Evidence Behind Effective Cervical Screening and Colposcopy

The purpose of this essay is to consider some of the evidence that influences and supports Public Health England (PHE) NHS Cervical Screening Programme: Colposcopy and Programme Management (2016). According to Nursing and Midwifery Council (NMC) Code of Conduct (2015), nurses assess patients’ needs and deliver timely, efficient and effective patient care based on the best available evidence. Evidence Based Practice is the integration of best research evidence with nursing practice and patient needs and values to facilitate effective care, it also promotes quality, safe and cost-effective treatment for patients, families, healthcare providers and health care system (Brown, 2014; Craig and Smyth, 2012). This assignment aims to look at an area in nursing, identifying gaps between theory and practice. I will use research and discuss the evidence behind the guidelines as well as looking at overcoming related issues in the specified area. In addition, this assignment will also include an analytical reflection, analysing skills developed within finding the best evidence based practice for nursing.

Cervical Cancer begins in a women’s cervix and is when abnormal cells in the lining start to grow. Cervical intraepithelial neoplasia (CIN) or cervical dysplasia is the name given to the most common type of abnormal cells found during cervical screening (Macmillan, 2018). In the United Kingdom, there are 3,200 new cervical cancer cases each year (Cancer Research UK, 2014) and according to the Department of Health (DH) (2012a) detecting cervical cancer at an early stage can prevent around 75% from developing. Mishra et al. (2011) states that early detection and prevention of cervical cancer is cost effective and a long-term healthcare strategy. In addition, research studies show cervical screening to be associated with improved treatment for invasive cervical cancer (Andrae, et al 2012). Therefore, this brings attention to the importance of cervical screening programmes. Bennet (2017) states that ‘cervical screening is applicable to nursing care because nurses can make a huge difference in ensuring that patients have correct information to make informed decisions and choices about screening and in providing accessible services that make screening as easy as possible’. As nurses we must educate our patients through effective communication and by doing so gives patients a proactive role in their own healthcare (Brooks and Heath, 1985:8). Therefore, it is important for building patients' knowledge, understanding, and preparedness for self-management. Additionally, Bosch-Capblanch et al., (2009) believe that health promotion is essential to a nurse’s role and stated that ‘health promotion by nurses can lead to many positive health outcomes including adherence, quality of life, patients’ knowledge of their illness and self-management’.

The Guideline produced by Public Health England (2016) considers a number of different issues related to screening programme management and colposcopy. The guideline is intended for health professionals working in the NHS Cervical Screening Programme and providers of cervical screening services; to understand how different interventions supported by health professionals influences the health of individuals undergoing a cervical screening examination. The aim of the NHS Cervical Screening Programme (NHSCSP) is to reduce the incidence of and mortality from, cervical cancer through a systematic, quality assured population-based screening programme for eligible women. The scope of the guideline ranges from women aged 25-64 that live in England, Scotland, Wales and Northern Ireland.

Public Health England (2016) utilized various research methods such as quantitative and qualitative studies. The combination of qualitative and quantitative approaches to collecting research provides a more complete understanding of a research problem than either approach alone. The evidence within this guideline helps to give a better understanding on management of women in the NHS Cervical Screening Programme. The evidence focus is on prevention and identifying the problems within the NHSCSP as early as possible using a combination of policies and appropriate practice. In this section of the assignment, I will discuss some of the evidence within the guideline. In recommendation 5.2 PHE (2016) states, ‘Each woman should be offered verbal information and sent written information before and after cervical screening, and before colposcopy’. This recommendation is based on evidence by Swancutt et al. (2011) who conducted a qualitative in-depth interview with 18 women consisting of different ethnicities and aged 23-59 referred for colposcopy in the West Midlands, UK. Seers (2011) describes qualitative research as a ‘systematic and careful approach that aims to answer questions concerned with what something is like (such as a patient experience), what people think or feel about something that has happened, and it may address why something has happened as it has. Qualitative data often takes the form of words or text’. The interviews were designed to elicit the experience of colposcopy from the patients' perspective. Results suggest that effective information and communication are crucial to reducing anxiety. Pencak (2017) supports this and states that ‘you can help reduce or even avoid patient’s anxiety by listening to patients and introducing yourself and your role and orienting patients to whatever is to follow’. The results also suggested that women felt very apprehensive before their appointment, but when attending, appreciated being consulted about their preferences.

In addition, delays in referral and feeling 'rushed' by staff impacted negatively on women's experience. This sample size would be considered small as only 18 participants where used from a specific region within the United Kingdom. Therefore, this sample is very unrepresentative of the population. In addition, everyone has their own feelings and or emotions in specific situations therefore this evidence would be considered subjective as only personal perspectives, feelings, or opinions are used to come to a conclusion. In contrast, objective research refers to the elimination of subjective perspectives and a process that is purely based on facts (Glen, 2013).

An outside study from this guideline, Mortensen et al. (2010) supports the idea that verbal information and sent written information before and after cervical screening is important to reducing anxiety. Strengthening the idea that effective information and communication are crucial to reducing anxiety regarding cervical screening. Mortensen et al. (2010) conducted a qualitative study of women’s anxiety and information needs after a diagnosis of cervical dysplasia. The study consisted of a focus group and individual interviews with 12 Danish women diagnosed with different stages of cervical dysplasia. Interview guides were prepared on the basis of a literature review that identified important issues and questions for the participants. The evidence states that it is extremely important to address women’s fears, their need for information and to ensure better communication with medical practitioners about cervical screening and cervical dysplasia before and immediately after diagnosis. In comparison, both studies used qualitative research by conducting interviews with women in a healthcare setting. In contrast, Mortensen et al. (2010) used women aged 25-35 from Denmark whereas, Swancutt et al. (2011) used women aged 23-59 from West Midlands, UK. Swancutt et al. (2011) used a larger demographic of women which would enhance the results of the study as it provides a broader outlook of the topic of patient anxiety related to cervical screening. In addition, Mortensen et al. (2010) used a number of 12 participants within their study and Swancutt et al. (2011) used 18. The difference of 6 participants would not make a significant difference to the overall study and would be considered minimal to changing the results of the study. In conclusion it is stated in both studies that they would benefit from further research, as would work to identify strategies to reduce anxiety between referral and attendance for cervical screening and colposcopy.

Another piece of evidence referred to from this guideline in section 5.2.2 is an NHS Cancer Screening Programme publishing a guidance by Chui (2009). The Guidance is called ‘Promoting Informed Choices on Cancer Screening in a Diverse Community’ and is for healthcare providers and health promotors. The data within the guidance was collected via mixed methods such as quantitative and qualitative research from 2005 to 2008. The Objective of the guidance is to give healthcare professionals more information to the parameters of and limits of their role in promoting informed choice, specifically in diverse communities and individuals who are most vulnerable. The evidence of the study suggests that coverage is low in many black and minority ethnic communities. There are significant differences in awareness about cervical cancer across different groups. In addition, promoting informed choice and effective understanding of risk in a diverse community can help to improve understanding of and participation in cancer screening. However, this guidance does have some weaknesses as the evidence within the guidance is not an expert document on the topic of cancer or cancer screening. Furthermore, it does not offer a comprehensive and definitive view on risk communication and informed choice but rather suggestions based on evidence collected. Therefore, because of this it brings doubt to whether the information obtained may have been biased as no expert opinion was provided.

In comparison a study conducted by Marlow et al. (2015) supports the idea that coverage is low in many black and minority ethnic communities and that there are significant differences in awareness about cervical screening and cervical cancer across different groups. Moreover, strengthening the idea it is important for healthcare professionals to promote informed choice and effective understanding of risk in a diverse community can help to improve understanding of and participation in cancer screening. Marlow et al (2015) used quantitative and qualitative research and named the study ‘Understanding cervical screening non-attendance among ethnic minority women in England’. The attendance among 720 women from minority ethnic background and white British women was investigated and compared in difference. To clarify, ethnic minority are black, Asian and minority ethnicity (BAME). The results of the study show that ethnic minority women were less likely to attend cervical screening with 44-71% not attending compared to 12% white British women. The study also brings to attention and enhances Chui (2009) guidance that interventions are needed to improve knowledge and understanding of cervical cancer within ethnic minority communities, and investment in training for health professionals may improve experiences and encourage repeat attendance for all women. To conclude, from both studies culturally appropriate information should be made available for members of minority ethnic groups. Therefore, good practice dictates that patients should have their history taken and be counselled with an independent interpreter present (Karliner, et al 2007).

An additional piece of evidence referred to in this guideline in section 5.5 is a research article by Sanders et al. (1992) who focuses on factors influencing default at a hospital coloscopy clinic. Sanders et al. (1992) states that the ‘objective is to identify factors reducing compliance at diagnosis, treatment, and review stages among women referred with abnormal cervical smears to a hospital colposcopy clinic’. A retrospective analysis of sociodemographic data from hospital notes of the attenders and defaulters during one year (1989-90) was collected and a prospective collection of information by qualitative in-depth interviews of a sample of defaulters and attenders during a period of five months from May-September 1990 took place within a coloscopy clinic at Newcastle General Hospital. A number of 238 women that had defaulted on two appointments where used and 188 women attending regularly (collected via retrospective analysis) took place within the study. In addition, a number of 40 defaulters and 24 attenders participated in an in-depth qualitative interview. The interview contained open and closed questions and the answers were taped recorded.

Retrospective analysis is type of research method that is used when the result of an event is already known. Whereas, a prospective study is the opposite and the outcome of the study is unknown (Song, et al 2010). The results of the study show that a large proportion (93%) of the defaulters came from a gynaecology or antenatal clinic and a large number had childcare responsibilities. In addition, a lack of knowledge about coloscopy and staff attitudes where further reasons for defaulting on their appointment. To conclude, to decrease the number of women defaulting their appointments, health promotion by nurses to help women understand their treatment and encouraging health professionals to develop a sensitive attitude to the multiple requirements of women in different socioeconomic groups would be beneficial (Kumar, et al 2012). Overall, this study could be considered outdated as it was conducted in 1990, therefore PHE (2016) could have obtained more recent evidence to support their guideline. However, the findings of the study may still hold true in the contemporary world.

In comparison, a piece of evidence to support Sanders et al. (1992) is a British Medical Journal (BMJ) publishing a piece of medical research by Linde et al. (2018). The journal article focuses on causes of attendance and non-attendance to a follow-up cervical cancer screening among human papillomavirus (HPV)-positive women. It is important to note that British Medical Journal is an internationally recognised and respected peer reviewed medical journal (BMJ, 2018). Qualitative interviews were conducted with 15 women who had tested HPV-positive during a patient-initiated screening and been requested for a follow-up screening fourteen months later. The interviews took place in Tanzania, in a hospital setting. The results of the study show that the main benefit to a follow up screening is prevention of disease. The perceived screening challenges and reasons for non-attenders was lack of knowledge of HPV, emotional costs and fear of the examination process. These results can be supported by Wise (2019) who states that ‘women delay or fail to attend cervical screening appointments because of embarrassment and a fear of being hurt’. Both pieces of evidence obtained bring to attention the need to further health promotion by nurses. In addition, patients should be made to feel comfortable and be provided with the appropriate information to encourage non-attenders to attend their appointments (Wise, 2019).

I will now discuss barriers to cervical screening and how the recommendations that I have discussed may help in the up-take of screening. Firstly, ethnic minority women are less likely to attend cervical screening and awareness of cervical cancer and its preventions is lower amongst BAME women. According to Marlow et al. (2015) different perceptions and lack of awareness of cervical cancer within their communities were experienced by these women. In addition, a large proportion of BAME women do not recognise the term ‘cervical screening’ or ‘smear test’ (Jo’s Trust, 2016). Furthermore, women within the study felt fear and embarrassment and preferred a female health practitioner. To improve future practice, more information and support should be provided via support groups within a community setting to discuss screening. Addressing concerns such as embarrassment and shame could take place and acknowledgement of the importance of screening. Overall, reiterating earlier on in the essay, research collected by Marlow et al. (2015), investment in training for health professionals may improve experiences and encourage repeat attendance for all women.

An additional barrier is that women over the age of 50 face increased threat of cervical cancer and potential loss of life due to lack of understanding about prevention. According to research conducted by Cancer Research UK (2014) over one third of the cervical cancer diagnoses in England were in women over the age of 50. In addition, the number of older women (50-64) attending their cervical screening appointments is at a 20-year low (Brodersen, 2018). Lack of knowledge on the topic of cervical cancer and often perceived as a young women’s disease are massive contributing factors to why older women aged 50-64 are not attending cervical screening. As nurses, intervention to improve uptake would be beneficial by considering various approaches for women of different age groups to improve practice (Wardle, 2016). Furthermore, healthcare professional should help change the perception of cervical cancer and encourage older women to attend their screening appointments (Jo’s Trust, 2016).

In conclusion, I have researched and discussed the evidence behind PHE (2016) guideline as well as looking at overcoming related barriers in the specified area. The guideline created by PHE (2016) provides suitable information for healthcare professionals on the topic of cervical screening and coloscopy. Key findings within guideline suggest that further support and training is required by healthcare professionals to provide a more adequate and tailored approach to developing skills that can improve future practice. In addition, several barriers to cervical screening where identified within the guideline. Cervical cancer is preventable and simple to diagnose, and nurses can play an important role in improving cervical screening patient experience. Nurses should respect patients such as; allowing the patient to undress in private and to ensure informed consent before the procedure. In turn this could encourage the uptake of attendance within the cervical screening programme.