Barriers to and facilitators of compliance with clinic-based cervical cancer screening: population-based cohort study of women aged 23-60 years

PLoS One. 2015 May 26;10(5):e0128270. doi: 10.1371/journal.pone.0128270. eCollection 2015.


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.

Materials and 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.

Conclusion: 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.

Publication types

  • Clinical Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Cohort Studies
  • Costs and Cost Analysis
  • Female
  • Humans
  • Mass Screening / economics*
  • Middle Aged
  • Patient Compliance / psychology*
  • Patient Education as Topic*
  • Socioeconomic Factors
  • Surveys and Questionnaires*
  • Sweden
  • Uterine Cervical Neoplasms* / diagnosis
  • Uterine Cervical Neoplasms* / economics
  • Uterine Cervical Neoplasms* / psychology

Grants and funding

Swedish Cancer Foundation (070623, CAN 2007/1044, 11 0544, CAN 2011/471) URL:, SA; Karolinska Institutet Cancer Strategic grants (5888/05-722) URL:, SA; Swedish Research Council (521-2008-2899) URL:, SA; Stockholm County Council (20130097) URL, SA. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.