Cervical screening programme accessibility for healthcare staff: ‘a call to action!’
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Introduction
The National Health Service (NHS) cervical screening programme has significantly reduced the incidence and mortality of cervical cancer. However, this vital service may not reach the whole eligible population. The national coverage remains below the 80% target, with only 68.7% of eligible people screened in 2023 in England.1 Practical, psychological and socioeconomic barriers, alongside low perceived risk, continue to limit uptake.2–4 NHS statistics reported there were 1.16 million females employed in December 2024,5 the majority of whom are eligible for cervical screening. Shift work, rota inflexibility and staff shortages are likely to exacerbate practical barriers to screening for healthcare professionals. We therefore aimed to determine the prevalence and nature of screening barriers among staff at University Hospitals Bristol and Weston (UHBW) and whether on-site, staff-only cervical smear clinics could mitigate these barriers.
Ad hoc cervical smear clinics for staff have been running at St Michael’s Hospital (STMH), UHBW, for several years. This study analysed the pilot expansion of this service to Weston General Hospital (WGH), creating a biannual, multisite service and discussing implications for staff-focused gynaecological health services. Throughout, ‘participants’ refers to women and gender-diverse individuals with a cervix.
Methods
Setting and participants
WGH and STMH. All employees aged ≥24 years with a cervix were eligible.
Design
We ran two plan-do-study-act cycles following the Standards for Quality Improvement Reporting Excellence guidelines.6
Baseline survey (plan)
An anonymous online baseline survey was emailed to eligible WGH staff in December 2023. This survey assessed behaviours associated with cervical screening and identified barriers to uptake rated on a 5-point Likert scale (1=strongly disagree, 5=strongly agree). Questions were informed by barriers noted in the literature. Demographic information and screening knowledge were also captured, alongside free-text boxes allowing participants to suggest changes to improve access.
Intervention (do)
Staff-only cervical smear clinics were expanded to WGH, alongside STMH in collaboration with the STMH colposcopy team. Clinics were held in January 2024 (cycle 1) and June 2024 (cycle 2), delivered by a nurse colposcopist and an administrator. Clinics were advertised via staff email lists and posters.
Postclinic survey (study)
Clinic attendees received an evaluation survey assessing convenience, perceived barrier reduction and suggestions for improvement. Following cycle 1, ethnicity and income items were added.
Act
Findings informed adjustments to clinic implementation and frequency. Clinics continue to run at WGH and STMH biannually.
Results
Baseline survey
Demographics
Fifty-six healthcare professionals completed the baseline survey. Six were excluded as not yet eligible for cervical screening. Of the 50 participants included in the analysis, 62% (n=31) were aged between 24 and 34 years, 16% (n=8) between 35 and 45 years, 20% (n=10) between 46 and 56 years and one participant between 57 and 65 years. All identified as female. The majority were clinical staff (82%, n=41; including doctors, nurses, allied health professionals and healthcare support workers), while the remainder were in non-clinical roles (18%, n=9; including administrative, managerial and other staff).
Understanding and accessibility
All participants understood the importance of screening and the procedure. Only 74% (n=37) agreed/strongly agreed they were up to date with their smear tests, with 48% (n=24) reporting previous late attendance. Stratifying by occupation, 76% (n=31) of clinical and 67% (n=6) of non-clinical staff were up to date. By age group, 74% (n=23) of those aged 24–34 years, 63% (n=5) of those aged 35–45 years, 80% (n=8) of those aged 46–56 years and the one participant aged 57–65 years old were up to date.
Barriers to access
Many participants (66%, n=33) agreed/strongly agreed that work contributes to difficulty booking or attending smear appointments, 44% (n=22) disagreed/strongly disagreed that they could approach work to request time off to attend, while 86% (n=43) agreed/strongly agreed that they would attend during working hours if permitted. Additional barriers included inconvenient appointment times at general practitioner (GP) or sexual health clinics (64%, n=32), and long waiting times or difficulties with phone queues (48%, n=24).
Free-text responses identified two overarching themes (figure 1):
Practical barriers: rota inflexibility, booking difficulties, transport issues and the need to take time off work.
Personal barriers: discomfort discussing gynaecological issues in the workplace and the need to share sensitive personal information to obtain leave.
Reported barriers to cervical screening among University Hospitals Bristol and Weston staff, as identified in baseline survey free-text responses. Barriers were grouped thematically into practical (eg, rota inflexibility, transport) and personal (eg, discomfort discussing intimate health needs) categories. This combination of logistical and interpersonal barriers contributed to reduced screening uptake. GP, general practitioner; LLETZ, large loop excision of transformation zone.
Changes to improve access
Authorisation to attend appointments during working hours was commonly highlighted. Participants suggested more GP/sexual health out-of-hours appointments and on-site clinics for staff would improve access.
Postpilot survey
Survey responses
Cycle 1 included 17 attendees at STMH and 9 at WGH. In cycle 2, five patients attended each site. All were invited to complete a follow-up online survey. The response rates were 69% (n=18) for cycle 1 and 20% (n=2) for cycle 2. Responses were pooled (n=20) for analysis.
Demographics
Three respondents were aged between 50 and 65 years, 45% (n=9) between 35 and 49 years and 40% (n=8) between 24 and 34 years. The majority identified as White (UK/Ireland) (60%, n=12), followed by 20% (n=4) as Asian or Asian British/Irish, 15% (n=3) as mixed or multiple ethnic groups and 5% (n=1) as White other. None identified as Black, Caribbean or African. All identified as female. Clinical and non-clinical roles were represented. Ten participants reported no specific religion. Other reported religions were Christian (n=7), Buddhist (n=1) and Hindu (n=1).
Screening status and accessibility
All participants had been invited for screening and understood its purpose and the procedure. At the time of the survey, 80% (n=16) were up to date and of these, 81% (n=13) were clinical staff. Notably, all participants who were not up to date were non-clinical staff and reported middle-income brackets. All respondents aged between 24 and 34 years were up to date. Both the 35–44 years and 45–55 years age brackets had 67% of participants up to date (n=6 and n=2, respectively). Stratified by ethnicity, 75% (n=9) of White (UK/Ireland), 75% (n=3) of Asian, 100% of mixed or multiple ethnic groups (n=3) and 100% of White other (n=1) participants were up to date. Of those not up to date, one participant was Asian, and the remainder were White (UK/Ireland).
Clinic analysis
Seventeen participants completed the Likert scale evaluating clinic accessibility, convenience and perceived utility (figure 2). Clinics were significantly oversubscribed, with 75 booking requests unable be accommodated. Participants strongly agreed that the clinic was convenient and easy to book (94.1%, n=16), with convenient timings (82.4%, n=14). All participants strongly agreed that the location was convenient, that they would recommend the clinics and that they would attend again. None experienced difficulty attending during working hours.
Utility and accessibility of staff-only cervical smear clinics, based on postpilot survey responses (n=17). Participants rated convenience, communication, booking ease and likelihood of future use. Right panels show persistent barriers and suggestions for broader on-site services. Data highlight strong support for continued provision and expansion. GP, general practitioner.
All participants wanted cervical screening clinics for staff to continue, alongside broader on-site gynaecology and general health services, including menopause clinics, sexual health, mammogram/breast clinics, blood tests and mental health services.
Discussion
Cervical screening is a core preventive service, yet our findings highlight that healthcare professionals face unique barriers to accessing it. Practical constraints, especially rota inflexibility, difficulty arranging time off and reliance on annual leave, were frequently cited barriers. This pilot provides proof of concept for scalable, staff-specific cervical screening services that are feasible and highly valued. Clinics improved access due to location, timings, ease of booking, required no time off and were oversubscribed, indicating a substantial unmet need. Clinics will continue at both sites biannually after this pilot.
There is a strong appetite for continuation, alongside implementing a more comprehensive gynaecological health service for staff. Vaginal and urine HPV self-sampling confers similar specificity while being cost-effective.7 Although not yet offered in the screening programme, self-sampling is convenient and may address practical barriers.
Race inequality in gynaecology remains an urgent concern. Studies show ethnic minority groups experience inequality in screening uptake.3 8 Black and ethnic minority individuals constitute 15% of the NHS workforce in the southwest of England .9 None of the postclinic survey respondents identified as Black, African or Caribbean. We disseminated information widely across UHBW. Patient involvement groups to understand specific barriers affecting ethnic minority populations will inform initiatives to reach these groups, promoting equitable access. A recent audit of invasive cervical cancer cases has highlighted that patients aged between 25 and 64 years in the lowest quintile of deprivation were more likely to have never been screened than those in less deprived quintiles,10 emphasising the need to improve screening access in underserved populations of working age.
Limitations
External validity is limited in this small, local study. The baseline survey included 56 participants. Clinics accommodated 36 patients. The postclinic survey was completed by users who attended clinics, hence it does not capture views of those not accommodated due to capacity. Response bias is possible, as those attending clinics may hold more favourable views than those not seeking on-site services. Cycle 2 response rates were poor, likely due to technical difficulties. Broader participation, including non-attendees, is needed in future evaluations.
Conclusion
Access to cervical screening remains a challenge for NHS staff, with practical and systemic barriers disproportionately affecting access. This project demonstrates that on-site, staff-only clinics are a feasible and effective solution, highly used and capable of improving uptake without increasing clinical burden. There is a clear demand for sustained and expanded provision of such services, ideally embedded within broader occupational health offerings. Future iterations must be designed with inclusion in mind, addressing the needs of staff from underserved ethnic and socio-economic backgrounds.
ASP and IW are joint first authors.
Contributors: ASP has acted as joint first author of the manuscript. She was involved in the synthesis and analysis of data, drafting of the manuscript and final review, as well as in promoting the clinics in the local area and, alongside HC, supporting the implementation of future clinics and initiatives. She is the guarantor and corresponding author. IW has also acted as joint first author. She led the initiation of the project through a baseline survey, identified the need to understand barriers to screening in healthcare, liaised with the colposcopy team at STMH to expand the clinics to WGH and to audit this, contributed to survey design and data collection, and presented the work to regional stakeholders for promotion and to explore funding opportunities. She also gave an oral presentation at the Cancer Alliance National Conference and contributed to the drafting and final review of the manuscript. EL initiated the project by conducting a baseline survey and identifying the need to explore barriers to screening in healthcare. She liaised with the STMH colposcopy team to support the expansion and audit of clinics at WGH, contributed to survey design, data collection and data analysis, and was involved in drafting and final review of the manuscript. She also presented the project at national conferences, supporting wider dissemination. HC contributed to data synthesis, figure creation, drafting and final review of the manuscript, and has been a key contact in drawing up a proposal to fund future clinics. She also presented the project at the Cancer Research Early Careers Symposium at the University of Bristol. MW contributed to dissemination of the project within UHBW and at national and regional events, including the BASHH Annual Conference, Clinical Oncology Audit and QI Update and ePoster Competition, and the Royal College of Radiologists abstract submission to the Cancer Research Early Careers Symposium. She was involved in drafting and final review of the manuscript. KS has been instrumental in expanding the staff-only cervical smear clinics from STMH to WGH and remains a key contact for the continuation of the service. She organised its implementation in terms of staff and administrative needs, liaised with several teams to promote the clinics locally, and contributed to drafting and final review of the manuscript.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Competing interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review: Not commissioned; externally peer reviewed.
Ethics statements
Patient consent for publication:
Not applicable.
Acknowledgements
We are grateful to the STMH colposcopy team for the ongoing cervical smear clinics that have been offered at this site for several years and for their innovation in introducing this to WGH. Their ongoing support has allowed for the continuation of biannual clinics at WGH. We extend our gratitude in particular to Mrs Karen Shaw, Lead Nurse Colposcopist at STMH, who introduced the clinics to WGH and has been our key contact throughout this project.
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