Making Cervical Screening More Accessible

3713 words (15 pages) Essay

8th Feb 2020 Health Reference this

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I have based my evidence for practice assignment on Cervical Screening and making it more accessible to women. The aim of the assignment is to look at the evidence that supports a nurse in their role particularly around health promotion including increasing uptake of cervical screening. I will be using a relevant guideline which underpins my chosen topic and I will discuss the evidence that supports or contradicts it. I will also be highlighting any potential barriers and providing possible solutions. 

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Public Health England (2015) defines screening as the process that allows identification of individuals who may appear healthy but have an increased risk of a disease or a condition. The screening process has its flaws in every screen there are a number of false positives and false negatives.

Cervical screening; cytology; previously known as a Pap smear was first introduced in the 1980s and is usually performed by a Practice Nurse or GP, the screening is to detect early abnormal cell changes of the cervix, which if untreated could lead to cancer of the cervix. If the cell changes are identified early they can be treated to prevent the occurrence of invasive cancer. (NHS Choices, 2016). 

According to Cancer Research UK (2017) cervical screening is an important part of nursing practice as it’s a common cancer in the UK with around 3,200 women diagnosed every year; around 9 cases a day. This evidence also indicates that since the programme was introduced the number of women dying from cervical cancer has halved and it is estimated that screening saves around 4,500 lives every year in England.

Bennett (2017) states nurses can make a real difference in ensuring that women have accurate, reliable and up-to-date information to allow them to make informed decisions and choices about their care and whether or not to participate in screening. Bennett (2017) suggests nurses play a key role in being able to reassure a patient especially to eliminate any fear or embarrassment. It is important to make sure women understands screening is not a test for cancer but it is intended to detect abnormalities that could if left untreated develop into cervical cancer.

The National Institute for Health and Care Excellence (NICE, 2017) states the NHS Cervical Screening Programme (NHSCSP) aims to reduce the incidence of, and mortality from, cervical cancer through a systematic, quality assured population-based screening programme for eligible women. According to NICE (2017) the NHSCSP is available to women aged 25 to 64 in England. All eligible women who are registered with a GP automatically receive an invitation through the post. Women aged 25 to 49 receive invitations every 3 years and women aged 50 to 64 receive invitations every 5 years.

According to recent statistics published by NHS Digital (2017) the National Health Service has seen a decline in women attending for cervical screening and the number continues to decrease each year. Therefore, nurses have a vital role in promoting cervical screening, raising awareness and helping to reduce mortality rates.

Public Health England (2017) published guidance; Health matters: making cervical screening more accessible. The aim of this guidance is to look at the decline in attendance and present recommendations that can help increase access to screening and awareness of cervical cancer. Declining coverage of cervical screening not only has serious implications on diagnosis and mortality rates; it also has a large financial implication on the NHS.  

The Health matters: making cervical screening more accessible guidance published by PHE (2017) looks at the outcomes and impact of testing for the Human papillomavirus (HPV); which is to help manage women who have low grade abnormal cell changes and as a test of cure in women who have received treatment for abnormal cell changes on cervical cancer diagnosis and mortality rates. The World Health Organization (2018) states the Human papillomaviruses causes more than 99% of all cervical cancer cases.

Following on from a successful pilot scheme primary HPV testing is going to be introduced into the NHS Cervical Screening Program at some point next year. Public Health England (2018) states that all cervical screening samples will be tested for HPV first and will only go on to have cytology testing if HPV is found. According to PHE (2018) primary HPV testing has been shown to be a more effective screening test.

The guidance also looked at evidence surrounding whether screening age should be lowered but the evidence showed screening women before age 25 caused more harm than good as abnormal cell changes in the cervix develop more often than in older women but are much more likely to clear up by themselves.

The main issue highlighted in the guidance is around barriers to screening; not attending for cervical screening is one of the biggest risk factors for a woman to develop cervical cancer.

Some of the reasons found from women were:

  • Feeling embarrassed,
  • Worry surrounding the test itself or about the result,
  • Accessibility to screening (suitable times, female sample taker)
  • Cultural and Language barriers
  • Lack of understanding or education around cervical cancer and HPV.

NICE (2017) supports the NHSCSP and has produced pathways for practitioners to follow.

A qualitative study that was done on barriers to cervical cancer screening among ethnic minority women; compared to white British women conducted by Marlow et al (2017) was based in London, 43 women from a range of ethnic minority backgrounds including Indian, Pakistani, Bangladeshi, Caribbean, African, Black British and 11 White British women were interviewed which were recorded to allow for analysis. Results showed 15 women had delayed screening or had never been screened. Ethnic minority women felt that there was a lack of awareness about cervical cancer and several women did not recognise the terms ‘cervical screening’ or ‘smear test’. Barriers to cervical screening raised by all women were emotional including embarrassment and shame, practical including lack of appointments and suitable times and cognitive including women perceiving themselves as low risk and having no symptoms. Some of the emotional barriers were more prominent among Asian women. The study also found that women were not identified as non-attenders at the outset and most had previously attended cervical screening appointments.

The NHSCSP suggests that around 9% of women have never been screened; however this study only found one woman that had never attended for cervical screening. These findings are likely to represent women who intend to undergo screening but put it off or delay it, rather than women who have made a decision to not have screening.

The Health matters: making cervical screening more accessible guidance published by PHE (2017) suggests there is a need for GP practices and other services that offer cervical screening to provide a variation of appointment times throughout the day including evening and weekend appointments as this will then enable women to choose when they can attend for screening, as limiting access to screening appointments can impact on uptake. Whereas the above qualitative study done  by Marlow et al (2017) suggested this is not being done as it was highlighted as one of the practical barriers for women not attending screening.

In a further qualitative study done by Hewison et al (2017) involving nine focus groups and 15 individual interviews in the UK, it looked at a patient’s perspective on information and choice in cancer screening. The study found that information about the disease was as important as the risks and limitations. The study highlighted that women who were invited for screening had little or no knowledge of risks factors or symptoms to be aware of. Women felt that if they did not attend screening after receiving the invitation then they would be viewed as a “bad patient” by the GP practice. Women also expressed feeling of worry and anxiety about the test itself and the results.

The main result of the study done by Hewison et al (2017) was the difference in perspective around patients making an informed choice. The Health matters: making cervical screening more accessible guidance published by PHE (2017) advised the need for all local authorities to raise awareness around cervical screening, it states it is a necessity that a patient has awareness as this is the first stage before behaviour can occur; awareness is essential to allow a patient to have informed choice. However, Public Health England (2017) states half (44%) of local authorities have not undertaken any activities to increase screening attendance in the last two years. The evidence suggests that there would be a great impact on a nurse’s role especially around health promotion. Nurses need to make use of the government’s initiative of making every contact count; nurses should be asking every woman of the correct age if they are up to date with cervical screening and if not; why not, highlighting potential changes they could make to facilitate uptake. Also the fact that a high proportion of local authorities are not supporting initiatives to raise awareness around cervical screening suggests that nurse face an even tougher job as there maybe issues around education and training or a lack of allocated funding.

Qualitative research identified some practical factors that influenced uptake of cervical screening but still has not provided a complete explanation for women not attending. If healthcare professionals had a better understanding of determinants to screening uptake this would then allow for nurse interventions such as an increase in health promotion and new methods to be developed in nursing practice.

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Public Health England (2015) state cervical screening works well but like any screening test it has its flaws. There have been cases where patients tested positive for abnormal changes that were not really there; a false positive result. This leads to unnecessary worry for the patient and also further tests. Alternatively, there is also a risk that cell changes our missed; a false negative result. It is difficult sometimes to tell whether changes in the cervix will return to normal or will develop into cancer which leads to women having treatment for changes that would not have caused any harm if left alone; over diagnosis or overtreatment. According to Jo’s Cervical Cancer Trust (2017) treatment itself may cause problems for women; such as bleeding afterwards, plus there is an increase in women giving birth prematurely in any future pregnancies. Nurses can help in their roles as patient advocates and health promoter’s to ensure women are able to make an informed decision; insuring they have all the necessary information and by providing reassurance.

After reading the guideline and looking at the evidence it is apparent that the cervical screening program does save lives but barriers prevent its effectiveness. In recent surveys conducted by Jo’s Cervical Cancer Trust (2017) some of the following barriers became apparent.

Women have emotional barriers such as fear, shame, embarrassment and feeling nervous, women stated they did not feel the need to attend screening as they considered themselves low risk. Women from certain ethnic minorities stated they had not heard of cervical screening, did not understand what it was for or why it was important. Cultural practices, beliefs and assumptions influenced a woman’s understanding of cancer and prevention; also differences in relation to a person’s attitude towards health checks.

Women considered both the personal relevance and the value of screening when deciding whether they should attend. Women who had previously had a negative experience stated it informed their decisions about future participation and attendance for screening. It is part of a nurse’s role to spread positive messages about health and the idea of making every contact with a patient provides an opportunity to talk about how patients can make small changes to improving their health and also allows patients to express any concerns they may have, this is very important.

Women who wanted to attend screening appointments struggled to find time especially outside working hours. Other barriers include the lack of available appointments; women preferred to see a female nurse and felt appointments were not flexible enough. A possible solution to this would be to allow extended access clinics in the evening and weekends for cervical screening, this would increase the likelihood of a woman attending for screening if appointments were more accessible and convenient; the problem with this would be around funding for these sessions.

After reading the evidence around potential barriers I feel the main issue highlighted and something that could be a potential solution is the need to educate women. If women had better knowledge about the test and understood its importance this could encourage them to attend the screening, as patient advocates it’s important to give patients all the facts to allow them to make an informed decision, this applies to screening if women were more aware of the benefits of cervical screening and understood fully then in turn there should be an increase in the uptake of cervical smear tests.

Reflection

Once I completed this assignment and allowed myself time to reflect on the process I had taken to complete this it, it became evident that evidence based practice supports the research and knowledge that underpins nursing care to be able to provide the best practice and to enable a nurse to provide the best care for their patients using available, reliable and up to date evidence.

Evidence-based practice is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise including a patient’s preferences and their values. When delivered properly and efficiently the highest quality of care can be delivered resulting in positive patient outcomes. (Melnyk et al., 2010)

The Nursing and Midwifery Council (2015) states registered nurses require the confidence and ability to think critically, apply knowledge and skills, and provide expert, evidence-based and direct nursing care.

I have learnt it is important to make sure that the evidence applied is of the most up to date available to ensure patient safety, and I understand the need for care to be delivered in such ways and for it to be updated regularly is essential for a nurse to work competently. I understand the importance of being up to date with the relevant evidence and research, and how this can contribute to improved patient outcomes, higher quality care and greater nurse satisfaction. It is also important to read as much as possible as this will increase my own knowledge further.

This assignment has made me question and think critically why as Nurses we do certain things in certain ways in practice; I am now able to research and find the reasons and the evidence that underpins it. I am able to narrow down my literature searches and locate evidence that is specific to my chosen topic or area of interest; this in turn has highlighted the rationale behind the use of evidence based practice.

I feel an area that I can further develop is to gain further insight and knowledge into the different types of research studies and how they are applied, for example quantitative, qualitative research and systematic review; and their effectiveness.

Upon completion of this assignment I feel I have gained valuable knowledge and skills and feel more competent as a nurse in providing best practice with the evidence to underpin this.

Even as a student it is never too early to start thinking like a nurse who is driven by evidence-based practice, if we learn evidence-based interventions then patient outcomes can be improved. We can provide high quality care, reduce costs and eliminate practices that have become obsolete or are not effective. As a student nurse and once qualified I will be continually learning, and it is essential to build evidence-based knowledge over a period of time.

 

Reference List

I have based my evidence for practice assignment on Cervical Screening and making it more accessible to women. The aim of the assignment is to look at the evidence that supports a nurse in their role particularly around health promotion including increasing uptake of cervical screening. I will be using a relevant guideline which underpins my chosen topic and I will discuss the evidence that supports or contradicts it. I will also be highlighting any potential barriers and providing possible solutions. 

Public Health England (2015) defines screening as the process that allows identification of individuals who may appear healthy but have an increased risk of a disease or a condition. The screening process has its flaws in every screen there are a number of false positives and false negatives.

Cervical screening; cytology; previously known as a Pap smear was first introduced in the 1980s and is usually performed by a Practice Nurse or GP, the screening is to detect early abnormal cell changes of the cervix, which if untreated could lead to cancer of the cervix. If the cell changes are identified early they can be treated to prevent the occurrence of invasive cancer. (NHS Choices, 2016). 

According to Cancer Research UK (2017) cervical screening is an important part of nursing practice as it’s a common cancer in the UK with around 3,200 women diagnosed every year; around 9 cases a day. This evidence also indicates that since the programme was introduced the number of women dying from cervical cancer has halved and it is estimated that screening saves around 4,500 lives every year in England.

Bennett (2017) states nurses can make a real difference in ensuring that women have accurate, reliable and up-to-date information to allow them to make informed decisions and choices about their care and whether or not to participate in screening. Bennett (2017) suggests nurses play a key role in being able to reassure a patient especially to eliminate any fear or embarrassment. It is important to make sure women understands screening is not a test for cancer but it is intended to detect abnormalities that could if left untreated develop into cervical cancer.

The National Institute for Health and Care Excellence (NICE, 2017) states the NHS Cervical Screening Programme (NHSCSP) aims to reduce the incidence of, and mortality from, cervical cancer through a systematic, quality assured population-based screening programme for eligible women. According to NICE (2017) the NHSCSP is available to women aged 25 to 64 in England. All eligible women who are registered with a GP automatically receive an invitation through the post. Women aged 25 to 49 receive invitations every 3 years and women aged 50 to 64 receive invitations every 5 years.

According to recent statistics published by NHS Digital (2017) the National Health Service has seen a decline in women attending for cervical screening and the number continues to decrease each year. Therefore, nurses have a vital role in promoting cervical screening, raising awareness and helping to reduce mortality rates.

Public Health England (2017) published guidance; Health matters: making cervical screening more accessible. The aim of this guidance is to look at the decline in attendance and present recommendations that can help increase access to screening and awareness of cervical cancer. Declining coverage of cervical screening not only has serious implications on diagnosis and mortality rates; it also has a large financial implication on the NHS.  

The Health matters: making cervical screening more accessible guidance published by PHE (2017) looks at the outcomes and impact of testing for the Human papillomavirus (HPV); which is to help manage women who have low grade abnormal cell changes and as a test of cure in women who have received treatment for abnormal cell changes on cervical cancer diagnosis and mortality rates. The World Health Organization (2018) states the Human papillomaviruses causes more than 99% of all cervical cancer cases.

Following on from a successful pilot scheme primary HPV testing is going to be introduced into the NHS Cervical Screening Program at some point next year. Public Health England (2018) states that all cervical screening samples will be tested for HPV first and will only go on to have cytology testing if HPV is found. According to PHE (2018) primary HPV testing has been shown to be a more effective screening test.

The guidance also looked at evidence surrounding whether screening age should be lowered but the evidence showed screening women before age 25 caused more harm than good as abnormal cell changes in the cervix develop more often than in older women but are much more likely to clear up by themselves.

The main issue highlighted in the guidance is around barriers to screening; not attending for cervical screening is one of the biggest risk factors for a woman to develop cervical cancer.

Some of the reasons found from women were:

  • Feeling embarrassed,
  • Worry surrounding the test itself or about the result,
  • Accessibility to screening (suitable times, female sample taker)
  • Cultural and Language barriers
  • Lack of understanding or education around cervical cancer and HPV.

NICE (2017) supports the NHSCSP and has produced pathways for practitioners to follow.

A qualitative study that was done on barriers to cervical cancer screening among ethnic minority women; compared to white British women conducted by Marlow et al (2017) was based in London, 43 women from a range of ethnic minority backgrounds including Indian, Pakistani, Bangladeshi, Caribbean, African, Black British and 11 White British women were interviewed which were recorded to allow for analysis. Results showed 15 women had delayed screening or had never been screened. Ethnic minority women felt that there was a lack of awareness about cervical cancer and several women did not recognise the terms ‘cervical screening’ or ‘smear test’. Barriers to cervical screening raised by all women were emotional including embarrassment and shame, practical including lack of appointments and suitable times and cognitive including women perceiving themselves as low risk and having no symptoms. Some of the emotional barriers were more prominent among Asian women. The study also found that women were not identified as non-attenders at the outset and most had previously attended cervical screening appointments.

The NHSCSP suggests that around 9% of women have never been screened; however this study only found one woman that had never attended for cervical screening. These findings are likely to represent women who intend to undergo screening but put it off or delay it, rather than women who have made a decision to not have screening.

The Health matters: making cervical screening more accessible guidance published by PHE (2017) suggests there is a need for GP practices and other services that offer cervical screening to provide a variation of appointment times throughout the day including evening and weekend appointments as this will then enable women to choose when they can attend for screening, as limiting access to screening appointments can impact on uptake. Whereas the above qualitative study done  by Marlow et al (2017) suggested this is not being done as it was highlighted as one of the practical barriers for women not attending screening.

In a further qualitative study done by Hewison et al (2017) involving nine focus groups and 15 individual interviews in the UK, it looked at a patient’s perspective on information and choice in cancer screening. The study found that information about the disease was as important as the risks and limitations. The study highlighted that women who were invited for screening had little or no knowledge of risks factors or symptoms to be aware of. Women felt that if they did not attend screening after receiving the invitation then they would be viewed as a “bad patient” by the GP practice. Women also expressed feeling of worry and anxiety about the test itself and the results.

The main result of the study done by Hewison et al (2017) was the difference in perspective around patients making an informed choice. The Health matters: making cervical screening more accessible guidance published by PHE (2017) advised the need for all local authorities to raise awareness around cervical screening, it states it is a necessity that a patient has awareness as this is the first stage before behaviour can occur; awareness is essential to allow a patient to have informed choice. However, Public Health England (2017) states half (44%) of local authorities have not undertaken any activities to increase screening attendance in the last two years. The evidence suggests that there would be a great impact on a nurse’s role especially around health promotion. Nurses need to make use of the government’s initiative of making every contact count; nurses should be asking every woman of the correct age if they are up to date with cervical screening and if not; why not, highlighting potential changes they could make to facilitate uptake. Also the fact that a high proportion of local authorities are not supporting initiatives to raise awareness around cervical screening suggests that nurse face an even tougher job as there maybe issues around education and training or a lack of allocated funding.

Qualitative research identified some practical factors that influenced uptake of cervical screening but still has not provided a complete explanation for women not attending. If healthcare professionals had a better understanding of determinants to screening uptake this would then allow for nurse interventions such as an increase in health promotion and new methods to be developed in nursing practice.

Public Health England (2015) state cervical screening works well but like any screening test it has its flaws. There have been cases where patients tested positive for abnormal changes that were not really there; a false positive result. This leads to unnecessary worry for the patient and also further tests. Alternatively, there is also a risk that cell changes our missed; a false negative result. It is difficult sometimes to tell whether changes in the cervix will return to normal or will develop into cancer which leads to women having treatment for changes that would not have caused any harm if left alone; over diagnosis or overtreatment. According to Jo’s Cervical Cancer Trust (2017) treatment itself may cause problems for women; such as bleeding afterwards, plus there is an increase in women giving birth prematurely in any future pregnancies. Nurses can help in their roles as patient advocates and health promoter’s to ensure women are able to make an informed decision; insuring they have all the necessary information and by providing reassurance.

After reading the guideline and looking at the evidence it is apparent that the cervical screening program does save lives but barriers prevent its effectiveness. In recent surveys conducted by Jo’s Cervical Cancer Trust (2017) some of the following barriers became apparent.

Women have emotional barriers such as fear, shame, embarrassment and feeling nervous, women stated they did not feel the need to attend screening as they considered themselves low risk. Women from certain ethnic minorities stated they had not heard of cervical screening, did not understand what it was for or why it was important. Cultural practices, beliefs and assumptions influenced a woman’s understanding of cancer and prevention; also differences in relation to a person’s attitude towards health checks.

Women considered both the personal relevance and the value of screening when deciding whether they should attend. Women who had previously had a negative experience stated it informed their decisions about future participation and attendance for screening. It is part of a nurse’s role to spread positive messages about health and the idea of making every contact with a patient provides an opportunity to talk about how patients can make small changes to improving their health and also allows patients to express any concerns they may have, this is very important.

Women who wanted to attend screening appointments struggled to find time especially outside working hours. Other barriers include the lack of available appointments; women preferred to see a female nurse and felt appointments were not flexible enough. A possible solution to this would be to allow extended access clinics in the evening and weekends for cervical screening, this would increase the likelihood of a woman attending for screening if appointments were more accessible and convenient; the problem with this would be around funding for these sessions.

After reading the evidence around potential barriers I feel the main issue highlighted and something that could be a potential solution is the need to educate women. If women had better knowledge about the test and understood its importance this could encourage them to attend the screening, as patient advocates it’s important to give patients all the facts to allow them to make an informed decision, this applies to screening if women were more aware of the benefits of cervical screening and understood fully then in turn there should be an increase in the uptake of cervical smear tests.

Reflection

Once I completed this assignment and allowed myself time to reflect on the process I had taken to complete this it, it became evident that evidence based practice supports the research and knowledge that underpins nursing care to be able to provide the best practice and to enable a nurse to provide the best care for their patients using available, reliable and up to date evidence.

Evidence-based practice is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise including a patient’s preferences and their values. When delivered properly and efficiently the highest quality of care can be delivered resulting in positive patient outcomes. (Melnyk et al., 2010)

The Nursing and Midwifery Council (2015) states registered nurses require the confidence and ability to think critically, apply knowledge and skills, and provide expert, evidence-based and direct nursing care.

I have learnt it is important to make sure that the evidence applied is of the most up to date available to ensure patient safety, and I understand the need for care to be delivered in such ways and for it to be updated regularly is essential for a nurse to work competently. I understand the importance of being up to date with the relevant evidence and research, and how this can contribute to improved patient outcomes, higher quality care and greater nurse satisfaction. It is also important to read as much as possible as this will increase my own knowledge further.

This assignment has made me question and think critically why as Nurses we do certain things in certain ways in practice; I am now able to research and find the reasons and the evidence that underpins it. I am able to narrow down my literature searches and locate evidence that is specific to my chosen topic or area of interest; this in turn has highlighted the rationale behind the use of evidence based practice.

I feel an area that I can further develop is to gain further insight and knowledge into the different types of research studies and how they are applied, for example quantitative, qualitative research and systematic review; and their effectiveness.

Upon completion of this assignment I feel I have gained valuable knowledge and skills and feel more competent as a nurse in providing best practice with the evidence to underpin this.

Even as a student it is never too early to start thinking like a nurse who is driven by evidence-based practice, if we learn evidence-based interventions then patient outcomes can be improved. We can provide high quality care, reduce costs and eliminate practices that have become obsolete or are not effective. As a student nurse and once qualified I will be continually learning, and it is essential to build evidence-based knowledge over a period of time.

 

Reference List

  • Barker, J (2016). Evidence-Based Practice for Nurses & Healthcare Professionals. 3rd ed. London: SAGE Publications Ltd.
  • Bennett, V. (2017). Nurses play a key role in making cervical screening easier and more acceptable – Anne Mackie. Available: https://vivbennett.blog.gov.uk/2017/11/28/nurses-play-a-key-role-in-making-cervical-screening-easier-and-more-acceptable-anne-mackie/. Last accessed 25th April 2019.
  • Cancer Research UK. (2017). Cervical cancer. Available: https://www.cancerresearchuk.org/about-cancer/cervical-cancer. Last accessed 24th October 2018.
  • Gallagher-Ford, L. AJN The American Journal of Nursing. (2011). Evidence-Based Practice, Step by Step: Implementing an Evidence-Based Practice Change. American Journal of Nursing. 111 (3), p55-60.
  • Hewison, J., Jepson, R., Thompson, A and Weller, D. (2007) ‘Patient perspectives on information and choice in cancer screening: A qualitive study in the UK.’ Social Science & Medicine. [Online]. [24th March 2019] DOI: 10.1016/j.socscimed.2007.04.009
  • Jo’s Cervical Cancer Trust. (2016). Barriers to attending screening. Available: https://www.jostrust.org.uk/information-healthcare-professionals/information-practice-nurses-and-gps/barriers-attending. Last accessed 19th November 2018.
  • Jo’s Cervical Cancer Trust. (2017). Treatment of abnormal cervical cells. Available: https://www.jostrust.org.uk/about-cervical-cancer/cervical-screening-smear-test-and-abnormal-cells/treatment-of-abnormal-cervical-cells. Last accessed 23rd April 2019.
  • Marlow L, Waller J, Wardle J. (2015). Barriers to cervical cancer screening among ethnic minority women: a qualitative study .Available: https://srh.bmj.com/content/41/4/248. Last accessed 13th January 2019.
  • Melnyk, B., Overholt, E., Stillwell, S. and Williamson, K. (2010). Evidence-Based Practice, Step by Step: Asking the Clinical Question: A Key Step in Evidence-Based Practice. JN, American Journal of Nursing.. 110 (3), p58-61.
  • National Institute for Health and Care Excellence. (2017). Cervical screening. Available: https://cks.nice.org.uk/cervical-screening#!backgroundsub. Last accessed 24th October 2018.
  • National Institute for health and Care Excellence. (2017) Developing NICE guidelines: the manual, [online] [accessed 23/09/2018]
  • NHS Choices. (2016). Cervical screening test. Available: https://www.nhsdirect.wales.nhs.uk/encyclopaedia/c/article/cervicalscreeningtest/. Last accessed 25th April 2019.
  • NHS Digital. (2017). Cervical Screening Programme, England – 2016-17 . Available: https://webarchive.nationalarchives.gov.uk/20180307182938/https://digital.nhs.uk/catalogue/PUB30134. Last accessed 25th April 2019.
  • Nursing and Midwifery Council. (2015) The code: Standards of conduct, performance and ethics for nurses and midwives [online] [accessed 30/09/2018]
  • Public Health England. (2015). Cervical screening: programme overview. Available: https://www.gov.uk/guidance/cervical-screening-programme-overview. Last accessed 26th October 2018.
  • Public Health England. (2017). Health matters: making cervical screening more accessible. Available: https://www.gov.uk/government/publications/health-matters-making-cervical-screening-more-accessible/health-matters-making-cervical-screening-more-accessible–2#summary. Last accessed 20th June 2018.
  • Public Health England. (2018). Primary HPV testing update. Available: https://phescreening.blog.gov.uk/2018/03/01/primary-hpv-testing-update/. Last accessed 23rd April 2019.
  • Sasieni, P. (2009). Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data. BMJ 2009. 339 (Unknown), p88-93.
  • Waller, J., Bartoszek, M., Marlow, L., & Wardle, J. (2009). Barriers to cervical cancer screening attendance in England: a population-based survey. Available: https://journals.sagepub.com/doi/full/10.1258/jms.2009.009073. Last accessed 13th January 2019
  • World Health Organization. (2018). Human papillomavirus (HPV).Available: https://www.who.int/immunization/diseases/hpv/en/. Last accessed 26th April 2019.
  • World Health Organization. (2019). Human papillomavirus (HPV) and cervical cancer. Available: https://www.who.int/en/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer. Last accessed 13th January 2019.
  • Young, B., Bedford, L., Kendrick, D and Vedhara, K. (2017) ‘Factors influencing the decision to attend screening for cancer in the UK: a meta-ethnography of qualitative research.’ Journal of Public Health. [Online] [24th March 2019] DOI: 10.1093/pubmed/fdx026

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