126 Chapter 5 There have been several studies on cervical cancer and screening including marginalized women in the US.11,12 However, to our knowledge, European studies are lacking. Due to the differences between the US and Europe in population, organization of care, and screening for marginalized populations, there is a need for European input on this subject.8 The study had two specific aims. The first was to identify the prevalence of (pre)cancerous abnormalities among marginalized women. The second was to explore invitation approaches to enhance the screening uptake among this specific group of women in an urban setting in the Netherlands. Methods A cross-sectional intervention study among marginalized women was performed in Rotterdam, the Netherlands. Rotterdam is the second largest city of the Netherlands. The study was conducted between February 2019 and June 2019. The study population consisted of women in unstable living conditions, concerning: sex workers, homeless women, uninsured women (in the Netherlands, health insurance is obligatory by law; only a small minority is uninsured, mostly due to the lack of a home address), and undocumented women (women without a residency status). The inclusion criteria were: female sex, age 20-60 years, and the absence of a registered address at a given point in the last five years. Exclusion criteria were: having had a cervical smear in the preceding year, not having a cervix, being incapacitated, being pregnant, having a menstrual period at that specific moment, and having the option to access regular healthcare abroad. Recruitment of the women took place at homeless shelters, day and night shelters for undocumented people, respite care locations, safe houses for sexual trafficking victims, in brothels and sex worker walk-in houses. The cervical smears were performed by a medical team consisting of a female streetdoctor and a female nurse familiar with the study population. Topics such as contraceptives, sexual trauma and sexual health are part of the expertise of this medical team. Depending on the local options, either a direct or indirect invitation approach was used for recruiting the women. The direct invitation approach contained a pro-active offer of an immediate cervical smear. This was done during the consultation hours of the streetdoctor or combined with the consultations for sexual transmitted infections (STIs) by sexual health workers. The indirect approach consisted of distributing posters in relevant areas and announcements on a website, with information about the opportunity to have a cervical smear performed. Furthermore, mails were sent to all known care providers or case managers of the population under study, with the option to make an appointment for their client to have a cervical smear.
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