Interventions to improve cervical cancer screening uptake amongst young women: a systematic review.

OBJECTIVES: In view of declining screening uptake in young women, this review aims to summarise the available evidence relating to interventions designed to increase cervical screening uptake amongst women aged ≤ 35 years. METHODS: Electronic databases were searched and further articles located by manual searches. Study designs employing a valid comparison group and including women aged ≤ 35 years published through 2012 were considered. Data was extracted on the uptake from either screening programme statistics or as reported by the study subjects. A narrative synthesis was undertaken for each category of interventions identified. RESULTS: Ninety-two records were screened with 36 articles retrieved for further assessment. Four studies met the inclusion criteria, two of which evaluated more than one intervention. One of the studies evaluated the use of a modified invitation letter and reported no significant increase in uptake compared to a standard invitation. Three studies investigated the use of a reminder letter, with two reporting a positive effect on screening uptake in women aged 24-34. Three studies were included which supported the use of physician and telephone reminders. One study on HPV self-sampling reported a positive effect when compared with a reminder letter. CONCLUSIONS: There is a lack of randomised controlled trials designed to specifically address falling cervical screening uptake in amongst young women. Cervical screening programmes need to look beyond the use of invitation/reminders letters in this group of women to develop interventions which attempt to overcome as many barriers to uptake as possible.

'Information on the fly': Challenges in professional communication in high technological nursing. A focus group study from a radiotherapy department in Sweden.

BACKGROUND: Radiotherapy (RT) units are high-tech nursing environments. In Sweden, RT registered nurses (RNs) provide and manage RT in close collaboration with other professional groups, as well as providing nursing care for patients with cancer. Communication demands on these RNs are thus particularly complex. In this study, we aimed to better understand problems, strengths and change needs related to professional communication with and within the RT department, as a basis for developing a situation-specific intervention. METHODS: Focus groups discussions (FGDs) were conducted with different professional (RNs, assistant nurses, physicians, engineers and physicists) and user stakeholders. Transcripts of the FGDs were inductively analyzed by a team of researchers, to generate clinically relevant and useful data. RESULTS: These findings give insight into RT safety climate and are presented under three major headings: Conceptualization of professional domains; Organization and leadership issues; and Communication forms, strategies and processes. The impact of existing hierarchies, including how they are conceptualized and acted out in practice, was noted throughout these data. Despite other differences, participating professionals agreed about communication problems related to RT, i.e. a lack of systems and processes for information transfer, unclear role differentiation, a sense of mutual disrespect, and ad hoc communication taking place 'on the fly'. While all professional groups recognized extensive communication problems, none acknowledged the potential negative effects on patient safety or care described in the FGD with patient representatives. While RNs often initially denied the existence of a hierarchy, they placed themselves on a hierarchy in their descriptions, describing their own role as passive, with a sense of powerlessness. Potential safety hazards described in the FGDs include not reporting medical errors and silently ignoring or actively opposing new guidelines and regulations. CONCLUSIONS: There is a risk that RNs who view themselves as disenfranchised within an organization will act with passive resistance to change, rather than as change promoters. As interventions to strengthen teams cannot be stronger than the weakest link, RNs may need support in the transition "from silence to voice" in order to take a position of full professional responsibility in a multi-professional health care team.

How can young women be encouraged to attend cervical cancer screening? Suggestions from face-to-face and internet focus group discussions with 30-year-old women in Stockholm, Sweden.

BACKGROUND: cervical cancer screening (CCS) using Pap-smears has been carried out for decades and is still an essential tool for secondary cancer prevention. Focus has traditionally been on what hinders women's attendance, instead of researching this issue from a positive standpoint, i.e. what factors encourage women to take a Pap-smear? In this article, we therefore explore issues that 30-year-old women have addressed as encouraging CCS attendance, with particular focus on aspects susceptible to intervention. MATERIAL AND METHODS: through the population-based cervical cancer screening (PCCSP) registry in Stockholm, Sweden, a stratified random sampling technique was used to recruit women from the same birth cohort with varied CCS histories and results. Nine face-to-face focus groups discussions (FGDs) and 30 internet-based FGDs were conducted with a total of 138 women aged 30. Qualitative analysis was inspired by interpretative description, to generate clinically relevant and useful data. RESULTS: in general, these women expressed positive views about the PCCSP as an existing service, regardless of screening history. They described a wide range of factors encompassing the entire screening trajectory from invitation through follow-up which could motivate young women to CCS participation, including social marketing. Many of the suggestions related to individualization of the PCCSP, as well as a need to understand the relationship between human papilloma virus (HPV) and cervical cancer. DISCUSSION: [corrected these results are discussed in terms of the inherent tension between population-based public health initiatives and individually-oriented health care provision. Many suggestions given are already incorporated into the existing Stockholm-Gotland screening program, although this information may not reach women who need it. New research should test whether systematic information on HPV may provide a missing link in motivating young women to attend CCS, and which of their suggestions can serve to increase CCS participation.

Exploring childhood cancer survivors' views about sex and sexual experiences -findings from online focus group discussions.

PURPOSE: To explore childhood cancer survivors' views about sex and sexual experiences and, as an additional aim, their possible needs for care and support from health care professionals regarding sexual life. METHODS: Written online focus group discussions were performed with survivors of childhood cancer, identified through the Swedish Childhood Cancer Registry; 133 (36%; aged 16-25) participated. Written text was analysed using qualitative content analysis. RESULTS: The analysis resulted in one main category: Could my cancer experience have an impact on my sexual life? with four generic categories: Sex considered to be good, Feeling insecure and falling behind, Relating sex to a stable relationship and Concerns related to the physical body. In general, participants had not reflected on the possibility that their cancer experience could impact on sexual life. Sex was often considered to be something natural, important and taken for granted. However, thoughts and worries were expressed including being shy, feeling insecure and falling behind peers. Physical concerns included vaginal dryness and difficulties related to erection and reaching orgasm. Many participants stated that sexual issues had not been discussed with health care professionals, however, the need for such support differed. CONCLUSIONS: Many of the childhood cancer survivors' did not relate their sexual experiences to previous cancer treatment. However, problems were expressed, both of emotional and physical nature. Many participants stated that they had not received any information or support regarding sexual issues from health care professionals, why it is recommended to be regularly addressed in follow-up care.

When Life Got in the Way: How Danish and Norwegian Immigrant Women in Sweden Reason about Cervical Screening and Why They Postpone Attendance.

INTRODUCTION: Danish and Norwegian immigrant women in Sweden have an increased risk of cervical cancer compared to Swedish-born women. In addition, Danish and Norwegian immigrant women follow the national recommendations for attendance at cervical screening to much lesser extent than Swedish-born women. The aim of this study was to explore how Danish and Norwegian immigrant women in Sweden reason about attending cervical screening, focusing on women's perceptions as to why they and their compatriots do not attend. METHODS: Eight focus group discussions (FGDs) were conducted with Danish and Norwegian immigrant women living in Stockholm. The women were between 26 and 66 years of age at the time of the FGDs, and were aged between <1 and 48 years old when they immigrated to Sweden. A FGD guide was used, which included questions related to cervical screening, and obstacles and motivators to attend cervical screening. The FGDs were tape recorded and transcribed, and the results analysed according to the principles of qualitative content analysis. RESULTS: The main theme was "Women have a comprehensive rationale for postponing cervical screening, yet do not view themselves as non-attenders". Investigation of women's rationale for non-attendance after being invited to cervical screening revealed some complex reasons related to immigration itself, including competing needs, organisational and structural factors and differences in mentality, but also reasons stemming from other factors. Postponing attendance at cervical screening was the category that linked all these factors as the reasons to why women did not attend to cervical screening according to the recommendations of the authorities. CONCLUSIONS: The rationale used to postpone cervical screening, in combination with the fact that women do not consider themselves to be non-attenders, indicates that they have not actively taken a stance against cervical screening, and reveals an opportunity to motivate these women to attend.

The 'hows', 'whos', and 'whens' of screening: gynaecologists' perspectives on cervical cancer screening in urban Sweden.

Population-based screening has contributed to decreased mortality in cervical cancer. However, the 'hows', 'whos' and 'whens' of screening still concern health professionals and policy makers. As part of a research project aimed at examining a population-based cervical cancer screening program (PCCSP) from different stakeholders' perspectives, the aim of this qualitative interview study was to elucidate the views of gynaecologists, working in both public and private settings, as stakeholders in the PCCSP in the county of Stockholm, Sweden. Results from semi structured interviews with 17 physicians indicate ambiguity in their descriptions of the purpose of both the PCCSP and smear testing in general, leading to different views about appropriate time intervals for Pap-smear testing. The gynaecologists also described experiencing a number of dilemmas related to information content and provision-both prior to screening and in relation to test results. In addition, the gynaecologists tended to differentiate morally through choice of language between women who participate in some form of screening and non-attendees of the PCCSP. There also appeared to be distinctions in how these gynaecologists conceptualised and discussed women receiving Pap-smears, dependent on whether they were regarded as within the category of 'my patients' (seen by the gynaecologist in a private or public setting) or 'the population' (women unknown to the gynaecologist). This study indicates the importance of comprehensively analysing the context of professionals' work when attempting to understand professional attitudes. Seeming disparities in attitudes as well as varying practices may be explained by the simultaneous existence of multiple value systems, applied to different patient populations, as found in this study.

A study of Swedish midwives' encounters with infibulated African women in Sweden.

OBJECTIVES: to investigate Swedish midwives' perceptions and attitudes towards infibulation and infibulated women, midwives' experiences of providing care for them and the training the midwives describe having received to enable them to care for and deliver infibulated women. DESIGN: a multi-stage sampling procedure was used. Open-ended questionnaires were distributed to midwives in labour wards with the purpose of identifying midwives to contact for interviews and focus group discussions. SETTING AND PARTICIPANTS: twenty-six midwives from three labour wards and two antenatal clinics situated in two towns in central Sweden participated in eight focus group discussions and three individual interviews. FINDINGS: there were three major themes: (a) emotions and communicational challenges entailed in the care of infibulated women, (b) knowledge and skills needed for caring and (c) the midwives' reliance on the Swedish law when dealing with the dilemmas they face in their interactions with the women and their families. The data indicate communication problems on different levels between midwives and the women and their families. There appear to be few or no guidelines in the units on how to provide good care for infibulated women and little or no co-ordination between antenatal care and the maternity wards. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the care of infibulated women during pregnancy and childbirth seems to be a marginalised issue in the areas where this study was performed. Early acknowledgement of female genital mutilation during pregnancy as well as improved communication between health care units may help professionals to offer culturally sensitive professional care to the women and their families.

Between youth and adulthood: focus group discussions with 30-year-old women about cervical cancer and its prevention in urban Sweden.

BACKGROUND: Although there is a significant amount of research on cervical cancer screening (CCS), few studies address screening experiences of women related to reasoning about health maintenance and disease prevention in general. Research tends to neglect experiences in different phases of life and experiences of women with different screening histories. Recent literature primarily focuses on adolescents targeted for human papilloma virus vaccinations, whereas perspectives of women who need continued CCS are lacking. OBJECTIVE: The aim of the study was to explore how 30-year-old women reason about health, ill health, health maintenance, and disease prevention, in relation to cervical cancer, its prevention, and screening. METHODS: Through a population-based CCS registry, we randomly sampled women to attend focus group discussions stratified by previous patterns in screening history and test results. Data from 38 attendees were inductively analyzed. RESULTS: Women's discussions encompassed temporal aspects of the past and the future, with youth in the rearview mirror and the demands of adulthood ahead. Matters related to sickness, including cancer and its prevention, were described as distant and not prioritized in this phase of life. This situation was compounded by lack of relevant information about cervical cancer and screening. CONCLUSIONS: The manner 30-year-old women self-defined themselves in the transition between youth and adulthood appears to strongly influence their reasoning about CCS and other forms of health maintenance and disease prevention. IMPLICATIONS FOR PRACTICE: Cervical cancer screening programs are challenged to adapt both information and organizations to new cohorts of women with different needs and life situations.

Assessing perceived risk and STI prevention behavior: a national population-based study with special reference to HPV.

INTRODUCTION: To better understand trends in sexually transmitted infection (STI) prevention, specifically low prevalence of condom use with temporary partners, the aim of this study was to examine factors associated with condom use and perceptions of STI risk amongst individuals at risk, with the underlying assumption that STI risk perceptions and STI prevention behaviors are correlated. METHODS: A national population-based survey on human papillomavirus (HPV) and sexual habits of young adults aged 18-30 was conducted in Sweden in 2007, with 1712 men and 8855 women participating. Regression analyses stratified by gender were performed to measure condom use with temporary partners and STI risk perception. RESULTS: Men's condom use was not associated with STI risk perception while women's was. Awareness of and disease severity perceptions were not associated with either condom use or risk perception though education level correlated with condom use. Women's young age at sexual debut was associated with a higher risk of non-condom use later in life (OR 1.95 95% CI: 1.46-2.60). Women with immigrant mothers were less likely to report seldom/never use of condoms with temporary partners compared to women with Swedish-born mothers (OR 0.53 95% CI: 0.37-0.77). Correlates to STI risk perception differ substantially between sexes. Number of reported temporary partners was the only factor associated for both men and women with condom use and STI risk perception. CONCLUSIONS: Public health interventions advocating condom use with new partners could consider employing tactics besides those which primarily aim to increase knowledge or self-perceived risk if they are to be more effective in STI reduction. Gender-specific prevention strategies could be effective considering the differences found in this study.

The encounters that rupture the myth: contradictions in midwives' descriptions and explanations of circumcised women immigrants' sexuality.

The purpose of the study was to analyze how Swedish midwives (n = 26) discuss sexuality in circumcised African women patients. In focus groups and interviews, discussions concentrated on care provided to circumcised women, training received for this care, and midwives' perceptions of female circumcision. An analytic expansion was performed for discussions pertaining to sexuality and gender roles. Results from the analysis show the following: (1) ethnocentric projections of sexuality; (2) a knowledge paradox regarding circumcision and sexuality; (3) the view of the powerless circumcised women; and (4) the fact that maternity wards function as meeting places between gender and culture where the encounters with men allow masculine hegemonic norms to be ruptured. We conclude that an increased understanding of cultural epistemology is needed to ensure quality care. The encounters that take place in obstetrical care situations can provide a space where gender and culture as prescribed norms can be questioned.

Women's experiences of cervical cellular changes: an unintentional transition from health to liminality?

Cervical cancer screening is a preventive intervention directed towards women to both detect cervical cancer and identify those at risk for developing this disease. It has been argued that participation in screening programmes and early detection situations may lead to new kinds of sickness experiences. This article is based on qualitative phenomenological hermeneutical analysis of interviews with women who have received abnormal Pap smear test results through a population-based outreach screening programme in urban Sweden. The aim of this article is to illuminate the meaning, for the participating women, of the lived experience of receiving notification about an abnormal Pap smear result. The data are presented in terms of two themes: Pap smear for routine and recurrent confirmation of health and unexpected and ambiguous communication about Pap smear results. The findings are discussed as an unintentional transition from confirmation of health to liminality. Whereas medical diagnosis has been discussed as structuring the inchoate, an abnormal Pap smear did not create order for the interviewed women. On the contrary, the notification of an abnormal Pap smear created disorder as the women had expected to be confirmed as healthy but instead neither health nor disease were confirmed or excluded. Even 'simple' technology is shown to have an ontological dimension, with the ability to transform daily taken-for-grantedness of ourselves as primarily healthy to (potentially) unhealthy.

The role of nursing in cervical cancer prevention and treatment.

Nurses today assume multiple roles, such as patient advocate, care provider, and research investigator. At the Second International Conference on Cervical Cancer (April 11-14, 2002, Houston, TX), nurses presented original research describing these roles in the context of cervical cancer screening, prevention, and detection in the United States and Sweden; outlined the uses of practice guidelines; and suggested future directions for nursing research. In the 20th century, nurses expanded their patient care responsibilities and promoted cancer control by expanding their skills. Some sought to broaden the spectrum of care by investigating cervical cancer screening disparities, behavioral aspects of screening, and differences between the stated purposes of screening programs and those of the nurse-midwives operating them. In the 21st century, nurses interested in cervical cancer control expect to broaden the scope of their care and their research roles further by continuing to improve training, advocating screening (and increased education about screening), and helping to establish new sources of funding for research.