Why would a woman screen? Facilitators and barriers for women least likely to participate in cervical screening in Australia

Background

The cervical screening test, which detects potential and existing high-risk lesions to prevent invasive cervical carcinomas, is provided at no cost to eligible women in Australia. Nonetheless, national cervical screening participation has been gradually declining from 63.7% in 1998–1999 to approximately 55%.¹ An estimated 238 cervical cancer deaths were expected in 2020.²

The uptake of cervical and breast cancer screening services internationally has been associated with multilevel factors related to the individual, (age, knowledge, attitude and perception, language, health status, ethnicity, migration background, education, socioeconomic status), health service (gender of treating doctor, distance to service, cost and availability of service) and local area (remoteness, socioeconomic status).^3-5 Although barriers and facilitators to screening participation have been identified in international studies, there is limited evidence from Australian studies.

We aimed to gain insight into factors influencing cervical screening among women from an area characterised by disadvantage and ethnic diversity. The Western Sydney Local Health District human research ethics committee approved the study, (HREC: AU RED LNR/18/WMEAD/77) which was part of a larger project aimed at improving screening awareness and participation, coinciding with changes introduced 6 months earlier by the National Cervical Screening Program.

Methods

Trained staff approached women entering a supermarket located in a Western Sydney suburb characterised by high proportions of disadvantaged populations, migrant and Indigenous communities and low uptake of cancer screening services. Eligible participants were women aged 18 years and older who, after reviewing the information sheet, consented to participate in our survey.

The survey was conducted from mid-June to early July 2018 on five occasions that included weekdays, a weekend, and mornings and afternoons, and utilised convenience sampling. Researchers administered the questionnaire in English. It sought information about the participant’s age, country of birth, knowledge of and participation in cervical screening and used open-ended questions to elicit all reasons women would undergo, delay or avoid screening. The full questionnaire is available as a supplementary file from: figshare.com/articles/online_resource/Cervical_screening_survey_pdf/16418790. We used the Australian Bureau of Statistics Standard Australian Classification of Countries to group women’s country of birth.

Calculations using an alpha of 0.05 and power of 85% identified the sample size. Researchers undertook ongoing reviews of participants’ responses to ensure the sample size was sufficient to report on women’s screening behaviour, specifically if the incidence of screening was higher than estimated for the sampling calculations. We applied 95% confidence intervals for comparisons between younger and older women.

All female and male shoppers who were interested were offered information about the cervical screening test in multiple languages and a brochure detailing local general practices with female providers.

Results

Over approximately 4 weeks, three interviewers surveyed 127 women in the vicinity of a local supermarket. Most respondents were in the 25–74 year age range (89%), with 8% aged 18–25. About two-fifths were born in Australia (36%) or New Zealand (5%), and when combined with women from Polynesia (Fiji, the Cook Islands and Samoa) accounted for almost half of all respondents. The second- and third-largest groups by country of birth were women from Maritime South-East Asia and Southern Asia (mainly from India and Pakistan).

Respondents’ most common reasons for delaying or avoiding (hereafter referred to as delaying) screening were embarrassment or discomfort (Table 1). A ‘lack of knowledge’, comprising responses of no knowledge of the cervical screening test and no knowledge about its purpose, was more common among younger women than those aged 50 years and older (‘lack of knowledge’: 30.9% vs 15.3%). Overall, the issue of lack of time ranked lower than the need for education (11% versus 14%).

Reassurance of no illness was given as a main reason to screen (expressed by 63.8% of respondents), irrespective of respondents’ country of birth or age group. Other reasons to screen were to ensure timely detection (37.8%) and being encouraged by one’s doctor/nurse (21.3%). Promotional material and telephone/mail reminders were less common reasons for undergoing screening, accounting for 5.4% of responses when combined.

Discussion

We undertook the survey in an area that has one of the lowest participation rates in the National Cervical Screening Program^6,7 to identify local women’s reasons for having or not having a screening test.

Women most commonly identified negative emotions and physical discomfort as reasons for delaying or not attending for a cervical screening test. Emotional (or psychological) barriers⁸, namely embarrassment, discomfort and fear, were greater inhibitors than the practical barrier of lack of time; practical barriers such as the time required to have a screen have been identified elsewhere as the stronger type of predictor of women’s screening status.^9,10 The association between emotional barriers and screening is consistent with previous studies examining different ages and screening status.^9,11 Reassurance of no cervical cancer, early detection and a recommendation from the woman’s clinician were the most common reasons given for screening.

Notably, women lacked knowledge about the cervical screening test and its importance to their efforts to prevent cervical cancer, suggesting that inadequate knowledge is at least as strongly linked to under-screening as the historically well documented ‘lack of time’. Knowledge about screening guidelines is fundamental to participation but is evidently lacking for women who do not know when they should have their first screen¹² and the purpose of screening¹³, i.e., to detect precancerous changes not cancer. Strategies for ongoing cervical screening education are particularly important in areas with growing migrant populations^14,15 who are most likely to be unfamiliar with publicly funded accessible preventive healthcare.¹⁶ We took the opportunity to provide information about cervical screening and the new cervical screening test at the survey venue; in turn, women enquired about the rationale for the increased time interval between screens, and, albeit mostly overseas-born women, about the benefits of the cervical screening test.

Cervical screening participation is known to differ by locality and be strongly influenced by socioeconomic status.¹⁷ Our study was undertaken in a suburb where residents experience higher-than-average unemployment and lower-than-average median weekly personal income compared to the state.¹⁸ General practitioners have a central role¹⁹ in addressing practical facilitators – flexible appointment times²⁰ and supportive²¹, female clinicians¹¹ – as they encourage opportunistic screening²² in disadvantaged communities with strong migrant representation.²³ Self-sampling can alleviate some emotional and practical barriers²⁴ to ease the concentrated responsibility on general practitioners.

Researchers estimated that one in four women declined to participate in the survey, and less than 10% of the refusals were because of language difficulties. The 55% of respondents found to be due or late for a cervical screening test suggests either a slightly above average participation²⁵ or that respondents provided what they believed to be a desired response, i.e., social desirability bias.²⁶ The survey questions reflected no assumptions, with an early item questioning whether the respondent knew about cervical screening.

A larger sample size would have allowed investigation of barriers and facilitators by women’s characteristics, such as age group and region of birth – a factor that would provide the potential to investigate the role of culture in nonparticipation. However, tackling the inherent complexities of culture²⁷ was beyond the scope of our study.

Conclusion

Efforts to ameliorate the seemingly immutable low uptake of cervical screening in disadvantaged and migrant communities must tackle emotional barriers, within a framework of sustainable educational strategies and supportive primary health care.

Acknowledgements

This paper was supported by a grant from Cancer Institute NSW. We thank Leendert Moerkerken and Suzanne Schindeler for assistance with data management and analysis respectively, Margie Drake for support via WentWest, Western Sydney Primary Health Network, and Aldi Australia for its support by providing us physical space within its premises.

Peer review and provenance

Externally peer reviewed, not commissioned.

Author contributions

KL and HA conceived the study. All authors contributed to the drafting of the manuscript or revising it for intellectual content.

Competing interests

None declared.