133 Cervical cancer screening among marginalized women Due to several (practical) choices, the study has its limitations. In order to engage with marginalized women, a flexible expert-based approach is essential at the right time and the right place. But, consequently, a direct comparison of invitation methods was not possible. This since not all the approaches were equally suitable at every location. Furthermore, it is not known how many, and more important which women decided to decline participation and what their characteristics were. Reasons mentioned for not participating, collected during the direct approach, varied widely and mostly involved women who were more hesitant and cautious. A last limitation is that data on the HR-HPV vaccination status of the women was not collected. Participants younger than 21 years of age (n=2) could have received a HR-HPV vaccination; the vaccination program has been in existence in the Netherlands since 2009. In future studies, more participants might be vaccinated for HR-HPV. As this might influence the study results, it should be recorded. The study included 37 women (50%) who were eligible for the Dutch CSP but did not participate. This raises the question whether there is a necessity to embark on a tailormade approach for specific high-risk groups within the national CSP. As mentioned in a prior study, involvement of primary care or other relevant care providers for risk groups might enhance screening uptake.7 There are several differences between the Dutch cervical CSP and the study. Since special efforts are needed to enhance screening uptake among marginalized women, these differences are highlighted so further studies can be based on ‘lessons learned’. Box 1 summarizes suggestions for implementing a cervical screening program for marginalized women. One of the aims of the study was to remove as many of the access barriers as possible. Marginalized women were invited in a pro-active individual manner, without the necessity of a health insurance. The cervical smear was performed directly at the locations where these women would already be present to work, reside or receive care. Engagement and participation based on trust was shown to be crucial in the study, especially as many women mentioned a history of sexual trauma. The topic of cervical screening was introduced by a close care provider from the location, and this care provider introduced the women to the medical team. The medical team was all female and invested time in gaining the trust of the participant before taking the cervical smear. In the Dutch CSP, the smear is performed by a person’s GP. The studied population, however, often does not have guaranteed access to the typically Dutch GP-oriented healthcare system. Therefore, an approach based on creating a safe environment seemed an effective alternative. The study shows that involving peers in educating and raising awareness among the target population will most definitely lead to higher participation rates. The 5
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