Factors associated with Pap smear taking in general practice: focusing public health initiatives

Abstract

2. an unsuccessful offer to take a Pap smear or making an appointment for a smear. In a cross-sectional study of 3478 women presenting to 230 randomly selected general practitioners in Brisbane and Toowoomba, information about most recent Pap smear, screening in the consultation, and independent variables were collected from patients and doctors. Relationships between three levels of outcome variable (no action, Pap smear taken or referral, appointment or refusal), and independent variables (practitioner variables, consultation variables, patient variables) were modelled using polytomous logistic regression. Presenting for a routine checkup and breast cancer screening were associated with all types of action. Younger age, longer consultations and consultations with a female practitioner were associated with Pap smear taking and referrals, and not appointments or refusals. Being due for a Pap smear, having blood pressure measured, consulting a younger general practitioner and one who ascribed to current guidelines on screening were associated with an appointment or a refusal, when compared with no action. Results i d e n q different profiles of those who get a Pap smear and those who do not, the former indicating a more proactive patient group, while the latter suggest more active general practitioners who attempted opportunistic screening of passive patients, or women who do not specifically seek Pap smears. We have identified factors that have significance for developing public health programs focused on consumers and providers. (Aust N ZJPublic Heatth 199% 20: 260-6) ERVICAL cancer is the fifth most common cancer of women.' It is potentially preventable, C and incidence is reduced in populations in which screening programs are intense.'^^ Screening of Australian women occurs primarily in general p r a c t i~e .~.~ While screening of women in Australia may well have reached the targets set for 1995,6 there still remains a proportion of the female population who continue to be screened inadequately or not at a11.45~7-9 To develop strategies to improve uptake of Pap smear screening, we need to understand better those factors associated with both provision and acceptance of this procedure in general practice. Studies have identified patient factors (younger age, oral contraceptive user, higher income, higher education, urban dweller, higher morbidity, patient's intention, long-time attendance, patient's mobility) ,%I6 provider factors (female, younger age, perceiving the test efficacious, salaried, higher level of continuing education) ,l6I9 and practice factors (smaller patient clientele, organised screening program)15 associated with Pap smear provision and uptake. Various measurement procedures have been used in these studies, with the majority relying on retrospective self-report of physician or patient.m Only one study matched actual care provided in the consultation with patient information."All of these studies focused on Pap smear taking, but none reported practitioners' failed attempts, or deferral of act...

Avoiding piecemeal research on participation in cervical cancer screening: the advantages of a social identity framework

“…Women with higher levels of knowledge about the risk factors associated with cervical cancer are also more likely to report this type of participation than women with lower levels of such knowledge 14,18,19 . Compliance participation is also higher among women who are recommended by their physician for cervical cancer screening 20 and who have a regular physician 20,21 and a female physician 10,20 . Factors found to be negatively associated with compliance participation include fear, pain, embarrassment, anxiety and beliefs regarding who should be screened for cervical cancer, as well as cynicism regarding the medical profession 22–30 …”

“…Moreover, only a limited number of studies have explored alternative types of participation in relation to cervical cancer screening intervention programmes 47–49 . Indeed, as noted earlier, most researchers have implicitly equated participation in cervical cancer screening in compliance with medical recommendations to undertake a test or to be screened for cervical cancer (See for example references: 20, 50–52), and most research in the field has had the underlying objective of increasing cervical cancer testing (See example references: 8, 10, 20, 36 and 53–58). Researchers have tended to take a fairly traditional ‘biomedical model’ approach to health and ‘participation’: that is, they have tended to make the assumption that medical or scientific knowledge is superior to other types of knowledge such as ‘lay knowledge’ and that the patient should be a passive recipient of medical care 59 .…”

“…Researchers have tended to take a fairly traditional ‘biomedical model’ approach to health and ‘participation’: that is, they have tended to make the assumption that medical or scientific knowledge is superior to other types of knowledge such as ‘lay knowledge’ and that the patient should be a passive recipient of medical care 59 . Indeed, as argued by researchers such as, 60–62 ‘compliance participation’ in cervical cancer screening research is usually assumed to be a positive norm and is often presented as a ‘morally neutral’ health behaviour that is an unproblematic and rational response to health education regarding cancer prevention (For examples of such treatment, refer to references: 7, 8, 10, 54 and 57). In short, to date, there has been little explicit consideration in this area of research of the best way to conceptualize participation or of the potential health implications associated with emphasizing one type of participation more than another.…”

“…Participation has been conceptualized in various ways across interdisciplinary research in health, social and community psychology (See for example references: 1–3 ). However, such research is frequently plagued by poor definitions 4–6 and there is room for greater specificity regarding the concept of participation and to better recognize that it can be multifaceted and complex, involving much more than simply seeking and receiving medical services (hereafter termed ‘compliance participation’), as per the definition most commonly utilized in cervical cancer screening literature 7–10 . Exploring a broader conceptualization of participation than simple compliance with medical requests is important to our understanding of women’s cervical cancer screening because other types of participation are associated with positive health outcomes such as increased patient satisfaction, heightened feelings of self‐efficacy and more constructive dialogue between patients and health‐care practitioners.…”