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  • br Practical facilitators have been


    Practical facilitators have been examined in regards to screening attendance in intervention studies. A Cochrane review of 38 rando-mized controlled trials shows that invitations to screen were more ef-fective than educational interventions (e.g., media education cam-paign) (Everett et al., 2011), especially individualized reminder prompts and physician recommendations (Marcus and Crane, 1998; Yabroff et al., 2003). GP status (i.e., regular GP vs. no regular GP) is another practical facilitator linked to screening history. For example, engagement with health services can facilitate screening behavior in women (Australian Bureau of Statistics [ABS], 2017; Henderson and Weisman, 2005), and GP-related factors are reported to increase screening attendance, including access to health care (Black et al., 2011), flexible appointment times (Logan and McIlfatrick, 2011; Waller et al., 2009) and opportunistic screening (e.g., test done when person attends clinic for another reason). Thus, GP status will be examined as a specific screening facilitator in this DETA NONOate study, along with the facilitators identified by female study participants.
    In the psychological literature, the most commonly reported psy-chological barrier is emotional response to the test including embar-rassment (Armstrong et al., 2012; Lovell et al., 2015), anxiety (e.g., fear of abnormal test result) (Eaker et al., 2001; Waller et al., 2009), and distress related to pain or discomfort during the procedure (Armstrong et al., 2012; Waller et al., 2009). Poor knowledge is also nominated as a key psychological barrier (Islam et al., 2017; McFarland et al., 2016). Several studies have shown that women often have poor knowledge about the purpose and efficacy of screening (Neilson and Jones, 1998; Philips et al., 2003) and the cervical screening guidelines (e.g., correct age to start testing) (Mather et al., 2012), but awareness of cervical cancer screening does not necessarily lead to timely screening (Viens et al., 2016).
    However, few prior studies have examined the screening barriers and facilitators in regards to women's screening status (i.e., up-to-date vs. overdue for screening). Waller et al. (2009) showed that women en-dorsed emotional screening barriers more often than practical barriers, especially older women, but younger women were more likely to en-dorse practical barriers and only the latter predicted women's screening status. Similarly, Eaker et al. (2001) showed that women who reported a lack of time as a practical barrier were less likely to have screened; and Catarino et al. (2016) found that practical barriers were the main reason for not screening, especially in women who were young, working, sexually inactive or without insurance. Results suggest that practical barriers will tend to interfere the most with women's screening behavior, but abiogenesis is unclear if this is the same or different for women who have not screened before. In this study, women were deemed overdue for screening if they had not screened in the past 27 months (i.e., overdue by at least three months).
    Thus, no prior studies have examined whether prior screening varies with regard to the experience of screening barriers and facilitators (Chorley et al., 2016). Only two studies show that the key screening barriers reported by women who had mostly not screened included the cost of the test, perceived cervical cancer risk (Were et al., 2011), knowledge gaps, and worry (Al-Naggar et al., 2010). Thus, the re-lationship between screening barriers and facilitators and prior screening was examined in this study. Prior screening was oper-ationalized as: never screened (0) vs. prior screen (1). Women who had prior screening were asked to provide the year and month of their most  Social Science & Medicine 220 (2019) 396–402
    recent test. They were provided with a definition of the Pap test prior to the screening questions.
    In summary, few studies have examined the cervical cancer screening barriers and facilitators nominated by women in regards to their screening status. Three studies showed that practical barriers were more likely to interfere with women's screening behavior than psy-chological barriers, but few studies have concurrently examined cer-vical cancer screening barriers and facilitators in a single study. Furthermore, no studies have examined the barriers and facilitators in regards to prior screening. Thus, we examined if the number of screening barriers and facilitators, and individual barriers and facil-itators listed by women, were related to their screening status and prior screening. Women in two age groups (25–35 years and 45–55 years) were recruited for the study as they have the lowest and highest re-ported screening rates of all Australian women, respectively (AIHW, DETA NONOate 2017).