4. Discussion
cancer, high-grade abnormalities, traumatic
CANCER, CERVICAL CANCER
Reminders for cervical screening were conducted as part of routine care; the randomised design was conducted as part of quality improvement to consider the best outcomes and use of staff time in conducting the program.Limitations of this study included the small sample size and that it was delivered in a single site. The first step of this project included reviewing the electronic medical record of all regular clients and reviewing eligibility for CST against the state register (now incorporated into the NCSR). Some people may not access primary care regularly and thus may not be included in regular prevention programs within health services and thus not have reminders for cervical screening recorded in their electronic medical record. Those who have never undertaken cervical screening or who have declined enrolment may not be listed on the state or national cervical screening registers.At the time of this study, contacting the state cervical screening register to check eligibility could be conducted for individuals by telephone (not feasible for large samples of women) or by faxed/mailed request (feasible but longer response time). Updates in electronic medical record software may mean that linkage with the NCSR is possible, allowing instant review of eligibility, for example, at the time of an annual preventive Health Assessment. The study then involved sending reminders to those who were due for screening. The response to reminders was lower than expected (17.6% and 12.5%) after up to three reminders, compared to 31% for other Australian women [Several barriers were noted to letter reminders, including slow delivery times (anecdotal reports of taking two weeks for letters to be delivered) and a change of address. Telephone reminders allowed instant booking of appointments and transport. The team noted that phone calls from unidentified numbers might be ignored and purposely called from numbers that were known to be that of the health service. The team noted that SMS was likely to be responded to as workers could identify themselves. Women were more likely to book an appointment with a phone call/SMS, but a number of women then did not attend, possibly because they felt that they felt pressured to book in.Some women were not contactable due to a lack of address or phone number recorded in the electronic medical record; reception staff in health services play an important role in reviewing and updating contact details at every visit. Mobility was high among clients, highlighting the need for a formal transfer of medical records, for example, to new practices, aged care providers, and correctional settings. Women who did not respond to three reminders were not likely to respond to further reminder attempts, and reminders beyond this point appeared to be futile. While reminders are not legally required, quality primary care services are able to promote prevention activities by providing reminders, and these supplement reminders sent by the NCSR. As per Hunt’s study [This cervical screening program was delivered in the context of an ACCHO. This service used to care that was considered culturally appropriate, including calls from Aboriginal workers, provided transport from female drivers, and conducted promotional activities, such as providing culturally appropriate health promotion material and incentives to make women’s health services respectful and welcoming. All services were free of charge. McLachlan et al. interviewed women and found that clear explanations from health providers about the process of testing, trusting relationships with health providers, and recognition of participants’ past experiences, including traumatic experiences, had the potential to increase screening [This reminder program was initiated in the context of an integrated cancer care team; that is, the coordination of screening programs, support for clients through diagnosis (for example, recall to discuss abnormal results), treatment (for example, assisting in arranging appointments and accompanying vulnerable clients for colposcopy) and during cancer survivorship or even to end of life (although no participants were diagnosed with, or died from cervical cancer during the course of this study). This meant that women who received an abnormal result on cervical screening could be supported through referral to colposcopy, surgery, or other treatment, by the same team, ensuring continuity of care and that the woman was supported by trusted team members.This study promoted self-collected tests to women who were eligible at the time, which is under-screened women who had declined sample collection with a speculum. Self-collected CST is now offered to all people with a cervix aged 25–74 in Australia, and this may mean cervical screening is acceptable to more women, especially those who have declined a speculum examination. Self-collection may be more amenable to group screening, for example, ‘well-women days’ led by nurses or AHWs, supported by general practitioners. Outreach services, for example, delivered to a person’s home, can make screening more accessible [As for previous studies, this trial demonstrated that some women experienced additional barriers to participation in preventive care. The qualitative data presented here concurs with qualitative data collected elsewhere [Reminder systems also need to consider women who are not eligible for CST, for example, those who have never been sexually active, and consider respectful ways to remove them from reminder systems. Registration in medical records should ideally allow the nomination of a range of gender identification but be able to identify if clients have a cervix and require screening.Few abnormal findings were identified on CSTs collected in this small sample. In another study that analysed data for 23,482 female Queensland residents aged 20–69 years who had one or more Pap smears during 2000–2011, the prevalence of histologically confirmed high-grade abnormalities for Aboriginal Torres Strait Islander women was 16.6 per 1000 women screened, 95% confidence interval [CI] 14.6–18.9 [