Cytology Case

For the purpose of this assignment the author has chosen to investigate the reasons why some women fail to attend for cervical sample collection. The author aims to critically analyse the available evidence around theses key issues and to discuss implications for practice by the use of refection.

More than 2,000 women die each year in the United Kingdom from cervical cancer. In 1992 the document Health of the Nation called for 'a reduction in the incidence of invasive cancer of at least twenty per cent by the year 2000' (DOH 1992). However despite improvements in technology and screening programmes, cervical cancer still remains the sixth most common cancer in Britain (Yu and Rymer 1998) and the second most common female cancer in the world and yet it is an almost totally avoidable cause of mortality (Cooksley 1995).

Endeavours to improve the response to invitations for cervical screening continue to produce variable response rates across the country. A study by Majeed et al (1994) found that uptake rates varied from 16.5% to 94.1% and that low uptake rates were most evident among practices in socially deprived areas and areas with high ethnic minority populations. Camberlain (1984) states that 80% of women who die from cervical cancer have never been screened.

It is therefore vital that women are screened on a regular basis, but many women fail to attend, many of these women even after several invitations will continually not come forward for cervical screening. There are a number of reasons why women will not have this test performed, and myths may need to be dispelled. (McPhearson and Waller 1997). Some of the reasons for this reluctance to attend are fear, anxiety and a misunderstanding about the test and its results. Research suggests that barriers to screening have remained constant (Fylon 1998, Summers and Fullard 1995). Cooksley (1995) suggests that whether women will attend for a routine smear may depend on her attitudes, knowledge, her own belief system, awareness and skills in problem solving, decision making and communication. There are many more reasons for failure to attend and the list could prove to be exhaustive.

Little is known about women's anxieties and attitudes to health, yet this information is highly relevant in the planning of services if we are to meet the needs of these women

appropriately (McPhearson and Waller 1997). It is clear that gaps exist in the service and theses need to be addressed if mortality rates are to be reduced and agreed targets achieved. Nurses need to help identify factors which influence health behaviour, consider barriers to change and develop strategies for health professionals to follow, avoiding a victim blaming approach. Cooksley (1995) suggests an effective strategy will be based on the skills of empowerment and helping the individual to take control over those areas of her life where change is possible.

There are a number of articles published around the area of non attendance for cervical smears; the author will explore some key issues around this problem as this appears to be a key issue within many practises.

Poor knowledge and understanding of the procedure itself is a major reason for non attendance. Studies have shown that many women believe that the test is designed to detect cancer and are therefore alarmed by an abnormal result, many women simply do not understand the concept of 'pre- cancerous' and believe that a positive smear is a diagnosis of cancer (Hubble 2000). In studies by McCormack (1988) and Nielson and Jones (1998) it would appear that women from social classes IV and V generally have a poorer understanding of cervical cancer and the associated screening programme. A larger proportion believed that they were not at risk from developing the disease, either because they had no symptoms or because they had passed the menopause and believed they were no longer at risk. This is supported by similar studies (McKie 1993a).

Cooksley (1995) states that the rationale for cervical screening is that the uniqueness of cervical cancer enables the disease to be identified at a pre - invasive stage when treatment effectively prevents invasive disease from developing. It has been well documented that well organised screening programmes can greatly reduce the incidence of and mortality from cervical cancer.

In a survey carried out by Summers and Fullard (1995) womens views were looked at regarding the screening programme since 1990, they found that three quarters of women who had had a smear made positive comments on the experience, but when asked specifically about the information they had received felt it was inadequate (McPhearson and Waller 1997).

It is obvious that improvements in health education and health promotion are required, as these are likely to have the most impact on improving coverage and quality of cervical screening from the viewpoint of the women. Baileff (2000) suggests that current health promotion programmes are not effective in reaching certain groups of women, specifically women in social classes IV and V and that opportunistic health promotion on an individual basis would be more appropriate for these groups. Other health professional who are not currently involved in the screening programme might also be enlisted to take responsibility for providing information, these might include health visitors, midwifes, nurses on gynaecological wards and occupational nurses. All of these professional have contact with women of screening age and are well placed to provide women with the correct information to empower them to make an informed decision about their participation in the screening programme (Baileff 2000).

Patients themselves frequently forget, misinterpret and misunderstand information given to them and it is therefore important that the practitioner finds ways to make relevant information both adaptable and comprehensible to patients as individuals. It is also essential to have a nurse or practitioner who is sufficiently trained and knowledgeable to answer any questions regarding cervical smears and the screening programme that may arise (Cooksley 1995).Evidence suggests that properly trained and experienced nurses are not only highly competent smear takers, but are perceived by women in general as being more approachable and more willing to spend time on providing explanations and answering questions.

Austoker and Davey(1997) recommended six points every women should know before having a smear test these were;

1. What cervical screening can detect.

2. The likelihood of a negative result (approximately 90%).

3. The meaning of a negative result (implies