A four-week remote group intervention to increase cervical cancer screening

‍ P. Karadag^a., S. Abdin^b., A. Burton^a

 ^aStaffordshire University

 ^b Birmingham City Council

 The work was completed at City of Wolverhampton Council.

 Corresponding Author: Paige Karadag, Email: paige.karadag@research.staffs.ac.uk

Author statements

Acknowledgements

The authors would like to thank all individuals who took part in the group intervention. The authors would also like to thank the communication team, community outreach team and project management team including Riva Eardley, Parmdip Dhillon, Victoria Downes, Raymond Codner and Sophie Pagett for their support in implementing the programme at the City of Wolverhampton Council. Lastly, the authors would like to acknowledge the City of Wolverhampton Council for funding this project.

Ethical approval

None sought.

Funding

The programme was solely funded by the City of Wolverhampton Council.

Competing Interests

There are no competing interests declared by the authors.

Abstract

Objectives: The aim of this project was to design and deliver a group intervention to increase uptake of cervical cancer screening in Wolverhampton, United Kingdom.

Study Design: This short communication outlines the development process and service evaluation outcomes for a pilot group online cervical screening intervention.

Methods: The intervention used the COM-B model and was informed by a literature review and survey responses. The four-week online intervention was delivered for 30-45 minutes per week via Zoom. The intervention employed behaviour change techniques including behavioural practice and rehearsal, modelling, and information about health consequences. Service evaluation was completed using open-text questions and multiple-choice survey responses including a knowledge quiz at: baseline, after session one, after session four, and at six-week follow-up.

Results: Nine individuals took part in the intervention and six attended all four sessions. The service evaluation illustrated that increased capability, opportunity, and motivation to attend cervical screening was not achieved after one week but was achieved following four weeks of attendance. Attendee feedback suggested that the sessions were useful. However, the most common recommendations for improvement were to have longer sessions and more time for questions.

Conclusion: Online group interventions may improve intentions to attend cervical screening appointments. However, this form of intervention was unable to address the practical barriers surrounding obtaining an appointment.

Keywords

Cervical Screening; Public Health; Behaviour Change; Intervention; Cervical cancer

Background

Cervical cancer is the 14^th most common cancer in females in the UK, with approximately 3,200 new cases every year (Cancer Research UK, 2018). Screening can significantly reduce the incidence of cervical cancer and it is routinely offered to women aged between 25 and 64 years in England. Those who do not attend cervical screening are at higher risk of developing cervical cancer (Szarewski et al., 2011). 

Wolverhampton in the United Kingdom (UK) is an ethnically diverse city as 18% of the population are Asian, 6.9% are Black and 5.1% are mixed race (ONS, 2011). Over half of the population (54%) are living in the most deprived areas of England (ONS, 2011). Life expectancy in Wolverhampton is also lower than the national average, as the life expectancy in Wolverhampton is 77.2 for males and 81.4 for females whereas the average life expectancy in England is 79.6 for males and 83.2 for females (Public Health England, 2019). In addition, cervical cancer screening rates (65.1%) are substantially lower than the average in England (69.1%) (Office for Health Improvement and Disparities, 2022). The demographics of the city are likely to have an influential role on the uptake of cervical cancer screening and there is a clear need to better understand this population and how to facilitate screening attendance. New interventions must be explored and therefore the aim of this project was to design a group intervention to increase uptake of cervical cancer screening in Wolverhampton.

Intervention Development

To inform the intervention design a literature review was conducted to explore barriers and facilitators to cervical screening within the UK. This review highlighted that women experience emotional, practical, and cognitive barriers to cervical cancer screening. Emotional barriers include fear and embarrassment surrounding cervical screening (Logan & Mcilfatrick, 2011), practical barriers comprised of inaccessible appointment times and locations (Logan & Mcilfatrick, 2011; Marlow et al., 2019), whereas cognitive barriers refer to a lack of knowledge regarding cervical screening (Lovell et al., 2021; Thomas et al., 2005). More specifically, within Wolverhampton the most common reasons for not attending cervical screening were embarrassment, a lack of body confidence and feeling uncomfortable being undressed in front of a stranger (Healthwatch Wolverhampton, 2020). Other barriers included lack of convenient appointment times, inability to take the time off work and male practitioners conducting the screening. Several facilitators to attend cervical screening in Wolverhampton have also been reported. Facilitators include celebrities discussing screening in the media, flexible appointments, online booking systems, reminder texts, peer support, and access to a female health care professional (Healthwatch Wolverhampton, 2020).

The literature review highlighted that a variety of behavioural psychology approaches have previously been used to understand cervical screening uptake. In a study by Sheeran and Orbell (2000), implementation intentions were used to increase cervical cancer screening uptake. Implementation intentions involve creating specific plans to ensure that the decision is acted upon (Sheeran & Orbell, 2000). This differs to motivation, whereby the decision to perform a behaviour is made. Participants in the experimental condition were asked to form an implementation intention detailing when, where and how they would make an appointment for a cervical screening test. Sheeran and Orbell (2000) also used the Theory of Planned Behaviour (TPB) to assess women’s attitudes and behaviours to cervical screening in the UK. They found that despite having equal motivation to attend screening, the group who had to provide implementation intentions were much more likely to attend screening compared to the control group (92% vs 69%). This suggests that the TPB provided a good prediction of attendance and showed that motivation alone was not enough for women to attend screening. The Health Belief model has also been applied to understand disparities in uptake of cervical screening among Women in Scotland highlighting that health beliefs, number of sexual partners, and socio-demographic variables account for 57% of variance in screening uptake (Orbell et al., 1996).

Recent research has suggested that the COM-B model (Michie et al., 2011) can be beneficial to identify specific barriers to cervical screening uptake. This model proposes that there are three essential components of behaviour change: capability, opportunity, and motivation. In addition to this, research has emphasised that the Behaviour Change Wheel can be used to develop tailored intervention strategies that are likely to be effective in addressing socioeconomic inequalities in cervical cancer screening (Wearn, 2020). Therefore, as part of the design process for this intervention, appropriate intervention functions from the Behaviour Change Wheel were identified, alongside behaviour change techniques (BCT) from the Behaviour Change Techniques Taxonomy V1 (Michie et al., 2013).

To assess the target demographic a survey was administered across Wolverhampton. The survey consisted of open-ended questions that explored understanding of why smear tests are performed; perceived risk factors for developing cervical cancer; experiences of cervical screening; barriers to screening; motivations to attend screening; and ways to improve uptake. Fifty-seven women aged 16-65 completed this survey and respondent demographics reflected the ethnic diversity within Wolverhampton. The survey found that barriers to cervical screening included a lack of understanding, with more than half of the sample believing that the purpose of cervical screening was to detect cancer or cancerous cells. Previous negative experiences posed an additional barrier to attending screening, as individuals felt that it was “pointless”, “undignified”, “embarrassing” and “extremely painful”. Moreover, practical barriers were reported such as being unable to book appointments, inconvenient appointment times and a lack of information in different languages. Nevertheless, the survey identified several facilitators to cervical screening such as “fear of cancer” and “early detection and intervention”. Additionally, 50% of the sample reported positive previous experiences of cervical cancer screening. Recommendations to increase uptake of cervical screening were provided by survey completers including using inclusive language, sending reminder letters to patients in their chosen language, increasing the amount of advertising and information about cervical screening and having more appointments available.

Intervention Delivery

 The intervention was promoted across multiple communication channels, including direct text messages from a GP practice, but this did not prompt a response. A member of the council outreach team then promoted the intervention via community contacts and this approach was successful in recruiting nine individuals. A baseline survey was sent out via email prior to Session 1 to assess capability, opportunity, and motivation of the attendees. The group had high levels of self-efficacy, opportunity, and motivation to attend cervical screening but poor knowledge regarding the purpose of cervical screening and risk factors for cervical cancer, including Human Papilloma Virus (HPV). This suggests that the group had low health literacy regarding cervical screening, which reflects their ability to obtain, process and understand information that are needed to make health decisions. Previous literature has suggested that low health literacy is associated with poorer use of health care services and poorer health outcomes (Berkman et al., 2011). Therefore, this informed the psycho-educational approach for the intervention.

The target and contents of each session can be seen in Table 1. The intervention was delivered remotely reflecting the public demand for increasing online health resources (Griffiths et al., 2006). Sessions were 30-45 minutes and occurred once a week for four weeks via Zoom. Four sessions seemed to be an appropriate amount as it would provide adequate time to cover the content and there is existing evidence for four-week interventions (Fillion et al., 2008). A group format was chosen to facilitate unique benefits, such as learning from one another and providing an element of social support (Turk & Gatchel, 2018). However, it was imperative that group dynamics were taken into consideration, as confrontation and interruptions occur more frequently in online sessions (Griffiths et al., 2006). Similarly, it was important that a therapeutic relationship was developed with the group (Hilton & Johnston, 2017). To achieve this, emphasis was placed on building group cohesion, showing empathy, and listening to feedback (Norcross & Wampold, 2011).  For group activities, online platforms were used so that individuals could provide anonymous responses, allowing the group to be open without feeling embarrassed. Group discussions were also introduced within later sessions to encourage knowledge transfer. PowerPoint slides were developed to aid each session and a supplementary information leaflet was provided, so that the key information was given in a written format that individuals could refer to and share with others. A prominent BCT that was used throughout sessions to increase psychological capability was ‘behavioural practice and rehearsal’ (Michie et al., 2011) which was encouraged through homework tasks and group activities.

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Table 1:  Intervention Content.

Evaluation

To inform intervention development the group were continually assessed throughout Session 1 via interactive tasks and discussions. These tasks and discussions assessed their knowledge and understanding of the purpose of cervical cancer screening and risk factors for cervical cancer. They were also assessed at the end of Session 1 via a second survey, which showed that after attending one educational session, there was still poor understanding of cervical screening. For example, several individuals misunderstood the purpose of cervical screening, as they thought it was to detect cancer. There was also some misunderstanding around risk factors for cervical cancer. Consequently, the intervention content was adapted to have a more educational focus in future sessions.

Evaluation of the intervention was achieved through a series of surveys: baseline, after Session 1, after Session 4, and 6-week follow-up. However, response rate at 6-week follow-up was poor. Due to the pilot nature of this intervention, it was not possible to collate data on increased uptake in cervical screening behaviour, therefore, intentions to attend future screening appointments were recorded as a proxy.

Knowledge surrounding cervical screening increased across the four sessions, which implies that psychological capability improved in the group. For instance, open responses at baseline and after Session 1 highlighted that the group misunderstood the purpose of cervical screening, yet by Session 4 all responses for the purpose of cervical cancer screening and risk factors were correct. Ongoing evaluation and repeated content across several weeks therefore proved valuable for facilitating behaviour change for this group.

It is important to note that motivation to attend cervical screening was already high prior to the intervention, and the results may have differed if the group initially had low motivation to attend cervical screening.  However, the survey responses demonstrated that motivation increased as the intervention progressed. At baseline individuals also reported that they had regular opportunities to attend cervical screening, yet multiple barriers were specified including lack of information and difficulty obtaining an appointment. Open responses after Session 4 suggested that these barriers had been reduced, which implies that opportunity to attend screening increased. However, the practical barrier of being unable to obtain an appointment remained.

Overall, these findings show that the intervention successfully increased capability, opportunity, and motivation to attend cervical screening for this group. The largest increase was in knowledge and understanding of cervical screening following attendance at all four sessions. However, as only one person completed the 6 week follow up survey, it is unclear whether these increases were maintained. 

Qualitative feedback was collected to inform development of the intervention for future groups. Feedback was very positive, and attendees expressed that the sessions were useful. Although it was a group intervention, individuals valued different aspects that were important to their own needs. The most common recommendations for improvement were to have longer sessions and more time for questions. Additionally, the leaflet included too much information and not enough images which resulted in the group not reading it. Other suggestions included delivering the sessions in person to help increase motivation further.

Future Recommendations

 The service evaluation demonstrated that adapting the intervention to meet the needs of the group was valued, consequently, this is recommended for future interventions of this nature. The educational focus of this intervention was successful in creating behaviour change. However, in this instance a singular educational session alone was not effective and therefore a minimum of four sessions is recommended to improve capability, opportunity and motivation to attend cervical screening. Initially, recruitment for the intervention within a public health setting was challenging, and traditional recruitment methods such as posters, social media adverts and email communication were unsuccessful. Alternative means of recruitment and delivery were explored and participants were recruited through community organisations. Therefore, it is recommended that community contacts could be utilised to support future recruitment. Furthermore, interventions could be delivered within existing groups across the community, to reduce any cognitive, emotional, or practical barriers to attendance and increase the chance of reaching a wider audience. Sessions should be tailored to the group’s specific needs and any materials should be piloted with the target audience to ensure that they will be appropriate and effective. It is also recommended that intervention materials are translated into multiple languages to reach a broader demographic, particularly as uptake is often lower among ethnic minorities.  Further feedback from attendees included the use of text message reminders for appointments.

This intervention was delivered online which made it easier for residents to take part in the intervention. The intervention highlighted the strong relationship the public health department have with community groups through their place-based team. The findings of this intervention and the lessons learnt have provided rich insight that would support further public health priorities for Wolverhampton.

Conclusion

This short communication reported on the development and service evaluation of a group online intervention for improving cervical screening uptake in Wolverhampton. The intervention was delivered to nine women and the evaluation illustrated that attendance at four sessions was successful in improving capability, opportunity, and motivation to attend screening in this group. However, this form of intervention was not able to address practical barriers regarding appointment availability. Therefore, further initiatives are required regarding the practical barriers to appointment times and availability. Attendee feedback suggested multiple approaches to improving cervical screening uptake, including addressing systemic barriers and employing text message reminders for appointments could be trialled in future interventions. 

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