Journal of Psychosomatic Obstetrics & Gynecology, March 2008; 29(1): 23 31
Reasons for non-attendance at cervical screening as reported
by non-attendees in Sweden
MARIE G. OSCARSSON1,2, EVA G. BENZEIN1, & BARBRO E. WIJMA2
1 2
School of Human Sciences, Kalmar University, Kalmar, Sweden and Division of Gender and Medicine, Department of
Molecular and Clinical Medicine, Faculty of Health Sciences, Linköping 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 Chi2 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
screening have been described, and non-attendance
Cervical cancer is the second most common cancer in in relation to the gynecologic examination is common
women worldwide [1]. Screening by cytology seems [16 19]. The cervical smear procedure has been
to be an effective method to reduce the incidence found embarrassing, painful and undignified both
[2 4] and mortality [5] of cervical cancer and there- among adult women [20] as well as adolescents
fore many countries offer preventive cervical screen- [21,22], and such attitudes might be based on past
ing programs. A high coverage is essential in these experiences [23]. Wijma [24] found that the experi-
programs [6,7], and it has been suggested that un- ence of the first and the latest gynecologic examina-
screened women are at highest risk of cervical tion influenced the women s attitudes to subsequent
cancer [6]. gynecologic examinations. To our knowledge few
Since the organized population-based cervical studies concern the relationship between sexual abuse
screening program was introduced in the 1960s in and non-attendance in cervical screening. Young
Sweden, the incidence of cancer has decreased by sexually abused women tend to begin sexual activity at
almost 50% [2,4,8], still some women do not attend a young age and have more sexual partners [25,26],
cervical screening. A Swedish study showed [9], that which are risk factors for cervical cancer [27].
socioeconomic status was not associated with non- However, one study [28] showed that women who
attendance which is contradictory to results from other have been sexually abused in childhood were less
countries [10 15]. However, living in rural/semirural likely to have had a cervical smear. The gynecologic
areas is shown to be related to non-attendance [9]. examination may be experienced as re-traumatizing
A variety of reasons for non-attendance at cervical [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]
ISSN 0167-482X print/ISSN 1743-8942 online Ó 2008 Informa UK Ltd.
DOI: 10.1080/01674820701504619
24 M. G. Oscarsson et al.
Comparisons with international studies should be definition of non-attendees, 31 questions included
evaluated with caution, for example due to variation in general questions about age, education and civil
sample sizes, selection of participants, and various status, reasons for non-attendance (one open ques-
research questions. Further, cervical screening pro- tion and 12 with preset alternatives), experiences of
grams are organized in various ways, i.e., computer- gynecologic examination and sexual abuse, atten-
ized databases cover both the organized and the dance at mammography screening, smoking habits, if
opportunistic screening in some settings, but not in they would consider having a cervical smear taken
others. There are large differences between countries and one additional question related to the women s
and within countries in how the cervical screening experiences of answering the questionnaire. The
programs are designed, for example, concerning age questionnaire also had questions about future atten-
groups and time intervals between the taking of dance at cervical screening (to be presented else-
cervical smear [32]. Neither is there any international where). The response alternatives were   Yes  or
consensus as to what characterizes a non-attendee. In   No  , and four questions were open-ended. A
our study, non-attendees are defined as women, with seven-step self-assessment rating scale was used to
no registered cervical smear during the previous five measure how the non-attendees had experienced
years, in any county or country (excluding women their latest gynecologic examination, ranging from
who are totally hysterectomized, pregnant, newly   no discomfort at all  (ź1) to   extreme discomfort 
delivered or have never had sexual intercourse) [33]. (ź7) [24]. Sexual abuse was elicited by the question
It is necessary to identify reasons for non-attendance   Has anybody against your will touched parts of your
among high-risk women in order to meet their needs body or used your body to satisfy him/herself
and to find ways to promote their attendance at sexually?  (part of the definition of sexual abuse in
cervical screening. the NorVold Abuse Questionnaire [35]). One group
The aim of this study was to describe reasons for of staff members involved in the cervical screening
non-attendance at cervical screening as reported by program (midwives, obstetricians, enrolled nurses)
non-attendees in Sweden. affirmed the content validity. The questions were
Based on results from previous studies, the follow- tested in two groups: one group with a convenient
ing hypotheses were made: sample of women (nź15) of various ages, and one
group of 20 randomly selected non-attendees.
Hypothesis 1: Young age of non-attendees is The tests resulted in minor adjustments of the
associated with non-attendance due to experiences questionnaire.
of discomfort associated with the gynecologic
examination.
Setting
Hypothesis 2: Non-attendees, who report non-
attendance due to experiences of discomfort The Swedish National Board of Health and Welfare
associated with the gynecologic examination, has the national responsibility for health, guidelines
estimate a greater degree of discomfort at their and recommendations of the cervical screening pro-
latest gynecologic examination than non-atten- gram, and the health authority in each county
dees, who report other reasons for non-attendance. administers the program. The recommended screen-
Hypothesis 3: Non-attendees with a history of ing intervals for women aged 23 50 are every third
sexual abuse report non-attendance due to experi- year and for women aged 51 60 every fifth year. The
ences of discomfort associated with the gynecolo- system for calling, registration and follow-up is
gic examination more frequently than non- computerized and linked to the National Population
attendees with no history of sexual abuse. 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
Methods opportunistic screenings are coordinated in order to
avoid doubling of numbers of cervical smears. In
Cervical Screening Questionnaire
January 2004, the coverage in the county was 88%,
The authors constructed the Cervical Screening i.e., the percentage of women in the target group who
Questionnaire (CSQ) as a telephone interview sche- have been screened during the previous five years
dule exclusively for this study. This design was used (Figure 1).
as previous studies [20,34] and a foregoing pilot Women receive an invitation letter to the organized
study have shown the difficulties of reaching non- screening every third year. The invitation letter
attendees by postal questionnaires. includes time, place for appointment at the Antenatal
The questionnaire was developed from previous Health Clinics (ANHC), and general information
studies [24,35] and from clinical experience with about the purpose of cervical screening. Women who
patients. CSQ contained 36 questions; five questions are pregnant, newly delivered [33] or never have had
were constructed to exclude women in relation to the sexual intercourse are informed that they do not need
Non-attendance in cervical screening 25
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
Figure 1. Coverage, i.e., the percentage of women in the target
a deeper understanding of the women s thoughts
group who had a registered cervical smear during the previous five
years. Distribution in percentage in relation to the age of the about their non-attendance, a purposeful sample of
women in the target group in a county in southeast Sweden,
women were asked if they were willing to take part in
January 2004.
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
to attend or to respond. Women who do not respond conversations sometimes lasted up to 45 minutes.
to the invitation get a re-invitation letter every year The interviews were conducted between March and
until a cervical smear has been registered. October 2004. The Regional Ethics Committee for
Human Research, Faculty of Health Sciences,
Linköping University, Sweden, had approved the
Sample
study (Dnr 03-248). If the non-attendees expressed
Of 56 644 women (28 65 years old) in the county, the need for psychological support, such contact was
7715 women had no registered cervical smear in the arranged.
database during the previous five years (January
2004). A group of 1150 women (2%) had been
Statistics
exempted from the cervical screening program due to
total hysterectomy (nź706); handicap (nź96); From the database register, the latest registered
cervical smear taken in another county or country cervical smear for each woman was identified. The
(nź60); no reason reported, but wished to be non-attendees were divided into two subgroups
exempted (nź288). Thus, a total of 6565 women based on screening history: had no cervical smear/
had no registered cervical smear during the previous had at least one cervical smear taken during the
five years. A random sample of 400 women was previous 10 years (we excluded women 28 32 years
selected from this population in the database, and a old, as they otherwise could not have abstained from
total of 133 non-attendees (52%) completed the cervical screening the previous 10 years). Pearson s
whole questionnaire. The sampling procedure of Chi2 test was used to analyze differences of propor-
non-attendees is shown in Figure 2. tions. Logistic regression was used to study the
Respondents (nź133) and non-respondents relationship between explanatory variables and a
(nź122) were compared on two available variables: binary response variable. Mann Whitney U-test was
age and cervical smear history. The comparison used to analyze differences between non-parametric
showed no differences in age but differed in cervical data from two independent groups. P-values 50.05
smear history (pź0.002). The background charac- were referred to as statistically significant.
teristics of respondents and non-respondents are A box plot was used to summarize non-attendees
presented in Table I. Twenty non-respondents gave experiences of their latest gynecologic examination.
reasons for non-attendance by letter/phone, which The box used is outlined by the 25th and to the 75th
were similar to the respondents reasons. 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
Procedure
box outliers those values are represented by circles.
Each woman (nź400) embraced by the inclusion The SPSS package 14.0 and Minitab 13 were used
criteria: living in the county, 28 65 years old, and for the data analysis.
with no registered cervical smears during the previous
five years, received a letter in January 2004 with
Results
written information about the aim and procedure of
the study and a note that the researcher would phone In the open question, non-attendees answered why
them within 14 days. A response note and a stamped, they chose not to attend cervical screening. The four
26 M. G. Oscarsson et al.
Figure 2. The sampling procedure.
most common reasons were: lack of time due to work having a cervical smear taken and said they needed to
and family commitments (nź30), discomfort asso- be tested.
ciated with the gynecologic examination (nź26), Table II displays the reasons given by non-
other diseases (nź24), and feeling healthy (nź16). attendees for non-attendance, based on the preset
One hundred and twenty women could consider response alternatives in the questionnaire. The most
Non-attendance in cervical screening 27
common reason   I feel healthy  was chosen by more Hypothesis 1 was not confirmed. We found no
than half of the non-attendees (nź73), but almost association between young age and non-attendance
three quarters of them combined this reason with two due to experiences of discomfort associated with
others:   I feel discomfort being confronted with a the gynecologic examinations (OR 0.99, 95%
gynecologic examination  (nź24), and   I feel dis- CI: 0.96 1.03).
comfort seeking health care in general  (nź21). Hypothesis 2 was confirmed. Of the non-attendees
(nź133), 126 had had a gynecologic examination.
Two of them did not manage to self-assess the
experiences of their latest gynecologic examination.
Table I. Background characteristics of respondents and non-
respondents.
There was a difference regarding the experiences of
their latest gynecologic examination (pź0.000)
Respondents of Non-
between the non-attendees who stated non-atten-
questionnaire respondents
dance due to experiences of discomfort associated
(nź133) (nź122) P
with the gynecologic examination and those who
Age
stated other reasons (Figure 3).
Mean (SD) 48 (10.8) 48.5 (10.9) 0.55a
Sixteen and a half percent (nź22) of the non-
n (%) n (%)
attendees reported a history of sexual abuse. The
28 49 75 (56) 61 (50) 0.307b
50 65 58 (44) 61 (50) non-attendees added excuses to their answer and
seemed to feel a need to minimize their experiences
Education
of abuse, and some non-attendees spontaneously
Primary school 35 (26)
Secondary school 58 (44)
reported that they had received help to get over the
College/university 40 (30)
trauma for example by stating:   I have only been
Civil status raped once and it counts for nothing  ,   I have
Living with partner 77 (58)
received help for this so it doesn t bother me any
Single 56 (42)
more  . The most common reason for non-atten-
Parity
dance among those non-attendees was experiences of
Nulliparous 27 (20)
discomfort associated with the gynecologic examina-
Parous 106 (80)
tion (nź7). However, there were no differences
Smoker
regarding non-attendance due to experiences of
Yes 51 (38)
discomfort associated with the gynecologic examina-
No 82 (62)
tion between non-attendees who had no history of
Cervical smear history nź121* nź110*
sexual abuse and those who had. Thus, hypothesis 3
No cervical smear 59 (49) 76 (69) 0.002b
was not confirmed.
during the previous
10 years
At least one cervical 62 (51) 34 (31)
Discussion
smear during the
previous 10 years
The most common reasons for non-attendance in the
a open question were lack of time, due to work and
Variance analysis.
b
family commitments, discomfort associated with the
Chi2.
*Women 28  32 years old were excluded. gynecologic examination, other diseases, and feeling
Table II. Distribution in number and percent of non-attendees reasons for non-attendance, (95% confidence interval).
Respondents of the questionnaire (nź133)
I do not attend cervical screening because . . . . n % 95% CI %
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.
28 M. G. Oscarsson et al.
Figure 3. Non-attendees (nź124) experiences of their latest gynecologic examination in relation to reason for non-attendance due to
discomfort in association with the gynecologic examination.
healthy. In the preset alternatives women reported medical discourse define health/illness and normal-
the following reasons: feeling healthy, experience of ity/pathology [40]. From a medical discourse per-
discomfort associated with the gynecologic examina- spective, the cervical screening is viewed as a
tion, and feelings of discomfort about seeking health good and preventive health service which tends to
care in general.   pathologize non-attendance  [41]. When compli-
One reason for non-attendance was that the non- ance with cervical screening is taken for granted,
attendees felt healthy. This reason could be judged women s reasons for non-attendance can be viewed
by the medical profession as ignorance or lack of as irrational from a medical perspective [42], but still
information, and confirms the result that non- as rational from the perspectives of the non-
attendees have poor knowledge of cervical screening attendees. Women s experiences, beliefs, and perso-
[11,16]. However, poor knowledge of cervical nal circumstances influence their decisions and their
screening has been reported not only among non- motivation [43].
attendees but among attendees as well [17,20,38,39]. Lack of time was another main reason for non-
In our study, the non-attendees appeared to be quite attendance in cervical screening; similar findings
well informed of the preventive nature of cervical were reported in a review [20]. In our study, lack of
screening, but the value of cervical screening to time embraced factors related to work, caring for
improve health does not outweigh the total efforts to children, family commitments, and hospital visits in
attend and they justified this with the experience of relation to other diseases. The non-attendees found it
feeling healthy. This could be a consequence of the hard to prioritize cervical screening before these
differences between how the non-attendees and the other demands. This cannot only be explained as a
Non-attendance in cervical screening 29
problem related to the individual but can also be get over the trauma. Despite this result, 16.5% of the
explained by the structure of society. Women take a non-attendees in this study stated a history of sexual
great responsibility for housework and children in abuse. We agree with the recommendations which
addition to their work outside home, and this might propose examiners to inquire about prior experiences
affect their concern about their own health. As our of gynecologic examinations and sexual abuse to
study was performed in a rural area, the non- avoid re-tramautizing [28,44]. This might help to
attendees often had practical problems reaching the decrease the discomfort for sexually abused women
venue. Non-attendees reported difficulties atten- during gynecologic examinations.
ding a cervical screening when they had their home One strength of this study is that the sample includes
and work in different places and the cervical screen- non-attendees, women who are highly resistant to
ing in a third place. Such circumstances result in repeated proposals to attend cervical screening.
fairly high costs for attendance and loss of time. This Further, a low response rate was expected as these
might be an explanation why other studies [9,12,16] non-attendees should   by definition  be difficult to
show that non-attendance is higher among women reach [15,49], and unwilling to discuss attendance
who live in rural or semi-rural areas than women in at cervical screening. Therefore, a 52% response
urban areas. rate may be considered satisfactory. Another strength
Our results showed that experiences of discomfort is that the study is based on a random sample of
associated with the gynecological examination were a non-attendees from a register data of cervical
frequent reason for non-attendance, which supports smears.
earlier results [16 18]. Even if women have tolerance In conclusion, it seems as non-attendees did not
[44], and a positive attitude to gynecologic examina- attend cervical screening as they felt healthy, and
tion in general [24], embarrassment, humiliation, thereby did not give time to preventive efforts.
and shame are feelings expressed by women when Despite acceptance of the value of the cervical
describing their experiences of these examinations screening, earlier experiences,for example discomfort
[24,45].We found no association, however, between with their latest gynecologic examination,may guide
young age and non-attendance due to experiences of their decision not to attend cervical screening.
discomfort associated with the gynecological exam- Women with few or no cervical smears constitute a
ination. One explanation could be that the non- risk group for future cervical cancer. The question is
attendees in our study were aged 28 or older and whether to make any effort to promote attendance
could be expected to have had several previous or to accept their choice of non-attendance. This
gynecological examinations. Women who have had points to an ethical dilemma: to acknowledge the
repeated examinations seem to accept the discomfort women s autonomy versus the medical desirability of
during the gynecological examination to a greater a high attendance rate.
extent [45] than younger women and adolescents,
who have had their first gynecological examination
Acknowledgments
[24,46,47].
There was a difference in the experience of dis- We are grateful to the women who participated in the
comfort during the latest gynecologic examination study and to Alan Crozier for revising the English.
between non-attendees who reported non-attendance Special thanks to Olle Ericsson for statistical advice,
due to experiences of discomfort associated with the Gunnar Thorbert and Lennart Mellblom, for fruitful
gynecologic examination and those who stated other cooperation, and Gunnel Nyberg for support with
reasons. Earlier negative experiences during the gyne- register data. The study was funded by the Swedish
cologic examination may influence non-attendee s Research Council.
non-attendance at cervical screening. The result of
this study may indicate the importance of strategies
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Non-attendance in cervical screening 31
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.