SAPC PhD/Doctoral Prize 2021 blog by Emily McBride, UCL

I am delighted to have been awarded the SAPC PhD Prize 2021. As a Health Psychologist and Behavioural Scientist, one of my research interests is in how routine medical services and procedures can impact on mental wellbeing and health behaviours. Often, my work means working collaboratively with a range of stakeholders in policy, primary care, and population health. 

Over the last four years, I’ve been focussing on the psychological impact of women receiving different test results at cervical cancer screening. Particularly, evaluating a new cervical screening method called human papillomavirus (HPV) primary testing, which was fully implemented across England at the start of 2020. This topic formed the basis of my PhD at University College London and was funded as part of an NIHR Doctoral Research Fellowship.

Although the NHS cervical screening programme has been around since 1977, the recent integration of HPV as the primary test means that everyone who attends now gets tested for HPV and told whether they test positive or negative. Given that HPV is a sexually transmitted infection (STI) responsible for virtually all cervical cancers, there were concerns around how women might interpret an HPV-positive result. Especially given the majority of women who test HPV-positive don’t have abnormal cells (also known as normal cytology) and therefore only receive their result via mailed letter, with no routine clinical contact. There were concerns that some women may misinterpret their cancer risk or experience unnecessary distress.  As cervical screening is a population service, very large numbers of women are affected. In fact, over 400,000 women will test HPV-positive each year in England.

My PhD comprised four studies to explore this area in depth: a mixed method systematic review with meta-analysis (n=33); two large primary quantitative studies embedded in routine cervical screening (n=1127 and n=646); and one in-depth comparative qualitative study (n=30). I broadly sought to assess psychological response to receiving an HPV-positive result, and to examine reasons for differences in reactions between different women and groups of the population. My rationale was that if we could identify key ‘triggers’ of anxiety or adverse responses, then the NHS cervical screening programme and primary care practitioners could aim to address these concerns in routine practice.     

To illustrate some key findings, here is a relatively common scenario. Imagine a happily married woman in her 30s attending cervical screening, unaware she is being tested for a potentially cancer-causing STI. Imagine her confusion upon receiving an HPV-positive result. She takes out her laptop and googles “HPV”. This is shortly followed by shock, panic, and anxiety. What does her result mean; will she develop cervical cancer? She also feels “dirty” and ashamed upon learning she has an STI. Does this mean her husband has cheated on her; can she pass it on to him; will he leave her if he finds out? She starts crying and picks up the phone to make an appointment with her GP. What can she do to get rid of HPV; is there a cure or treatment? Perhaps she can request an earlier screen – her letter says she needs to wait 12 months which seems ridiculous, surely she can develop cancer in that timeframe. On second thought, maybe she should keep her result to herself as people might judge her as promiscuous. After a few weeks, the worst of her anxiety passes but she continues to avoid sex and intimacy with her husband. She also starts to take vitamin supplements in hope that they may boost her immune system. She knows HPV has no cure, but she finds comfort in doing something (anything) to control it.

From a more scientific standpoint, I found that testing HPV-positive was associated with adverse psychological and behavioural sequelae for some women. These impacts appeared to differentially affect subgroups of the population in terms of intensity, duration, and clinical significance. Preliminary findings suggest that these women may be younger, have low health literacy, be receiving their first HPV-positive result, living with pre-existing mental health issues, and/or those from BAME or religious backgrounds.  Misinterpretation of cancer risk and unhelpful beliefs about HPV seemed to partially account for clinically significant anxiety. Highly anxious women expressed being most afraid of developing cervical cancer and had concerns about potential relationship infidelity, as well as fertility concerns for younger women.

Overall, these findings have important implications for GPs and other primary care practitioners who perform cervical screens or see women following an HPV-positive result. The areas identified signpost to target areas that can be used to help address women’s key concerns in routine consultations. This will help prevent unnecessary anxiety and reduce additional patient visits to primary care. I have been fortunate to work closely with cervical screening policymakers, meaning that already my research has informed changes to national cervical screening communications and NHS practice. For example, the NHS Cervical Screening Programme (NHSCSP) integrated psychological recommendations into their clinician training content (primarily targeted at GPs and screening sample takers). Our research and contributions also informed wording of result letters sent to >3mn women per year. This directly led to the inclusion of additional inserts (FAQs) for women testing HPV-positive with normal cytology, aiming to address common concerns and reduce result misinterpretation.