Table 1 Examples of data contributing to summary statements, and of TDF domains matching the statements

‘I just wonder if it’s perhaps in a family history of when, like, I suppose if there’s been one or more people, like two or three people in your family that have had it, I would imagine that that would actually raise your risk of it... Maybe people that have been sort of a bit promiscuous, prone to infection, something like that might trigger it.’ Attender (LS24^a)

‘I’ve been with my husband since I was 18, we’re still together. I’m pretty certain he’s monogamous... I’m certainly monogamous, so I don’t feel like I’m at risk.’ Attender (LS17)

‘She [practitioner] should have sat me down in the first place, ascertained any problems around the smear – what do I understand about it? She never did any of that, it was just a question of the mechanics of it. So I, I want an explanation.’ Non-attender (LS2)

‘I think they just feel that if it was going to happen it should have all have happened by now – and that’s it for me now, just, my ovaries are switched off, it’s, everything’s winding down or wound down and that’s it.’ GP (HCP9^b)

My risk of getting cervical cancer is low.

I don’t know why I still need a screening test.

Knowledge.

‘I might be just in my sixties now but I mean I’m still… I’m quite a young 60, erm and I’m still having a sex life... I’ve been pushed on the scrap heap, they don’t wanna know!’ Attender (LS19)

‘I’ve been wondering at the, the diff, the different changes now, in patient’s, in people’s lives because there’s a lot of ladies and partners splitting up in their forties and fifties... And then there’s a lot more new partners... Maybe, do they see it that actually they don’t need, is it because they don’t need sexual protection because they’ve gone past the menopause? ... I’m beginning to, wondering if that is it, is that, if that’s the reason why it’s changed, because of the dynamics that have changed and people getting older, they’re no longer staying to that one partner.’ Practice Nurse (HCP5)

Doctors and nurses think no-one has a sex life after 60.

Role/Identity.

‘I can just feel it now, I can just, you know, remember it in my mind, it’s just like putting something really dry, oh, up something that’s all [laughs] sunk in, and it just doesn’t work, you just can’t do it.’ Non-attender (LS16)

‘It wouldn’t surprise me if, if a lot of the over fifties don’t attend because they’re not having regular sex, and therefore they perceive that it would be difficult, or sex is difficult.’ GP (HCP14)

‘I get uncomfortable because my body, my hip locks on me... Well usually you have to lie on the bed don’t you and hunch your legs right up and open? I can’t expand my legs... they pulled me right down to the edge, had like one of the nurses there and I had to put my feet on her as far up, and I mean it, it was painful.’Attender (LS21)

‘The laying down, that’s not the problem. It, it’s the actual physicalness of putting your ankles together. And, and, and opening, opening your knees. It’s your joints.’ Non-attender (LS15)

Inserting the speculum is painful because everything feels too dry.

I can’t get in the right position for the test any more, because it causes physical discomfort.

Beliefs about capabilities.

‘When you get to a certain age – age is a factor, illness is a factor – but age is a factor that you become more, more of a sponge to what’s going on in the world, and there’s not much you can do about dying or preventing your own death, so it becomes less important.’ Non-attender with multiple sclerosis (LS4)

‘I got to 50, I went and had my mammogram and they found a lump, so I had to, so it just put me off going to having anything done, I just don’t want to know, if I’ve got anything wrong I don’t want to know.’ Non-attender (LS23)

‘I don’t think you can do anything. I think if you’ve got something, you get it.’ Attender (LS3)

When I became ill, to be honest that was the furthest thing from my mind... it’s still too much, it would be too much for me stresswise to cope with if. If I came and had a smear and got a negative, erm, feedback.’ Non-attender with arthritis and circulatory problems (LS15)

I have too many other health issues – if the test picked up abnormalities, I wouldn’t want to go through treatment anyway.

There’s nothing I can do to stop myself getting cervical cancer.

If something is wrong, I’d rather not know, I wouldn’t cope.

Beliefs about consequences.

‘I had gone when I started with the problems after my menopause, to see a lady doctor at the surgery, and to be honest I felt, I felt that she thought I was just being, not stupid, but it wasn’t important the fact that I had no sexual intercourse or anything like that and the marriage was breaking down. And she, “Oh, if that’s all that’s bothering you!”, sort of thing. And she was an older lady doctor... I just felt after she’d said that, God I shouldn’t be troubling the doctors with things like this.’ Non-attender (LS5)

‘I think it’s quite bad really... it’s 65 then you’re kind of cut off... not everyone’s sort of past their sell by date and finished with are they really?’ Attender (LS21)

‘If I speak to women who have menopausal problems or pain with sex, which often you see people, and anyone who’s menopausal to be honest, I, if, if they’re coming to talk to me about the menopause, I will raise that and say actually use the oestrogen cream and lots of moisturiser. That’s what we should be telling everybody... we should be encouraging any women, over 50 to, to treat that as essential part of their healthy life.’ GP (HCP14)

I’ve had problems with dryness since hitting the menopause, but my GP told me these things aren’t worth addressing at my age.

Motivation and goals.

‘I’d have to have a reminder that, you know, you haven’t been for this examination for a while... I’ve just put it to one side and forgotten I’ve got it... I tend to, I don’t mean conveniently forget because I don’t, I just forget, you know... months later I’m going through the bottom of my bag [of paperwork] and thinking – ooh, what’s this?’ Attender (LS8)

‘They’ve put it in their pile of letters and the day’s gone on and they’ve forgotten or they’ve rung up and they couldn’t get through to the GP surgery and it, it gets forgotten. And then something happens and nobody follows it up and that does happen in, in some practices. And if that happens it can go on and on for years. And it’s, and it’s modern, busy life, it’s understandable.’ Practice Nurse (HCP17)

‘Time fades, doesn’t it really? And I think... if they were to come back after 5 years when they should have come back, whatever it were that triggered it in the first place is soon forgotten, unless there’s some other trigger factor that happens in the meantime.’ Practice Nurse (HCP21)

I put screening invite letters in my ‘to-do’ pile and they just get forgotten.

Memory, attention and decision processes.

‘We a good rapport with each other… when she actually said “Oh, have you had your smear test letter?” I said “yeah”, she said “Well let’s book you in”. I’d gone for erm a blood pressure test... So each time I got one, I said “Oh I’ve got my letter” when I’d go for a blood pressure test, she’d book me in rather than me waiting for the receptionist to buff you off and everything else that they do.’ Attender (LS13)

From the start [laughs] it just seems... little sort of avenues off. Never mind getting the appointment, never mind actually on the bed and doing what you need to do... The stress I think of having to check in at reception – no-one’s there, then she’s logging in, I’m thinking “For goodness’ sake, woman!”... And then, to top it all, [laughs] I know it’s a Well Woman Clinic, and she goes, “Oh, it’s important to be, erm, mentally alert!” – “Yeah, I do work in a [customer service] environment, I’m mentally alert, yeah”... I feel oh, just keep, I feel it drags me down. I know I shouldn’t say, but I feel the whole procedure of reception, seeing different people, different nurses.’ Non-attender (LS25)

‘Well I suppose if you’ve got a 20 min appointment, somebody’s not turned up, yeah, you could ring them. But then equally then that can make people feel really bad if they’ve forgotten. [laughs] And we’re not out, I’m not out as a blame culture.’ Practice nurse (HCP20)

Communication with my GP practice is important, and it’s not always easy.

Environmental context and resources.

‘I’ve had smears from doctors who treat you like a slab of meat... that turns you off a little bit.’ Attender (LS20)‘It can be a very intense sort of space… women just wanna get it over with… it’s a space that can be quite emotionally charged… it’s so emotional, this smear test, and I think that’s got to be tackled.’ Non-attender (LS2)‘I felt as if she was ramming something into me and it was just extremely, you know, personal and uncomfortable. And I I felt afterwards I’m not going to her again.’ Non-attender (LS1)‘The first horrid one I had... she had her back to me for a while, she’d left the thing [speculum] in... I said, “I’m shaking, I can’t stop my legs shaking, it hurts like mad!”... it was as if she didn’t hear me and she’s carrying on, and to me it was like some torture chamber or other.’ Non-attender (LS16)‘Ladies of a certain age might think to themselves it was an abusive experience, so therefore that could be a reason why some women are reluctant to go these days... I was terrified. I didn’t like my GP, he was – won’t mention any names for confidentiality purposes – but erm, don’t want to put this in too strong a terms but he made me very uncomfortable.’ Attender (LS17)

Whenever I’ve had intimate examinations in the past, I’ve felt uncomfortable/ severely distressed.I find the screening procedure intimidating and/or impersonal.Screening reminds me of past traumatic experiences.

Emotion.

‘Big red letters: “No smear! No smear! No smear! Offer smear! Offer smear!” No one ever discussed why I wasn’t going to have it with me. I thought, I’m not bringing it up. [laughs] I don’t bloody want it in the first place but, yeah. It was never discussed. Never discussed.’ Non-attender (LS2)

‘No-one’s ever asked me at the surgery where I was before about why I didn’t want to do anything or – not that I resent anything – but why, well basically any options... they just took it as mainstream, yeah, you’re going to come for a smear.’ Non-attender (LS25)

‘Ask the question. So remind them first of all that they need it, and then ask them the ‘Why’ [they don’t attend] in a way… and be prepared to do something about it.’ GP (HCP1)

‘They can treat it... they can take it away by scraping or, you know, whatever, so that that really is my knowledge of it... so yeah, daughters... they’re more aware of things like that... When you’re growing up in the seventies, you weren’t taught anything like that so it’s up to you to go out there and find out... but again not always, erm, people there to talk to is there? ... So but yeah, daughters, that’s why I know a little bit more about it... because they both had abnormal cells as well.’ Attender (LS18)

‘Occasionally you will get a couple that are kind of over their fifties. More often than not... their daughters have pushed them into it, because the daughters are kind of coming up to that age for it and they’ve been for theirs, and if they know their mum’s out of date... I have had a couple saying, “Oh my daughter came for hers last week and told me I had to book in for it”.’ Practice Nurse (HCP19)

‘One of my friends... she didn’t go for a smear test for years... she’d had letter after letter, and then she said “I am absolutely terrified”, and I said, “Well I’ll come with you” and we was in the, in the hospital waiting and she put her coat on and started walking. “Where you going?” She said “I can’t stay”. I said “Yes you can, you can, it’s your body and you need to know that you’re clear, do you want to end up bad with cancer or, or something and end up dying with it?” And she went “No”. And I said “Well, that’s your answer”. She was fine, and she still goes now. Attender (LS21)

No-one at my GP surgery ever has ever bothered to ask me why I don’t go for screening.

My daughter persuaded me to go for screening.

Friends my own age persuaded me to go for screening/I persuaded a friend to go.

Social influences.