cancer screening. Multivariable logistic regression was used to assess factors negatively associated with the outcome variables, using SPSS (version 29.0). Of the 12,026 AGYW included in this study, only 6.0% (95%CI: 5.6-6.8) and 5.1% (95%CI: 4.8-6.0) had undertaken breast and cervical cancer screening, respectively. Low education (AOR = 0.08, 95%CI: 0.02-0.34 and AOR = 0.48, 95%CI: 0.28-0.83), not working (AOR = 0.67, 95%CI: 0.46-0.97 and AOR = 0.59, 95%CI: 0.42-0.82), low wealth index (AOR = 0.55, 95%CI: 0.32-0.92 and AOR = 0.45, 95%CI: 0.25-0.81), no visit to a healthcare facility in the last 6 months (AOR = 0.48, 95%CI: 0.33-0.69 and AOR = 0.50, 95%CI: 0.35-0.71), and no birth record (AOR = 0.29, 95%CI: 0.13-0.62 and AOR = 0.58, 95%CI: 0.27-0.74), were the major barriers to both breast and cervical cancer screening, respectively. Moreover, having no access to newspaper (AOR = 0.67, 95%CI: 0.46-0.97) was a significant barrier to breast cancer screening while having big problems with distance to a healthcare facility (AOR = 0.49, 95%CI: 0.33-0.73) and not using modern contraception (AOR = 0.60, 95%CI: 0.42-0.86) hindered cervical cancer screening. In conclusion, more efforts are needed from both the government and cancer stakeholders to increase accessibility of breast and cervical cancer screening services, especially to those with low social economic status. More targeted education and sensitization, improving livelihoods of AGYW through various women empowerment efforts, and improving screening capacity of low-grade healthcare facilities are among the useful strategies to improve the low screening rates.

Intergenerational transmission of preventive health-seeking behaviors: Like mother, like daughter? The case of cancer screening in France

One of the driving forces behind the persistence of social health inequalities is the intergenerational transmission of health, which occurs through both hereditary and environmental factors. Within this second pathway, the literature has primarily focused on the transmission of lifestyle-related health behaviors. This study expands on these mechanisms by focusing on the intergenerational transmission of preventive health-seeking behaviors, specifically cervical and breast cancer screening. We used data from the French E3N-Generations cohorts, which, despite being highly selected, uniquely track several generations of women over a long period. Our analysis draws on surveys conducted at the mothers' level between 1990 and 2014, and on a survey at the daughters' level launched in 2018. We employed conditional mixed process models to estimate the association between mothers' mammogram use (n = 6386) and their daughters' likelihood of regularly undergoing mammograms and Pap smears (n = 7012), while controlling for additional explanatory channels such as risk, socioeconomic status, and territorial context. Daughters whose mothers reported mammogram use across all survey waves, compared to none, were 8.4pp [4; 12pp] more likely to have a Pap smear at least every three years, and 17pp [12; 22pp] more likely to have a mammogram every two years, suggesting a transmission of preventive health-seeking behaviors. Thus, interventions aimed at increasing screening rates among women with lower engagement in preventive care could benefit both current and future generations, helping to break the cycle of social health inequalities.

“Not from home”: Cancer screening avoidance and the safety of distance in Eswatini

This paper shows how travel and distance make cervical cancer screening safer for women in Eswatini. It is based on three months of original ethnographic research conducted in a semi-urban town in Eswatini from September to December 2014, involving daily participant observation and semi-structured, in-depth interviews with 20 women and 7 health workers. Results of the research show how women use travel to create safer clinical spaces and encounters in the context of cancer screening. Specifically, the research found that in the cervical cancer screening clinic, women's bodies are negatively judged and talked about. This creates fear - of judgment, verbal violence and gossip - all of which are intensified in hospitals and with nurses who are close to home. It is a fearful, laborious and difficult clinical encounter which causes a medical migration, where women seek screening in distant hospitals and with nurses who are "not from home." Distance provides anonymity and minimizes pathways of gossip, thus mitigating fear and making cervical cancer screening safer for women. The social rationale around distance shows how travel can create or recreate clinical spaces and experiences of care in the context of local medical migration. It also upsets culturalist assumptions about women's avoidance of cervical screening. Improving cancer screening programs in Eswatini calls for an approach sensitive to the clinical and social realities that create fear and constrain women's choices.

Cervical cancer screening invitations in low and middle income countries: Evidence from Armenia

Roughly 90 percent of cervical cancer deaths occur in low- and middle-income countries (LMICs), where the lack of adequate infrastructures hampers screening, while informational, cultural, and socio-economic barriers limit participation in the few programs that do exist. We conducted a field experiment with the Armenian cervical cancer screening program to determine whether, despite these barriers, the simple, economical invitation strategies adopted in high-income countries could enhance screening take-up in LMICs. We find that letters of invitation increase screening take-up, especially when there are follow-up reminders. Different ways of framing messages appear to have no impact. Finally, women in rural areas are more likely to respond to invitation by letter, helping to narrow the urban-rural screening gap.

Do reasoned action approach variables mediate relationships between demographics and cervical cancer screening intentions or behaviour? An online study of women from the UK

In the UK, approximately 3,200 women are diagnosed with cervical cancer each year. Regular screening is one of the best ways to prevent cervical cancer from developing, yet screening rates are declining and vary by sociodemographic variables. The present stratified online study aimed to investigate relationships between sociodemographic factors and screening intentions and past behaviour. Reasoned Action Approach (RAA) variables were assessed as potential mediators. In total, 500 women living in the UK were recruited via an online research recruitment website to an online cross-sectional survey. Participant recruitment was stratified by age, socioeconomic status and ethnicity to ensure adequate representation of each strata. Participants completed measures on RAA variables (affective attitudes, cognitive attitudes, injunctive norms, descriptive norms, capability, autonomy, and intention) as well as screening past behaviour. Among the demographic variables, age, ethnicity and deprivation were significantly related to screening intention. Younger women, those from less deprived areas, along with white women were more likely to report higher intentions to attend screening. Past behaviour was significantly negatively predicted by deprivation only, indicating that individuals from less deprived areas were more likely to be up to date with their screening. Both intention and past behaviour were significantly positively correlated with all RAA variables. Capability and cognitive attitude partially mediated the relationship between age and intention and fully mediated the relationship between ethnicity and intention. Capability fully mediated the relationships between deprivation and intention and between deprivation and past behaviour. Intentions toward attending cervical cancer screening are related to age, ethnicity, and level of deprivation, with older women and those from areas of greater deprivation and ethnic minority groups reporting lower intentions. Capability (confidence engaging in cervical screening) and cognitive attitudes (how useful/beneficial screening is seen to be) are key variables to target to promote cervical screening attendance and reduce potential inequalities.

Mirror, mirror on the wall, when are inequalities higher, after all? Analysis of breast and cervical cancer screening in 30 European countries

Screening for breast and cervical cancer is strongly related with a reduction in cancer mortality but previous evidence has found socioeconomic inequalities in screening. Using up-to-date data from the second wave of the European Health Interview Survey (2013-2015), this study aims to analyse income-related inequalities in mammography screening and Pap smear test in 30 European countries. We propose a framework that combines age group and screening interval, identifying situations of due-, under-, and over-screening. Coverage rates, standard and generalised concentration indices are calculated. Overall, pro-rich inequalities in screening persist though there are varied combinations of prevalence of screening attendance and relative inequality across countries. Bulgaria and particularly Romania stand out with low coverage and high inequality. Some Baltic and Mediterranean countries also present less favourable figures on both accounts. In general, there are not marked differences between mammography and Pap smear test, for the recommended situation ('Due-screening'). 'Extreme under-screening' is concentrated among lower income quintiles in basically all countries analysed, for both screenings. These women, who never screened, are at risk of entering the group of 'Lost opportunity', once they reach the upper-limit age of the target group. At the same time, there are signals of 'Over-screening', within target group, due to screening more frequently than recommended. In several countries, 'Over-screening' seems to be concentrated among richer women. This is not only a waste of resources, but it can also cause harms. The inequalities found in 'Extreme under-screening' and 'Over-screening' raise concerns on whether women are making informed choices.

Pathways to personalisation: The practice of BRCA stratification

Personalised medicine is gathering pace across advanced cancer settings in the UK NHS, and care pathways are becoming increasingly filled with different steps, stages and treatments. One key personalised medicine practice is stratifying patients according to their molecular profile. Nevertheless, understanding how this practice shapes lived experience of cancer patients remains an under-researched area. To shed light on this question this paper focuses on the practice of stratifying patients according to their BRCA gene prior to or at the beginning of a late-stage ovarian cancer personalised medicine pathway. I draw on interviews and observations with 17 ovarian cancer patients, who formed part of a larger comparative ethnographic study, which took place between 2020 and 2021 in a tertiary hospital in the South-East of England. Focus on this one practice made it possible to demonstrate how as well as being a diagnostic tool stratification is an affective technology that cultivates range of feelings including inclusion or exclusion, and novel kinds of 'biosociality' (Rabinow, 1999). These findings offer critical insight into the importance to separate and scrutinise its practices on long pathways to understand the lived and felt experience of care.

Trajectories and individual determinants of regular cancer screening use over a long period based on data from the French E3N cohort

Despite several incentive policies for cancer screenings over the last two decades, the overall and regular use of cancer screenings remains insufficient in France. While the individual determinants of cancer screening uptake have been fairly well studied, the literature has rarely focused on the regularity of screening uptake, which is key to early cancer detection. We aimed to address this issue by studying cancer screening behaviors over 15 years, emphasizing the regularity and diversity of use. Using data from 40,021 women in the French E3N cohort, we studied the individual trajectories of screenings for breast, colorectal and cervical cancer between 2000 and 2014. We employed optimal matching methods to identify typical behaviors of use for each cancer screening. Then, we determined the associations between the identified behavior screening patterns for the different cancer screenings and, finally, assessed the associated individual determinants with logistical and multinomial models. We found that screening behaviors were fairly stable over time, with few typical screening patterns for each cancer. Overall, once a woman starts screening, she continues, and once she stops, she no longer returns. Cancer screening behaviors appear consistent; in particular, insufficient use of mammography appears to be associated with long-term nonuse of other cancer screenings. Factors associated with low or nonuse of screening are overall common between cancer screenings and are similar to those identified in the literature of screening use at a single point in time. Ultimately, these barriers prevent some women from entering a screening process in the long run, ultimately reinforcing social inequalities in health. Targeting women with insufficient mammography uptake may reach women outside of cancer screening settings more generally and, thus, both increase the overall uptake of cancer screening and reduce social inequalities in cancer screening.