This post was written by Dr Jo Waller & Dr Laura Marlow. Jo is a reader in cancer behavioural science & has a particular interest in cervical cancer prevention and has published extensively on barriers to screening uptake, the psychological impact of HPV testing, and attitudes to HPV vaccination. Laura is a research psychologist in the behavioural science team within the Cancer Prevention group, where she has a particular interest in ethnic inequalities and has also worked on understanding cancer fear, fatalism and stigma.
Last week we posted a blog outlining why a move to 5-yearly cervical screening for the 25-49 age group has happened in Wales and some other countries with cervical screening programmes, including Australia and the Netherlands. Changes to the screening interval have been met with public dismay in Wales, with over a million people now having signed a petition against the changes. These are not the first examples of how changes to screening recommendations can lead to concern and scepticism, with evidence of negative views towards recommendations for extended intervals in Canada and the US and a similar petition some years ago in Australia.
In this blog, we consider what might influence the acceptability of a change to screening intervals and whether there are ways to improve this.
What is acceptability?
There is increasing recognition among behavioural scientists that acceptability is an important aspect of any health intervention in both clinical and public health contexts. Acceptability refers to how well an intervention (e.g. screening test or treatment) is received by the desired audience – including both those who receive and those who deliver it. It can be measured ahead of a new public health intervention or a change to an existing one, as well as during or after implementation. In general, this might be as simple as asking if someone finds an intervention ‘acceptable’ but there is an argument for digging deeper and assessing other dimensions of acceptability, such as how well an intervention fits with someone’s existing beliefs, how ethical they find an intervention or how effective they think it will be.
What influences the acceptability of screening interval changes?
In the online petition that was set up after the announcement of changes to the cervical screening programme in Australia, concerns about women’s rights and cost-cutting were common issues. In 2021 we explored views on extended intervals in England (work not yet peer-reviewed). We found that people were unaware of the move to HPV primary screening, leading some participants to question why there was an interval change happening. Acceptability of extended intervals was largely influenced by perceptions of the importance of screening, taken alongside people’s own perceptions of risk and their trust in healthcare decision-makers, and in science more generally.
‘I think in a lot of people’s mind, including mine, is that that you need to get in there quickly and you’ve got a better chance if things are treated early.’
It’s important to remember that for many years public health campaigns have encouraged those aged 25-49 years to be screened regularly, letters and reminders have landed on doormats every 3 years and GPs are prompted to remind people who are overdue. These measures have emphasised the importance of timely screening for preventing cervical cancer. In the broader context, cervical cancer is largely seen as something that is asymptomatic and can develop quickly. With generally high public enthusiasm for screening and a general sense that more screening is better to catch cancer early, we shouldn’t be surprised that reduced screening is perceived as a retrograde step.
Are some people more likely to find interval changes unacceptable?
Perceptions of personal risk play an important role when considering extended intervals. Individuals who feel less at risk tend to express less concern about extended intervals. But those who have previously experienced abnormal cell changes are understandably more concerned.
Our work also suggests that people who are currently regular attenders are more likely to find the changes unacceptable. The positive way of looking at this is that those who are most concerned tend to be engaged with screening already, so there are opportunities to explain the change and address concerns, e.g with invitations, results letters and at appointments.
It’s also important to highlight that for some, less frequent screening is positively received. The need to have fewer speculum examinations and the potential for a longer period of reassurance was a benefit discussed by some of the participants we interviewed. These views are unlikely to be represented in the petitions for intervals to remain at 3-years since those signing petitions feel strongly that screening should be more frequent.
Are there ways to improve acceptability?
Explaining the rationale for extended intervals can help improve acceptability, though some remain unconvinced. In online studies, we randomised screening-eligible people to see different messages about the rationale for extended intervals, explaining the long timeline between HPV infection and cervical cancer, the improved accuracy of HPV testing and the safety of a 5-year interval for those who are HPV negative. Those who read these messages were more likely to find 5-yearly screening acceptable.
‘At the end of the day, if there’s a way for them to directly test for the HPV and, you know, you’ve got the stage one, then I can understand why it would be every five years, especially if your results come back as normal, then yes, that would make sense’
In our study, participants were able to ask questions throughout and by the end of the interviews, many felt more positive about extended intervals. Though hour-long discussions are not feasible at a population level, this does suggest that views can be shifted for many through the provision of information. It Is likely, though, that those who feel particularly at risk may need more personalised reassurances that longer intervals are safe for them.
In summary, communicating the rationale for changes to screening is important and behavioural science studies have increasingly demonstrated that acceptability can be improved once people understand the change to HPV primary screening. The dislike of longer intervals largely comes from a place of concern about increased risk if less frequent screening is offered and in the absence of scientific rationale and reassurances of safety, it is understandable that people would feel this way.
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