Abstract
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Incidence
of cervical cancer has fallen dramatically since the introduction of the NHS
Cervical Cancer Screening Programme, yet this largely preventable disease
disproportionately affects women of lower socioeconomic status (SES). This
thesis set out to explore the evidence for, and possible mechanisms of,
socioeconomic inequalities in cervical screening uptake in England. Studies
1-3 were cross-sectional observational studies exploring the relationship
between routinely collected Primary Care Trust (PCT)-level cervical and
breast screening coverage and area-level deprivation, and testing for
associations between population- and programme-delivery characteristics and
cervical screening coverage. Study 4 used semistructured qualitative
interviews to explore the views of health professionals on the factors that
support or hinder cervical screening uptake. Study 5 used cross-sectional
observational survey data to assess whether perceived benefits of cervical
screening explained the association between SES and screening attendance.
Study 6 was a crosssectional, observational analysis of the relationship
between colposcopy attendance and area deprivation. Analysis of variance
showed no significant reduction in cervical screening inequalities from
2007-12 but an improvement in breast screening coverage among lower SES
women. Regression analyses revealed that population factors explained more of
the variation in PCT-level cervical screening coverage than did
programme-delivery factors. Health professionals considered programme-specific
factors to support, and population factors to hinder, cervical screening
participation. Women from lower SES backgrounds were more sceptical about the
benefits of cervical screening but these beliefs explained little of the
variance in screening attendance. Logistic regression analysis demonstrated
that although colposcopy attendance was high, it was lower in income-deprived
areas. This thesis demonstrated persistent SES inequalities in cervical
screening attendance despite efforts to address the problem, and delayed
uptake of colposcopy among women living in deprived areas. The work points
strongly to the influence of population factors in explaining variation in
cervical screening in women of all ages. Programme-delivery factors were also
important for screening uptake in younger women. Some PCTs (now CCGs), were
identified as exemplars of good practice and others as requiring further
support. Women of lower SES delay attendance at colposcopy appointments, but
earlier attendance may be achieved with support.
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