Overcoming barriers to cervical screening in Pacific women

Cervical screening rates in New Zealand have continued to increase following the introduction of the National Cervical Screening Programme in 1990. The Programme has a target of 75% coverage for all eligible women (increasing to 80% in 2011).¹ Data from 2009 show that this target was only achieved by European/Other women (Figure 1), and only 59% of eligible Pacific women were screened.²

The groups of women who consistently have cervical screening rates less than the National Cervical Screening Programme target are:

• Pacific
• Māori
• Asian
• Women living in the lowest socioeconomic areas

Cervical cancer mortality in Pacific women

The incidence of cervical cancer is higher for Pacific women than for women in the European/Other ethnic groups.³ Pacific women aged 45–64 years have a mortality rate from cervical cancer of 14 per 100 000 compared with a national average rate of rate of 8 per 100 000.⁴

The increased incidence is thought to reflect the lower cervical screening rate among Pacific women. Improving screening rates is an important step in reducing the disparities. Approximately half of all women who develop, or die from, cervical cancer have never been screened and about one-third have only been screened irregularly and infrequently.⁵

Improving quality of care for Pacific peoples cannot be addressed with a “one size fits all” approach. The cultural identification and needs of Pacific peoples are diverse and changeable. In addition, the barriers faced by an immigrant Pacific person may be quite different from those faced by a Pacific person born in New Zealand. Attention to individual factors and multiple approaches are likely to be more successful.

There is limited research relating specifically to the barriers that Pacific women may experience in accessing cervical screening. Barriers such as shyness and cost may prevent women of any ethnicity from having regular cervical screening, while other barriers may be more specific for Pacific women. To ensure the disparities in cervical screening are overcome, it is important that any barriers are identified.

Figure 1: National cervical screening rates 2009,² by ethnicity (Ministry of Health, 2009 MC: change “other” to European/other

Barriers to cervical screening for many women include:⁶

• Embarrassment
• Shyness
• Cost
• Fear e.g. of cancer
• Pain or discomfort
• Not knowing what to expect

Be considerate of the power imbalance and a fear of loss of control in what is perceived to be a smear-collector controlled procedure. A clinician who is not rushed is likely to have more success with women who have previously avoided having a cervical smear than someone who is time-pressured.

Overcoming barriers and targeting disparities

While it is important to be aware of the barriers to cervical screening for Pacific women, knowledge alone is not sufficient to overcome them. Planning at a practice level is necessary to address disparities. It is important that any intervention is carefully targeted to the women that need it most.

The first step is to invest time in establishing an effective relationship. Talk to Pacific women in your practice and try and understand what is important to them. It may take several consultations before some women are ready to have a cervical smear, but it is important to acknowledge their concerns and fears, and provide clear information about the procedure.

Make cervical screening a positive experience

Many women have concerns about having cervical screening performed. Therefore it is important the experience is as positive as possible. Women who have a positive experience are more likely to return, and to encourage their friends and family to attend.

Aspects that may make cervical screening a more positive experience include:

Making it less embarrassing

It is important to take practical steps to reduce embarrassment or vulnerability while the smear is being collected. This may include:

• Ensuring the woman is covered while lying on the bed
• Pulling curtains around the bed
• Ensuring the environment is relaxed, e.g. warm temperature
• Offering different positions to lie in
• Offering disposable plastic speculums
• Warming the speculum

Providing reassurance about confidentiality

Some women may not want to have a cervical smear because this acknowledges that they are sexually active, particularly if sexual activity outside marriage is viewed as unacceptable by their family.⁷ This may be a particular issue for younger women, or women that know someone in the practice.

Women should be reassured that the consultation is entirely confidential, and that all health workers are bound by that confidentially. Remind them that they do not need to disclose to others the reason for their consultation. It may be worth discussing what an appropriate response could be if family or friends ask why they have attended the practice.

Where possible, give women the choice of who their smear taker will be. Do not assume that all Pacific women would like a Pacific smear taker. In many cases, as Pacific communities are relatively small, Pacific women would prefer a smear taker of different ethnicity to themselves.⁸

Consider any language barriers

If language is a barrier, try to provide access to a smear taker with appropriate language skills. If this is not possible, consider using a telephone interpretation service. Language Line is a service managed by the Office of Ethnic Affairs and funded by some PHOs. An interpreter can be available via the telephone almost immediately, with 40 different languages available, and a choice of gender.

Consider financial barriers

The cost of having cervical screening may be a barrier for many Pacific women. Some PHOs have initiatives in place to provide free or low cost cervical screening. Practice Nurses, Pacific providers or family planning clinics may offer a lower cost alternative. There may also be assistance available for transportation. Become familiar with the services available in your area and ensure the patients who would benefit most have access to these services.

Start with your practice population

Practical steps to identify Pacific women who require a cervical smear:

• Perform a computer search to identify all Pacific women in your practice and highlight those who have never had a smear or who are overdue
• Contact the National Cervical Screening Programme (0800 729 729) to check if a smear has been performed by another provider, and to check screening histories and recall, if necessary
• Place an alert on the medical record, so the issue can be discussed when the patient next attends.
• Invite all women who are overdue, by letter or telephone, to receive a cervical smear
• Tailor specific approaches to your practice population

Health educational resources

The National Cervical Screening Programme provides educational resources to help primary care teams achieve better results for their Pacific patients. These resources are available in Samoan, Tongan, Cook Island Māori, Niuean, Tokelauan, Tuvaluan and Fijian languages, and include:

• National Cervical Screening Programme Pacific Poster
• “Facts about cervical screening” and “Understanding cervical smear test results” pamphlets

To order resources, visit: www.healthed.govt.nz (keyword cervical screening).