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Challenges for cervical screening in people experiencing homelessness
  1. Katie Eirian Hawkins1,
  2. Kyra Gourlay2,
  3. Kate Cuschieri3
  1. 1 The Access Place, Edinburgh, UK
  2. 2 Medical School, The University of Edinburgh, Edinburgh, UK
  3. 3 Scottish Human Papillomavirus Reference Laboratory, NHS Lothian, Edinburgh, UK
  1. Correspondence to Dr Katie Eirian Hawkins, The Access Place, 6 South Gray's Close, Edinburgh, UK; katiehawkins{at}

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There are over 3000 new cases of cervical cancer each year across the UK, most being associated with persistent infection with human papillomavirus (HPV). Cervical screening greatly reduces the risk of cancer and is offered in Scotland to women and individuals with a cervix aged 25–64 years. Cervical screening has been based on HPV testing since 2020.

Two of the main risk factors for the development of cervical cancer are non-engagement in regular screening and socioeconomic deprivation.1 Women experiencing homelessness are particularly vulnerable due to challenges in accessing healthcare. These women are also more likely to smoke, have multiple sexual partners, and are less likely to have received HPV vaccination – all risk factors for cervical cancer. Additionally, women experiencing homelessness are more likely to have experienced childhood sexual abuse than the general population, which may affect their ability to engage in cervical screening.

The Access Place offers primary care, social work and housing services for those experiencing homelessness or who are vulnerably housed in Edinburgh, Scotland, UK. As part of a service improvement project, the team assessed data from the Scotland-wide cervical screening IT database to assess level of screening engagement in patients registered at the practice. The aim was to assess screening uptake in those who met the cervical screening criteria as of 1 December 2021. Of 163 patients who were eligible for screening, 50 (31%) were up to date, 65 (40%) were overdue and 48 (29%) had no recorded screening event in Scotland. Of those overdue, 27 (42%) were overdue by five or more years.

Uptake of screening in the general population is 69%2 whereas uptake in those supported by the Access Place was 31%.2 This percentage may be lower still in the wider female homeless population in Edinburgh given that many experiencing homelessness are not registered with a general practitioner (GP). Women experiencing homelessness may have challenges with access, lack of knowledge, and perception of risk/importance of screening among other priorities and life experiences.3

In the population studied, those aged 25–29 years were most likely to miss screening, with only 24% being up to date. In the general screening population, this age group is also associated with the lowest uptake although with a (higher) percentage of 55%.2 The study population aged 55–59 years were most likely to engage (71% uptake) to a similar level observed in the general screening population (79%).2 Across all levels of socioeconomic deprivation, younger age is associated with lower uptake of screening due to issues including regular changes of address or not being registered with a GP. These factors are exacerbated in women experiencing homelessness.

Equitable means to encourage screening uptake in vulnerable groups, including those experiencing homelessness, are essential. One such method may be to offer self-sampling (as opposed to clinician-based sampling) for HPV testing. This would obviate the requirement for a screening clinic visit and a speculum-based sample. Evidence attests to similar clinical performance of HPV tests in self-samples compared with clinician-taken samples.4 While self-sampling is clearly an important tool, women who are HPV-positive then require a clinic visit (for a clinician-taken sample) and, where required, colposcopy follow-up; so while self-sampling may address some barriers for the initial screen, care must be taken to educate and engage women in all potential aspects of the process including follow-up. In addition to improvements in sampling, gaining a better specific understanding of local barriers to screening in women experiencing homelessness through qualitative research would surely support evidence-based developments in information provision and practice.5

Ethics statements

Patient consent for publication

Ethics approval

The study was approved as service evaluation as per the University of Edinburgh’s ethical requirements, written in conjunction with the National Research Ethics Service of the Health Research Authority of Scotland. No modification of investigation, treatment or other aspects of clinical practice was involved. The dataset was anonymised to ensure confidentiality.



  • X @drkatieh

  • Contributors The concept of the project was under KEH's direction. KG examined the data from the Scottish Cervical Recall system and drafted the initial manuscript. KC provided advice regarding HPV self-testing and wrote the section on HPV testing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests KC is the Director of the Scottish HPV Reference Laboratory, NHS Lothian, which processes samples for HPV testing for service and research work.

  • Provenance and peer review Not commissioned; externally peer reviewed.