Introduction
Cervical cancer screening (CCS) targets the reduction of cervical cancer incidence and mortality rates [1]. Unfortunately, in Eastern Europe cervical cancer is still a considerable public health problem, with high cancer incidence and low rates of CCS participation [2]. Differences in cervical cancer mortality trends can be plausibly explained by the differences in screening uptake [3].
Cervical cancer screening participation is influenced by women’s beliefs. Perceived psychosocial barriers are among commonly listed psychosocial determinants of CCS uptake [4]. Perceived barriers predicted performance of 48 different health-related behaviors (including CCS) across 100 different populations [5]. The balance between perceived psychosocial barriers and facilitating factors prompts individuals to form a strong intention and then to act upon the intention [4]. Perceived barriers may refer to the characteristics of the individual (e.g., emotions, skills, self-evaluations), as well as the social (e.g., communication with health professionals) and physical environment (e.g., perceived distance to CCS facilities) [4, 6].
Research evaluating the prevalence of perceived psychosocial barriers and their role in CCS uptake yielded diverse conclusions. Systematic reviews aim at integrating and synthesizing the accumulated results by means of collating empirical evidence which fits pre-specified eligibility criteria, using explicit, replicable search and evaluation methods, selected to minimize biases [7]. In sum, systematic reviews allow for a summary of overarching findings after appraising the available evidence [7].
Applying the systematic review strategies, our study aims at integrating research discussing the role of perceived psychosocial barriers in CCS uptake. In particular, we analyzed the evidence for the associations between CCS uptake and perceived psychosocial barriers of any types, and types and frequency of psychosocial barriers identified by women residing in European, North American or Australian continents.
Material and methods
Search procedure
A systematic search of peer-reviewed journal papers published until 2011 was conducted in PsycINFO, PsychArticles, Health Source: Nursing/Academic Edition, Medline, and ScienceDirect. Applied key-words referred to CCS behavior (e.g., “cervical cancer screening”) and barriers. No language restrictions were applied. Manual searches of the reference lists were conducted to identify additional sources. Two reviewers independently screened identified studies (k = 655). The search strategies, data abstraction and synthesis used systematic reviews’ guidelines [7]. All steps were conducted by two researchers to reduce biases; any discrepancies were resolved by the consensus method [7].
Inclusion and exclusion criteria, categorizing, and data synthesis
The following research was excluded: studies with less than 50 participants, narrative reviews, dissertations, book chapters, studies conducted in Africa, Asia and South America (cultural/health system differences may influence the results [8]), research on objective economic indicators (e.g., actual income), research on ethnic minorities, immigrants, homeless populations. Studies with multicomponent interventions (i.e., interventions combining psychosocial barriers and other components) were excluded. If two or more studies used the same dataset, only one investigation was included. The screening process resulted in selecting 71 publications.
In the next step, the quality assessment was conducted using the quality evaluation tool [9], which allows one to investigate whether original studies adhere to 14 quality criteria, referring to objectives, methods, analyses, confounders, and results. The concordance coefficients for quality assessment were high ( ≥ 0.71, ps < 0.01). Descriptive data were extracted and verified by two reviewers. In sum, 48 studies met > 65% of quality criteria [9] and were further analyzed.
For the purpose of data presentation 10 broader barrier categories were proposed, referring to:
• the physical environment (CCS facilities),
• individual characteristics (perceived CCS-related financial expenses, time management, other priorities, CCS perceived as not needed, threat related to CCS results, emotional barriers, CCS awareness),
• social characteristics (a lack of social support, past experiences with health professionals).
Applying meta-analysis was not possible due to heterogeneity of methods. Thus, our analysis focuses on identifying significant findings, replicated in at least 2 studies.
Results
Analyzed studies predominantly applied correlational design (89.6%, k = 43), with 10.4% (k = 5) using experimental design (Table 1). Data from 155,954 women were analyzed (M = 3249.04, SD = 10832.75, minimum: 62, maximum: 66,425). The majority of studies were conducted in the U.S. (66.7%), 8.3% were conducted in Australia, 8.3% in Western Europe, and 10.4% in Eastern Europe. Across studies, 39.6% enrolled participants from the general adult population, 23.7% focused on women without valid CCS, and 23.7% focused on women aged 40+.
Experimental research indicated a significant positive effect of psychosocial barriers interventions on the main outcome in 75% of studies, resulting in an increase of CCS uptake (Table 1). The overall effects were small (Cohen’s d < 0.19), with the largest study (17 008 participants) showing only a 1% increase of CCS participation. All interventions addressed mixed types of barriers. Therefore the identification of barriers responsible for the observed effect is not possible.
Across correlational research, 41.9% (k = 18) analyzed associations between psychosocial barriers and CCS. Overall, 100% of studies which analyzed barrier–CCS relationships indicated that perceiving lower relevance of barriers significantly predicted CCS uptake. The remaining 51.1% of studies focused on eliciting frequently reported barriers, without analyzing barrier–CCS associations.
Overall, 53 psychosocial barriers were listed in at least 2 original correlational studies. Five barriers were related to CCS facilities/environment, 36 dealt with personal characteristics, and 12 addressed social factors. Table 2 displays a summary of barriers elicited in the review.
Cervical cancer screening facilities-related perceived barriers referred to: long distance/transportation to CCS facilities (25.6% of correlational studies listed this barrier), difficulties in making a feasible appointment (18.6%), long waiting time (7.0%), long lines (4.7%), and discomfort if CCS is done at the workplace (4.7%).
Personal barriers referring to time management included: no childcare (11.6% of studies), tendencies to procrastinate (11.6%), a lack of time for CCS (9.3%), perceiving CCS as time-consuming (4.7%), and bad weather causing delays (4.7%). Additional costs, related to CCS uptake, were indicated in 23.3% of studies. Barriers related to other priorities included: having other diseases (16.3%), having other priorities (16.3%), and other personal problems (7.0%). The following barriers referring to beliefs that CCS is not needed were elicited: CCS is not needed if there are no symptoms (11.6%), overall no need for CCS (9.3%), not needed for women my age (4.7%), CCS not needed if there is no sexual activity (4.7%), CCS not important (4.7%). Awareness-related barriers included: difficulties in obtaining reliable CCS information (9.3%), a lack of awareness about the need for CCS (7.0%), and confusing CCS information (7.0%). Two remaining barrier categories dealt with emotional aspects. The first one referred to CCS results: beliefs that it may be too late to apply successful treatments (11.6%), being afraid of detecting other diseases (7.0%), unwillingness to learn if results indicate diseases (7.0%), any results perceived as emotionally disturbing (7%), no trust in CCS results (4.7%), being afraid of bad news (4.7%), avoiding problems if CCS is not performed (4.7%), and being afraid of any CCS results (4.7%). Other emotion-related barriers referred to CCS examination and included: shame (11.6%), being afraid of embarrassment (9.3%), embarrassment (9.3%), discomfort (9.3%), CCS being unpleasant (9.3%), being afraid of CCS (9.3%), pain (4.7%), not liking CCS (4.7%), touching during CCS being unpleasant (4.7%), being nervous during CCS (4.7%), and perceiving conversations about CCS as unpleasant (4.7%).
Perceived social barriers, referring to prior experiences with health professionals, included: prior CCS contacts perceived as an overall bad experience (16.3%), male physicians performing CCS (11.6%), CCS not recommended by a family physician (11.6%), unsatisfactory contacts with physicians (7.0%), a lack of women-friendly CCS facilities (4.7%), different physicians performing CCS (4.7%), a lack of CCS discussion with a physician (4.7%), unsatisfactory contacts with healthcare personnel (4.7%), being patronized (4.7%). Barriers referring to social support included: a lack of CCS-related support (4.7%), being afraid that others would learn about results (4.7%), family/friends are not supporting CCS participation (4.7%).
Research targeting women aged 40+ highlighted the importance of perceived problems with transportation/distance to CCS facilities and other diseases perceived as hindering CCS uptake. Both barriers were indicated in 55.6% of studies conducted among middle-to-older age women.
Discussion
The results of the systematic review suggest that perceiving psychosocial barriers is related to lower participation in CCS (100% of reviewed correlational studies). These associations were observed across different samples, such as adolescents, older women, economically disadvantaged groups, female doctors, patients with a chronic illness, women who performed CCS regularly, and those who did not perform CCS.
The majority of simple psychosocial interventions discussing perceived barriers affected CCS participation (75% of reviewed experimental studies). In particular, all interventions using leaflets/handouts or automated phone message resulted in a significant increase of CCS at follow-ups. A media-based campaign had a negligible influence on CCS participation. Importantly, the observed effects of these interventions were small.
In line with previous research [6], a broad range of psychosocial barriers was identified. The majority of barriers dealt with personal characteristics of women (67.9%). In particular, as many as 35.9% of perceived barriers referred to two categories, one referring to negative emotions evoked during CCS examination and the other focusing on negative emotions related to receiving CCS results. Notably, the next broadest category of barriers concerns prior contacts with health professionals (25.7%).
Our findings have some practical implications. Leaflets discussing dealing with barriers women perceive and ways of overcoming those barriers might be a powerful tool to increase CCS uptake and thus reduce cervical cancer mortality rates. Communication skills training for health professionals conducting CCS and primary care physicians may focus on psychosocial barriers reported by patients. Research suggested that compared to standard care, training physicians to discuss psychosocial barriers results in a higher likelihood of implementing health behavior change by their patients [57].
Several limitations of this systematic review result from issues identified in original studies. Trials applied various questionnaires, sampling, and analytical strategies, therefore the heterogeneity in the methodology hinders any conclusions. The character of samples adds to the heterogeneity of the results and limits conclusions about the most frequent type of barriers within specific subsamples. Regardless of the limitations, this systematic review provides an insight into the types of barriers perceived by women and their role in cervical cancer screening uptake.
Both authors were supported with a grant from the Foundation for Polish Science, Master Program.
The authors declare no conflict of interest.
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Address for correspondence
Prof. Aleksandra Luszczynska
Trauma, Health, & Hazards Center, University of Colorado
1861 Austin Bluffs Pkwy
80918 Colorado Springs, CO
United States
e-mail: aluszczy@uccs.edu
Submitted: 22.12.2012
Accepted: 16.07.2013
