1. For the EUROCHIP-3 project
Women’s reasons for low attendance in the cervical cancer screening programme: experience from Estonia
Piret Veerus, MD, PhD
Department of epidemiology and biostatistics
National Institute for Health Development
Estonia
For the EUROCHIP-3 project
Ispra, February 27, 2012

2. Cervical cancer in Estonia
Population of Estonia 1,339,681 (2012)
Among the female population, cervical cancer is the 3rd most common cancer site
ASIR(w) 18.1 per 100,000 with 187 new cases in 2007
ASMR(w) 4.3 per 100,000 with 53 deaths in 2007
In the age-group from 20 to 49 yrs the incidence rates more than doubled in to

3. Cervical cancer incidence by age groups in Estonia
Estonian Cancer Registry

4. Cervical cancer screening in Estonia
Organised nationwide cervical screening started in 2006, pilot studies in 2003
Target group women aged 30 to 59 years
Screening interval 5 yrs after a negative result
Women diagnosed with cervical cancer, without health insurance and those having had a Pap-smear in past 12 months excluded from the list of invitees
Trained midwives take Pap-smears at 20 clinics, tests performed at 7 labs
Pathological results handled according to clinical guidelines
Lab quality assurance carried out in 2007

5. Attendance in the cervical cancer screening programme in Estonia

6. Aims of the present study
To study:
reasons for low attendance in the organised cervical cancer screening programme
women’s wishes for improving the screening programme
the present knowledge about cervical cancer risk factors and screening among the screening target group

7. Methods
Anonymous postal survey to a random sample of 2,942 women in the screening population together with the invitation to screening and a prepaid return envelope; reminders to 1,600 non-attenders in the screening programme
21 questions in the Estonian and Russian language - respondent’s background information, general health behaviour, knowledge about cervical cancer and screening, attitude about screening activities and wishes for better organisation of the screening programme

8. Results: respondents
Response rate 36%, altogether 1054 questionnaires returned (69.1% in Estonian)
Mean age of respondents 43 years
Most respondents married or cohabiting (74.3%), actively working (76.9%), and living in big towns (69.0%)
Mean number of children per respondent 1.8
Less than half (46.2%) had had a gynaecological check-up in past 12 months; nearly one quarter were regular smokers (22.0%); about half (49.8%) had ever used OC; most (62.4%) had never been diagnosed with a STD; many women (39.9%) had had more than five sexual partners per lifetime

9. Results: women’s awareness about risk factors of cervical cancer

10. Results: awareness about cervical cancer screening 72
Results: awareness about cervical cancer screening 72.3% of respondents were aware of screening
RR (95% CI), crude
RR (95% CI), adjusted
Age group
30, 35 yrs 1
40, 45 years
1.08 ( )
1.04 ( )
50, 55 years
1.02 ( )
1.04 ( )
Nationality
Non-Estonian
Estonian
1.65 ( )
1.64 ( )
Living-place
Urban
Rural
1.17 ( )
1.02 ( )
Parity
0-1
>=2
1.13 ( )
1.09 ( )

11. Results: willingness to attend the screening programme
RR (95% CI), crude
RR (95% CI), adjusted
Age group
30, 35 yrs 1
40, 45 yrs
1.12 ( )
1.13 ( )
50, 55 yrs
1.06 ( )
1.03 ( )
Nationality
Estonian
Non-Estonian
1.00 ( )
1.02 ( )
Living-place
Urban
Town
0.99 ( )
1.02 ( )
Parity
0-1
>=2
1.02 ( )
0.99 ( )

12. Results: reasons for non-attendance in the screening programme (N=442)

13. Results: women’s wishes to improve the screening programme
Most respondents (71%) were satisfied with the current organisation of the programme
Most of them wanted to make the appointment by phone (83.2%) and to have the test taken by a midwife (92.1%)
Women wanted to receive information about the test result by phone (33.9%), by (34.3%) or by ordinary mail (29%)
Most respondents (74.8%) wanted to recieve information about screening by mail together with the personal invitation

14. Results: women’s wishes for receiving information about screening
Number
Proportion
Personally mailed invitation with a detailed information leaflet
784
74.8%
Articles in women’s magazines
198
18.9%
Information by medical staff
189
18.0%
Advertisements on TV
103
9.8%
No wish for more information 61
5.8%
Other sources (Internet, etc) 28
2.7%

15. Conclusions
In Estonia, women prefer to be personally and delicately informed about cervical cancer screening
Minorities need more information about the screening programme in their mother langauage
All women need more detailed information about the programme, and encouragement for participation
Better organisation of screening services has to be provided
Opportunistic smears outsied the programme are discouraged

16. Thank you!
Kivistik A, Lang K, Baili P, Anttila A, Veerus P. Women’s knowledge about cervical cancer risk factors, screening, and reasons for non-participation in cervical cancer screening programme in Estonia.
BMC Women’s Health 2011,11:43.