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Cervical screening participation rates - what influences them

The impression that foreign-born women in Sweden more often are excluded from gynecological cancer screening needs to be reconsidered. A study from Sahlgrenska Academy, published in the journal PLOS One, makes it clear that foreign-born women participate to the same extent as women born in Sweden with a corresponding educational level and income.

"This came as a surprise to us. The difference in participation disappeared in large immigrant populations, such as those from the Middle East and Latin America, when women with the same socioeconomic status were compared with Swedish-born women," says Björn Strander, gynecologist and lead researcher in the study.

"For other immigrant groups - from Europe, for example - the difference decreased significantly. This may mean that the differences in participation do not depend as much on culture and language comprehension as we might have imagined, but rather that social inequality is the main reason," he says.

In Sweden women are offered regular gynecological cancer screening with the aim of early detection and treatment of cell changes that can lead to cervical cancer. This organized screening has been going on since the 1960s and has led to a sharp reduction in the number of cancer cases.

The current study examines background factors among women in Sweden who have chosen to participate in the screenings and those who failed to do so. The study is the largest of its kind in the world, with combined registry data on a total of 581,008 women. It has been done in collaboration with researchers at Karolinska Institutet.

That women with higher education and income participated more often was less sensational than the fact that country of birth in itself often was not a factor. Another result is the great importance of where in Sweden the women lived. County councils such as Dalarna, Kalmar and Västernorrland had a significantly lower proportion of non-participants than Kronoberg, Skåne, Stockholm and Uppsala, for example.

"Since we could compensate for differences in population structure by making statistical adjustments for income, education, country of birth and other factors, this indicates that the way county councils have organized activities has great significance," says Björn Strander.

Björn, who also chairs the national working team for prevention of cervical cancer, emphasizes that many county councils are actively engaged in encouraging participation in screening.

He believes that the ongoing transition to a new national health care program for gynecological cancer screening - with flexible rescheduling of appointments, more notices and phone calls to those who fail to respond, opportunities for self-testing at home, more telephone advice and so on - will raise participation rates.

"When the care program is introduced in the county councils, it will be easier for many women to participate and the differences across the country will even out," says Björn.



Cervical screening programs are highly protective for cervical cancer, but only for women attending screening procedure.


Identify socio-economic and demographic determinants for non-attendance in cervical screening.


Design: Population-based case-control study.

Setting: Sweden.

Population: Source population was all women eligible for screening. Based on complete screening records, two groups of women aged 30–60 were compared. The case group, non-attending women, (N = 314,302) had no smear registered for 6–8 years. The control group (N = 266,706) attended within 90 days of invitation.

Main outcome measures: Risk of non-attendance by 9 groups of socioeconomic and demographic variables.

Analysis: Unadjusted odds ratios (OR) and OR after adjustment for all variables in logistic regression models were calculated.


Women with low disposable family income (adjOR 2.06; 95% confidence interval (CI) 2.01–2.11), with low education (adjOR 1.77; CI 1.73–1.81) and not cohabiting (adjOR 1.47; CI 1.45–1.50) were more likely to not attend cervical screening. Other important factors for non-attendance were being outside the labour force and receiving welfare benefits. Swedish counties are responsible for running screening programs; adjusted OR for non-participation in counties ranged from OR 4.21 (CI 4.06–4.35) to OR 0.54 (CI 0.52–0.57), compared to the reference county. Being born outside Sweden was a risk factor for non-attendance in the unadjusted analysis but this disappeared in certain large groups after adjustment for socioeconomic factors.


County of residence and socio-economic factors were strongly associated with lower attendance in cervical screening, while being born in another country was of less importance. This indicates considerable potential for improvement of cervical screening attendance in several areas if best practice of routines is adopted.

Content updated January 2018

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