206 Chapter 8 In Chapter 5, we demonstrate the importance and effectiveness of a specific invitation strategy for vulnerable subpopulations. Therefore, we consider this study a ‘proof of concept study’. In the city of Rotterdam, we conducted a cross-sectional intervention study, inviting marginalized women to participate in a screening study for cervical cancer. For this study, women were considered marginalized if they had not received, or could not receive, invitation letter(s) for the cervical cancer screening program (CC-SP) due to their living conditions. Our study focused on sex workers in unstable conditions, homeless women, and women without official documentation. In total, we were able to collect samples from 74 women for this study. The collected samples were analysed for both the presence of high-risk human papillomavirus (hrHPV) and cytological abnormalities. In doing so, we intentionally deviated from the standard practice within the current CC-SP. We compared the results of the samples we collected with regional prevalence data from women who had participated in the CC-SP. We obtained this data through the national screening organisation, region South-West (Bevolkingsonderzoek Zuid-West). The main findings from this study are that marginalized women seem to have a four times higher risk of hrHPV infection with cytological abnormalities compared to women screened through the CC-SP. Additionally, through this study, we demonstrated that a direct proactive approach is by far the most effective way to reach marginalized women. In our study, 92% of all women were included for participation in the study through this proactive approach. Based on this study, we believe that much more attention should be paid to vulnerable women without stable housing in relation to the development of (precursors to) cervical cancer. Since our earlier studies suggested that primary care providers might play an important role in optimizing participation rates of the CSPs, in Chapter 6, we focused on general practitioners (GPs) and surveyed them about their current role regarding the CSPs and whether they believe it should be different. For this purpose, we conducted a stepped ‘mixed-methods’ study by first developing a questionnaire and distributing it among GPs. Subsequently, we interviewed a selected number of GPs using semi-structured in-depth interviews to interpret the data resulting from these questionnaires. The main findings from this study are that GPs generally hold a positive view of CSPs and their role therein. Furthermore, GPs indicated their willingness to further support and reinforce the CSPs. However, they clearly stated their reluctance to take on (additional) logistical and organizational tasks. A proactive neighbourhood-based approach emerged as one of the possible options to optimize the current screening programmes. In this regard, GPs emphasized the need to pay more attention to involving people residing in low socioeconomic status (SES) neighbourhoods. The most innovative idea to achieve
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