What works: Addressing inequalities in the uptake of cervical screening

Using our Living Evidence Map, we identified 19 research articles examining what works to address inequalities in cervical screening. Interventions fall into four categories:

• Support workers
• Outreach with culturally competent education
• Telephone/mailed reminders, endorsed invitations and scheduled appointment strategies
• Self-sampling

Our 10 evidence-informed recommendations focused on multi-component interventions including support workers for specific disadvantaged communities, culturally competent information, endorsements from a GP and scheduled appointments or self-sampling for those who do not attend. Other key recommendations include disaggregating data, using equity-focused quality improvement, building flexibility into pathways, and creating system flags.

In the UK, cervical screening (also known as a smear test) is offered to women and individuals with a cervix aged 25 to 64 to test for high-risk Human Papillomavirus (HPV), a major cause of cervical cancer, and to check the health of the cervix. There were 753 deaths across England and Wales due to cervical cancer in 2021 (1). Cervical screening has contributed to an 80% reduction in deaths from cervical cancer over the last few decades.

The NHS cervical screening programme (NHSCSP) aims to reduce the number of people who develop cervical cancer, and subsequent mortality. In 2022 NHS England reported that 69.9% of eligible individuals aged 25 to 64 had been adequately screened (2). Latest data from the Office for Health Improvement and Disparities (OHID) for 2021/22 show that the gap in screening coverage between the most and least deprived quintile for women aged 25-49 years is 11% (64.5% in the most deprived and 75.7% in the least deprived, Figure 1) (3). The gap for women aged 50-64 years is 8% (70.2% most deprived and 78.3% least deprived, Figure 1). It is estimated that in England each year 520 cases of cervical cancer are linked with deprivation (4).

Figure 1: Average percentage of cervical screening coverage of individuals aged 25-64 across deprivation quintiles

The gap in screening coverage between the most and least deprived quintile for women aged 25-49 years was 11% (64.5% in the most deprived and 75.7% in the least deprived). The gap for women aged 50-64 years was 8% (70.2% most deprived and 78.3% least deprived). It is estimated that in England each year 520 cases of cervical cancer are linked with deprivation (4).

Understanding the scale of inequalities across ethnic groups is difficult because of poorly recorded ethnicity data. However, analysis from Hull York Medical School identified inequalities across ethnic groups with Asian women having a 32% lower uptake of cervical screening compared to white women (5). Latest data available from 2017-19 shows that age standardised mortality rates for cervical cancer are higher for black African women (4.9 per 100,000 per year) compared to white women (2.7 per 100,000 per year) (6). This evidence aligns with previously published research identifying socioeconomic (7) and ethnic (8) inequalities in screening uptake.

Drawing upon our evidence map, we included 19 research articles examining what works to address inequalities in cervical screening; 16 were either a systematic review, meta-analysis, scoping review or rapid review and three were primary studies.

The research articles identified the following categories of interventions:

• Support workers
• Outreach with culturally competent education
• Telephone/mailed reminders, GP-endorsed invitations, and scheduled appointment strategies
• Self-sampling

Support workers

Ten articles found that support workers were effective in improving cervical screening across socioeconomic and ethnic groups (7,9–17). The majority of interventions were delivered in person at a clinical or community setting. Support workers were often culturally representative of the targeted population group. Two of the systematic reviews (11,14) identified a randomised control trial (RCT) which delivered two workshops (3 hours each) on cervical cancer to women who belong to a minority ethnic group led by support workers. This RCT found a significant difference in screening rates between the intervention and control groups at 6 months (71% compared with 22%) (14). Other approaches which improved uptake included combining support worker home visits with phone support (11). A separate systematic review identified a multi-component approach of support workers offering education, appointment scheduling assistance and reminder/follow-up calls to increase compliance with screening (17).

Outreach with culturally competent education

Complementary to support workers, the impact of outreach education providing culturally competent and relevant information on cervical screening for minority ethnic women has been explored. Eight articles assessed the effectiveness of outreach education for cervical cancer screening for minority ethnic groups (7,9–11,13–15,18).

Research explored informational brochures, visual tools, or a combination. Examples include Atere-Roberts et al.’s (2020) scoping review (13) which included an RCT examining minority ethnic women who had not been screened. They were shown a video with the support of a community worker and were significantly more likely to attend screening than the control group (53% compared with 34%). Chan and So (2015) included a trial focused on women from a minority ethnic group (Samoan) which combined weekly education sessions around cervical cancer with two separate educational booklets. Findings showed that the intervention group were significantly more likely to be screened than the control group (61% compared with 38%) (14).

Telephone/mailed reminders, endorsed invitations, and scheduled appointment strategies

Six papers included telephone/mailed reminders, endorsed invitations, and scheduled appointment strategies that aimed to increase cervical cancer screening (7,11,19–22). A Cochrane review demonstrated that invitations for women who had not attended screening were more successful if they were personalised to include a GP letter or contained a fixed appointment time compared to standard reminders (11). A rapid review identified interventions to improve participant engagement in cancer screening services (19). Of the cervical cancer interventions included in the review, a Dutch national screening programme study found that invitations endorsed by a GP led to a 7.9% higher attendance compared with invitations endorsed by the local health authority, especially for minority ethnic groups.

Self-sampling

Seven papers assessed the efficacy of self-sampling for increasing cervical cancer screening (7,9,21,23–26). Human papillomavirus (HPV) self-sampling is a new method of screening as an alternative to clinician-based screening. HPV self-sampling interventions are delivered by mailed self-test kits or home visits. A systematic review by Rees et al. (2018) highlighted that both methods of delivery showed statistically significant increases in screening across lower socioeconomic groups (7). A separate systematic review/meta-analysis additionally found that providing HPV self-sampling methods was the most effective intervention for improving screening among immigrant women (9). A recent international randomised trial with almost 700 under-screened women from low-income backgrounds compared mailed HPV self-sampling plus support if required with a standard scheduled appointment. Screening uptake was statistically significantly higher in the self-sampling group (72%) than scheduled appointment group (37%) (26).

While self-sampling is currently not included in the national screening programme, there is currently a national study being undertaken to ascertain the effectiveness of self-sampling in the general population of the UK (27).

The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework has been adopted to grade the quality of the evidence and support recommendations (28).

Health professionals in Norfolk and Suffolk have implemented a targeted cervical screening programme using the Eclipse/NHS Pathways data to identify patients who were eligible for cervical screening but overdue. Patients identified were reviewed by practices and received targeted letters and phone calls. Findings from the interventions show that an additional 12-14% of eligible patients attended cervical screening appointment following the intervention; 459 people who would not have otherwise been screened. More details can be found here.

• Help Us Help You
• Jo’s Cervical Cancer Trust
• The ‘small c’ Campaign
• Public Health England (PHE) Screening Inequalities Strategy

What is the Living Evidence Map on What Works to address health inequalities in primary care?

Using AI-powered software called EPPI-Reviewer, the Health Equity Evidence Centre has developed a Living Evidence Map of what works to address health inequalities in primary care. The software identifies research articles that examine interventions to address inequalities. The evidence map contains systematic reviews and umbrella reviews. More information can be found on the Health Equity Evidence Centre website.

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Torres O, Dehn Lunn A, Ford J. Evidence brief: What works – Addressing inequalities in the uptake of cervical screening. Health Equity Evidence Centre; 2024.