Abstract
Low uptake of cancer screening services is a global concern. Our aim was to understand factors that influence the screening decision, including screening and treatment subsidies and a gain-frame message designed to present screening as a win-win. We analyzed preferences for mammography and Pap smear among women in Singapore by means of discrete choice experiments while randomly exposing half of respondents to a gain-framed public health message promoting the benefits of screening. Results showed that the message did not influence stated uptake, and given the levels shown, respondents were influenced more by treatment attributes, including effectiveness and out-of-pocket cost should they test positive, than by screening attributes, including the offer of a monetary incentive for screening. Respondents also underestimated the survival chances of screen-detected breast and cervical cancers. Combined, these findings suggest that correcting misconceptions about screen-detected cancer prognosis or providing greater financial protection for those who test positive could be more effective and more cost-effective than subsidizing screening directly in increasing screening uptakes.
Highlights
Cancer is a leading cause of morbidity and mortality worldwide
We included an attribute focusing on treatment costs conditional on a positive diagnosis. We presented this cost in dollars as opposed to percentage reductions as done in the prior discrete choice experiments (DCEs), as many women have no idea of the actual costs of treatment and there is a wide range depending on the approach taken
We found that screening cost was not statistically significant for mammography (P = .25) or Pap smear (P = .67)
Summary
Cancer is a leading cause of morbidity and mortality worldwide. In 2018, more than 18.1 million people were diagnosed with cancer and more than 9.6 million cancer deaths were reported.[1]. Mammography and Pap smear are the two most common screening services for women. In Singapore, the focus of this study, the Health Promotion Board (HPB) recommends women aged 50 to 69 to screen every 2 years, and women aged 40 to 49 with higher cancer risk to screen every year.[5] HPB further recommends Pap smears for women aged 25 to 69 who have ever had sexual intercourse to screen every 3 years.[5] Despite the HPB recommendations, screening rates for both services are low. In 2016, only 38.6% of women aged 50 to 69 underwent mammography screening within the last 2 years and 50.7% of eligible women aged 25 to 69 underwent Pap smear screening within the last 3 years.[6] Incomplete screening uptake is not unique to Singapore, some countries screen at much higher rates.[7,8] These cross-country differences suggest opportunities to increase rates above current levels in Singapore
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