Missed opportunities for cervical screening at Worcester Hospital and Worcester Community Health Centre, Worcester, South Africa
Background: Cervical cancer is the only gynaecological malignancy for which a screening modality is widely accepted and recommended for all women. Just as in other developed countries, the decline in deaths from cervical cancer in the white population in South Africa after the mid-1960s has been attributed to cytological screening. The purpose of this study was to determine the extent of missed opportunities for cervical cancer screening by the healthcare service at Worcester Hospital and the closely associated Worcester Community Health Centre (CHC) for patients 30 years and older who presented at these centres for reasons unrelated to cervical cancer screening. Methods: A descriptive cross-sectional survey was conducted using a questionnaire that was administered through personal interviewing. A sample of 235 patients was selected from six sampling units. Sampling was done proportionately, according to the average numbers of patients normally seen daily at the various units. Results: The mean age of the sample was 47, with 30 and 81 being the youngest and oldest patients respectively. The mean level of education for the sample was Grade 7 (Std 5). The overall rate for missed opportunities for cervical cancer screening was 93.2% (95% Confidence Interval (CI) 90%96%), as only 6.8% of patients were asked about cervical (Papanicolaou) smears during consultation. None of the patients that were seen at the medical, surgical and orthopaedic clinics and casualty were asked about whether they had had a cervical pap smear; 56.5% (95% CI 36%76%) of the patients that were seen at the gynaecology clinic were asked and 2.3% (95% CI 0.3% 4.8%) from Worcester Community Health Centre were asked whether they had had a cervical smear. A total of 15.7% [37/235: 95% CI 11%20%)] had never had a cervical smear, while 84.3% (198/235) had had a cervical smear previously. Of those who had had a cervical smear previously, 51% [101/198: (95% CI 44%58%)] had it performed at a local clinic, 40.4% [80/198: (95% CI 34%47%)] at a secondary hospital, 5.6% [11/198 (95%CI 2.3%8.7%)] privately and 3% [6/ 198: 995% CI 0.6%5.4%)] at a tertiary hospital. Of those patients who had a smear done before (198), 52% [103/19852% (95% CI 45%59%)] were not given an appointment to return for the results, 32% (95% CI 25.8%38.8%) did not receive their results and 78.3% (95% CI 72.5%84.0%) were not advised on further management in the future. It is noteworthy that only 2.1% (5/235) of the patients had personally requested a cervical smear from a doctor at Worcester Hospital and Worcester CHC. A total of 6.8% (16/235) patients were asked during the consultation whether they had had a cervical smear done before. On enquiry, a total of 99.2% (95% CI 97.9%100%) of the patients said that they would have preferred to have received information about a cervical smear from their doctor. Conclusion: Opportunities for cervical cancer screening were missed in patients attending Worcester Hospital and Worcester CHC. Women 30 years and older should routinely be asked about whether they are up to date with their cervical smears, irrespective of their presenting complaint. If they are found not to be up to date, they should have a cervical smear done or be referred appropriately to their clinics to have a cervical smear performed. When a smear has been done, a follow-up appointment should be made for them to be given the results, as well as advice regarding when the next smear is due. All such interactions between the patient and the healthcare worker should be clearly documented in the patient's record.