Table 3 Examples of barriers and facilitators from the data which fed in to good practice recommendations

Examples from data:

• Non-attenders’ perception of poor/impersonal communication from practitioners.

• Attender and non-attender experiences of problems discussing sex and relationship changes associated with aging with practitioners.

• Experiences of screening tests from previous decades becoming a ‘guiding light’ (non-attender interviewee) for decisions about attendance in the present.

• Lack of practitioner sensitivity to pain and discomfort caused by vaginal dryness.

• Difficulties keeping appointments which have to be booked far in advance.

Examples from data:

• Lack of networking between practice nurses who carry out cervical screening.

• Difficulties in making older women comfortable when they have menopausal or mobility issues; lack of continuity with patients in addressing difficulties.

• Difficulties with equipment (table height not adjustable, lighting inadequate, etc).

• Diversity and strength of expectations among older patients – may need pragmatic or ‘businesslike’ (attender interviewee) approach, or empathetic and understanding approach, dependent on screening history.

1. How to identify and communicate with non-attenders.

e.g. Draw on person-centred communication procedures (non-judgemental language/open approach); facilitate networking between practice nurses around non-attendance.

2. How to make appointment protocols flexible in a way which encourages attendance among older women (advice which can be customised by each GP practice dependent upon capacity).

e.g. Offering a pre-screening appointment to discuss issues; matching patient with appropriate nurse based on key issues.

3. How to develop rapport with older women attending for screening.

e.g. Examples of ‘history-taking’ techniques – how to talk to older women about sexual or relationship difficulties connected with screening avoidance; recognising importance of previous screening experiences; asking women what they know about their anatomy (i.e. previous experiences of gynaecological exams evidencing difficult positioning of cervix).

4. How to tailor the screening process to older women’s needs.

e.g. Provide instructions for addressing gynaecological issues such as menopausal dryness, mobility issues/problems associated with chronic illnesses. Instructions about positioning women in different ways for the procedure, and use of speculums/lubrication.