title: Barriers to and facilitators of compliance with clinic-based cervical cancer screening: population-based cohort study of women aged 23-60 years.
abstract: OBJECTIVE
  This study aims to identify possible barriers to and facilitators of cervical cancer screening by (a) estimating time and travel costs and other direct non-medical costs incurred in attending clinic-based cervical cancer screening, (b) investigating screening compliance and reasons for noncompliance, (c) determining women's knowledge of human papillomavirus (HPV), its relationship to cervical cancer, and HPV and cervical cancer prevention, and (d) investigating correlates of HPV knowledge and screening compliance.
  
  
  METHODS
  1510 women attending the clinic-based cervical cancer screening program in Stockholm, Sweden were included. Data on sociodemographic characteristics, time and travel costs and other direct non-medical costs incurred in attending (e.g., indirect cost of time needed for the screening visit, transportation costs, child care costs, etc.), mode(s) of travel, time, distance, companion's attendance, HPV knowledge, and screening compliance were obtained via self-administered questionnaire.
  
  
  RESULTS
  Few respondents had low socioeconomic status. Mean total time and travel costs and direct non-medical cost per attendance, including companion (if any) were €55.6. Over half (53%) of the respondents took time off work to attend screening (mean time 147 minutes). A large portion (44%) of the respondents were noncompliant (i.e., did not attend screening within 1 year of the initial invitation), 51% of whom stated difficulties in taking time off work. 64% of all respondents knew that HPV vaccination was available; only 34% knew it was important to continue to attend screening following vaccination. Age, education, and income were the most important correlates of HPV knowledge and compliance; and additional factors associated with compliance were time off work, accompanying companion and HPV knowledge.
  
  
  CONCLUSIONS
  Time and travel costs and other direct non-medical costs for clinic-based screening can be considerable, may affect the cost-effectiveness of a screening program, and may constitute barriers to screening while HPV knowledge may facilitate compliance with screening.
authors.affiliation: Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska University Hospital-Solna, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Ellinor
authors.initials: E
authors.lastname: Östensson
authors.affiliation: Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska University Hospital-Solna, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Susanna
authors.initials: S
authors.lastname: Alder
authors.affiliation: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
authors.forename: K Miriam
authors.initials: KM
authors.lastname: Elfström
authors.affiliation: Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Karin
authors.initials: K
authors.lastname: Sundström
authors.affiliation: Medical Management Centre (MMC), Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden.
authors.forename: Niklas
authors.initials: N
authors.lastname: Zethraeus
authors.affiliation: Belgian Cancer Centre/Unit of Cancer Epidemiology, Scientific Institute of Public Health, J Wytsmanstreet 14, B1050, Brussels, Belgium.
authors.forename: Marc
authors.initials: M
authors.lastname: Arbyn
authors.affiliation: Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska University Hospital-Solna, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Sonia
authors.initials: S
authors.lastname: Andersson
mesh_terms: D000328:Adult; D015331:Cohort Studies; D003365:Costs and Cost Analysis; D005260:Female; D006801:Humans; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D010349:Patient Compliance / Q000523:psychology*; D010353:Patient Education as Topic; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D013548:Sweden; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000191:economics / Q000523:psychology