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Associations between the signing status of family doctor contract services and cervical cancer screening behaviors: a cross-sectional study in Shenzhen, China
BMC Public Health volume 23, Article number: 573 (2023)
As a core part of the primary healthcare system, family doctor contract services (FDCS) may help healthcare providers promote cervical cancer screening to the female population. However, evidence from population-based studies remains scant. This study aimed to investigate the potential associations between the signing status of FDCS and cervical cancer screening practices in Shenzhen, China.
A cross-sectional survey among female residents was conducted between July to December 2020 in Shenzhen, China. A multistage sampling method was applied to recruit women seeking health services in community health service centers. Binary logistic regression models were established to assess the associations between the signing status of FDCS and cervical cancer screening behaviors.
Overall, 4389 women were recruited (mean age: 34.28, standard deviation: 7.61). More than half (54.3%) of the participants had signed up with family doctors. Women who had signed up for FDCS performed better in HPV-related knowledge (high-level rate: 49.0% vs. 35.6%, P<0.001), past screening participation (48.4% vs. 38.8%, P<0.001), and future screening willingness (95.9% vs. 90.8%, P<0.001) than non-signing women. Signing up with family doctors was marginally associated with past screening participation (OR: 1.13, 95%CI: 0.99–1.28), which tended to be robust among women with health insurance, being older than 25 years old at sexual debut, using condom consistently during sexual intercourse, and with a low level of HPV related knowledge. Similarly, signing up with family doctors was positively associated with future screening willingness (OR: 1.68, 95%CI: 1.29–2.20), which was more pronounced among women who got married and had health insurance.
This study suggests that signing up with family doctors has positive associations with cervical cancer screening behaviors among Chinese women. Expanding public awareness of cervical cancer prevention and FDCS may be a feasible way to achieve the goal of cervical cancer screening coverage.
Cervical cancer is the fourth most frequent malignancy in females, leading to a heavy burden of 570,000 cases and 311,000 deaths worldwide . Over 99% of cervical cancer cases are attributed to the infection of high-risk human papillomavirus (HPV) . Except for vaccination against HPV infections, early detection of precancers in the cervix via routine screening is regarded as the most effective way to eliminate cervical cancer. Evidence from the UK has shown that primary healthcare plays a key role in preventing cervical cancer as the health providers will discuss cancer risk with the patients and promote risk reduction strategies . In the primary healthcare system of China, community health service centers act as vital frontline places in the network of cervical cancer prevention and control . A community health service center usually provides basic medical care services related to cervical cancer prevention in Shenzhen city , such as health consultation, HPV vaccination, gynecological examination, cervical sampling, interpretation of screening results, referral to hospitals for abnormal results, etc. Despite the accessibility of screening services, the key to promoting screening participation lies in increasing the knowledge of cervical cancer prevention and the awareness of screening services among the female population as previous studies have indicated , in which frontline health workers usually undertake the responsibility to disseminate correct health information and guide proper screening behaviors . Here, a contract for family doctor services may be a useful tool that greatly helps to build the connection between healthcare providers and the female population in fighting against cervical cancer.
Family doctor contract services (FDCS) have been promoted in mainland China since 2009 as a result of medical reform . It takes a “gate-keeper” role in the hierarchical medical system, providing comprehensive and continuing community health care . In Shenzhen city, residents can choose to sign up with a preferred family doctor team that consists of general practitioners (as the team leader), nurses, and public health doctors from community health service centers nearby . As the contract generally lasts for at least one year, family doctors will keep a relatively stable relationship with the signing resident. Under the working principles, family doctors will offer standardized services, e.g. the establishment and maintenance of health records, delivery of basic medical care and public health services, personalized health support if required (home visits or home care beds), etc. . In this context, people who have signed up for FDCS may be more likely to capture the up-to-date message and engage in health management behaviors, as researchers have found among noncommunicable disease patients . Previous studies have found that visiting general practitioners may help to enhance the uptake of cervical cancer screening in European countries [12, 13], which indicates the potential role of family doctors in facilitating cervical cancer screening at the community level. However, further evidence from population-based studies still remains scant.
Given these research gaps, this study aimed to investigate the utilization of both FDCS and cervical cancer screening services among female residents based on a cross-sectional survey in Shenzhen city. Furthermore, whether signing up with family doctors impact women’s behaviors on cervical cancer screening was also evaluated with particular interest.
Study design and sampling
This community-based cross-sectional study was conducted in the Baoan district of Shenzhen city, China between July to December 2020. According to the latest data of the seventh national census, more than 4.47 million residents are living in the Baoan district, which ranks as the most populous district in Shenzhen. A multistage sampling method was applied to recruit participants (Fig. 1). First, two representative administrative streets (Xixiang Street and Shajing Street) in the Baoan district were selected by simple random sampling. Subsequently, one regional community health service center was randomly chosen to be the survey site on these two streets, respectively. During the survey period, women who received health services in the survey sites would be invited to participate in this survey. Eligible participants were defined to be aged from 21 to 65 years, living in the responding district, engaged in sexual intercourse, and willing to participate in the survey. With the help of medical staff, candidate women were provided with a full introduction of the study objectives, contents, and procedures, followed by a Quick Response code linking to the electronic questionnaire. Through scanning the two-dimensional barcode with their smartphones, women were asked to confirm their voluntary participation for informed consent, and then got access to the questionnaire. The questionnaire was hosted by a popular Chinese survey platform named WenJuanXing (Changsha Haoxing Information Technology Co., Ltd., China).
The sample quantity was calculated using the formula of the cross-sectional study: n = μ2 αp(1–p)/δ2. Here, α = 0.05 (two sides), μα = 1.96, δ = 0.015, and the screening rate of cervical cancer in Shenzhen p = 35.1% (according to previous findings). The required sample size was 3890. With the no-response rate controlled within 10%, the final sample size was determined to be 4280. During the survey period, a total of 4733 women clicked the online link of this survey. We further excluded 344 respondents who did not meet the eligibility criteria, leaving 4389 participants in the final database.
The present questionnaire mainly focused on evaluating knowledge related to HPV, awareness, participation, and willingness of cervical cancer screening, accompanied by information on socio-demographic characteristics, sexual behavioral characteristics, pre-existing health conditions, health services utilization, etc.
In this survey, whether women were receiving the family doctor contract service was measured by asking ‘Have you already signed up with family doctors in Shenzhen?’ (Yes/No). Otherwise, women needed to offer the major reason for not signing. Women were required to estimate HPV-related knowledge with a total of nine-question items (Cronbach’s alpha in this sample: 0.91) if they had heard of HPV before. For each question, three answer options (Yes/No/Don’t know) were provided. Here, the answer of ‘Don’t know’ was considered to be incorrect. A sum score of nine items (range: 0–9) was assigned according to the number of correct answers. Women who had never heard of HPV or scored below 6 were regarded as with a low level of HPV-related knowledge. Awareness of cervical cancer screening was estimated by asking ‘Have you ever heard of cervical cancer screening?’. If a positive answer was provided, women further needed to answer which screening method they know. Past screening participation was assessed by asking ‘Have you ever participated in cervical cancer screening? (Yes/No)’. If a woman had ever received screening services, details of the latest screening were collected, such as the screening time, method, and result. Willingness of cervical cancer screening was measured by the question ‘Are you willing to receive cervical cancer screening in the following days? (Yes/No)’. Furthermore, women were required to choose the expected screening cost and frequency if they were ready to be screened.
All variables were categorically presented with frequency and percentage (%). The Chi-square test was applied to detect distributed differences in HPV-related knowledge, cervical cancer screening related awareness, and behaviors between the signing and non-signing groups. Binary logistic regression models were established to assess the associations between signing up with family doctors and cervical cancer screening behaviors. We established three models in the following order: model 1 (unadjusted), model 2 (adjusted for age, ethnicity, local household registration, marital status, education level, occupation type, monthly income, and health insurance), and model 3 (further adjusted for age at sexual debut, the number of lifetime sexual partners, consistent condom use during sexual intercourse, parity, and HPV related knowledge based on model 2). The odds ratios (OR) and 95% confidence intervals (CI) were calculated. In addition, stratified analyses were further conducted according to all adjusted variables to detect potential modified effects, in which multiplicative interactions between modified factors and the signing status were calculated by including the product terms in multivariate logistic regression models. All statistical analyses were performed by using SPSS software (version 21.0, IBM SPSS Statistics, New York, United States). The statistical significance level was set to be P < 0.05 (two-sided).
A total of 4389 participants were included in the final analysis (mean age: 34.28, standard deviation: 7.61). More than half (54.3%) of them had signed up with family doctors. The most common reason for not signing was that women did not know FDCS before (35.8%). Characteristics of the study subjects were shown in Table 1.
Among the participants, 62.6% of them had heard of HPV, but only 42.9% of them had a high level of HPV-related knowledge. Regarding the HPV knowledge question items, women signing up with family doctors demonstrated significantly higher correct rates of 8 question items than non-contracted counterparts (all P<0.05), except for Q1 (P = 0.72). Distinct levels of HPV-related knowledge existed between the signing and non-signing groups (high-level rate: 49.0% vs. 35.6%, P<0.001) (Table 2). Most of the respondents (84.4%) had heard of cervical cancer screening, but only 44.0% of them had been screened before. Moreover, 93.6% of them were willing to be screened in the following days. Compared to non-signing women, women signing up with family doctors performed better in awareness (89.9% vs. 77.8%, P<0.001), past screening participation (48.4% vs. 38.8%, P<0.001), and future screening willingness (95.9% vs. 90.8%, P<0.001) of cervical cancer screening (Table 3). Moreover, signing women were more likely to hear of specific screening methods, such as HPV testing, cytology, and visual inspection methods (all P<0.05). Signing women also tended to be screened within 3 years, to have fewer unknown screening methods, and to expect free and frequent screening services (all P<0.05).
After adjusting for potential confounding variables, signing up with family doctors was marginally associated with past screening participation (OR: 1.13, 95%CI: 0.99–1.28) when compared to their non-signing counterparts (Fig. 2). When stratified by socio-demographic characteristics, the effect of FDCS on past screening participation tended to be robust among women with health insurance (OR: 1.21, 95%CI: 1.05–1.39), being older than 25 years old at sexual debut (OR: 1.59, 95%CI: 1.16–2.18), using condom consistently during sexual intercourse (OR: 1.55, 95%CI: 1.11–2.16), and with a low level of HPV related knowledge (OR: 1.39, 95%CI: 1.17–1.65). Multiplicative interactions of the signing status with health insurance, age at sexual debut, condom use, and HPV-related knowledge level were detected (P for multiplicative interactions: <0.001, 0.009, 0.042, and 0.004, respectively) (Table 4).
Similarly, signing up with family doctors was positively associated with future screening willingness in the adjusted model (OR: 1.68, 95%CI: 1.29–2.20) (Fig. 2). This association was more pronounced among women who got married (OR: 1.91, 95%CI: 1.42–2.56) and had health insurance (OR: 1.97, 95%CI: 1.47–2.64). Multiplicative interactions of the signing status with marital status and health insurance were detected (P for multiplicative interactions: 0.026 and 0.005, respectively) (Table 4).
Identifying potential facilitators and enhancing participation in cervical cancer screening greatly help to achieve cervical cancer elimination targets. To our knowledge, this study is the first investigation to link FDCS with cervical cancer screening behaviors. Notably, women signing up with family doctors tended to have higher past screening participation and future screening willingness, suggesting the application value of promoting cervical cancer screening through FDCS.
FDCS is a core part of the primary healthcare system opening to the general public. The signing rate of FDCS in the current study was 54.3%, which was similar to the findings in Guangdong (54.7%) and Zhejiang province (50.43%) [14, 15], but much higher than that from a nationwide survey in mainland China (approximately 6.0% in the female population) . Researchers also found lower signing rates among people over 60 years old (28.2%) and with chronic diseases (29.3%) in rural China [17, 18]. Here, the socioeconomic and regional differences may provide a potential explanation for these inconsistencies to some extent. As prior studies suggested, the signing rate may differ by the survey year, region, and household residence status . Moreover, people’s signing behavior may be affected by the awareness of FDCS as well as sociodemographic characteristics (e.g. age, education, marital status, and household registration) . The Chinese government aims to expand FDCS to cover the entire population by 2020 , however, the present signing rate in Shenzhen city is still far from this goal. In recent years, the reform of the primary health-care system has persisted by establishing networks of integrated management, shared responsibilities, and common interests between community health service centers and hospitals in Shenzhen , which gradually orients residents toward primary healthcare. With the improvement of primary healthcare system capacity, health education should be conducted to increase public awareness and utilization of FDCS.
As a nationally representative survey reported, only one in five Chinese females aged ≥ 21 years have screened for cervical cancer, with geographical and socioeconomic variations . It’s urgently needed to accelerate the increase in the awareness and accessibility of cervical cancer screening in China. Here, our survey showed that women had better HPV-related knowledge and cervical cancer screening behaviors in Shenzhen city. In the current study, women demonstrated a lower proportion (57.1%) of low HPV-related knowledge levels when compared to our previous survey in 2015 (67.6%) regardless of different question items . Both the past screening rate (44.0%) and future screening willingness (93.6%) were also higher than the data from our previous surveys in 2014 (35.1% and 82.8%, respectively) . These improved indicators may be owing to a policy that cervical cancer screening has been included in the basic public health services of Shenzhen city since 2017, accompanied by an expansion in the coverage of cervical cancer prevention related work (e.g. health education, technical training, and organized screening). However, these achievements still have a certain distance to the WHO cervical cancer elimination target by 2030 (70% coverage of twice-lifetime screening) . Furthermore, there was a notable gap between past screening participation and future screening willingness in our survey, implying the fact that more than half of those willing to be screened remained unscreened. Hence, future health interventions should be placed on the shift from screening willingness to screening practice.
It’s proved that primary healthcare settings have strengths in cancer prevention because the physicians contribute to information provision as well as the promotion of screening uptake and informed choice . In this study, our findings shed light on the positive impacts of family doctors to guide cervical cancer prevention. Women signing up with family doctors performed better in HPV-related knowledge, past screening participation, and future screening willingness than their non-signing counterparts. These results were similar to those of studies in other countries that general practitioners helped to increase participation in cervical cancer screening [12, 13, 27]. Researchers further detected that high awareness of health promotion among general practitioners achieved high rates of cervical cancer screening in a multinational modeling study . Moreover, educational intervention for general practitioners about the importance of cervical cancer screening was effective in increasing the uptake of screening among immigrants . As the core members of the family doctor team, on one hand, general practitioners may contribute to providing screening recommendations that affect patients’ healthcare decisions, which has been identified as a facilitator of cervical cancer screening behavior [7, 30, 31]. In this context, women who know little about cervical cancer may receive more benefits from family doctors. As our findings suggested, the association between signing up with family doctors and past screening participation was confined to women with a low level of HPV-related knowledge. On the other hand, the facilitating effects may be also explained by a specific service advantage that some members (general practitioners or specialized doctors) of the family doctor team usually undertake gynecological examination and cervical sampling procedures. A cross-sectional survey in Poland found that nearly two-thirds of patients were willing to undergo cervical cancer screening by their family doctors . Therefore, FDCS may attract signing women to engage in screening behaviors as a result of operational accessibility. Additionally, we noticed that the association between signing up with family doctors and cervical cancer screening behaviors tended to be more robust among women who were married, had health insurance, or behaved more discreetly during sexual behavior. These women may have better adherence to family doctors owing to more concerns for healthcare issues. Both the signing status and cervical cancer screening behaviors could be affected by marital status, health insurance, and sexual behaviors [15, 33, 34], therefore, further investigations should be conducted to verify these potential relationships.
There were some limitations in this study. Firstly, we could not infer causal relationships between signing up with family doctors and cervical cancer screening behaviors due to the cross-sectional design. Secondly, as the survey sampling site were restricted to be community health service centers in the Baoan district of Shenzhen city, the implications of our findings might not be able to generalize to the whole population. Thirdly, signing women were not required to report the demographic characteristics of their family doctors (e.g. age, gender, major, and working years) and the details of daily health guidance in our survey, which may restrict to investigating the role of family doctors in facilitating cervical cancer screening behaviors. Thus, more longitudinal studies with a comprehensive evaluation of FDCS are needed.
Family doctors play a gatekeeper role in the primary healthcare system in China. The self-reported rates of signing up with family doctors and cervical cancer screening participation were acceptable among women in Shenzhen city. Notably, signing up with family doctors was associated with cervical cancer screening behaviors, including past screening participation and future screening willingness. Expanding public awareness of cervical cancer prevention and FDCS may be a feasible way to achieve the goal of cervical cancer screening coverage.
Availability of data and materials
The raw data supporting the conclusions of this article will be made available by the corresponding author, upon reasonable request.
Family doctor contract services
Arbyn M, Weiderpass E, Bruni L, de Sanjosé S, Saraiya M, Ferlay J, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Glob Health. 2020;8:e191-203. https://doi.org/10.1016/S2214-109X(19)30482-6.
de Sanjosé S, Brotons M, Pavón MA. The natural history of human papillomavirus infection. Best Pract Res Clin Obstet Gynaecol. 2018;47:2–13. https://doi.org/10.1016/j.bpobgyn.2017.08.015.
Funston G, O’Flynn H, Ryan N, Hamilton W, Crosbie EJ. Recognizing gynecological cancer in primary care: risk factors, red flags, and referrals. Adv Ther. 2018;35:577–89. https://doi.org/10.1007/s12325-018-0683-3.
Chen Y, Xu Y, Wu D, Li Z, Zhang Z, Meng Y, et al. Survey of cervical cancer and precancerous lesion prevention knowledge within community health service centers in shanghai, china. Medicine (Baltimore). 2019;98:e15002. https://doi.org/10.1097/MD.0000000000015002.
Shenzhen Municipal Health Commission. Free screening service institutions list of cervical and breast cancer for women of screening age in Shenzhen. Available online: http://wjw.sz.gov.cn/gsgg/content/post_7963886.html. Accessed 20 June 2022.
Tatar O, Thompson E, Naz A, Perez S, Shapiro GK, Wade K, et al. Factors associated with human papillomavirus (hpv) test acceptability in primary screening for cervical cancer: a mixed methods research synthesis. Prev Med. 2018;116:40–50. https://doi.org/10.1016/j.ypmed.2018.08.034.
Chan CW, Choi KC, Wong RS, Chow KM, So WK, Leung DY, et al. Examining the cervical screening behaviour of women aged 50 or above and its predicting factors: a population-based survey. Int J Environ Res Public Health. 2016; 13. https://doi.org/10.3390/ijerph13121195
Chen Z. Launch of the health-care reform plan in china. Lancet. 2009;373:1322–4. https://doi.org/10.1016/S0140-6736(09)60753-4.
Yip W, Fu H, Chen AT, Zhai T, Jian W, Xu R, et al. 10 years of health-care reform in china: progress and gaps in universal health coverage. Lancet. 2019;394:1192–204. https://doi.org/10.1016/S0140-6736(19)32136-1.
Shenzhen Municipal Health and Family Planning Commission. Family doctor services management rules in Shenzhen (for trial implementation). Available online: http://www.sz.gov.cn/zfgb/2017/gb1029/content/post_4945557.html. Accessed 20 June 2022.
Huang J, Zhang T, Wang L, Guo D, Liu S, Lu W, et al. The effect of family doctor-contracted services on noncommunicable disease self-management in shanghai, china. Int J Health Plann Manage. 2019;34:935–46. https://doi.org/10.1002/hpm.2865.
Labeit AM, Peinemann F. Determinants of a gp visit and cervical cancer screening examination in great britain. Plos One. 2017;12:e174363. https://doi.org/10.1371/journal.pone.0174363.
Burton-Jeangros C, Cullati S, Manor O, Courvoisier DS, Bouchardy C, Guessous I. Cervical cancer screening in switzerland: cross-sectional trends (1992–2012) in social inequalities. Eur J Public Health. 2017;27:167–73. https://doi.org/10.1093/eurpub/ckw113.
Feng S, Cheng A, Luo Z, Xiao Y, Zhang L. Effect of family doctor contract services on patient perceived quality of primary care in southern china. Bmc Fam Pract. 2020;21:218. https://doi.org/10.1186/s12875-020-01287-7.
Shang X, Huang Y, Li B, Yang Q, Zhao Y, Wang W, et al. Residents' awareness of family doctor contract services, status of contract with a family doctor, and contract service needs in zhejiang province, china: a cross-sectional study. Int J Environ Res Public Health. 2019; 16. https://doi.org/10.3390/ijerph16183312
Nie Z, Chen C, Chen G, Wang C, Gan Y, Feng Y, et al. Development and validation of a model to predict the contract service of family doctor: a national survey in china. Front Public Health. 2022;10:750722. https://doi.org/10.3389/fpubh.2022.750722.
Yang S, Li J, Fu P, Chen Y, Wang Y, Zhao D, et al. Do older people with cardiovascular-metabolic multimorbidity prefer to sign contracts for family doctor services? Evidence from a cross-sectional study in rural Shandong, China. BMC Geriatr. 2021;21:579. https://doi.org/10.1186/s12877-021-02543-w.
Li Z, Li J, Fu P, Chen Y, Jing Z, Yuan Y, et al. Family doctor contract services and health-related quality of life among patients with chronic diseases in rural china: what is the role of socioeconomic status? Int J Equity Health. 2021;20:191. https://doi.org/10.1186/s12939-021-01530-2.
Liu S, Liu Y, Zhang T, Wang L, Huang J, Liang H, et al. The developing family doctor system: evidence from the progress of the family doctor signing service from a longitudinal survey (2013–2016) in pudong new area, shanghai. Bmc Fam Pract. 2021;22:11. https://doi.org/10.1186/s12875-020-01353-0.
Huang J, Liu S, He R, Fang S, Lu W, Wu J, et al. Factors associated with residents’ contract behavior with family doctors in community health service centers: a longitudinal survey from china. Plos One. 2018;13:e208200. https://doi.org/10.1371/journal.pone.0208200.
Li X, Krumholz HM, Yip W, Cheng KK, De Maeseneer J, Meng Q, et al. Quality of primary health care in china: challenges and recommendations. Lancet. 2020;395:1802–12. https://doi.org/10.1016/S0140-6736(20)30122-7.
Bao H, Zhang L, Wang L, Zhang M, Zhao Z, Fang L, et al. Significant variations in the cervical cancer screening rate in china by individual-level and geographical measures of socioeconomic status: a multilevel model analysis of a nationally representative survey dataset. Cancer Med. 2018;7:2089–100. https://doi.org/10.1002/cam4.1321.
Lin W, Chen B, Hu H, Yuan S, Wu B, Zhong C, et al. Joint effects of hpv-related knowledge and socio-demographic factors on hpv testing behaviour among females in shenzhen. Eur J Public Health. 2021;31:582–8. https://doi.org/10.1093/eurpub/ckab049.
Lin W, Chen B, Wu B, Yuan S, Zhong C, Huang W, et al. Cervical cancer screening rate and willingness among female migrants in shenzhen, china: three-year changes in citywide surveys. Cancer Res Treat. 2021;53:212–22. https://doi.org/10.4143/crt.2020.219.
Canfell K, Kim JJ, Brisson M, Keane A, Simms KT, Caruana M, et al. Mortality impact of achieving who cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries. Lancet. 2020;395:591–603. https://doi.org/10.1016/S0140-6736(20)30157-4.
Rubin G, Berendsen A, Crawford SM, Dommett R, Earle C, Emery J, et al. The expanding role of primary care in cancer control. Lancet Oncol. 2015;16:1231–72. https://doi.org/10.1016/S1470-2045(15)00205-3.
Gyulai A, Nagy A, Pataki V, Tonté D, Ádány R, Vokó Z. General practitioners can increase participation in cervical cancer screening - a model program in hungary. Bmc Fam Pract. 2018;19:67. https://doi.org/10.1186/s12875-018-0755-0.
van Gool K, Mu C, Hall J. Does more investment in primary care improve health system performance? Health Policy. 2021;125:717–24. https://doi.org/10.1016/j.healthpol.2021.03.004.
Møen KA, Kumar B, Igland J, Diaz E. Effect of an intervention in general practice to increase the participation of immigrants in cervical cancer screening: a cluster randomized clinical trial. JAMA Netw Open. 2020;3:e201903. https://doi.org/10.1001/jamanetworkopen.2020.1903.
Chua B, Ma V, Asjes C, Lim A, Mohseni M, Wee HL. Barriers to and facilitators of cervical cancer screening among women in southeast asia: a systematic review. Int J Environ Res Public Health. 2021; 18. https://doi.org/10.3390/ijerph18094586
Harper DM, Tariq M, Alhawli A, Syed N, Patel M, Resnicow K. Cancer risk perception and physician communication behaviors on cervical cancer and colorectal cancer screening. Elife. 2021; 10. https://doi.org/10.7554/eLife.70003
Nessler K, Chan S, Ball F, Storman M, Chwalek M, Krztoń-Królewiecka A, et al. Impact of family physicians on cervical cancer screening: cross-sectional questionnaire-based survey in a region of southern poland. Bmj Open. 2019;9:e31317. https://doi.org/10.1136/bmjopen-2019-031317.
Wang C, Yan S, Jiang H, Nie Z, Miller M, He Y, et al. Residents’ willingness to maintain contracts with family doctors: a cross-sectional study in china. J Gen Intern Med. 2021;36:622–31. https://doi.org/10.1007/s11606-020-06306-y.
Haile ZT, Kingori C, Chavan B, Francescon J, Teweldeberhan AK. Association between risky sexual behavior and cervical cancer screening among women in kenya: a population-based study. J Community Health. 2018;43:238–47. https://doi.org/10.1007/s10900-017-0410-z.
The authors thank all the participants for their time and efforts. Special thanks go to all medical staffs from Gushu and Shajing community health service center of the Baoan district in Shenzhen for providing strong support in this survey.
This research received support from the Shenzhen Healthcare Research Project (No. SZGW2018005). The funder did not involve in any part of the study process, from design to submit the article for publication.
Ethics approval and consent to participate
This study was approved by the ethics committee of Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University (No. SFYLS2018185) and was conducted in accordance with the ethical standards of the Declaration of Helsinki. An informed consent was obtained from every participant before enrollment.
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Lin, W., Huang, W., Mei, C. et al. Associations between the signing status of family doctor contract services and cervical cancer screening behaviors: a cross-sectional study in Shenzhen, China. BMC Public Health 23, 573 (2023). https://doi.org/10.1186/s12889-023-15462-9
- Family doctor contract services
- Cervical cancer
- Past screening participation
- Future screening willingness