Institute of Epidemiology & Health Care


Understanding socioeconomic inequalities in cervical screening

Author E. Douglas
Author J. Wardle
Author J. Waller
Abstract 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.