What do British women know about cervical cancer symptoms
and risk factors?

Emma L. Low

, Alice E. Simon

, Jane Lyons

, Debbie Romney-Alexander

Jo Waller

Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London,

1–19 Torrington Place, London WC1E 6BT, UK

Formerly of The Eve Appeal, Butler House, 177–178 Tottenham Court Road, London W1T 7NY, UK

Department of Health England (Cancer Team), Department of Health, Richmond House 79 Whitehall, London SW1A 2NS, UK

Available online 7 June 2012

KEYWORDS
Cervical cancer
Risk factor awareness
Symptom awareness
Cancer knowledge

Abstract

Objective: To identify levels of cervical cancer risk factor and symptom awareness,

as well as predictors of higher awareness in a United Kingdom (UK) female population.

Design: Population based survey.
Setting: Participants’ homes in the UK.
Sample: UK representative sample of females aged 16 years and over (n = 1392).
Materials and methods: Respondents completed the Cervical Cancer Awareness Measure

which included questions on awareness of cervical cancer symptoms and risk factors (both
recalled and recognised). Linear regression analyses were used to identify predictors of higher
symptom and risk factor recognition scores.

Main outcome measures: Awareness of cervical cancer symptoms and risk factors.
Results: Sixty-ﬁve percent of respondents were unable to recall any risk factors and 75% were

unable to recall any symptoms. Awareness was higher when women were prompted (95%
recognised at least one risk factor and 93% at least one symptom). Independent predictors
of risk factor recognition were older age and higher education. Symptom recognition was
associated with older age, White ethnicity, higher education and having a close experience
of cervical cancer.

Conclusions: To reduce inequalities in awareness, interventions should target younger women

with lower education and those from ethnic minority groups.
Ó 2012 Elsevier Ltd. All rights reserved.

0959-8049/$ - see front matter

http://dx.doi.org/10.1016/j.ejca.2012.05.004

The views expressed in this paper are those of the individual authors and not of the Department of Health.

⇑

Corresponding author: Tel.: +44 (0) 20 7679 1736; fax: +44 (0) 20 7679 8354.
E-mail address:

e.low@ucl.ac.uk

(E.L. Low).

European Journal of Cancer (2012) 48, 3001– 3008

A v a i l a b l e a t

w w w . s c i e n c e d i r e c t . c o m

j o u r n a l h o m e p a g e : w w w . e j c a n c e r . i n f o

1. Introduction

Cervical cancer mortality rates have dropped by

almost 70% since 1979.

This fall can be attributed to

the introduction of the national cervical cancer screen-
ing programme in 1988, a call-recall programme
designed to detect potentially cancerous abnormalities
in the cervix.

In 2008, the National Health Service

(NHS) also implemented a national Human Papilloma-
virus (HPV) vaccination programme designed to protect
women against infection with HPV types 16 and 18 (the
cause of up to 71% of cervical cancer cases).

HPV vaccines have a very high preventative eﬃcacy

rate,

meaning that almost all vaccinated girls will be

protected against three-quarters of incidences of cervi-
cal cancer. The vaccine is currently oﬀered to girls
aged 12–13 (a three-year ‘catch-up’ programme was
also run in addition to the main programme for girls
aged 14–18 in 2008). However, as cervical cancer is
most common in women aged 30–39

the eﬀects of

the vaccine on incidence will not be evident until the
vaccinated girls near this age (although we should
see a marked drop in abnormal cytology earlier as
women are oﬀered screening from age 25 in the
United Kingdom (UK)).

Around a quarter of the routine vaccination cohort

(girls aged 12–13 years) did not complete the three-dose
HPV vaccination course (required for full protection) in
the academic year 2009–2010, according to latest ﬁg-
ures.

Further, the vaccine only protects against the

HPV types responsible for three quarters of cervical can-
cers,

therefore, even if vaccinated, women are not fully

protected from cervical cancer. For women who do con-
tract a high-risk HPV not covered by the vaccine, the
screening programme should detect any resulting cell
abnormalities, reducing the chances of these developing
into cervical cancer. However, almost 30% of cervical
cancers occur in women who appeared to have been
fully adherent to the screening programme.

Although there has been a decline, there were still-

around 950 deaths attributable to cervical cancer per
year in the UK between 2006 and 2008.

As England

and Wales have a signiﬁcantly lower survival rate than
the European mean,

there may be room for improve-

ment in cervical cancer survival rates in the UK. To
achieve this, it is important to identify modiﬁable factors
that could increase the likelihood of survival.

Cervical cancer diagnoses made at an earlier stage

(FIGO (International Federation of Gynecology and
Obstetrics) stages 1A1 to 1B2) are associated with higher
survival rates (80–99%) than diagnoses made at a later
stage (stages III–IV have associated ﬁve-year survival
rates of 20–50%).

At present, in England, almost

10% of cervical cancers are diagnosed at stage III or
worse.

If this ﬁgure can be decreased, cervical cancer

mortality can be further reduced.

Early-stage cervical cancer diagnoses may result from

prompt medical help-seeking in the presence of symp-
toms,

itself associated with factors such as symptom

and risk factor awareness.

13–17

By determining levels

of awareness of cervical cancer risk factors and symp-
toms in the UK population, we can identify areas of
poor knowledge that could be targeted in health educa-
tion programmes.

There are a number of risk factors for the develop-

ment of cervical cancer, varying in importance. While
the key risk factor is infection with high-risk HPV (as
this is a necessary cause of almost all cervical cancers),

it could be argued that irregular attendance at cervical
screening is a more important risk factor for women
to understand, as screening behaviour is likely to be eas-
ier to modify than behaviours that aﬀect the risk of
acquiring an HPV infection.

In 2007, Marlow et al.

tested unprompted recall of

several risk factors for cervical cancer (including not
going for regular screening) and prompted recognition
of HPV. Recall was low for all of the risk factors,
including HPV (3%) and not going for regular screening
(5%) and even when prompted, only 24% of participants
endorsed HPV.

In another earlier study, Wardle et al.

investigated

prompted awareness of risk factors for cancer, including
three cervical cancer risk factors (having many sexual
partners, having a virus or infection and smoking). Rec-
ognition, though higher than the recall in Marlow
et al.’s study, was fairly low for two of the three risk fac-
tors. Higher awareness of some cervical cancer risk fac-
tors has been associated with more education,

18,20

younger age and White ethnicity.

Further, a personal

or family history of cancer has been associated with
higher awareness of cancer in general.

As with risk factors, there are some symptoms of cer-

vical cancer that are more important than others. The
most important symptoms of cervical cancer are unusual
vaginal bleeding and persistent vaginal discharge that is
blood-stained or smells unpleasant. These are the most
common

and, in the case of unusual vaginal bleeding,

may be more likely to be present in earlier stage dis-
ease.

In the UK there has not yet been a systematic

attempt to assess population levels of cervical cancer
symptom awareness, either for these common symptoms
or for the less important symptoms, although there is
evidence that cancer symptom awareness in general is
low in UK women.

Predictors of higher symptom awareness include

older age, White ethnicity and higher socioeconomic sta-
tus (SES).

There is also evidence that knowing close

family or friends who have experienced cancer can
increase awareness of some symptoms of cancer.

The data in the current study were collected just prior

to the launch of the Department of Health’s key messages
on cervical cancer in 2010.

By measuring awareness at

3002

E.L. Low et al. / European Journal of Cancer 48 (2012) 3001–3008

this point in time, we can allow for a comparison of
awareness post-introduction of these messages, therefore
ascertaining the impact of the key messages on women’s
awareness of cervical cancer symptoms.

In the present study we aimed to determine cervical

cancer risk factor and symptom awareness in a UK
female population. We hypothesised that higher educa-
tion level (a commonly used marker of SES (e.g. Ref.

), having a personal or close experience of cervical

cancer and White ethnicity would predict higher risk
factor and symptom awareness. We also expected that
older age would be associated with symptom awareness,
but that younger age would be associated with risk fac-
tor awareness.

2. Materials and methods

2.1. Recruitment

UK females aged 16 years and over were recruited

through a social research agency (TNS-BMRB) using
random location sampling. Women who did not speak
English were excluded from participation in the survey.
As part of TNS-BMRB’s omnibus survey, 1392 women
self-completed the Cervical Cancer Awareness Measure
(Cervical CAM)

(a site-speciﬁc version of the generic

CAM),

at home using Computer Assisted Personal

Interviewing (CAPI) in the presence of fully trained
interviewers. Data were collected between November
and December 2009.

2.2. Sample characteristics

The number of non-White participants was very small

for each ethnic background, so we grouped respondents
from non-White ethnic backgrounds together, dichoto-
mising the women into ‘White’ or ‘non-White’. White
non-British women were included in the ‘White’ cate-
gory. An adequate level of spoken English to understand
the survey was a pre-requisite for participation. Educa-
tion was grouped into ‘Low-level/none’ (women edu-
cated to ONC, BTEC, O Level/GCSE A–G (ie
academic examinations normally taken at age 16 years
in the UK) and those with no formal education),
‘Mid-level’ (women educated to A Levels/Highers, higher
education below degree (ie academic examinations nor-
mally taken at age 18 years in the UK) and those who
answered ‘other’ or were still studying) and ‘High-level’
(degree level or higher). Women who answered ‘other’
were placed into the ‘Mid-level’ education group as pre-
liminary analysis (not reported here) revealed that they
had similar levels of recall and recognition to the other

education level categories in that group. Age was
measured as a continuous variable.

We asked respondents whether they had had cervical

cancer and/or whether they had known a close family
member or friend with cervical cancer. Respondents
scored ‘1’ if they had and ‘0’ if they had not.

2.3. Awareness of risk factors

We measured risk factor awareness with both open

and closed questions. The open question (presented
before the closed question to reduce bias) measured
recall and read: ‘What things do you think aﬀect a
woman’s

chance

developing

cervical

cancer?’.

Respondents were given a blank space to freely respond.

The closed question (measuring recognition) read:

‘The following may or may not increase the chance of
getting cervical cancer. How much do you agree or dis-
agree that the following can increase the chance of get-
ting cervical cancer?’. Participants were presented with
10 cervical cancer risk factors and response options:
‘Strongly agree’, ‘Agree’ (scored ‘1’), ‘Neither agree
nor disagree’, ‘Disagree’ or ‘Strongly disagree’ (scored
‘0’). A refusal to answer was coded as ‘missing’.

For the open question, participants scored ‘1’ for

each risk factor mentioned that corresponded with the
list in the closed question (target risk factors) for ease
of comparison (see

Table 2

for the full list). Scores from

the open and closed questions were each summed to cre-
ate an overall score for recall and for recognition (range
for both questions = 0–10).

We also measured how many women responded with

any risk factors that wouldn’t be deemed ‘incorrect’, but
did not match the target list in the closed question. Con-
sequently, we added two additional risk factors to the

Table 1
Sample characteristics (weighted/unweighted n = 1392).

Unweighted

Weighted

Age

16–24

158

11.4

208

14.9

25–39

425

30.5

343

24.7

40–59

416

29.9

431

30.9

60+

393

28.2

410

29.5

Ethnicity

White

1240

89.1

1261

90.6

Non-White

149

10.7

128

9.2

Education

High-level

256

18.4

285

20.5

Mid-level

230

16.5

233

16.8

Low-level/none

749

53.8

705

50.7

Close experiences of cancer

No-one

1171

84.1

1179

84.7

At least one person

221

15.9

213

15.3

Where % < 100%, this is due to missing data.

The full Cervical Cancer Awareness Measure can be downloaded

from the NAEDI (National Awareness and Early Detection initiative)
website at

www.naedi.org.uk

E.L. Low et al. / European Journal of Cancer 48 (2012) 3001–3008

3003

‘recalled’ list. Respondents received a score of ‘1’ if they
mentioned ‘Infection/STI/STD or virus’ and if they
mentioned ‘unprotected sex’. Otherwise, they received
a score of ‘0’.

2.4. Awareness of symptoms

We measured symptom recall using the question:

‘There are several warning signs and symptoms of cervi-
cal cancer. Please type in as many as you can think of’.
Participants were presented with a blank space for
responses.

Again, we measured recognition with a closed ques-

tion: ‘The following may or may not be warning signs
for cervical cancer. We are interested in your opinion’.
Participants were presented with 11 symptoms of cervi-
cal cancer and oﬀered response options ‘Yes’, ‘No’ or
‘Don’t know’, as well as the option to refuse to answer
the question. If participants chose this option, their data
were coded as ‘missing’.

For each symptom, a ‘Yes’ response scored ‘1’.

Responses ‘No’ and ‘Don’t know’ scored ‘0’. To allow
comparisons between recall and recognition scores,
recalled symptoms that corresponded with the list of
11 symptoms in the closed question (target symptoms)
(see

Table 4

for the full list) were scored as ‘recalled’

(‘1’) if they were mentioned. Scores from each question
were summed to give a total ‘recall’ score and a total
‘recognition’ score (range for both questions = 0–11).

Finally, we measured how many women responded

with any non-speciﬁc reference to vaginal bleeding
(including ‘irregular bleeding’/‘spotting’/‘non-speciﬁc
bleeding’) in the open question as, although these
answers do not speciﬁcally relate to the closed question
responses, they are not ‘incorrect’. If a respondent men-
tioned at least one of these symptoms, they received a
score of ‘1’. Otherwise, they received a score of ‘0’.

2.5. Analyses

Data were analysed using SPSS version 19. We ran

multiple linear regressions to determine independent
predictors of awareness (recognition) of symptoms and
risk factors. Recall and recognition of cancer symptoms
have been shown to have similar correlates; however,
recognition levels are usually considerably higher than
recall.

As some symptoms had a recall rate of zero,

it was easier to determine group diﬀerences by using rec-
ognition scores in the regression analyses. Further,
CAM symptom recognition scores have been shown to
be an independent predictor of time to help-seeking.

For both regression models we entered age, ethnicity,

education level and experience of cervical cancer as pre-
dictor variables. Data were weighted using a rim weight-
ing technique, in which target proﬁles were set for ﬁve
separate demographic variables (occupational status,
parity, age group, social grade and geographical region)
to achieve a demographic proﬁle within the sample
which was representative of women aged 16 and over
in England.

3. Results

3.1. Sample characteristics

The sample consisted of 1392 women.

Table 1

details

the sample characteristics, showing both weighted and
unweighted data. Weighting had the biggest eﬀect on
age groups, with the youngest group over-represented
and those aged 25–39 under-represented. The remaining
variables

had marginal diﬀerences.

Characteristics

reported here use the weighted data. Participants were
aged 16–94 (M = 47 years). Most were from White eth-
nic backgrounds (91%) and either had no formal educa-
tion or were educated to a low level (51%). The majority
of participants had not had cervical cancer themselves,
nor had they known anyone close to them who had
(85%).

3.2. Awareness of risk factors

Two-thirds of respondents (65%, n = 905) were

unable to recall any of the target risk factors
(M = 0.44, SD = 0.67). The remainder (35%, n = 487)
correctly recalled at least one. ‘Having many sexual
partners’ was the most recalled target risk factor
(20%). The least recalled were ‘having many children’
(0.2%) and ‘having a weakened immune system (e.g.
because of HIV/AIDS, immunosuppressant drugs or
having a transplant)’ (0.1%). Mean recall score was
slightly higher (M = 0.52, SD = 0.78) when open
responses ‘Infection/STI/STD or virus’ (recalled by
1%) and ‘unprotected sex’ (recalled by 7%) were
included.

Table 2
Number of recalled and recognised cervical cancer risk factors
(weighted n = 1392).

Risk factor

Recalled

Recognised

(n)

Having many sexual partners

272 19.5

884 63.5

Smoking any cigarettes

121

8.7

706 50.7

Starting to have sex at a young age

111

8.0

758 54.4

Unprotected sex

101

7.3

–

Not going for regular smear (Pap) tests

5.6 1046 75.2

Infection, STI/STD or virus

1.4

–

Infection with Chlamydia

1.4

748 53.7

Infection with Human Papillomavirus (HPV)

1.1

643 46.2

Long term use of the contraceptive pill

0.3

460 33.0

Having a sexual partner with many previous

partners

0.3

740 53.1

Having many children

0.2

167 12.0

Having a weakened immune system (e.g.

because of HIV/AIDS, immunosuppressant
drugs or having a transplant)

0.1

692 49.7

3004

E.L. Low et al. / European Journal of Cancer 48 (2012) 3001–3008

Awareness was substantially higher when measured

by recognition (with 95% able to identify at least one
risk factor), however on average women still only cor-
rectly identiﬁed half of the risk factors presented
(M = 4.96/10, SD = 2.50). The most recognised risk fac-
tors were ‘Not going for regular smear (Pap) tests’ (75%)
and ‘Having many sexual partners’ (64%). The least
recognised was ‘having many children’ (12%) (

Table 2

When risk factor recognition score was regressed

onto the demographic and cancer experience variables
the model accounted for a small but signiﬁcant propor-
tion of the variance (Adj. R

= 0.02, F(4,1366) = 9.48,

p < 0.001). Older age and a higher level of education

signiﬁcantly predicted higher awareness of cervical can-
cer risk factors in the model. The eﬀect size was similar
for age (gp

= 0.02, p < 0.001) and education level

(gp

= 0.02, p < 0.001) (

Table 3

3.3. Awareness of symptoms

Two-thirds of the women were unable to recall any of

the target symptoms (75%, n = 1049). This ﬁgure was
lower (55%, n = 764) when responses ‘irregular bleed-
ing’/‘spotting’/‘non-speciﬁc

bleeding’

were

included

(M = 0.59, SD = 0.77). Recognition was better than
recall, with 93% correctly recognising at least one symp-
tom of cervical cancer (M = 6.08/11, SD = 2.85).

Although not on the target list, unusual vaginal

bleeding (including responses: ‘irregular bleeding’/‘spot-
ting’/‘non-speciﬁc bleeding’) was the most recalled
symptom of cervical cancer (29%), followed by ‘persis-
tent, abnormal or unusual vaginal discharge’ (15%). Pat-
terns were diﬀerent when women were asked to
recognise symptoms, with recognition highest for ‘vagi-
nal bleeding between periods’ (73%), and ‘persistent pel-
vic pain’ (70%). Few women knew that ‘persistent
diarrhoea’ was a symptom of cervical cancer as it was
both the least recalled (0%) and recognised (12%) symp-
tom (

Table 4

The multiple regression model explained 4% of the

variance in symptom recognition (Adj R

= 0.04,

F(4,1367) = 15.28, p < 0.001). Older age, White ethnic
background, higher level of education and having a
close experience of cervical cancer all predicted higher
cervical cancer symptom recognition. The eﬀect size
was strongest for ethnicity (gp

= .03, p < 0.001) and

education level (gp

= .01, p < 0.001) and weaker for

age (gp

= .01, p < 0.01) and close experience of cervical

cancer (gp

= .01, p < 0.01) (

Table 5

4. Discussion

Most respondents were unable to recall any symp-

toms or risk factors for cervical cancer. Awareness was
much higher for both when prompted; although even
then women were only able to recognise around half
of the symptoms and risk factors presented.

Although the most recognised risk factor was ‘not

going for regular smear (Pap) tests’ (>75%), a quarter
of women were not able to identify this risk factor even
when prompted. It has been suggested that lack of
awareness of the function of the cervical cancer screening

Table 4
Awareness of cervical cancer symptoms (weighted n = 1392).

Symptom

Recalled

Recognised

(n)

Unusual vaginal bleeding

397

28.5

Persistent/abnormal/unusual vaginal

discharge

202

14.5

861

61.9

Vaginal bleeding between periods

4.4

1020

73.3

Heavier/longer periods than normal

3.3

723

52.0

Vaginal bleeding during/after sex

2.3

886

63.7

Pain/discomfort during sex

2.0

864

62.0

Persistent pelvic pain

1.4

971

69.8

Unexplained weight loss

1.0

778

55.9

Blood in stool/urine

0.9

598

43.0

Persistent lower back pain

0.8

602

43.3

Vaginal bleeding after the menopause

0.3

923

66.3

Persistent diarrhoea

0.0

164

11.8

This includes any reference in the open responses to non-speciﬁc

vaginal bleeding, including ’irregular bleeding’/‘spotting’/‘non-speciﬁc
bleeding’ that did not match with the target symptoms in the closed
question.

Table 3
Regression for predictors of cervical cancer risk factor knowledge
(recognised) (weighted n = 1372).

95% conﬁdence interval (CI) SE

Lower

Upper

Constant

3.69

3.07

4.31

0.32

Age

0.02

0.01

0.02

0.00

0.12

Ethnicity

0.24

0.70

0.22

0.24

0.03

Education

0.40

0.23

0.57

0.09

0.13

Cancer experience

0.27

0.09

0.63

0.18

0.04

Signiﬁcant at 0.001.

Table 5
Regression for predictors of cervical cancer symptom recognition
(weighted n = 1373).

95% conﬁdence interval (CI)

Lower

Upper

Constant

3.55

2.85

4.25

0.36

Age

0.01

0.00

0.02

0.00

0.06

Ethnicity

1.46

0.94

1.98

0.26

0.15

Education

0.43

0.24

0.62

0.10

0.12

Cancer experience

0.56

0.16

0.97

0.21

0.07

Signiﬁcant at 0.01.

Signiﬁcant at 0.001.

Analyses (not reported here) showed that the relationship was the

same when the ‘other’ education group was not included.

E.L. Low et al. / European Journal of Cancer 48 (2012) 3001–3008

3005

programme can negatively aﬀect attendance.

Currently

around 20% of eligible women are not participating in
screening

; and coverage for women in the higher risk

age group (25–49 years) is falling.

Increasing awareness

that the cervical screening programme can reduce the
risk of cervical cancer may help to increase attendance,
resulting in lower incidence and consequently mortality.

Recognition of ‘smoking’ (51%) and ‘infection with

Chlamydia’ (54%) as risk factors for cervical cancer
appears to have improved in our study compared to ear-
lier research,

with over 50% of respondents able to rec-

ognise each. It was disappointing, however, that
awareness of HPV in particular was very low and that,
despite the introduction of the HPV vaccine in 2008
and the associated publicity, awareness of this risk fac-
tor was lower in the current survey than it was reported
to be in a survey carried out in 2006.

Unprompted awareness that having many sexual

partners is a risk factor for cervical cancer was much
higher (20%) than it was for HPV, suggesting that
although many women know there is a link between cer-
vical cancer and sex, the mechanism for this (i.e. HPV
infection) has yet to understood by most. Previous
research on public understanding of the link between
cervical cancer and smoking has highlighted the impor-
tance of having a coherent model linking a risk factor to
an outcome.

Future research might investigate ways of

helping women understand the role of sexual activity in
cervical cancer aetiology.

In contrast to our hypothesis, we found that younger,

not older women had lower awareness of risk factors for
cervical cancer. This is concerning, as incidence is high-
est in women aged 30–34

and there is evidence that

younger women may be more vulnerable to some risk
factors such as infection with Chlamydia.

One expla-

nation of our ﬁndings may be our use of a composite
risk factor score, whereas previous research has investi-
gated awareness of individual risk factors for cervical
cancer

18,19

or cancer risk factors in general.

A compos-

ite score may lead to higher awareness in older women
as younger women may be more aware of speciﬁc risk
factors (such as HPV)

but less aware of risk factors

overall.

The most recalled symptoms in our sample were

‘unusual vaginal bleeding’ (29%) and ‘persistent/abnor-
mal/unusual vaginal discharge’ (15%). This was particu-
larly reassuring given that they are the most common
symptoms of cervical cancer and are highlighted in the
Department of Health’s key messages.

However, less

reassuring was the fact that most women were unable
to recall any symptoms and even for these common
symptoms recall was still quite low.

Recognition was good for the ‘bleeding’ and ‘pain’

symptoms (

Table 4

), reﬂecting earlier ﬁndings that,

when participants were presented with symptoms of
cancer more generally, two of the three most recalled

symptoms were bleeding and pain symptoms.

This

suggests that women think of cervical cancer symptoms
as relatively alarming or dramatic. As they are not nec-
essarily so, it may be useful to raise awareness of the less
dramatic or vaguer symptoms of cervical cancer (such as
‘unusual vaginal discharge’ as recognition was not as
high for this common symptom (62%) as it was for the
bleeding symptoms).

Studies of help-seeking behaviour support this con-

clusion. They have shown that women are more likely
to seek help promptly for gynaecological cancers if they
perceive their symptom to be alarming (e.g. bleeding) or
serious (e.g. pain) and that they are less likely to seek
help promptly for cancer symptoms in general if they
experience a symptom which is perceived as more com-
mon or vague.

As expected, White ethnicity and higher education

predicted higher recognition of symptoms, reﬂecting
earlier research for cancer symptoms in general.

know that lower SES and non-White women have
poorer outcomes when diagnosed with cancer.

33,34

also know that GPs are less likely to refer these groups
of women to secondary care.

If women are unaware of

the symptoms for cervical cancer, they may be less likely
to insist on referral for further investigation. Increasing
awareness in these groups could ultimately aﬀect sur-
vival rates by increasing conﬁdence when seeking help
for symptoms, and thus increasing referrals for these
women.

4.1. Strengths and limitations

We used a validated tool to systematically measure

both risk factor and symptom awareness for cervical
cancer, making the task of assessing changes in aware-
ness over time easier. These data were collected just
prior to the launch of the cervical cancer key messages;
using the cervical CAM to assess awareness again in the
future may give an indication of the impact of these key
messages on awareness.

An important limitation was that although we identi-

ﬁed some variables that signiﬁcantly predicted both risk
factor and symptom awareness, the total amount of var-
iance explained by each model was very small, suggest-
ing that there are other, stronger inﬂuences on
awareness that we have not included in our analyses.
Further work should be carried out to identify these
variables.

A ﬁnal limitation of this study was that, as the sample

was population representative, the proportion of non-
White participants was inevitably small. Given that
women from non-White backgrounds had lower symp-
tom awareness than White women, we feel that ethnic
diﬀerences in awareness should be explored in future
studies, which should include a higher proportion of
non-White participants.

3006

E.L. Low et al. / European Journal of Cancer 48 (2012) 3001–3008

5. Conclusions

Awareness of both risk factors and symptoms of cer-

vical cancer was low in UK women. Future research
should investigate awareness of the link between sexual
behaviour, HPV and cervical cancer as our ﬁndings sug-
gest that this relationship may not be fully understood.

Some population sub-groups may beneﬁt from more

education on risk factors and symptoms in general –
including younger women, ethnic minorities and those
with less education. It is hoped that by improving
awareness in these groups, prompt help-seeking will be
encouraged, reducing the chances of a poor outcome.

Contribution to authorship

J. Waller, J. Lyons and D. Romney-Alexander con-

ceived of and designed the study, and commissioned
the data collection. E. L. Low, J. Waller and A. Simon
analysed the data. E. L. Low wrote the ﬁrst draft of the
paper. J. Waller and A. Simon contributed to writing the
paper. All the authors approved the ﬁnal version of the
manuscript.

Ethical approval

The study was exempt from ethical approval as no

identifying details were collected from the participants.

Conﬂict of interest statement

None declared.

Acknowledgements/funding

This research was funded by the Department of

Health as part of the Cervical Cancer Awareness and
Symptoms Initiative, a collaborative partnership be-
tween the Department of Health, The Eve Appeal and
the UCL Health Behaviour Research Centre. Jo Waller
and Alice Simon are funded by Cancer Research UK.
Emma Low is funded by an IMPACT studentship
(co-sponsored by UCL, Cancer Research UK and
Target Ovarian Cancer).

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