Combined Incentive Actions, Focusing on Primary Care, to Improve Cervical Cancer Screening in Women Residing in Socio-economically Disadvantaged and Untracked Geographical Areas: a Hybrid Efficacy and Implementation Trial
Combined Incentive Actions, Focusing on Primary Care, to Improve Cervical Cancer Screening in Women Residing in Socio-economically Disadvantaged and Untracked Geographical Areas: a Hybrid Efficacy and Implementation Trial
Though potentially eradicable, cervical cancer is the 3rd most prevalent gynecological
 cancer, and the 2nd most prevalent before the age of 45. In France, approximately 1100 women
 die from cervical cancer each year, with 5-year survival strongly linked to the stage at
 diagnosis (93%, 63%, 35% and 16% for stages IA, IIA, IIIA and IVA). The prevention of
 cervical cancer is currently based on the combination of the vaccination of adolescent girls
 against the most common high-risk oncogenic human papilloma virus types and routine
 Papanicolaou cytology (Pap smears) every three years in women aged 25 to 65 years. The Health
 and Social Protection Survey conducted by the Institute for Research and Documentation in
 Health Economics in 2012 showed that young women who are not vaccinated have a socio-economic
 profile similar to that of women who do not attend cervical cancer screening, mainly: (i) the
 least screened women and least vaccinated young women live in low-income families; (ii) a low
 level of education is associated with fewer Pap smears; (iii) an absence of pap smears in
 mothers in the last three years is associated with less human papillomavirus vaccination in
 their daughters. Cervical cancer is the female cancer which, in France, has the highest
 proportion attributable to precariousness (21.1%), and for which there are strong territorial
 disparities in incidence.

 Several factors may explain the difficulties in obtaining satisfactory rates of screening,
 such as geographical remoteness, the disengagement of general practitioners, economic
 constraints, or the geographical origin of women. Several countries such as the Netherlands
 have started routinely screening for cervical cancer by testing for human papillomavirus.
 This approach appears to be as beneficial as a screening campaign based on the Pap smear.

 This approach has also just been validated by the French Health Authority which, in its
 public health recommendation dated 11 July 2019, states that "From the age of 30, the High
 Authority for Health recommends that the human papillomavirus test replace the cytological
 examination in primary screening for cervical cancer." In addition, this recommendation
 states that "Vaginal self-sampling is an alternative to cervical sampling by a health
 professional to detect the human papillomavirus test for undetected or under-detected women.
 This makes it easier to screen women who never get tested or who do not get tested as
 recommended." Moreover, the French Authority for Health specifies "In addition, complementary
 studies should be carried out to evaluate the feasibility and effectiveness of the different
 modalities for making these vaginal self-samples available, depending on the specific
 populations concerned (French Guyana, Mayotte, women living on the street, in shantytowns,
 migrant women, with limited access to health services, etc.)".

 Two French trials show that when women ignored a letter sent to the home to invite them to
 receive a Pap smear, only 16 to 18% of women performed vaginal self-sampling when a kit was
 subsequently sent to their home. The delivery of a vaginal swab by a health professional does
 not increase adherence to screening compared to a reminder letter for a Pap smear (12% vs.
 11.9%). Economic incentives may increase adherence to prevention policies, including those
 against human papillomavirus infections. They are often used to combat "present bias", i.e.
 the tendency to seek immediate, even limited, satisfaction rather than greater future
 satisfaction. A factorial design will be used to analyze the respective contribution of the
 delivery of the vaginal swab to a healthcare professional and an economic incentive of 20€.
 The hypothesis is that the the fact of returning the vaginal self-sampling to a health
 professional or an economic incentive will increase the participation of socially
 disadvantaged women in cervical cancer screening compared to simply returning it by mail
 without an incentive. It also postulate that health professionals will encourage women to
 perform a vaginal swab and adhere to the recommendations of the French Health Authority in
 case of a positive human papillomavirus test and that socially disadvantaged women will
 accept vaginal swabbing as a method of cervical cancer screening. Factors such as
 precariousness, life and migration paths, the socio-sanitary context, and the provision of
 primary care all play a role in prevention behaviors and may explain the heterogeneity of the
 observed effects.
Inclusion Criteria:

 -  Woman between 30 and 65 years of age.

 -  Covered by a Regional Cancer Screening Coordination Centre for cervical cancer in 4 of
 the pilot departments for the implementation of this organised screening, and
 participating in the study.

 -  eligible for cervical cancer screening.

 -  Having not had a cervical smear test for at least three years.

 -  Not having responded within 6 months to a letter inviting a cervical-uterine smear
 test.

 -  Residing in a Block Grouped for Disadvantaged Statistical Information, quintiles 4 & 5
 according to the European Deprivation Index classification.

 -  Covered by health insurance or AME

 Exclusion Criteria:

 -  Ineligible for screening (e.g. hysterectomy or history of cervical cancer).

 -  Pregnant woman beyond 6 months of age.

 -  Under guardianship or trusteeship.