Reasons for non-attendance at cervical screening as reported
by non-attendees in Sweden

MARIE G. OSCARSSON

1,2

, EVA G. BENZEIN

1

, & BARBRO E. WIJMA

2

1

School of Human Sciences, Kalmar University, Kalmar, Sweden and

2

Division of Gender and Medicine, Department of

Molecular and Clinical Medicine, Faculty of Health Sciences, Linko¨ping University, Sweden

(Received 4 December 2006; accepted 6 June 2007)

Abstract
Purpose.

To describe reasons for non-attendance at cervical screening, as reported by non-attendees, in Sweden.

Methods.

Four hundred women were randomized from a population-based register, of which 133 non-attendees answered

the Cervical Screening Questionnaire (CSQ) in telephone interviews. Pearson’s Chi

2

and Mann–Whitney U-test were used

to analyze differences between groups. Logistic regression was used to study the relationship between explanatory variables
and a binary response variable.
Results.

The most common reasons for non-attendance were: feeling healthy, lack of time, and feelings of dis-

comfort with the gynecologic examination. Non-attendees, who reported non-attendance due to experiences of discomfort
associated with the gynecologic examination, estimated great discomfort at their latest examination. A history of sexual
abuse was reported by 16.5%, but there were no differences regarding non-attendance due to experiences of dis-
comfort associated with the gynecologic examination, between non-attendees who had no history of sexual abuse and those
who had.
Conclusion.

It seems as though non-attendees did not attend cervical screening as they felt healthy, and thereby did not give

time to preventive efforts. Earlier negative experiences such as discomfort during earlier gynecologic examinations seem to
guide their decision not to attend.

Keywords: Cervical screening, non-attendance, gynecologic examination, sexual abuse, questionnaire

Introduction

Cervical cancer is the second most common cancer in
women worldwide [1]. Screening by cytology seems
to be an effective method to reduce the incidence
[2–4] and mortality [5] of cervical cancer and there-
fore many countries offer preventive cervical screen-
ing programs. A high coverage is essential in these
programs [6,7], and it has been suggested that un-
screened women are at highest risk of cervical
cancer [6].

Since the organized population-based cervical

screening program was introduced in the 1960s in
Sweden, the incidence of cancer has decreased by
almost 50% [2,4,8], still some women do not attend
cervical screening. A Swedish study showed [9], that
socioeconomic status was not associated with non-
attendance which is contradictory to results from other
countries [10–15]. However, living in rural/semirural
areas is shown to be related to non-attendance [9].
A variety of reasons for non-attendance at cervical

screening have been described, and non-attendance
in relation to the gynecologic examination is common
[16–19]. The cervical smear procedure has been
found embarrassing, painful and undignified both
among adult women [20] as well as adolescents
[21,22], and such attitudes might be based on past
experiences [23]. Wijma [24] found that the experi-
ence of the first and the latest gynecologic examina-
tion influenced the women’s attitudes to subsequent
gynecologic examinations. To our knowledge few
studies concern the relationship between sexual abuse
and non-attendance in cervical screening. Young
sexually abused women tend to begin sexual activity at
a young age and have more sexual partners [25,26],
which are risk factors for cervical cancer [27].
However, one study [28] showed that women who
have been sexually abused in childhood were less
likely to have had a cervical smear. The gynecologic
examination may be experienced as re-traumatizing
[29–31].

Correspondence: Marie Oscarsson, School of Human Sciences, Kalmar University, Kalmar, Sweden, S-391 82 Kalmar, Sweden. Tel:

þ46480 446080.

Fax:

þ46480 44 69 55. E-mail: [e-mail]

Journal of Psychosomatic Obstetrics & Gynecology, March 2008; 29(1): 23–31

ISSN 0167-482X print/ISSN 1743-8942 online Ó 2008 Informa UK Ltd.
DOI: 10.1080/01674820701504619

Comparisons with international studies should be

evaluated with caution, for example due to variation in
sample sizes, selection of participants, and various
research questions. Further, cervical screening pro-
grams are organized in various ways, i.e., computer-
ized databases cover both the organized and the
opportunistic screening in some settings, but not in
others. There are large differences between countries
and within countries in how the cervical screening
programs are designed, for example, concerning age
groups and time intervals between the taking of
cervical smear [32]. Neither is there any international
consensus as to what characterizes a non-attendee. In
our study, non-attendees are defined as women, with
no registered cervical smear during the previous five
years, in any county or country (excluding women
who are totally hysterectomized, pregnant, newly
delivered or have never had sexual intercourse) [33].
It is necessary to identify reasons for non-attendance
among high-risk women in order to meet their needs
and to find ways to promote their attendance at
cervical screening.

The aim of this study was to describe reasons for

non-attendance at cervical screening as reported by
non-attendees in Sweden.

Based on results from previous studies, the follow-

ing hypotheses were made:

Hypothesis 1: Young age of non-attendees is
associated with non-attendance due to experiences
of discomfort associated with the gynecologic
examination.
Hypothesis 2: Non-attendees, who report non-
attendance due to experiences of discomfort
associated

with

the

gynecologic

examination,

estimate a greater degree of discomfort at their
latest gynecologic examination than non-atten-
dees, who report other reasons for non-attendance.
Hypothesis 3: Non-attendees with a history of
sexual abuse report non-attendance due to experi-
ences of discomfort associated with the gynecolo-
gic

examination

more

frequently

than

non-

attendees with no history of sexual abuse.

Methods

Cervical Screening Questionnaire

The authors constructed the Cervical Screening
Questionnaire (CSQ) as a telephone interview sche-
dule exclusively for this study. This design was used
as previous studies [20,34] and a foregoing pilot
study have shown the difficulties of reaching non-
attendees by postal questionnaires.

The questionnaire was developed from previous

studies [24,35] and from clinical experience with
patients. CSQ contained 36 questions; five questions
were constructed to exclude women in relation to the

definition of non-attendees, 31 questions included
general questions about age, education and civil
status, reasons for non-attendance (one open ques-
tion and 12 with preset alternatives), experiences of
gynecologic examination and sexual abuse, atten-
dance at mammography screening, smoking habits, if
they would consider having a cervical smear taken
and one additional question related to the women’s
experiences of answering the questionnaire. The
questionnaire also had questions about future atten-
dance at cervical screening (to be presented else-
where). The response alternatives were ‘‘Yes’’ or
‘‘No’’, and four questions were open-ended. A
seven-step self-assessment rating scale was used to
measure how the non-attendees had experienced
their latest gynecologic examination, ranging from
‘‘no discomfort at all’’ (

¼1) to ‘‘extreme discomfort’’

(

¼7) [24]. Sexual abuse was elicited by the question

‘‘Has anybody against your will touched parts of your
body or used your body to satisfy him/herself
sexually?’’ (part of the definition of sexual abuse in
the NorVold Abuse Questionnaire [35]). One group
of staff members involved in the cervical screening
program (midwives, obstetricians, enrolled nurses)
affirmed the content validity. The questions were
tested in two groups: one group with a convenient
sample of women (n

¼ 15) of various ages, and one

group

of

20

randomly

selected

non-attendees.

The tests resulted in minor adjustments of the
questionnaire.

Setting

The Swedish National Board of Health and Welfare
has the national responsibility for health, guidelines
and recommendations of the cervical screening pro-
gram, and the health authority in each county
administers the program. The recommended screen-
ing intervals for women aged 23–50 are every third
year and for women aged 51–60 every fifth year. The
system for calling, registration and follow-up is
computerized and linked to the National Population
Register, which includes all residents of Sweden. In
the county, all women (aged 23–65 years) are
registered in a database and the organized and the
opportunistic screenings are coordinated in order to
avoid doubling of numbers of cervical smears. In
January 2004, the coverage in the county was 88%,
i.e., the percentage of women in the target group who
have been screened during the previous five years
(Figure 1).

Women receive an invitation letter to the organized

screening every third year. The invitation letter
includes time, place for appointment at the Antenatal
Health Clinics (ANHC), and general information
about the purpose of cervical screening. Women who
are pregnant, newly delivered [33] or never have had
sexual intercourse are informed that they do not need

24

M. G. Oscarsson et al.

to attend or to respond. Women who do not respond
to the invitation get a re-invitation letter every year
until a cervical smear has been registered.

Sample

Of 56 644 women (28–65 years old) in the county,
7715 women had no registered cervical smear in the
database during the previous five years (January
2004). A group of 1150 women (2%) had been
exempted from the cervical screening program due to
total hysterectomy (n

¼ 706); handicap (n ¼ 96);

cervical smear taken in another county or country
(n

¼ 60); no reason reported, but wished to be

exempted (n

¼ 288). Thus, a total of 6565 women

had no registered cervical smear during the previous
five years. A random sample of 400 women was
selected from this population in the database, and a
total of 133 non-attendees (52%) completed the
whole questionnaire. The sampling procedure of
non-attendees is shown in Figure 2.

Respondents

(n

¼ 133)

and

non-respondents

(n

¼ 122) were compared on two available variables:

age and cervical smear history. The comparison
showed no differences in age but differed in cervical
smear history ( p

¼ 0.002). The background charac-

teristics of respondents and non-respondents are
presented in Table I. Twenty non-respondents gave
reasons for non-attendance by letter/phone, which
were similar to the respondents reasons.

Procedure

Each woman (n

¼ 400) embraced by the inclusion

criteria: living in the county, 28–65 years old, and
with no registered cervical smears during the previous
five years, received a letter in January 2004 with
written information about the aim and procedure of
the study and a note that the researcher would phone
them within 14 days. A response note and a stamped,

addressed envelope were enclosed, which was to be
returned within five days if the woman did not allow
the researcher to phone her. The response note also
included space for comments.

During the phone call, women not corresponding

to the non-attendees definition were excluded as well
as women unable to understand and answer the
questionnaire. The first author performed the tele-
phone

interviews,

and

consecutively

asked

the

questions from the questionnaire. All additional
information reported by non-attendees in connection
with the question was written down. In order to reach
a deeper understanding of the women’s thoughts
about their non-attendance, a purposeful sample of
women were asked if they were willing to take part in
a longer interview at a later date (to be presented
elsewhere). The time required to answer the ques-
tionnaire was 5–15 minutes, although the telephone
conversations sometimes lasted up to 45 minutes.
The interviews were conducted between March and
October 2004. The Regional Ethics Committee for
Human

Research,

Faculty

of

Health

Sciences,

Linko

¨ ping University, Sweden, had approved the

study (Dnr 03-248). If the non-attendees expressed
the need for psychological support, such contact was
arranged.

Statistics

From the database register, the latest registered
cervical smear for each woman was identified. The
non-attendees were divided into two subgroups
based on screening history: had no cervical smear/
had at least one cervical smear taken during the
previous 10 years (we excluded women 28–32 years
old, as they otherwise could not have abstained from
cervical screening the previous 10 years). Pearson’s
Chi

2

test was used to analyze differences of propor-

tions. Logistic regression was used to study the
relationship between explanatory variables and a
binary response variable. Mann–Whitney U-test was
used to analyze differences between non-parametric
data from two independent groups. P-values

50.05

were referred to as statistically significant.

A box plot was used to summarize non-attendees’

experiences of their latest gynecologic examination.
The box used is outlined by the 25

th

and to the 75

th

percentile [37]; the highest and lowest values are
represented by lines, except for values that were
situated more than 1,5 inter-quartile ranger from the
box outliers—those values are represented by circles.
The SPSS package 14.0 and Minitab 13 were used
for the data analysis.

Results

In the open question, non-attendees answered why
they chose not to attend cervical screening. The four

Figure 1. Coverage, i.e., the percentage of women in the target
group who had a registered cervical smear during the previous five
years. Distribution in percentage in relation to the age of the
women in the target group in a county in southeast Sweden,
January 2004.

Non-attendance in cervical screening

25

most common reasons were: lack of time due to work
and family commitments (n

¼ 30), discomfort asso-

ciated with the gynecologic examination (n

¼ 26),

other diseases (n

¼ 24), and feeling healthy (n ¼ 16).

One hundred and twenty women could consider

having a cervical smear taken and said they needed to
be tested.

Table II displays the reasons given by non-

attendees for non-attendance, based on the preset
response alternatives in the questionnaire. The most

Figure 2. The sampling procedure.

26

M. G. Oscarsson et al.

common reason ‘‘I feel healthy’’ was chosen by more
than half of the non-attendees (n

¼ 73), but almost

three quarters of them combined this reason with two
others: ‘‘I feel discomfort being confronted with a
gynecologic examination’’ (n

¼ 24), and ‘‘I feel dis-

comfort seeking health care in general’’ (n

¼ 21).

Hypothesis 1 was not confirmed. We found no

association between young age and non-attendance
due to experiences of discomfort associated with
the

gynecologic

examinations

(OR

0.99,

95%

CI: 0.96–1.03).

Hypothesis 2 was confirmed. Of the non-attendees

(n

¼ 133), 126 had had a gynecologic examination.

Two of them did not manage to self-assess the
experiences of their latest gynecologic examination.
There was a difference regarding the experiences of
their latest gynecologic examination ( p

¼ 0.000)

between the non-attendees who stated non-atten-
dance due to experiences of discomfort associated
with the gynecologic examination and those who
stated other reasons (Figure 3).

Sixteen and a half percent (n

¼ 22) of the non-

attendees reported a history of sexual abuse. The
non-attendees added excuses to their answer and
seemed to feel a need to minimize their experiences
of abuse, and some non-attendees spontaneously
reported that they had received help to get over the
trauma for example by stating: ‘‘I have only been
raped once and it counts for nothing’’, ‘‘I have
received help for this so it doesn’t bother me any
more’’. The most common reason for non-atten-
dance among those non-attendees was experiences of
discomfort associated with the gynecologic examina-
tion (n

¼ 7). However, there were no differences

regarding non-attendance due to experiences of
discomfort associated with the gynecologic examina-
tion between non-attendees who had no history of
sexual abuse and those who had. Thus, hypothesis 3
was not confirmed.

Discussion

The most common reasons for non-attendance in the
open question were lack of time, due to work and
family commitments, discomfort associated with the
gynecologic examination, other diseases, and feeling

Table I. Background characteristics of respondents and non-
respondents.

Respondents of

questionnaire

(n

¼ 133)

Non-

respondents

(n

¼ 122)

P

Age

Mean (SD)

48 (10.8)

48.5 (10.9)

0.55

a

n (%)

n (%)

28–49

75 (56)

61 (50)

0.307

b

50–65

58 (44)

61 (50)

Education

Primary school

35 (26)

Secondary school

58 (44)

College/university

40 (30)

Civil status

Living with partner

77 (58)

Single

56 (42)

Parity

Nulliparous

27 (20)

Parous

106 (80)

Smoker

Yes

51 (38)

No

82 (62)

Cervical smear history

n

¼ 121*

n

¼ 110*

No cervical smear

during the previous
10 years

59 (49)

76 (69)

0.002

b

At least one cervical

smear during the
previous 10 years

62 (51)

34 (31)

a

Variance analysis.

b

Chi

2

.

*Women 28 – 32 years old were excluded.

Table II. Distribution in number and percent of non-attendees’ reasons for non-attendance, (95% confidence interval).

I do not attend cervical screening because . . . .

Respondents of the questionnaire (n

¼ 133)

95% CI %

n

%

1. I feel healthy

73

55

(46–63)

2. I feel discomfort to be confronted with gynecologic examination

39

29

(21–37)

3. I feel discomfort to seek Health Care in general

30

23

(15–30)

4. I fear that they discover something abnormal e.g., cancer

19

14

(8–20)

5. I am embarrassed to show myself naked

17

12

(8–21)

6. It is too expensive

11

8

(4–13)

7. I suffer from anxiety/depression or mental disorder

11

8

(4–13)

8. I know the examiner

8

6

(2–10)

9. Principally, I dislike such controls

8

6

(2–10)

10. I have a handicap or disability which makes it difficult for me

7

5

(1–9)

11. I am dissatisfied with my body

6

5

(1–9)

12. I have difficulties to understand Swedish

3

2

(0–5)

The non-attendees could agree or disagree to the statements above. The women were allowed to select one or more alternatives.

Non-attendance in cervical screening

27

healthy. In the preset alternatives women reported
the following reasons: feeling healthy, experience of
discomfort associated with the gynecologic examina-
tion, and feelings of discomfort about seeking health
care in general.

One reason for non-attendance was that the non-

attendees felt healthy. This reason could be judged
by the medical profession as ignorance or lack of
information, and confirms the result that non-
attendees have poor knowledge of cervical screening
[11,16].

However,

poor

knowledge

of

cervical

screening has been reported not only among non-
attendees but among attendees as well [17,20,38,39].
In our study, the non-attendees appeared to be quite
well informed of the preventive nature of cervical
screening, but the value of cervical screening to
improve health does not outweigh the total efforts to
attend and they justified this with the experience of
feeling healthy. This could be a consequence of the
differences between how the non-attendees and the

medical discourse define health/illness and normal-
ity/pathology [40]. From a medical discourse per-
spective, the cervical screening is viewed as a
good and preventive health service which tends to
‘‘pathologize non-attendance’’ [41]. When compli-
ance with cervical screening is taken for granted,
women’s reasons for non-attendance can be viewed
as irrational from a medical perspective [42], but still
as rational from the perspectives of the non-
attendees. Women’s experiences, beliefs, and perso-
nal circumstances influence their decisions and their
motivation [43].

Lack of time was another main reason for non-

attendance in cervical screening; similar findings
were reported in a review [20]. In our study, lack of
time embraced factors related to work, caring for
children, family commitments, and hospital visits in
relation to other diseases. The non-attendees found it
hard to prioritize cervical screening before these
other demands. This cannot only be explained as a

Figure 3. Non-attendees’ (n

¼ 124) experiences of their latest gynecologic examination in relation to reason for non-attendance due to

discomfort in association with the gynecologic examination.

28

M. G. Oscarsson et al.

problem related to the individual but can also be
explained by the structure of society. Women take a
great responsibility for housework and children in
addition to their work outside home, and this might
affect their concern about their own health. As our
study was performed in a rural area, the non-
attendees often had practical problems reaching the
venue. Non-attendees reported difficulties atten-
ding a cervical screening when they had their home
and work in different places and the cervical screen-
ing in a third place. Such circumstances result in
fairly high costs for attendance and loss of time. This
might be an explanation why other studies [9,12,16]
show that non-attendance is higher among women
who live in rural or semi-rural areas than women in
urban areas.

Our results showed that experiences of discomfort

associated with the gynecological examination were a
frequent reason for non-attendance, which supports
earlier results [16–18]. Even if women have tolerance
[44], and a positive attitude to gynecologic examina-
tion in general [24], embarrassment, humiliation,
and shame are feelings expressed by women when
describing their experiences of these examinations
[24,45].We found no association, however, between
young age and non-attendance due to experiences of
discomfort associated with the gynecological exam-
ination. One explanation could be that the non-
attendees in our study were aged 28 or older and
could be expected to have had several previous
gynecological examinations. Women who have had
repeated examinations seem to accept the discomfort
during the gynecological examination to a greater
extent [45] than younger women and adolescents,
who have had their first gynecological examination
[24,46,47].

There was a difference in the experience of dis-

comfort during the latest gynecologic examination
between non-attendees who reported non-attendance
due to experiences of discomfort associated with the
gynecologic examination and those who stated other
reasons. Earlier negative experiences during the gyne-
cologic examination may influence non-attendee’s
non-attendance at cervical screening. The result of
this study may indicate the importance of strategies
used by examiners to minimize the discomfort during
gynecological examinations, which was also argued by
Wijma [24,48].

Hypothesis 3 was not confirmed. It is, however,

important to point out that the sample size of the
sexually abused non-attendees is small. One might
assume that there are a number of unrecorded cases
in our randomized sample (n

¼ 400) as some of the

sexually abused non-attendees in the interviews
seemed to have a need to minimize and apologize
for having been abused. Perhaps the sexually abused
women who chose to participate in the study were a
selected group of women who had received help to

get over the trauma. Despite this result, 16.5% of the
non-attendees in this study stated a history of sexual
abuse. We agree with the recommendations which
propose examiners to inquire about prior experiences
of gynecologic examinations and sexual abuse to
avoid re-tramautizing [28,44]. This might help to
decrease the discomfort for sexually abused women
during gynecologic examinations.

One strength of this study is that the sample includes

non-attendees, women who are highly resistant to
repeated proposals to attend cervical screening.
Further, a low response rate was expected as these
non-attendees should ‘‘by definition’’ be difficult to
reach [15,49], and unwilling to discuss attendance
at cervical screening. Therefore, a 52% response
rate may be considered satisfactory. Another strength
is that the study is based on a random sample of
non-attendees from a register data of cervical
smears.

In conclusion, it seems as non-attendees did not

attend cervical screening as they felt healthy, and
thereby did not give time to preventive efforts.
Despite acceptance of the value of the cervical
screening, earlier experiences,for example discomfort
with their latest gynecologic examination,may guide
their decision not to attend cervical screening.
Women with few or no cervical smears constitute a
risk group for future cervical cancer. The question is
whether to make any effort to promote attendance
or to accept their choice of non-attendance. This
points to an ethical dilemma: to acknowledge the
women’s autonomy versus the medical desirability of
a high attendance rate.

Acknowledgments

We are grateful to the women who participated in the
study and to Alan Crozier for revising the English.
Special thanks to Olle Ericsson for statistical advice,
Gunnar Thorbert and Lennart Mellblom, for fruitful
cooperation, and Gunnel Nyberg for support with
register data. The study was funded by the Swedish
Research Council.

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30

M. G. Oscarsson et al.

Current knowledge

.

Unscreened women are at highest risk of cervical
cancer.

.

The experiences of first and latest gynecologic exam-
inations influence women’s attitudes to subsequent
gynecologic examinations.

.

Women who have been sexually abused in childhood
are less likely to have a cervical smear.

What this study adds

.

Reasons for non-attendance are feeling healthy, having
lack of time, and feelings of discomfort associated with
the gynecologic examination.

.

Non-attendees who report non-attendance due to
experiences of discomfort associated with the gyneco-
logic examination, experienced discomfort at their
latest examination.

.

Sexually abused women do not abstain from cervical
screening due to discomfort associated with the
gynecologic examination.

Non-attendance in cervical screening

31