Factors affecting participation in cervical cancer screening among elderly Chinese women

Amy O Y Wong 黃藹怡, Kin-Sang Ho 何健生, Wai-Man Chan 陳慧敏

HK Pract 2005;27:223-229

Summary

Objective: To study the factors affecting participation in a cervical cancer screening programme and the level of knowledge about cervical cancer screening among elderly Chinese women in Hong Kong.

Design: A cross-sectional study.

Subjects: 1054 elders, aged 65 and above, who attended four Elderly Health Centres of the Department of Health, HKSAR, were invited for an interview.

Main outcome measures: The demographics of the participants, their knowledge about Pap smears and cervical cancer and their reasons for accepting or refusing the Pap smear.

Results: 1000 elders participated in the survey with a response rate of 94.9%. Their ages ranged from 66 to 85, with about half in the 70-75 age group. 79% of them admitted that they were not fully aware of the presenting symptoms of cervical cancer. 64.6% (N= 646) of elders had had a Pap smear performed within the past three years. Among these elders, the main reasons for having had a Pap smear were: its inclusion in a health assessment (49.2%); concerned about own health (23.1%); having gynaecological symptoms (6.6%); having a history of prior gynaecological disease (2.5%) and concern about cervical cancer (6%). 34.9% (N=349) of elders did not have the Pap smear and the main reasons given were: they were asymptomatic (66.1%); they had already had a Pap smear done (6.2%); they had not been asked by the doctor (6.5%); they did not understand the test (2.4%); embarrassment (2.4%); fear of pain (2.2%) and lack of availability of a female doctor (1%). Logistic regression analysis revealed that the following factors were associated with uptake of the Pap smear examination: a history of gynaecological disease, worry about cervical cancer, knowledge of cervical cancer symptoms, knowledge about the need for Pap smears even if not sexually active, fear of pain, gender of the doctor and history of giving birth.

Conclusion: There is a general lack of knowledge among the elderly about cervical cancer and the Pap smear examination. This is an important barrier to participation in Pap smear screening. Through effective health education focusing on areas of deficiency, health awareness among the elderly could probably be improved. A positive and caring attitude on the part of medical staff towards cervical screening might alleviate anxiety about pain during the procedure.

Keywords: Pap smear, elderly, acceptance

摘要

目的： 研究香港年長女仕對柏氏抹片普查的認識程度和影響她們參與普查的因素。

設計： 橫切面式研究。

研究對象： 邀請共1054位65歲或以上，曾到訪四間香港特別行政區衛生署的長者健康中心的女仕進行面談。

主要測量內容： 參與者的人口統計特徵，對柏氏抹片和子宮頸癌的認識，同意或拒絕此檢查的原因。

結果： 共1000名長者參與調查，回應率為94.9%。年齡介乎於66至85歲，半數屬於70至75歲的組別。 79%認為她們並不完全了解子宮頸癌的病徵。64.6%過去3年曾接受柏氏抹片檢查。接受柏氏抹片檢查的主要 原因為： 這是健康評估的部份；關注個人健康；有婦科疾病的病徵；有婦科疾病的病史和對子宮頸癌的關注。 34.9%的長者未有參與子宮頸癌普查，主要因為：沒有病徵；過往曾接受柏氏抹片檢查；醫生沒有主動提出； 對檢查認識不足；感覺尷尬；害怕痛楚與及沒有女性醫生負責檢查。統計顯示婦科疾病的病史，對子宮頸癌的憂慮， 對子宮頸癌病徵的認識，對於經後仍需要柏氏抹片檢驗的認知，對痛楚的畏懼，醫生的性別和分娩歷史均與柏氏枺片檢查有相關性。

結論： 研究顯示長者廣泛對子宮頸癌和柏氏抹片認識程度不足是阻礙推廣柏氏抹片健康普查的重要原因。 透過針對知識缺乏的有關範疇，進行有效的健康教育，可以提昇長者的健康意識。 醫護人員正面關心的態度可以減低檢查引起焦慮和痛楚。

詞彙： 柏氏抹片，長者，同意。

Introduction

Cervical cancer was the fourth commonest female cancer in Hong Kong in 2001 after cancers of the breast, colon and lung. Although the number of new cases is highest in the 50-55 age group, the incidence rate per 100,000 peaks in the 75-80 age group.¹ Thus cervical cancer is not uncommon in the elderly as compared with the younger age groups. This could be due to the fact that many elderly women have no regular health screening.

The Papanicolaou smear (Pap smear) was introduced by Papanicolaou in the 1930s and has been widely used in many countries as a screening test for cervical cancer. However the rate of utilization of this service varies. In the United Kingdom, the uptake rate varies from 16.5% to 94.1%.² In Hong Kong, a telephone survey on the self-reported uptake of cervical smear screening in the 44-55 age group was 35.4%.³ According to a survey conducted by the Family Planning Association, which has been offering regular cervical cancer screening in Hong Kong, the one year coverage of Pap smear screening was 32% in the year 1992.⁴ In our elderly health centres, where we conducted health assessment for elderly people aged 65 and above, about one third of women eligible for Pap smear screening declined.

Studies have shown that increasing age is inversely associated with participation in Pap smear screening programmes.^5,6 In this study, our main aim was to identify factors affecting participation in the Pap smear screening programme by elderly people. By exploring and focusing on these factors, better planning of the Pap smear programme for the elderly could be implemented and perhaps uptake rates could be improved.

Methods

The studied population was chosen from the Elderly Health Centres, Department of Health, Government of the Hong Kong Special Administrative Region. These Centres were established in 1998, with the aim of promoting the health of the elderly population and preventing disease at the primary health care level. They provide regular health assessments, screening and education to the participating elderly population in Hong Kong. Subjects are scheduled for follow-up yearly for health assessment and screening. Cervical cancer screening is part of the health assessment protocol, but is offered on a voluntary basis. Based on administrative convenience, four elderly health centres located in different parts of Hong Kong were selected for this study. 500 cases were recruited from two centres where female doctors were in-charge while another 500 were recruited from the other two centres with male doctors in-charge.

Consecutive patients consulting these clinics from September 2003 to February 2004 were asked to participate in the study. The recruitment stopped once 1000 patients were recruited. The exclusion criteria were total hysterectomy; lifelong celibacy and communication difficulties, such as severe hearing impairment, a language barrier or cognitive impairment. Written consent was obtained and approval was given by the Ethics Committee of the Department of Health. The number of subjects who were excluded and those who refused were recorded. Two research assistants were trained to interview all the subjects and to complete a structured questionnaire. The questionnaire included demographic details, education level, health status, knowledge about cervical cancer and Pap smear examinations, and reasons for accepting or refusing the Pap smear examination. The elders were free to choose more than one answer.

Statistical analysis

Data were collected and analyzed by SPSS for Windows (SPSS Inc., USA). Univariate analysis was performed by student's t-test for continuous variables and by the chi-square test for categorical variables to assess the factors associated with participation in Pap smear screening. Multiple logistic regression analysis was then performed on the significant parameters to determine the factors associated with participation in Pap smear screening. A p-value of <0.05 was considered statistically significant.

Results

1054 elders were invited for interview and 1,000 subjects agreed to complete the questionnaire during the period September 2003 to February 2004, with a response rate of 94.9%. The demographic characteristics of the subjects are shown in Table 1. About half of them were in the age group 71-75. Over 90% of subjects were either illiterate or received primary school education only, showing that these elderly were of relatively low education level. Only 1% of subjects were never married and 94% of subjects had given birth before.

Among the 1,000 respondents, 64.6% (N=646) had had a Pap smear within the past three years, while 34.9% (N=349) had not. 0.5% (N=5) reported that they could not remember whether a Pap smear had been done within the last three years. When asked whether they thought the Pap smear examination was painful, 62% (N=621) thought that it was not painful while 23% (N=229) believed the contrary. The remaining 15% (N=150) responded "do not know". 83% (N=830) were not worried about cervical cancer. 28% (N=282) said that the gender of the doctor might affect their willingness to have a Pap smear.

Knowledge about cervical cancer and the Pap smear was also assessed in this study; the results are shown in Table 2. Among this cohort, 79% (N=793) of the elderly admitted that they were not fully aware of the presenting symptoms of cervical cancer. Only 45% (N=450) realized that cervical cancer can be asymptomatic. 32% (N=320) did not know that Pap smears are still needed after menopause and 41% (N= 418) did not think the Pap smear should be continued if they were no longer sexually active. 86% (N=859) reported that they had never encountered information about cervical cancer and the Pap smear.

As shown in Table 3, among the 646 elderly women who had had the Pap smear performed, some elders gave more than one reason for accepting the Pap smear examination, thus giving a total of 649 answers. 49.2% (N=319) revealed that they agreed to the Pap smear because it was part of the health assessment. 23.1% (N=150) said they had it because they were health conscious. 6.6% (N=43) had gynaecological symptoms. 2.5% (N=16) had a history of prior gynaecological disease. 6.0% (N=39) expressed concern about cervical cancer. The rest (3.4%) gave other reasons such as family history of cervical cancer, advice from peers, fear of infection and having other medical diseases.

Table 4, 349 subjects who had not had a Pap smear (some gave more than one answer for the refusal) with a total of 370 reasons collected. 66.1% (N=245) declined the test because they felt they did not need a Pap smear examination in the absence of gynaecological symptoms, 6.5% (N=24) mentioned that the doctor had not asked them to do the test.

Univariate analysis of the data in Table 5 showed that the following factors were associated with participation in Pap smear screening: having previous gynaecological problems; being sexually active within the past one year; worry about cervical cancer; knowledge that the Pap smear can prevent cervical cancer; knowledge that there is a need to have Pap smears even if not sexually active; considering the Pap smear examination to be not painful; female gender of the doctor; not on public assistance; being married and having a history of giving birth.

Multivariate analysis for predicting the willingness of the elderly to have a Pap smear is shown in Table 6. It is worth noting that knowledge of cervical cancer symptoms and fear of pain were associated with Pap smear uptake among these elders.

Discussion

This study demonstrates various factors associated with uptake of the Pap smear among elderly women and gives a picture of their knowledge of this test. More than half of the subjects said that they agreed to have a Pap smear because it was part of the health assessment and was recommended by the medical staff. Hence the attitude of the medical staff plays an important role in encouraging the elderly to undergo screening tests. Previous studies have shown that staff with a positive attitude towards screening are important in affecting its uptake rate and future participation.^7,8 The message that elderly women in Hong Kong still need Pap smear screening because cervical cancer does occur in the elderly age group should be delivered clearly by doctors, especially those working in the primary health care setting. Compliance with cervical screening in elderly women could be significantly improved by including it as part of the consultation, supplemented if possible by a short explanation.

Nearly half (47%) of our subjects were illiterate. Studies have shown that low education level is associated with a low uptake rate in screening.^7,9 Elderly people who are illiterate are usually less amenable to health education and they are less aware of the significance of health screening. Among those who did not have Pap smears, two-thirds gave the reason that they were asymptomatic. In this study, only 7% knew that cervical cancer could be asymptomatic and about two-thirds of the subjects did not have Pap smears because they were asymptomatic. In other words, many elderly people in this study did not understand the principle of cervical screening.

The level of knowledge about cervical cancer and the Pap smear was generally deficient. Nearly half of the subjects thought there was no need to have Pap smears after menopause and only 38% knew that Pap smears should be continued even if the woman became sexually inactive. This could be explained by the fact that only 12% of the subjects had previously received information about preventive measures against cervical cancer. More effective measures to educate the public about the prevention of cervical cancer should be undertaken. These measures might include heath talks, promotion through mass media campaigns and opportunistic screening during consultations, although an organized screening programme might encourage a better response rate.

In this study only 17% of the elderly expressed anxiety about cervical cancer. This could also reflect their lack of knowledge about cervical cancer, in that they think that this kind of cancer does not occur in elderly women or in those without any gynaecological symptoms. However it has been shown that worry about cervical cancer is an important factor in determining one's willingness to participate in screening. Again, health education could increase peoples' awareness that cervical cancer is not rare in the elderly.

Forward stepwise logistic regression showed that knowledge about the presenting symptoms of cervical cancer and awareness of the need for Pap smears after menopause are significant factors associated with uptake rate of the test. The other determining factors are perceived pain or fear of pain during the procedure and female gender of the doctor. 23% of the studied subjects believed that the Pap smear procedure was painful. The fear of pain might be decreased by providing an explanation of the procedure, using the appropriate size of speculum and warming it with water to a suitable temperature. Measures to minimize the patients' anxiety level might help as well.

The factors associated with agreeing to the Pap smear are consistent with data obtained from other studies. Watkins et al showed in their study on rural Mexican women that reasons for not obtaining a Pap smear included lack of knowledge and difficulty in accessing health care. As in our study, women who had delivered children were significantly more likely to receive a Pap smear.¹⁰ A study conducted in Hong Kong middle-age women revealed that barriers to the Pap smear included the fear of pain.⁷ Another local descriptive study demonstrated that older women were more likely to experience pain during the procedure.¹¹ A possible explanation could be that insertion of the speculum tends to be more painful in elderly women due to vaginal atrophy and dryness. Provider gender, however, is more controversial. While one study showed that this does not act as a barrier to compliance with Pap smear screening,⁸ other studies have found the opposite.^7,12

This studied population was a group of elderly women who volunteered to have health assessments. It is reasonable to assume that they might be more health conscious than the general population. The demographics of this population do differ from the general population, although not to a great extent, as reported in our other study.¹³ Generally speaking, the barriers identified in this more health conscious group would be expected to be present in the general population as well.

Most of the guidelines on cervical cancer screening recommend that it should be continued until the age of around 70.¹⁴ Nevertheless, in Hong Kong there is still a need to continue the Pap smear in the elderly. This is because the incidence remains high in the elderly and the recommendation only applies when the women have been receiving Pap smears regularly in the past. Most of the elderly women in Hong Kong did not adhere to regular screening and many of them had never had the opportunity to have it done before.

Conclusion

Acceptance of the Pap smear examination is affected by the level of knowledge about cervical cancer and Pap smear screening, perceived pain or fear of pain during the test, and the gender of the doctor. There is room for improvement in the coverage of the Pap smear in Hong Kong. Since this study has demonstrated that the general lack of knowledge about cervical screening is a major barrier, effective health education focusing on the specific areas of deficiency, might enhance health awareness among the elderly population. A positive attitude on the part of medical staff towards cervical screening and a caring manner might alleviate the elderly women's anxiety and their perception of pain during the procedure. It is reasonable to hope that with a better educated population and increased health awareness, the prevalence of cervical cancer will be minimized.

Acknowledgement

We are indebted to staff of Nam Shan Elderly Health Centre, Tsuen Wan Elderly Health Centre, Tseung Kwan O Elderly Health Centre and Ha Kwai Chung Elderly Health Centre for their help and Ms Shelly Chan for statistic input in the project.

Key messages

1. Most elderly women in Hong Kong do not adhere to regular Pap screening.
2. Fear of pain is one of the barriers to acceptance of the Pap smear by the elderly.
3. Studies have shown that centre staff with a positive attitude towards screening are important in having an effect on uptake rate and future participation.
4. Acceptance of the Pap smear examination is very much affected by the individual's knowledge about cervical cancer and Pap smear screening.
5. More health education about the purpose and the procedure of the Pap smear examination is needed in order to improve the uptake rate.