Identifying the key barriers, facilitators and factors associated with cervical cancer screening attendance in young women: A systematic review

Initial cervical screening is most commonly recommended to 25-29 year olds across high- and low-income countries.

“initial cervical screening is most commonly recommended to 25–29 year olds, across both high- and low-income countries 18”

• cites [18] Bruni L Serrano B Roura E, et al. Cervical cancer screening programmes and age-specific coverage estimates for 202 countries and territories worldwide: a review and synthetic analysis. Lancet Glob Heal 2022; 10(8): e1115–e1127. PMC9296658 35839811 sourcePartly supported

  The Results report that 25–29 years was the most common starting-age range overall (55 of 139 countries). But the Results table does not support that pattern in both income groups: high-income countries more often recommended starting at 24 or younger (28 versus 23), and low-income countries more often recommended 30–34 (6 versus 4). (LLM, conf=0.90)

  Experimental — accuracy not yet measured

The overall quality of the 106 included studies was rated as medium based on the MMAT quality score.

“The overall quality of the 106 studies were rated as medium, based on the MMAT quality score.”

• cites [14] O’Donovan B Mooney T Rimmer B, et al. Advancing understanding of influences on cervical screening (non)-participation among younger and older women: a qualitative study using the theoretical domains framework and the COM-B model. Heal Expect 2021; 24(6): 2023– 2035. PMC8628586 34476875 sourceCould not verify

  The Results (Characteristics of the study participants; page unavailable) describe interviews with 48 women, and Methods (Coding and analysis; page unavailable) describe analysis of those interviews. A search of our copy for 106 included studies and MMAT quality assessment found no passage reporting a medium quality rating for 106 studies. (LLM, conf=0.76)

  Experimental — accuracy not yet measured

A large portion of women now reaching the screening age are likely to have been vaccinated (or offered the vaccine).

“as a large portion of women now reaching the screening age are likely to have been vaccinated (or offered the vaccine),8,19”

• cites [8] UK Health Security Agency. Human papillomavirus (HPV) vaccine coverage estimates in England: 2020 to 2021, https://www.gov.uk/government/statistics/human-papillomavirus-hpv-vaccine-coverage-estimates%0A (2022, accessed 30 January 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [19] Colzani E Johansen K Johnson H, et al. Human papillomavirus vaccination in the European Union/European economic area and globally: a moral dilemma. Euro Surveill 2021; 26(50): 2001659. 34915976 PMC8728487 sourcePartly supported

  The paper’s Background section, under “Policies on human papillomavirus vaccination in EU/EEA countries” (page unavailable), says all EU/EEA countries had introduced HPV vaccination by December 2021 and lists vaccination programmes dating from 2007. That supports the possibility that women reaching screening age had been offered vaccination, but the paper does not establish that a large portion of that group was offered or received it. (LLM, conf=0.78)

  Experimental — accuracy not yet measured

A gap remains regarding understanding the full range of factors associated with screening attendance in women aged 30 or under, including socio-demographic or psychological factors.

“However, a gap remains regarding understanding the full range of factors associated with screening attendance in this age group, including socio-demographic or psychological factors, as well as the identified perceived barriers/facilitators themselves.”

• cites [17] Kirubarajan A Leung S Li X, et al. Barriers and facilitators for cervical cancer screening among adolescents and young people: a systematic review. BMC Womens Health 2021; 21(1): 122. 33757512 PMC7989022 sourcePartly supported

  The Discussion (Main findings; page not available) says it has been difficult to characterize the breadth of young people’s perspectives on screening, supporting a gap in understanding barriers and facilitators. But the review concerns people under 35, not specifically women aged 30 or under, and it does not explicitly identify a gap in the full range of socio-demographic and psychological factors associated with screening attendance. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

In alignment with an earlier review, perceptions and screening behaviours of the LGBTQ+ group are underrepresented in research.

“In alignment with an earlier review, 17 perceptions and screening behaviours of this group are underrepresented in research.”

• cites [17] Kirubarajan A Leung S Li X, et al. Barriers and facilitators for cervical cancer screening among adolescents and young people: a systematic review. BMC Womens Health 2021; 21(1): 122. 33757512 PMC7989022 sourcePartly supported

  The Discussion (‘Next steps and implications for care’) says none of the included studies specifically targeted the beliefs of non-heterosexual or non-cisnormative participants, and that the search found no studies of transgender men specific to young people. This supports underrepresentation in research on cervical cancer screening among young people, but not the broader, unqualified claim about LGBTQ+ screening behaviours in research generally. (LLM, conf=0.82)

  Experimental — accuracy not yet measured

Psychological barriers were far more prevalent in the current review in comparison to a previous review.

“Psychological barriers were far more prevalent in the current review in comparison to a previous review. 17”

• cites [17] Kirubarajan A Leung S Li X, et al. Barriers and facilitators for cervical cancer screening among adolescents and young people: a systematic review. BMC Womens Health 2021; 21(1): 122. 33757512 PMC7989022 sourcePartly supported

  The Results (Analysis of notable barriers; page unavailable) report psychological barriers to screening, including fear of pain in ten studies and embarrassment in 13 of 36 studies. The source does not compare those findings with the citing authors’ current review, so it cannot establish that psychological barriers were far more prevalent there. (LLM, conf=0.78)

  Experimental — accuracy not yet measured

The current review implemented a stricter age limit of under 30 compared to under 35.

“Alongside these factors, the current review also implemented a stricter age limit of under 30 compared to under 35. 17”

• cites [17] Kirubarajan A Leung S Li X, et al. Barriers and facilitators for cervical cancer screening among adolescents and young people: a systematic review. BMC Womens Health 2021; 21(1): 122. 33757512 PMC7989022 sourceSupported

Negative experiences with cervical cancer screening would be limited at this age compared to older individuals.

“Moreover, as negative experiences with CC screening would be limited at this age, compared to older individuals, 140”

• cites [140] Marlow L McBride E Varnes L, et al. Barriers to cervical screening among older women from hard-to-reach groups: a qualitative study in England. BMC Womens Health 2019; 19(1): 38. 30808349 PMC6390581 sourcePartly supported

  The Results (Thematic structure; page not provided) report that older women described previous bad or painful screening experiences, and the Discussion says these experiences often shaped decisions not to attend again. The paper does not compare their experiences with those of younger people or establish that negative experiences would be limited at the younger age in the claim. (LLM, conf=0.78)

  Experimental — accuracy not yet measured

A previous review found moderate strength of evidence that telephone support increased screening uptake in ethnic minorities.

“Furthermore, a previous review found moderate strength of evidence that telephone support increased screening uptake in ethnic minorities. 130”

• cites [130] Glick SB Clarke AR Blanchard A, et al. Cervical cancer screening, diagnosis and treatment interventions for racial and ethnic minorities: a systematic review. J Gen Intern Med 2012; 27: 1016– 1032. 22798213 PMC3403140 sourcePartly supported

  The Summary of Results and Impact of Interventions to Increase Screening sections report moderate-strength evidence that telephone support *with navigation* increases cervical cancer screening in minority populations. The claim omits navigation, so the review does not establish the effect of telephone support on its own. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

A lack of trust in screening was noted in 9 studies as a barrier.

“Nine studies noted a lack of trust in screening as a barrier,24,31,39,55,68,72,77,78,110”

Women vaccinated against HPV were more likely to have screened than those not vaccinated against HPV.

“Studies also highlighted that those vaccinated were more likely to have screened than those not vaccinated against HPV.”

Healthcare provider recommendations were a frequently reported facilitator of screening in young women (n = 11).

“healthcare provider recommendations (n = 11)”

Hesitancy to visit a gynaecologist or other healthcare services was reported in 4 studies as a barrier.

“hesitancy to visit a gynaecologist or other healthcare services (n = 4),40,72,79,102”

Ten studies cited that young people felt a lack of encouragement by healthcare workers, or in general, to attend screening.

“Ten studies cited young people felt a lack of encouragement by healthcare workers, or in general, to attend screening.29,42,123,54,77,95,97,102,108,109,117”

Concerns over the cost of screening and it being too expensive were reported in 35 studies.

“including concerns over the cost of screening and it being ‘too expensive’ (n = 35)23,24,27,29,30,34,38 –42,49,53,56,60,61,64,68,71,72,74,76 –78,95,97,98,103,106,108,109,119,123,124,128”

Factors adjusted for in multivariate analysis were not consistently reported in the included studies.

“However, factors adjusted for in multivariate analysis were not consistently reported in the included studies.”

Negative feelings regarding the result after screening were cited in 24 studies.

“Negative feelings regarding the result after screening were also cited in 24 studies.”

A lack of belief that the purpose of screening is to diagnose cancer was reported as a barrier.

“and a lack of belief that the purpose is to diagnose cancer. 24”

Being generally worried about screening was reported in 2 studies as a barrier.

“and being generally worried about screening (n = 2)24,29 were notable barriers.”

Feelings of vulnerability were reported in 8 studies as a barrier to screening.

“feelings of vulnerability (n = 8)30,53,54,68,78,81,109,124”

Participants not knowing where to get screening was reported in 19 studies.

“including participants not knowing where to get screening (n = 19),24,28,29,33,39,42,46,53,56,61,65,71,72,74,75,77,79,95,109”

Stating the test is not useful was reported in 3 studies as a barrier.

“stating the test is not useful (n = 3)31,39,72”

Previous negative experiences were cited in 4 studies as reducing young people's trust in healthcare recommendations to attend screening.

“Previous negative experiences also were cited in reducing young people’s trust in healthcare recommendations to attend screening (n = 4).31,55,77,110”

Difficulty getting an appointment was reported in 12 studies as a barrier to screening.

“and difficulty getting an appointment (n = 12).42,61,71,72,74,76 –78,91,100,109,110”

Some studies reported that participants noted no desire to dedicate time to screening.

“Some studies also reported that participants noted no desire to dedicate time37,63,80,92”

Time constraints were cited in 24 studies as a barrier to screening.

“Time constraints were cited in 24 studies, including being ‘too busy’ and having ‘no time’.28,30,34,36,46,53,61,65,75,77,78,95,100 –102,110,116,121”

Low accessibility to obtaining screening was commonly reported in 34 studies.

“Low accessibility to obtaining screening was also commonly reported (n = 34),23,24,26,28 –30,33,37,39,42,46,53,54,56,58,61,65,71,72,74 –79,86,91,95,97,98,100,109,110,123”

Being sexually active was a key factor associated with attendance at cervical cancer screening in young women.

“Age (older), marital status (in a relationship) and sexual activity (active) were key factors associated with attendance at screening.”

Lack of clarity around qualitative methods of analysis used was the biggest issue among the qualitative studies and mixed-method studies (n = 3).

“Lack of clarity around qualitative methods of analysis used was the biggest issue among the qualitative studies and mixed-method studies (n = 3).”

Inconvenient locations were reported in 14 studies as a barrier to screening.

“inconvenient locations (e.g. too far; n = 14)23,30,37,42,46,54,58,61,77,78,86,97,98,123”

Knowledge of cervical cancer was a frequently reported facilitator of screening in young women (n = 12).

“knowledge of CC (n = 12)”

Fear of pain or discomfort was reported in 28 studies as a barrier to screening.

“This was followed by fear of pain/discomfort (n = 28),24,28 –30,41,42,46,49,53,54,57,58,60 –62,64,65,74 –78,91,103,106,110,121,124”

Older age was a key factor associated with attendance at cervical cancer screening in young women.

“Age (older), marital status (in a relationship) and sexual activity (active) were key factors associated with attendance at screening.”

Financial constraints were the most frequently reported barrier to cervical cancer screening in young women (n = 36).

“the most frequently reported barriers were financial constraints (n = 36)”

Childcare constraints were reported in 2 studies as a barrier to screening.

“childcare constraints (n = 2)46,78”

Fear of the procedure was reported in 4 studies as a barrier to screening.

“and fear of the procedure (n = 4).64,117,123,129”

Being in a relationship was a key factor associated with attendance at cervical cancer screening in young women.

“Age (older), marital status (in a relationship) and sexual activity (active) were key factors associated with attendance at screening.”

Communication with friends was a frequently reported facilitator of screening in young women (n = 11).

“communication with friends (n = 11)”

Financial constraints were reported in 36 studies as a barrier to cervical cancer screening.

“Most notably, financial constraints were reported in 36 studies, including concerns over the cost of screening and it being ‘too expensive’ (n = 35)23,24,27,29,30,34,38 –42,49,53,56,60,61,64,68,71,72,74,76 –78,95,97,98,103,106,108,109,119,123,124,128 and lack of insurance cover, 25 reported in Malaysia, Oman, Nigeria, Uganda, Kenya, Thailand, Pakistan, Greece, United States, Australia, Ghana, Nige”

Reported barriers to cervical cancer screening were grouped into four overarching themes: practical barriers, negative perceptions and feelings towards screening, knowledge and misinformation, and cultural perceptions/biases.

“Barriers were grouped into four overarching themes: practical barriers, negative perceptions and feelings towards CC screening, knowledge and misinformation and cultural perceptions/biases (see Tables 3 and 4 in Supplemental materials).”

• Also stated in: § Main findings · plain

  “Reported barriers to screening were grouped into four main sub-themes: practical barriers, negative perceptions and feelings towards CC screening, knowledge/misinformation and cultural perceptions/biases.”

Young people's embarrassment and/or fear of a positive result was a notable barrier to screening.

“Young people’s embarrassment and/or fear of a positive result,28,30,34,36,38,46,54 –56,60,61,71,72,75 –79,81,97,109,118,122,129”

Lack of insurance cover was reported in 25 studies as a barrier to cervical cancer screening.

“and lack of insurance cover, 25 reported in Malaysia, Oman, Nigeria, Uganda, Kenya, Thailand, Pakistan, Greece, United States, Australia, Ghana, Nigeria, Ethiopia, Dominica, Nepal and India.”

Some studies reported that screening was time-consuming.

“and that screening was time-consuming.26,41,109”

Not knowing how to make the appointment was reported in 5 studies as a barrier to screening.

“Other reported barriers included not knowing how to make the appointment (n = 5),26,54,61,77,95”

Low accessibility to obtaining screening was a frequently reported barrier to cervical cancer screening in young women (n = 34).

“low accessibility to obtaining screening (n = 34)”

Embarrassment of the procedure was cited in 35 studies as a barrier to attending cervical cancer screening.

“In 35 studies, participants cited embarrassment of the procedure as a barrier to attending CC screening.24,27,29,34,38,39,41,46,49,57,60 –62,64,65,71,72,75,76,78,79,91,95,102,103,106,108,110,117 –119,121,123,125,129”

About 66 of the 106 studies reported barriers to cervical cancer screening.

“About 66 of the 106 studies reported barriers to CC screening.”

Embarrassment was a frequently reported barrier to cervical cancer screening in young women (n = 35).

“embarrassment (n = 35)”

The long-term benefit of screening was reported as a facilitator.

“and the long-term benefit of screening.53,77”

Only one study found that having a regular place for care was positively associated with screening.

“although only one found that having a regular place for care was positively associated with screening. 126”

Nine studies based in African countries and Oman reported that young people had never heard of Pap smear or screening.

“Nine of these studies based in African countries and Oman reported that young people had never heard of Pap smear/screening28,31,34,36,37,54,55,65,125”

Factors associated with screening were grouped into themes: socio-demographic factors, vaccination status, psychological factors, knowledge and previous experiences.

“These were grouped into four overarching themes: Socio-demographic factors, vaccination status, psychological factors, knowledge and previous experiences (see Tables 7 and 8 in Supplemental materials).”

Eleven of 13 studies examining HPV vaccination status reported a significant positive association with being vaccinated.

“Eleven of 13 studies examining HPV vaccination status reported a significant positive association with being vaccinated.43,47,52,66,79,80,83,84,90,108,111”

Friends' encouragement and open conversation around the procedure and topic were recognised as a facilitator in seven studies.

“Specifically, friends’ encouragement and open conversation around the procedure and topic were recognised as a facilitator in seven studies.25,30,44,53,77,119,121”

Those working in outpatient wards had higher odds of screening compared to other wards in a hospital.

“as well as those working in outpatient wards compared to other wards in a hospital. 61”

Five studies reported that those working were more likely to attend screening than those unemployed or of housewife status.

“Five reported that those working were more likely to attend screening than those unemployed or of housewife status32,51,73,80,115”

When also adjusting for race, three studies reported that vaccination still increased the odds of being screened.

“When also adjusting for race, three studies reported that vaccination still increased the odds of being screened.52,66,111”

Seven of 10 studies reported significant results regarding lifetime sexual partners.

“Seven of 10 studies reported significant results regarding lifetime sexual partners,”

Healthcare provider recommendations and reminders were commonly reported facilitators of screening.

“Healthcare provider recommendations and reminders were also commonly reported facilitators.30,33,44,46,59,103,109,110,119,121,130”

General awareness was reported as a facilitator of screening.

“general awareness,77,81,101”

Eighteen studies included reports of facilitators of cervical cancer screening.

“Eighteen studies included reports of facilitators of CC screening (see Tables 5 and 6 in Supplemental materials).”

Spousal and familial roles, including a spouse not allowing attendance, were reported as barriers to screening in eight studies from Malaysia, Ethiopia, India and Ghana.

“Spousal and familial roles as barriers to screening were also reported. In eight studies from Malaysia, 29 Ethiopia,54,60,61,64,65 India 109 and Ghana 24 young women reported a spouse not allowing attendance to screening as a barrier.”

Six of nine studies that reported place of residence found this to be a significant factor.

“Six of nine studies that reported place of residence found this to be a significant factor.”

Cultural biases and/or prejudices against screening were reported in four studies.

“Cultural biases and/or prejudices against screening were reported in four studies.54,86,98,120”

Five out of six studies reported that greater perceived benefits and/or prevention orientation was significantly positively associated with screening uptake.

“Five out of six studies reported greater perceived benefits and/or prevention orientation was significantly positively associated with screening uptake.26,49,70,107,120”

Five studies reported significant positive associations between screening and having had a routine check-up and/or visited a gynaecologist.

“Five studies reported significant positive associations between screening and having had a routine check-up and/or visited a gynaecologist.32,96,108,120,121”

One study cited being able to afford screening as a facilitator of attendance.

“One study also cited being able to afford screening as a facilitator of attendance. 77”

Five studies reported an overall lack of interest in screening.

“Five studies reported an overall lack of interest in screening.23,26,34,65,98,109”

When adjusting for age differences in participants, six out of seven studies also found a similar positive association between HPV vaccination and screening.

“When adjusting for age differences in participants, six out of seven studies also found a similar association.47,48,66,69,82,111”

One study reported that increased knowledge of HPV was associated with screening uptake.

“One study also reported that increased knowledge of HPV was associated with screening uptake. 108”

The belief that screening reduces risk was reported as a facilitator.

“the belief that screening reduces risk,25,77,121”

One study reported that students who had been screened scored higher in self-efficacy than those who had not been screened.

“Likewise, one study also reported that students who had been screened scored higher in self-efficacy than those who had not been screened. 70”

Working was associated with being 5.9 times more likely to attend screening compared with being at school.

“and were 5.9 times more likely to attend screening when working compared with being at school. 45”

Sixteen studies reported significant positive associations between knowledge and attending screening.

“Sixteen studies reported significant positive associations between knowledge and attending screening.31,32,35,36,37,41,44,55,59,64,75,93,95,122,128”

Healthcare professionals had higher odds of screening when compared to those in the Air Force and cleaners.

“Healthcare professionals had higher odds of screening when compared to those in the Air Force 113 and cleaners, 122”

Only five studies found that greater perceived susceptibility was significantly associated with uptake of screening.

“Only five studies found that greater perceived susceptibility was significantly associated with uptake of screening,32,41,80,124”

Five of six studies examining perceived logistical barriers reported that those who had received screening perceived fewer logistical barriers than those who had not.

“Five of six studies examining perceived logistical barriers to screening reported that those who had received screening perceived fewer logistical barriers than those who had not.26,41,50,70,80”

Those living in urban areas or major towns were more likely to attend screening compared to those living in rural areas.

“Those living in urban areas51,88,94,104 or major towns 85 were more likely to attend screening when compared to those living in rural areas.”

Five studies based in Ghana, Oman, Nigeria, Uganda and India cited cost-free cervical cancer screening as a financial facilitator.

“Five studies based in Ghana, 101 Oman, 30 Nigeria, 103 Uganda 77 and India 109 cited the financial facilitator of CC screening being cost-free, whether in general, at work or during a CC screening awareness month incentive. 101”

One study reported that use of a hormonal contraceptive increased odds of screening compared to those using condoms only or an ineffective method.

“One study also reported that the use of a hormonal contraceptive increased odds of screening compared to those using condoms only or an ineffective method. 85”

Four articles from Greece, the United Kingdom, Uganda and Japan cited young age as an inhibiting factor, with views that screening should be done at a later age.

“and four articles from Greece, United Kingdom, Uganda and Japan cited young age as an inhibiting factor, with views that screening should be done at a later age.30,77,79,110”

Two studies reported that a previous invitation to screening was positively associated with attending screening compared to those who had not received an invitation.

“Two studies reported that a previous invitation to screening was positively associated with attending screening compared to those who had not received an invitation.55,95”

Understanding the importance of screening was reported as a facilitator.

“understanding the importance of screening30,77”

Attitudes of fatalism regarding young people's overall health were reported in 36 studies.

“Notably, attitudes of fatalism regarding young people’s overall health were reported in 36 studies.”

Four studies reported screening as simply not necessary with no further explanation.

“Four studies reported screening as simply not necessary with no further explanation.28,74,92,121”

Seventy-four studies analysed factors associated with cervical cancer screening.

“Seventy-four studies analysed factors associated with CC screening.”

Almost all significant associations, excluding one, reported a positive association between being sexually active and attending screening.

“Almost all significant associations, excluding one, 33 reported a positive association with being sexually active and attending screening.39,62,77,107,114,126”

Two studies reported that increased perceived seriousness of cervical cancer alone or more than other cancers was significantly associated with increased screening attendance.

“and two studies reported that increased perceived seriousness of CC alone 35 or more than other cancers 50 was significantly associated with increased screening attendance.”

Greater perceived susceptibility was significantly associated with uptake of screening even when comparing LGBTQ+ individuals with heterosexual individuals.

“even when comparing LGBTQ+ individuals with heterosexual individuals. 108”

The majority of studies reported increased odds in screening with increased education or years in college.

“The majority reported increased odds in screening with increased education or years in college,30,44,56,59,62,64,67,73,75,77,120,125”

Increased knowledge of and belief in cervical cancer screening were the most commonly reported facilitators in 12 studies.

“Increased knowledge of and belief in CC screening were the most commonly reported facilitators in 12 studies.25,30,44,53,59,77,81,101,103,109,119,121”

The majority of the 20 significant relationships indicated an increase in screening attendance with older age.

“The majority of the 20 significant relationships indicated an increase in screening attendance with older age,31,41,85,94,95,108,127,129,51,55,56,62,63,69,73,80”

A lack of awareness and knowledge surrounding all aspects of cervical cancer screening was cited in 35 studies across Africa, Europe, North America, Oceania and Asia.

“A lack of awareness and knowledge surrounding all aspects of CC screening was cited in 35 studies across Africa, Europe, North America, Oceania and Asia.23,26,28,30,34,36 –39,42,46,54 –57,60,64,65,72,78,79,86,95,97,98,101,109,110,116,119,123 –125,128,129”

Pap testing is more common amongst those with more sexual partners compared to those with none.

“indicating pap testing is more common amongst those with more sexual partners compared to those with none.41,75,77,80,107,108,122”

Only a few studies reported equivocal or negative results for the association between education and screening.

“with only a few studies reporting equivocal39,92,123 or negative results. 88”

A lack of symptoms was cited 24 times as a reason for not attending screening.

“A lack of symptoms was cited 24 times,25,27,30,33,36 –38,41,56,57,60,64,65,75,79,81,103,108,117 –119,123,124,129”

Eleven studies reported that participants did not believe that cancer affected them.

“whereas 11 studies also reported that participants did not believe that cancer affected them.39,42,61,77 –79,81,95,110,117,118”

One study reported an increased prevalence of screening amongst those who identify as bisexual compared to those who identify as lesbian.

“One study reported on sexual orientation, indicating an increased prevalence of screening amongst those who identify as bisexual compared to those who identify as lesbian. 108”

Of the 28 studies that examined marital status, all significant findings reported increased odds of screening in those married or in a relationship compared with those who were single.

“Of the 28 studies that examined marital status, all significant findings reported increased odds of screening in those married or in a relationship when compared to those who are single.26,30 –34,39,55,56,62,77,87,88,107,108,114,118,126”

Maternal involvement in promoting cervical cancer screening and as a source of information was noted in three studies.

“Similarly, maternal involvement in promoting CC screening and as a source of information was noted in three studies.25,53,68,130”

Some studies reported declining attendance with older age.

“although some studies reported declining attendance with older age.36,113,121,122”

Eleven studies examined the perceived susceptibility of cervical cancer and screening.

“Eleven studies examined the perceived susceptibility of CC and screening.26,32,35,41,49,63,70,80,108,121,124”

Fear of being seen or spoken about was reported in six studies from Nigeria, Uganda, Japan and the United States.

“Fear of being seen or spoken about was reported in six studies from Nigeria, Uganda, Japan and United States.”

Concerns of loss of virginity due to the nature of screening were reported in three studies from Malaysia, Ghana, Pakistan and India.

“as well as concerns of ‘loss of virginity’ due to the nature of screening, reported in three studies from Malaysia, Ghana, Pakistan and India.24,29,65,128”

A family member's previous screening was positively associated with screening.

“A family member’s previous screening was also positively associated with screening. 95”

Five studies reported that not being sexually active was a reason for not being screened.

“Five studies reported that not being sexually active was a reason for not being screening,34,79,92,101,121”

Two studies from Japan and Ethiopia reported individuals never having heard of cervical cancer.

“and another two studies from Japan and Ethiopia reported individuals never having heard of CC.37,79”

Reporting was not always consistent in the included studies.

“Furthermore, reporting was not always consistent.”

Only 14 studies statistically tested the relationship between at least one psychological factor and screening uptake.

“However, only 14 studies statistically tested the relationship between at least one psychological factor and screening uptake.24 –26,49,50,59,68,70,78,87,97”

Only one study looked at screening in the LGBTQ+ community and the unique barriers that may impact their screening attendance.

“Only one study looked at screening in the LGBTQ+ community and the unique barriers that may impact their screening attendance. 108”

A lack of awareness and knowledge surrounding cervical cancer and screening was consistently reported as a barrier for young women across countries.

“A lack of awareness and knowledge surrounding CC and screening was consistently reported as a barrier for young women across countries.”

Feelings of fear and embarrassment surrounding multiple aspects of the screening procedure and fear of the results were the most often reported barriers for young women.

“Feelings of fear and embarrassment surrounding multiple aspects of the screening procedure and fear of the results were the most often reported barriers for young women.”

Only two studies from the United States focused on non-native women of this age group.

“Similarly, only two studies from the United States focused on non-native women of this age group.”

The current review extended the inclusiveness of the original review by including 106 studies across low-, middle- and high-income countries.

“Moreover, the current review extended the inclusiveness of the original review by including 106 studies across low-, middle- and high-income countries.”

Factors reflecting psychological capabilities were not prominent in studies that analysed factors associated with screening.

“Interestingly, factors reflecting psychological capabilities were not prominent in studies that analysed factors associated with screening.”

The current review identified that vaccinated women were more likely to attend screening than those who were not vaccinated.

“The current review identified that vaccinated women were more likely to attend screening than those who were not vaccinated;”

Most included studies were closed-ended cross-sectional surveys.

“Most included studies were closed-ended cross-sectional surveys.”

Uptake rates for HPV vaccination and screening have been decreasing over recent years, particularly in young women.

“uptake rates for both the HPV vaccination and screening have been decreasing over recent years, particularly in young women,7 –9”

• cites [7] Digital N. Cervical screening programme England 2020–2021, http://digital.nhs.uk/pubs/cervical2021 (2021, accessed 30 January 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [8] UK Health Security Agency. Human papillomavirus (HPV) vaccine coverage estimates in England: 2020 to 2021, https://www.gov.uk/government/statistics/human-papillomavirus-hpv-vaccine-coverage-estimates%0A (2022, accessed 30 January 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [9] Roland KB Benard VB Soman A, et al. Cervical cancer screening among young adult women in the United States. Cancer Epidemiol Biomarkers Prev 2013; 22(4): 580– 588. 23355601 PMC4480768 sourceNot checked — no full text of the source

Previous research has indicated a positive impact of past behaviour on intention and future health behaviours.

“Previous research has also indicated the positive impact of past behaviour on intention and future health behaviours,15,16”

• cites [15] Hodgkins S Orbell S. Can protection motivation theory predict behaviour? A longitudinal test exploring the role of previous behaviour. Psychol Health 1998; 13(2): 237– 250. sourceNot checked — no full text of the source
• cites [16] Ferguson E Bibby PA. Predicting future blood donor returns: past behaviour, intentions, and observer effects. Heal Psychol 2002; 21(5): 513– 518. 12211519 sourceNot checked — no full text of the source

Focusing on women 30 years old and under is likely to better capture initial screening behaviours.

“hence, focusing on those 30 years old and under is likely to better capture initial screening behaviours.”

Given the small number of significant findings in relation to perceived severity and susceptibility, it is difficult to draw a strong conclusion.

“However, given the small number of significant findings in relation to perceived severity and susceptibility, it is difficult to draw a strong conclusion.”

Financial constraints were the most prominent barrier in countries or regions where free screening programmes were not available.

“Financial constraints were the most prominent barrier in countries or regions where free screening programmes were not available.”

This is the first systematic review of barriers, facilitators and factors associated with cervical cancer screening for women under 30.

“This is the first systematic review of barriers, facilitators and factors associated with CC screening for women under 30.”

All 27 countries that have introduced HPV vaccination programmes in the last 15 years would be affected by the impact of vaccination status on cervical cancer screening.

“On an international level, this would be the case for all 27 countries that have introduced HPV vaccination programmes in the last 15 years. 137”

• cites [137] Gavi. Five charts on 15 years of the HPV vaccine. Gavi, the Vaccine Alliance, https://www.gavi.org/vaccineswork/five-charts-15-years-hpv-vaccine#:~:text=Since%20the%20inception%20of%20Gavi%27s,in%20Sierra%20Leone%20this%20week (2022, accessed 30 January 2024).Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Lack of encouragement or communication about cervical cancer screening from social circles and health professionals likely further enhances negative perceptions.

“Additionally, lack of encouragement or communication about CC screening from social circles and health professionals which were often reported by participants likely further enhances these negative perceptions.”

The suggestion that vaccination could result in a perceived false sense of protection against cervical cancer has not been supported by the current literature.

“The suggestion that vaccination could result in a perceived false sense of protection against CC has also not been supported by the current literature. 134”

• cites [134] Kulasingam SL Pagliusi S Myers E. Potential effects of decreased cervical cancer screening participation after HPV vaccination: an example from the US. Vaccine 2007; 25(48): 8110– 8113. 17961877 sourceNot checked — no full text of the source

The most frequently reported facilitators related to social opportunity and psychological capabilities.

“The most frequently reported facilitators related to social opportunity (e.g. open communication) and psychological capabilities (e.g. knowledge).”

The lack of attention on psychological factors in studies testing factors associated with screening in young women is surprising given the frequency of these factors as reported barriers.

“The lack of attention on psychological factors in studies testing factors associated with screening in young women is surprising given the frequency of these factors as reported barriers.”

Title and abstract screening were specifically more inclusive and did not exclude potential studies at this stage, for example due to the lack of mention of the age profile of the sample.

“Title and abstract screening were specifically more inclusive and did not exclude potential studies at this stage, for example due to the lack of mention of the age profile of the sample.”

In the current review, reported barriers aligned predominantly with psychological capabilities and physical opportunity components of the COM-B model.

“In the current review, reported barriers aligned predominantly with psychological capabilities (e.g. knowledge) and physical opportunity components (e.g. accessibility).”