There are many barriers that may explain the reluctance of some woman to attend for cervical screening. Some are common
to all women, such as shyness or cost, while other reasons may be specific to some groups, such as cultural and language
For many women having a cervical smear is often associated with thoughts of nervousness, vulnerability and embarrassment.
Whakamā is thought to be one of the main barriers to screening for Māori women. This may be due to the strong
Māori belief in the sacredness of te wharetangata, and a perceived insensitivity of smear takers.11
The association between sexual activity and cervical screening may make many women uncomfortable about presenting for
a smear. Some women are also concerned that personal information of a sexual nature may not remain confidential. Traditionally
Asian women are typically less open about their sexuality and are generally discouraged from expressing their sexuality
until they are married.12
Many women are embarrassed by having a smear performed by a male GP. Most Māori women feel more comfortable with
a Māori smear taker, although Pacific women generally prefer a non-Pacific smear taker, who they would be less likely
to know through their social networks.
Cost is frequently a barrier to having a cervical smear.11 There is considerable variation within New Zealand
in the cost of having a smear taken. Other cost issues include transport, childcare and wages lost due to taking time
off work. In many cases when money is an issue, a test such as a cervical smear, becomes a low priority.
For women who are not enrolled in a PHO, the cost of a consultation is not subsidised, and their consultation will be
charged at the “casual” rate.
Although the fear of cancer is a motivating factor for many women, it is also a significant deterrent for others,11 as
many would rather not know. Different cultures have their own belief systems about cancer and illness.13 These
may act as a barrier for cervical screening, e.g. the belief that cancer means certain death, and there is little that
can be done to treat it.
Pain or discomfort
Many women identify the pain and discomfort of having a smear taken as a barrier.11 This may include a number
of factors, such as: pain and discomfort during the procedure, male doctors being less gentle than female doctors, and
the invasiveness of the procedure.
Not knowing what to expect
Some women are discouraged by a previous negative experience of having a smear taken, especially if they feel the procedure
was not explained properly, or they did not feel fully informed.11 Furthermore, if these uncertainties are
shared with friends or family/whānau, this barrier can become widespread.
Some new immigrants to New Zealand will not be familiar with cervical screening if they have not previously been exposed
to a cervical screening programme. Although routine cytological screening is common in wealthier countries, most developing
countries lack the infrastructure and trained personnel needed to provide a programme.
Approximately 25% of new immigrants report needing assistance with the health system, which may be further complicated
by one in five rating their English language ability as moderate to poor.14 One study found that in women immigrants
to New Zealand not previously exposed to a cervical screening programme, not knowing where to go and not realising it
is necessary, were the most frequently cited reasons for never having had a smear.15
While the values of European New Zealand women are generally aligned with New Zealand health practice, this is less
likely for women with other cultural influences. Acculturation is the process of one cultural group adopting the beliefs
and behaviour of another group, usually a minority group adopting habits and language patterns of the dominant group.
When women have been in a country for some time and have become more acculturated, they are more likely to participate
in cervical screening.
Cultural viewpoint of health
As a way of understanding more complex scientific and medical concepts, people may relate the information back to the
things in their life they do understand.16 Māori, along with many other indigenous people, often hold
an overall view of health that is quite different to Western views. For example, common beliefs about cancer may include
that it is contagious, it implies certain death and it may be a punishment, curse, payback or is predetermined. People
may not seek treatment because they think they have the power to fight cancer through their beliefs, feelings and perceptions.
For some cultures, visits to health providers do not occur until there are symptoms. It is also commonly believed that
primary prevention is achieved by the individual, through maintaining a good diet, achieving good spiritual balance and
consuming herbs that promote health, rather than by attending a doctor when there are no symptoms of disease.
Being aware of the barriers to cervical screening is not sufficient to overcome them. In addition to national initiatives
(see sidebar), carefully targeted planning at a practice level is necessary to address disparities.
The first step to increasing cervical screening rates is to invest time in becoming familiar with the needs of the local
community and establishing the trust of the women being targeted.
National initiatives to promote cervical screening
The importance of increasing cervical screening rates is recognised by the PHO Performance Management Programme. Most
PHOs have initiatives to reduce the barriers to having a smear. Many of these initiatives include free smears for Māori
and Pacific women and women from areas of high deprivation, as well as women overdue for smears, free women’s clinics
and mobile cervical screening services.
Recently the NCSP has initiated a significant social marketing campaign/health promotion programme, to educate and
encourage Māori, Pacific and Asian women in particular, to have regular cervical smears.
Although the NCSP campaign can be expected to help reduce the disparities in cervical screening rates, there will continue
to be women who remain unscreened or under-screened. General practice is in a unique position to encourage all women
to participate in the NCSP.
Target the disparities.
Currently European women are accessing cervical screening services at acceptable
levels, and as a result have the lowest levels of cervical cancer and associated mortality. Resources should be targeted
to the women who are not receiving cervical smears – Māori, Pacific and Asian women and women from areas of high
Although we often refer to the “hard to reach” – it is more helpful to consider a broader range of reasons
why women do not have regular cervical smears, e.g. women who are:
Consider – are these people “hard to reach” or is your service “hard to use”?
Start with your practice population
Starting with your own practice population here are some practical steps:
- Perform a computer search to identify the women in your practice who have never had a smear or who are overdue for
- Contact the National Cervical Screening Programme (0800 729 729) to check if smear has been performed by another smear
taker, and to check screening histories and recall, if necessary
- Place an alert on a medical record, so the issue can be discussed when the patient next attends.
- Invite all women who are overdue by letter or telephone to participate
- Think of approaches relevant to your practice population
Invest time in building relationships and trust
“It comes down to the basics. Taking time to talk to women, listening to their concerns, respecting
their wishes and building trust. It can take some women a long time to be ready, but it is important to keep building
that relationship.” – Māori/Pacific Health Nurse
It may take several consultations for some women to feel comfortable about having a smear. Depending on their own personal
experiences, some women may never be ready. It is important to acknowledge concerns and fears and provide clear information
about the procedure.
Mā te rongo, ka mohio; Mā te mohio, ka mārama;
Mā te mārama, ka mātau; Mā te Mātau, ka ora
Through listening comes awareness,
Through awareness comes understanding,
Through understanding comes knowledge,
Through knowledge comes life and well-being.
Make it a positive experience
Emphasise how cervical screening benefits both the patient and their family/whānau. Validate their decision to
participate and encourage them to encourage others. It is also important that women are made to feel as comfortable as
possible about the process. Women who have had a positive experience are more likely to return.
Ensure women feel prepared
It is important to take the time to ensure the woman is well prepared, relaxed and comfortable prior to the collection
of the cervical smear. Important things to consider are:
- Don’t rush the woman, if she’s not ready this time, talk to her in preparation for the next time
- Encourage her to ask questions to gauge her understanding of the information you are sharing
- Reduce her discomfort by giving her time to absorb the information
- Ask her if she would like to see the speculum. Allow her to hold it if she chooses, and explain how it will be used
- Let her know she can have a support person
- Tell her to let you know if she is uncomfortable during the procedure
Make it less embarrassing
Give women a choice of smear taker and ensure they know the process is confidential. This may be difficult if they know
someone in the practice, especially if they are worried that aspects of their sexuality may be revealed.
It is important to take practical steps to reduce embarrassment or vulnerability while the smear is being collected.
This may include:
- Being covered while lying on the bed
- Pulling curtains around the bed
- Ensuring the environment is relaxed (e.g. pictures, warm room, music)
- Offering different positions to lie in
- Offering disposable plastic speculums
- Warming the speculum
Provide culturally appropriate smear takers
Some Māori and Pacific health providers have smear takers and may provide a free or low cost service. Cervical
Screening health promoters, specialising in the promotion of screening to Māori, Pacific and Asian women, are also
available in most areas (contact your DHB) and will be able to assist practices in ensuring their services are culturally
appropriate. It may be worth exploring what options for smear taker training are available in your area. Depending on
availability, nurse smear taker training is free.
Language difficulties are a major barrier for many Asian and some Pacific and Māori women, therefore it is important
to provide access to a smear taker with appropriate language skills where possible, otherwise the use of an interpreter
is encouraged. Many PHOs are clients of Language Line, a telephone interpreting service managed by the Office of Ethnic
Affairs. If the service is available through the PHO, an interpreter can be available via the telephone almost immediately.
There are 40 different languages available with a choice of gender of the interpreter.
Reassure patients that an abnormal cervical smear result rarely indicates cancer but rather screening provides the opportunity
to detect early changes and if necessary, treatment can be initiated.
Ask patients about their preferred method of receiving results. They may wish that even normal results are communicated
to them. Make sure the patient knows when their next smear is due and place a recall on your PMS.
Tell the patient that they may be asked to return for a repeat test if the smear is reported as unsatisfactory. The
rate of unsatisfactory smears is likely to be less with the advent of liquid based cytology.
In recognition of cost being a major barrier for many women, most PHOs have initiatives in place to provide free or
low cost cervical screening, for targeted populations.
Māori/Pacific providers, family planning clinics and practice nurses may offer a low cost or free alternative.
Become familiar with the services available in your area and ensure the patients who would benefit most have access to
Competencies for Smear Taker Training is a new document available.17
This has been
developed by the NCSP in consultation with stakeholders and replaces the NCSP Training Standards for Smear Takers 2002.
It is available from www.nsu.govt.nz
September is Cervical Screening Awareness Month
The NCSP is promoting September as “Cervical Screening Awareness Month”.18 This is a national
initiative, supported by the New Zealand Cancer Society and the Family Planning Association. There will be an increased
awareness of the cervical screening programme, providing the opportunity for local promotional activities, supported
by national advertising and promotions.
The aim is to get women talking about the benefits of cervical screening, and to encourage the women around them to
have a cervical smear.
All clinics and smear-taking practices throughout New Zealand have been provided with promotional resources for the
- Awareness Month posters for display in practices during September
- Free 30 mL hand and body lotion samples for distribution to women who have their smear test during September (while
- Miniature promotional stands for display on reception counters