Wednesday, April 3, 2019

Increasing Cervical Screening for BME Women in the UK

Increasing Cervical Screening for BME Women in the UKIt was non until 1988 that the NHS cervical look at song programme began since then it has proved to be a successful scheme in the detection and prevention of cervical crabby person saving 4500 lives per course of instruction (NHS Cervical Screening Programme 2008, C ar burster 2008). Despite the effectiveness of abuse tests, evidence shows that hardly 80% of women with cervical burn downcer would feature had cervical natural c everywhereing (Bloomfield 2007 cited in Gannon and Dowling 2008).In 2007 2,828 untested cases of cervical crabby person were diagnosed in the UK, and worldwide at that function argon 493,000 cases e genuinely year (Cancer re try UK 2010a, Ashford and Collyto a greater extent 2005). With the prevalence of cervical malignant neoplastic disease increasing at that patch ar concerns with the expenditure of cervical exhibit in the UK detailly among social nonage of women. Evidence by Mo ser et al (2009) has shown there is a low in disengage of cervical masking in heathenishal groups of women British women were 1.35 to 3.42 propagation more believably to have a cervical mark in equation with women from an pagan minority. Although too soon(a) factors much(prenominal) as age and socioeconomic as demonstrated in Moser et al (2009) have an impact on the consumption of cervical masking, heathenishity seems to be a significant influence. Cervical exhibit is offered to women vulcanised 25-64 years old for women aged 25-49 cover is at 3 year intervamyotrophic posterioral sclerosis and for women aged 50-64 it is every 5 years (DOH 2006). Although white plague of cervical screen is lower over every(prenominal) in cultural minority groups, there argon engagements in the usance amidst heathen groups (Luke at al 1996, Webb et al 2004).The aim of this literature suss out is to discover how the economic consumption of cervical screen can be transform magnitude amongst ethnic minority women in the UK. In doing so the literature review sets out to identify ethnic womens stamps and attitudes towards cervical covering fire, identify and evaluate ethnic womens obstructions to cervical screening and to evaluate the intercessions utilise to increase the use of cervical screening.A literature search was conducted apply the search terms cervical smears, ethnic minorities, crabmeat , screening , bulwarks, go through , women , prevention, interpellations and UK. As individual search terms did non nominate a fruitful result of papers that were relevant, these search terms were combined as followscervical smears + women attitudes +UKcervical pubic louse prevention and screening +ethnic groups,cervical screening + interventions UK,cervical cancer + ethnic minorities UK,cervical screening + obstacles UKcervical screening friendship + ethnic minoritiescervical smears + ethnic minoritiesThe combined search terms were phthisisd in the search strategies of CINAHL, MEDLINE-via PubMed, BNI, Google Scholar and PsycArticles (see Appendix 1)A total of 11 studies (Appendix 2) were launch with the inclusion criteria of primary inquiry and query published after 1990. It was crucial that the literature reviewed old research as it was further when in 1988 that national cervical screening was introduced and the progeny of cervical screening in ethnic minorities has been on-going. Hence this en opend a comparison of how ethnic minority views on cervical screening have changed over time. The forcing out criteria were primary research published outside the UK. This was cod to the unfamiliarity with methods of cervical screening outside the UK. The use of electronic searching did not assume as umpteen research as hoped for, furthermore it was very impenetrable to find research on interventions that were tested on ethnic minority groups of women.Cervical cancer is the second most common cancer in women under a ge 35 in the UK (Bedford, 2009). As the name suggests cervical cancer is cancer of the cervix uteri. The cervix (neck of the womb) is part of the fe masculine reproductive dodging and connects the uterus to the vagina. The cervix has many functions during menstruation it all(a)ows the passage of blood guide and during childbirth it dilates for the baby to pass through the uterus and into the vagina (Cancer Research UK 2010b).The stalls of the cervix can develop to pre-cancerous changes known as dysplasia. Dysplasia (which is abnormal cells on the cervix) can be categorised development cervical intraepithelial neoplasia (CIN) classification (see Appendix 2). For this correspondence it is grievous that women have regular smears as early detection of cervical abnormalities can initiate treatment before cancer develops (Patient UK 2010).There are two types of cervical cancers squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma is the most common stochastic varia ble of cervical cancer and accounts for 80- 90% of cervical cancers. Squamous cell carcinoma invades the squamous epithelium of the ectocervix (Dunleavey 2009). The former(a) form of cervical cancer is adenocarcinoma, although less common as it accounts for only 10% in all cases it is considered to be the more severe than squamous cell carcinoma. (Dunleavy 2009, What is cervical cancer? 2011). moreover the cervical smear is not intentional to detect adenocarcinoma, notwithstanding is mainly intended at detecting the early changes of squamous cell carcinoma (Poulsen 2005).As cervical cancer progresses slowly it whitethorn be asymptomatic, however as it advances the symptoms such(prenominal) as irregular bleeding, bleeding or wo(e) after sexual intercourse and increased discharge whitethorn be a sign of cervical cancer Smeltzer et al (2009). According to Shiffman et al (1993) there is muscular evidence to suggest that Human Papilloma computer virus (HPV) draws cervical cancer , with types 16 and 18 deemed to be strongly associated with cervical cancer. another(prenominal) risk factors include, smoking, number of sexual partners, age of first intercourse and use of oral contraceptives (Cancer Research UK 2009b).Internal BarriersFrom the literature it is apparent that internal barriers such as , beliefs, attitudes, confusion, and lack of association have an influence on the uptake of cervical screening in ethnic minorities (Doyle 1991, Naish et al 1994, cut 1998, doubting doubting Thomas et al 2005, Abdullahi 2009). There seems to be a consensus most beliefs and attitudes of ethnic minority women and cervical screening. Naish et al (1994) investigated factors that deter women from serveing there GP for cervical screening. A concenter group of women from Turkish, Kurdish, Bengali, Chinese, Vietnamese, Punjabi and Urdu speaking women was conducted. It was ground that most of the women divided fatalistic beliefs somewhat cervical cancer. It was sa y that if you have it, then that is it and it would be better if were detected early (Naish et al 1994, p.1127). in like manner a more recent think over by Abdullahi et al (2009) excessively found Somalian women had fatalistic beliefs about cervical cancer however these beliefs stemmed from a religious view rather than a heathenish view as described in Naish et al (1994). Using a purposive model, Abdullahi et al (2009) recruited Somali women from Camden. Somali women commonly intendd that cervical cancer was the will of theology. This belief is further conducted by participants in nook (1998) and Thomas et al (2005) take in. Box (1998) aimed to seek the views and experiences of black and minority ethnic (BME) women on smear test screening for cervical cancer. The findings showed attitudes and beliefs about cervical cancer were cogitate with promiscuity and seen as a punishment from God. A woman in Boxs study (1998, p.7 ) stated cancer , yes it happens here, not with us w e stay with our men. hence for some ethnic minority women there is a chance of existence paganly and religiously stigmatised as a result of the belief that cervical screening is only appropriate for those who are promiscuous.For most ethnic minorities with strong religious and cultural backgrounds there is a high sizeableness tie to how women should behave when not married. The commitment to religion in ethnic minorities curiously those from a Muslim and Christian background means for most women they have to maintain their virginity until married otherwise may be exposed to affable consequences (Shripinda 2010). For mannequin in Moroccan and Turkish groups women found to have broken their virginity can be killed in what is known as honour kill (Shripinda 2010). This view is mollify strongly upheld. Young Pakistani, Arabic and Greek Orthodox females expressed resilient views on keeping the virginal state when entranceway marriage (Thomas et al 2005). Thomas et als (2005) study revealed young Pakistani women suggested they would go for a cervical screening only if the screener was not from their cultural background as they feared of cosmos found out. Likewise in Boxs study (1998), sexually active unmarried women were afraid their doctor or receptionist could not be trusted as to the close why they attended the GP.The unison on beliefs and attitudes towards cervical cancer is not shared across all types of ethnic groups of women. Interestingly the views of African women beliefs about cervical cancer are derived from superstition (Thomas et al, 2005). The African women in Thomas et als study (2005) believed cervical cancer was a verboten and that to mention cancer might cause the cancer to manifest. Furthermore cervical cancer was seen as a taboo more than other types of cancers. The evidence above provides a strong link between ethnic minorities cultural and religious beliefs as a barrier in cervical screening.Another concern over cervical screeni ng was the appear of embarrassment. The cervical smear test is invasive and for most ethnic women the procedure can be physically and psychologically uncomfortable (Box 1998, Abdullahi et al 2009). The switch off of embarrassment is particularly important to Somali women. For them the issue of embarrassment arises from female gender mutilation (FGM). WHO (2010) explains FGM as the total or partial remotion of the external female genitalia. FGM in most cultures is as result of both cultural, religious and refers to back to the ideology of maintaining premarital virginity. For some Somali women there is the anticipation of embarrassment as result of the reaction from the doctor or nurse fetching the samples (Abdullahi et al 2009). Consequently Abdullahi et al (2009) brings an understanding as to how FGM acts as a deterrence for Somali women in cervical screening.These studies (Naish et al 1994, Box 1998, Thomas et al 2005, Abdullahi 2009) have the use of focus groups in common. Th ough this suggests the appropriate use of focus groups in the study, it has its limitations. Parahoo (2006) states the disadvantage of focus groups is that dominant personalities can control the discussions. This was evident in Naish et al (1994), where it was noted that both Turkish and Kurdish women interacted spontaneously and informally compared to the other ethnic groups of women. This can affect the credibility of the study as the views of ethnic women mayhap only reflected those from Turkish and Kurdish backgrounds and not everyone else. Furthermore focus groups are not effective compared with in-depth interview in dealing with mass medium topics. For example in Abdullahis study (2009) the issue of promiscuity was discussed with discomfort. This presents one of the prime issues at bottom focus groups, where participants may note less inclined to discuss sensitive issues out of fear of scrutiny and criticism from others within the group. This is reinforced by Groups Plus (2 003) who states that sensitive topics are easily discussed if participants in the group all share the same problem.The lack of association of cervical screening is often prevalent in ethnic minority groups. Box (1998) identifies that there were misconceptions about the purpose of screening. Similarly Abdullahi et al (2009) found that Somali women failed to recognise the brilliance of cervical screening. This supports a previous study by Doyle (1991) which identify ethnic minorities un alertness of both the importance and existence of cervical screening. Somali women forgotten cervical screening because there was no cervical screening in Somalia the concept of preventative wellness was also unfamiliar. The concept of preventative health is unaccustomed in some cultures. Doyle (1991) suggests in the Asian communities the reliance on folk medicines meant screening was outside the traditional views of healing. The disregard towards preventative health is perhaps underpinned by rel igious beliefs. Thomas et al (2005) found that many ethnic groups felt it was important to turn to religion as a form of coping emotionally. There was a consensus amongst the groups that if things are left with God he resolves the problem.Despite the lack of knowledge of cervical screening amongst ethnic groups, other groups are more knowledgeable. Guajarati women in Boxs study (1998) were the only ones aware that cervical screening is able to detect pre-cancerous cells. Thomas et al (2005) found African groups were more able to identify cervical cancer as a commonly occurring cancer within their community. However age has an authoritative enjoyment on the amount knowledge that is embedded. Younger African-Caribbean participants had the least knowledge about cancer as there was a perception cancer affected older people (Thomas et al 2005).It appears that Thomas et als study (2005) has a methodological weakness. In their study they aimed to describe factors that act as barriers to effective uptake of breast and cervical screening. However the sample may not be representative of the target population as the sample consisted of men. Since men do not partake in breast and cervical screening, their inclusion may have distorted the findings, therefore reduces the transferability and credibility of the study. unheeding of this, Thomas et als (2005) study shows the significance in the link between age and lack of knowledge in cervical cancer.The lack of knowledge amongst ethnic minorities perhaps was as a result of spoken language difficulties. If they were able to communicate and comprehend information they received then this could enhance their understanding and knowledge of cervical screening. The majority of ethnic women declared that translated information in their languages was often inadequate and difficult to make sense of (Naish et al 1994, Abdullahi 2009, Thomas et al 2005, Box 1998). The translated information was not only seen as a problem, but for som e ethnic minority women who were illiterate translated information was s cashbox perplexing. As a result there was a preference for beingness told about the cervical test in their own languages rather than teaching a translated script (Box 1998).External BarriersOne major external barrier that was very frequently much expressed was the gender of the GP or screener. There were conceptions that if it was male practitioners that did the screening then women are less likely to uptake cervical screening. Some women in Boxs study (1998) felt that their bodies should only be seen by their husbands and it were adamant that the smear taker should be a female. Similarly Somali women, felt that as Muslim, women having a male practitioner pickings the smears is inappropriate. Abdullahi et als (2009) study is significant in identifying and providing dissolvents to the barriers that discourages Somali women from up taking up cervical screening. This study is commended well on its originality a s mentioned by Abdullahi (2009), and this was the only study investigating barriers to cervical screening that was found that pore on the views of Somali women. Conducting a study on Somali women brings upstart knowledge to this force field of research as the Somali community do not lend themselves to research because they are seen to be invisible compared to other Muslim ethnic minorities (Information centre about Asylum and Refugees ( ICAR) 2004).However, Naish et al (1994) found that both Kurdish and Turkish women did not mind male practitioners, as they are used to male doctors in their home countries. Nonetheless it appeared that a female practitioner still had more favour compared to that of a male practitioner.From the evidence the preference for a female doctor is not only collectible to cultural or religious views but also due to the lack of understanding and insensitivity that male doctors display towards ethnic women having cervical smears. This is particularly demons trated in Box et als study (1998, p.7) where a women stated the doctor was cross with me when I asked for the forceps (speculum) to be warmed, how would he feel if it was him? However Thomas et al (2005) suggests that this poor relationship between practitioners and patients was due to poor communication skills. In Thomas et als (2005) study BME women identified that the attitudes portrayed by their GP was very discouraging and at times it felt as if their GPs did not want them to be there. Moreover the issue of racism is problematic for ethnic minority women. For example in Box (1998) some of the Asian women were cited as being treated coldly by the smear taker because of their race. Health advocates noticed BME women were treated less favourably than exsanguine women and when smears were taken they were provided with less comfort (Box 1998).Childcare issues also play an prestigious part in preventing ethnic women in up taking cervical smears. Naish et al (1994) found with many w omen, having children in the same room was very distracting. This view was also supported by Somali women who indicated the lack of child care facilities was a barrier in attending cervical screening (Abdullahi et al 2009).There is a link between the perceived lack of antisepsis of equipment and the uptake of cervical screening. The views expressed by some ethnic women were that the speculum was not hygienic and that this could be a cause of cervical cancer or else of the association with HPV (Box 1998). One woman expressed the following concern the cancer might be there in the clinic you never know they need to cover it with water, wash it all away Ive never seen them do that (Box 1998 , p.g 9). The view is also reiterated in Naish et als (1994) study, where Chinese women were adamant that the use of unsterile equipment could induce infections. This demonstrates how important the lack of knowledge amongst ethnic minorities can affect the uptake of cervical smears.Interventions th at increase cervical screeningInterventions that increase cervical screening such as health publicity, education, invitations, psychological interventions and media interventions are examined below.Kernohan (1996) investigated the effectiveness of community-based intervention to change knowledge on the uptake of breast and cervical screening. The sample consisting of pace women from different ethnic backgrounds were involved in a health promotion intervention. The study focused on Bradfords main minority ethnic women (South Asian) and was touch with the impact of health education programmes on the knowledge of cervical screening in South Asian women. Compared to the other ethnic groups South Asian women had the lowest level of knowledge on cervical smears, however their knowledge had considerably improved from 35.8% to 68.7% after the intervention. Kernohan (1996) study is noteworthy for depicting a positive correlation between health promotion and knowledge of cervical screening . However as this study was a pilot study this compass of research would require further work in assign to provide robust evidence. Furthermore kernohan (1996) did not look at the impact of increased knowledge on the subsequent rate of uptake.Evidence from Abdullahi et al (2009) and Naish et al (1994) suggest that addressing barriers which deter women from having cervical smears can be used as interventions to increase cervical smear rates. The lack of knowledge of cervical screening is an apparent barrier in most ethnic women and a proposed solution would be to increase the levels of knowledge of cervical screening. Abdullahi et al (2009) suggests that education about the purpose of cervical screening is key to supporting Somali women to attend for cervical screening. However, suggesting such solutions to overcome barriers to cervical screening without trial may be futile, since without some testing the solutions there remains a infract in understanding the impact of the interve ntion suggested by Abdullahi et al (2009).More importantly Sabates and Feinstein (2006) investigated the role of education on the uptake of preventative health care, in this case cervical screening. Sabates and Feinstein (2006) suggest that educational personal effects on the uptake of preventative health results in raising the sensory faculty of and the importance of having a regular health check and therefore the inclination to uptake preventative health checks. The study found that women enrolled in courses or didactics exiting to qualifications had a positive impact on the probability of the uptake of cervical smears. Sabates and Feinsteins (2006) study provides further support to the socio-economic determinants of the uptake of screening. However, the effectiveness of this particular intervention is limited as women within ethnic minorities tend to not achieve the accolades of adult learning as a result of cultural demands. According to YWCA (2011) some black minority ethnic women are wanting(p) from the school register and are pulled out of school as a result of family duties to marital commitment.A systematic review conducted by Forbes et al (2009) reviewed interventions targeted at women to encourage the uptake of cervical screening. It concluded that invitation garner and educational materials were the most effective types of interventions. However evidence from Stein et al (2002) suggests that invitation garners were not effective. Stein et al (2006) investigated the effectiveness of three methods of inviting women with a want history of non -attendance to undergo cervical screening. The methods of invitation were a telephone call from a nurse, a letter from a well-known celebrity and letter from the local anaesthetic NHS Cervical Screening Commissioner. A telephone call and a letter from a celebrity were ineffective. A letter from the commissioner resulted in a minor(ip) increase in the uptake of cervical screening this was not statisticall y significant. Although Stein et al (2006) findings contradict that of Forbes et al (2009), this does not nullify the results of Forbes et als (2009) study. The findings from Stein et al (2005) highlight one of the limitations of doing a single study. eggar et al (2001) argues a single study often fails to detect a statistically significance between interventions when in fact such difference may exists, therefore are more likely to produce dour negative results. Moreover, in the hierarchy of evidence for interventions, systematic reviews are at the top as they are more likely to produce a strong and less-biased synthesis of findings that to show whether the intervention has an effective outcome (Melnyk and Fineout-Overholt 2010) . For this reason Forbes et al (2009) has a more valuable contribution towards knowledge on the interventions that increase the uptake of cervical screening.The NHS cervical screening programme (2011) highlights that encouraging women through reminders suc h as invitation letters is exceptionally important this may not be as effective in motivating ethnic minority women to attend cervical screening. Some ethnic minority women are more likely to ignore invitation letters if translation is unavailable ( Naish et al 1994). On the other hand, there is a link between be after when, where and how of making an betrothal and the success rate in uptake of cervical screening. This is referred to as carrying into action intentions the initiation of behaviour is determined if the conditions when, where and how are be after (Bartholomew et al 2011).This was demonstrated by Sheeran and Orbell (2000) who tested the concept of effectuation intentions as a method to increase non-attendance in cervical screening. It was found that the participants who produced implementation intentions were much more likely to attend for a cervical smear test compared to the control group. This demonstrates how empowering women to have more control on the choices in arranging their appointments can significantly encourage the uptake of cervical screening. This supports Abdullahi et al s (2009) study where it was identified that inconvenient appointment times were also considered to be a barrier. Consequently the use of implementation intention as an intervention is noteworthy of encouraging ethnic women to uptake cervical screening. Furthermore, an area of research that would increase existing knowledge is to investigate implementation intentions on ethnic minority women and subsequent uptake of cervical smears, in order to provide strong evidence for such intervention.The media has potentially an important role on the uptake of cervical screening. Howe et al (2002) investigated the impact of a video recording soap opera on the NHS cervical screening programme. Using a retrospective analysis on information of the NHS cervical screening databases, during the 6 month of the plot line, the number of smears performed in women whose previous sm ears were compared to women who had smears taken previously that year. The storyline involved a character that missed her regular screening appointments later she was diagnosed with cervical cancer and 6 weeks later she died. Howe et al (2002) found that there were substantial increases in the number of cervical smears- from 65 714 in 2001, to 79,712 in 2002, 19 weeks after the storyline. This demonstrates a significant link between the effects of media in motivating women to take up cervical screening. In support is the impact of a celebrity profile on uptake of cervical screening. The media reporting of Jade Goody from diagnosis of cervical cancer till death has been an influential motive for some women to uptake cervical screening. Parkers (2010) reports that, since the media coverage of Jade Goodys case, figures from NHS Rotherham showed an 80% improvement rate in the uptake of cervical screening.DiscussionFrom reviewing the literature it is apparent that increasing the uptake of cervical screening amongst ethnic minority women poses a challenging problem. Ethnic minority women are faced with internal and external barriers that play an important role on their non- attendance for cervical screening. It appears the internal and external barriers are interrelated. For instance the issue of embarrassment may arise as a result of being screened by a male practitioner, as well as FGM particularly in the case of Somali women as stated earlier. Moreover the culturally sensitive issues such as the loss of virginity still pays a impairment tag in many cultures and the stigmatisation attached towards it means some young ethnic minority women might feel reluctant to take up cervical smears.Needless to say the extent to which a barrier act as a deterrent to the uptake of cervical screening is very much culturally dependent. Women from African cultures see cervical cancer as a taboo, where as in Asian cultures cervical cancer is perceived as a disease for those who ar e promiscuous. Additionally, the cultural attitudes and beliefs may be a stronger barrier than child care issues for some ethnic minority women, whilst the sterility of equipment may have a stronger influence than the issue of embarrassment.The lack of knowledge was the most common barrier that was revealed and it appears this has not changed over the years amongst ethnic minority groups ( Box 1998, Thomas et al 2005 , Abdullahi et al 2009). From evaluating the interventions, it remains substantial that socioeconomic factors (lack of knowledge and education) are predictors in find out ethnic minority women attendance for cervical screening. For this reason, it would be beneficial for communities where ethnic minorities are prevalent to have health promotion projects that produce the awareness of cervical screening (kernohan 1996).There was sufficient evidence to suggest language difficulties as an important factor in deterring ethnic minority women from the uptake of cervical scree ning. Though research has not tested the effect of multilingual work as an intervention to increase cervical screening, an area in practice that needs room for improvement is the use bilingual services and bilingual interpreters in the cervical screening recall system. Forbes et al (2009) research supports the use of invitation letters as an intervention to improve the uptake of cervical screening and currently still remains the most popular intervention used. Therefore a recommendation for practice would be for invitation letters to be printed in the languages of ethnic minorities.What was interesting and surprising, was the issue of racism as a barrier to the uptake of cervical screening. The ethnic minority often experience health inequalities as a result of racism, karlsen (2007) reports racism can lead to differences in treatment and access to health promoting resources for the ethnic minority. This was reflected in Box (1998) where Asian women expressed their concerns of bei ng treated coldly and treated indecently as a result of their race. This area highlights the need for a change within the health services offered to ethnicity minorities in the UK. More importantly a contribution to research would be to tackle racism as an intervention to encourage ethnic minority women in the uptake of cervical screening (Szczepura 2005).Furthermore training needs to be put in place for health professionals to understand and embrace the forms of cultural and religious beliefs amongst ethnic minorities in order to reduce prejudice and discriminatory practices. This would be particularly important to women from ethnic minorities where FGM is seen as a custom practice. Denniston et al (2001) states FGM continues to take place in many cultures around the world health practitioners and screeners need to be taught to take a sensitive and a considerable approach when screening women with FGM.Sheeran and Orbells study (2000) makes a positive contribution towards the issue of improving the uptake of cervical screening in women from ethnic minority groups. The use of implementation intentions seemed to have an effect on women in their attendance for cervical screening. death penalty intentions would be advantageous for some ethnic minority women. Planning when, where and how an appointment would address some of the barriers identified, including the gender of the screener, ensuring that a bilingual interpreter was present, so if needed information stipulation could be clarified. Thomas et al (2005) implies that the think of an appointment for ethnic minority groups, especially for those with religious festivals is important. Ethnic women given the chance to decide when their appointment should take place would eradicate inconveniences such as being invited for screening during Ramadan. However further research would be necessary to establish the effectiveness as well as the cost-effectiveness of using implementation intentions amongst ethnic minorit y women and the uptake of cervical screening.To conclude, this literature review examined how to increase the uptake of cervical screening amongst ethnic minority women in the UK. The evidence discussed in this review has explored the internal barriers and external barriers that deter ethnic women in the uptake of cervical screening.It is hard to change peoples behaviour because of what we believe in and how this has shaped our social norms and values. Therefore to increase the uptake of cervical screening amongst ethnic minority groups remains complex and inconclusive. With the evidence examined in this review, the interventions (health promotion, education, implementation intentions, invitation letters and the media) to improve the attendance and uptake of cervical screening noticeably have an influential impact in encourag

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