Patient Preference and Adherence Dovepress open access to scientific and medical research Open Access Full Text Article ORIGINAL RESEARCH Preferences for cervical cancer screening service attributes in rural China: a discrete choice experiment This article was published in the following Dove Press journal: Patient Preference and Adherence Shunping Li1,2 Objectives: Compared with other cancers, screening for cervical cancer is highly cost- Shimeng Liu1,2 effective. However, due to limited awareness about cervical cancer and many other factors, Julie Ratcliffe3 women’s attendance rate in rural China for cervical cancer screening remains low. This study Alastair Gray4 aimed to determine women’s preferences for cervical cancer screening, to help enhance Gang Chen5 screening uptake. Methods: A discrete choice experiment (DCE) was conducted among a population-based 1 School of Health Care Management, random sample of 420 women (30–65 years old) in August 2015. Attributes included the Shandong University, Jinan 250012, People’s Republic of China; 2NHC percentage of cervical cancer-related death reduction, screening interval, screening location, Laboratory of Health Economics and screening pain, waiting time for screening results and out-of-pocket costs. Mixed logit Policy Research (Shandong University), Jinan, 250012, People’s Republic of China; models were used to analyze the relative importance of each screening attribute. 3Health Economics Group, College of Results: When considering a screening program, the screening cost, location and the Nursing and Health Sciences, Flinders percentage of cervical cancer-related death reduction were of most concern to women. University, Adelaide, South Australia 5042, Australia; 4Health Economics Among the presented attributes, the pain associated with the process of screening was of Research Centre, Nuffield Department of the least concern. Population Health, University of Oxford, Conclusions: All six attributes in our study were found to have a large influence on the Oxford, UK; 5Flinders Centre for Innovation in Cancer, College of Medicine preference for cervical cancer screening, and significant preference heterogeneity existed and Public Health, Flinders University, among participants. The findings indicate that the maintenance of a free screening program is Adelaide, South Australia 5042, Australia essential to increasing screening uptake in this vulnerable population. Keywords: discrete choice experiment, cervical cancer, screening, preference, China Introduction Cervical cancer is the fourth most common female cancer globally and the leading cause of cancer death among women, accounting for almost 12% of all female cancers.1 Around 87% of the cervical cancer deaths occur in developing countries, where the number of new cases ranks cervical cancer second among malignancies in female patients.2,3 In China, there were an estimated 100,700 new cases of cervical cancer in 2013, ranking as the sixth most common incident cancer among all newly diagnosed cancers in females.4 Although the incidence of cervical cancer in China is low in comparison to that of western countries, the mortality rate remains high, especially Correspondence: Gang Chen in rural areas.5 A total of 29,526 women died of the disease in 2012 in China, Flinders Centre for Innovation in Cancer, 2 Flinders University, Bedford Park, accounting for 11% all cervical cancer deaths worldwide. Furthermore, forward Adelaide, South Australia 5042, Australia projections indicate that the number of new cases will rise as high as 186,600 Tel +61 42 581 1029 6 Email gang.chen@flinders.edu.au by 2050. submit your manuscript | www.dovepress.com Patient Preference and Adherence 2019:13 881–889 881 DovePress © 2019 Li et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work http://doi.org/10.2147/PPA.S201913 you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Li et al Dovepress As a preventable and treatable disease, screening of patient experience and health outcomes, as well as to trade- precancerous lesions can reduce cervical cancer’s inci- offs between these and willingness to pay (WTP) for differ- dence and mortality. Compared to other cancers, screening ent attributes.11,17 In comparison with other quantitative for cervical cancer is very cost-effective, because no other methods (eg, a ranking task), a DCE task more closely cancer offers as good a means for primary and secondary resembles a real-world decision; in addition, the output prevention as cervical cancer.7,8 However, in many devel- from DCEs can facilitate future policy implementation (eg, oping countries, cervical cancer screening programs are the calculation of the uptake rate for hypothetical unavailable or are poorly accessible.9 Although China has scenarios).18 In the context of this study, it is assumed that provided free cervical cancer screening programs in some a cancer screening program can be described by a series of rural areas for women aged 35 to 59 years since 2009, attributes and their corresponding levels.19 The DCE design a lack of awareness and knowledge and the absence of and analysis was conducted following the International a nationwide organized cervical cancer screening program Society For Pharmacoeconomics and Outcomes Research has resulted in many rural women remaining unaware of (ISPOR) good practice principles outlined by Bridges et al.20 the benefits of screening and unwilling to undergo the The salient features or characteristics (attributes) asso- procedure. Consequently, cervical cancer remains an ciated with the provision of cervical cancer screening and important public health problem in mainland China.5 their associated levels were formulated from a literature To improve patient-centered health care, it is important review,12–15,21–24 coupled with a series of in-depth quali- to investigate women’s preferences for cervical cancer tative interviews with rural women (N=15) aged 30–65 screening. Obtaining insights into these preferences will years old, and consultation with clinical experts in the field provide valuable information to clinicians and policy deci- of cervical cancer screening in China. During the inter- sion makers for improving screening uptake.10 The deci- view, women were asked to comment on a candidate list of sion to participate or not in a screening program is cervical cancer screening attributes which were extracted preferably based on an individual decision-making process from the literature review and to indicate any additional of weighting (or trading off) the test burden against the candidate attributes that were omitted from the literature potential benefits of screening. review. Following this process and after consulting with Worldwide, discrete choice experiment (DCE) has the clinical experts, a total of six final attributes most been extensively applied in health care research, in relevant to cervical cancer screening in rural China were a wide range of contexts and addressing different policy selected: the percentage of cervical cancer-related death and research issues.11 To date, there have been very lim- reduction (with levels been determined by consulting clin- ited studies using DCE to explore the preferences for icians as well as the levels of attribute “chance of dying cervical cancer screening.12–15 These studies found that from cervical cancer” adopted by Wordsworth et al15), cost, chance of being recalled, waiting time for test results, screening interval, screening pain, screening location, sensitivity of test, pain and the provider’s gender were waiting time for screening results and the out-of-pocket relatively more important when choosing a cervical cancer (OOP) costs (with levels been determined by the relevant screening program by women. The objective of this study local government document) (Table 1). was to use a DCE, a quantitative methodology for inves- The combination of six attributes with three levels tigating these trade-offs, to assess women’s preferences for associated with each attribute resulted in 729 (36) possible cervical cancer screening in rural China. cervical cancer screening scenarios and a total of 265,356 possible pairwise choices ((729×728)/2). A sequential orthogonal factorial design was adopted to generate Methods a more manageable 27 choice scenarios (which were Discrete choice experiment further blocked into three versions containing 9 choice The methodology of DCEs is grounded in random utility sets each) using the Ngene version 1.1.2 DCE design theory, where a discrete choice is offered and participants software (Choice-Metrics, Sydney, Australia). Within choose the option with the highest utility among candidate each version, a single choice set was duplicated to exam- options.16 The technique has been increasingly used in health ine the internal consistency of participants. economics to consider attribute importance in delivering Each discrete choice set consisted of two cervical can- health care, with consideration both to the aspect of the cer screening alternatives.