Effect of Fee on Cervical Cancer Screening Attendance--ScreenFee, a Swedish Population-Based Randomised Trial

Abstract

Background: Attendance in the cervical cancer screening programme is one of the most important factors to lower the risk of contracting the disease. Attendance rates are often low in areas with low socioeconomic status. Charging a fee for screening might possibly decrease attendance in this population. Screening programme coverage is low in low socio-economic status areas in Gothenburg, Sweden, but has increased slightly after multiple interventions in recent years. For many years, women in the region have paid a fee for screening. We studied the effect of abolishing this fee in a trial emanating from the regular cervical cancer screening programme.

Method: Individually randomised controlled trial. All 3 124 women in three low-resource areas in Gothenburg, due for screening during the study period, were randomised to receive an offer of a free test or the standard invitation stating the regular fee of 100 SEK (≈11 €). The study was conducted during the first six months of 2013. Attendance was defined as a registered Pap smear within 90 days from the date the invitation was sent out.

Results: Attendance did not differ significantly between women who were charged and those offered free screening (RR 0.93; CI 0.85-1.02). No differences were found within the districts or as an effect of age, attendance after the most recent previous invitation or previous experience of smear taking.

Conclusion: Abolishment of a modest screening fee in socially disadvantaged urban districts with low coverage, after previous multiple systematic interventions, does not increase attendance in the short term. Other interventions might be more important for increasing attendance in low socio-economic status areas.

Trial registration: ClinicalTrials.gov NCT02378324.

Fig 1. Flow chart of the study.

There were no exclusions and no protocol violations.

Fig 2. Attendance 2011–2013 in the districts included in the study.

Attendance rate is calculated as smears taken within 90 days after sending invitation. Yearly re-invitations to non-participants are not included in the denominators.

Fig 3. Comparison of age between the intervention and control arm.

The central middle line is the median age. The boxes contain 50% of the data, the arms 25 and 25% of the remaining data. No outliers were found.

Fig 4. Attendance between the intervention and control group within the districts with 95% confidence intervals.