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A surprisingly high number of New Zealanders have significant health literacy gaps.

The Ministry of Health defines health literacy as: “a person’s ability to obtain, process and understand basic health information and services in order to make informed and appropriate health decisions”.

OECD statistics show that more than 56% of adult New Zealanders, 75% of Māori women, 80% of Māori men and 90% of Pacific peoples have low health literacy. Although these statistics appear to reinforce health literacy as a “brown patient” issue, our population spread means that in reality Pākehā comprise the majority of New Zealanders with low health literacy.

Health literacy is not entirely a patient-specific issue. Health systems, health professionals and health care providers all play a critical role because it is they who place many of the health literacy demands upon patients and families, such as complicated referral and booking systems.

Efforts to improve cervical screening uptakes should therefore recognise that complex processes are often involved, which can challenge all women – even those with strong health literacy skills.

Health screening study provides insights

Workbase recently undertook a (non-cervical) screening study that identified many barriers relevant to a cervical screening programme. For example, screening wasn’t always offered despite being recommended for all patients. Even when offered, communication about the screening minimised its importance. Furthermore, the rationale for screening did not always make sense to patients or highlight its importance.

Significantly, health professionals felt patients’ non-completion of screening procedures arose from a lack of patient compliance rather than from the health professionals’ failure to properly engage the patients and provide an adequate and relevant rationale for screening.

In other cases, patients actively decided to decline the screening offer. Some were influenced by family members who had not been screened when in the same situation; others felt the risks did not apply to them.

Patients who completed the screening did so because their health professional had made a compelling case that was inextricably linked to the patient’s (and wider family’s) wellbeing.

How to take a health literacy approach to cervical screening

Identify the barriers: It is important to understand why women are not participating in cervical screening. For example:

  • Is an offer actually being made?
  • Is it conveyed in a casual or desultory manner that makes the woman think screening is unimportant?
  • Does communication about the offer offend women because it makes them feel like they are being told off?
  • Is cervical screening a priority for the woman (and, if not, what would help make it so)?
  • Are women aware that screening is important?
  • Are personal resourcing issues a problem (e.g. transport, childcare)?
  • Are there cultural barriers?

This research can be conducted in several ways, including talking to women when they come into the clinic. Some people may feel more comfortable talking over the phone in the first instance rather than face to face, so also consider phone surveys.

Ask the women who get screened regularly what motivates them and, for those that don’t have regular screening, frame the question in a non-judgemental way: “We have realised we could do a better job of explaining cervical screening to people - tell me what would you like to know”.

Remove the barriers: Once the barriers are identified, then work can begin on removing or reducing them. For example, cultural barriers can be addressed by engaging local community leaders or community health workers to assist with talking to specific groups of women about their perceptions of cervical screening, and cultural or other barriers to participating.

Use the right resources: The National Screening Unit’s website has a wealth of resources so take time to select ones that work for your communities. For example, print out some of the personal stories and make them available for people to read. Some people respond better to real life examples so consider asking a patient who has had cervical cancer treatment to tell her story and advocate for screening.

Bear in mind that more information is not necessarily better. Communicate information in small chunks, which are relevant to a woman’s specific needs (e.g. what to expect when having a cervical screening test, what cervical cancer treatment involves) rather than overwhelming her by providing all of the information at once.

Use the right words: Find out which key words are typically used in your target community. For example, “cervical” is not always commonly used and is difficult to pronounce. Maybe “smear test” is more widely understood?

It is important to be sensitive about how requests are framed. For example, telling a woman who is overdue for a smear: “I notice your smear is overdue...” could immediately make her feel she has done something wrong and make her less inclined to engage in further discussion.

Improve your communication tools: Ask women how they would prefer to receive screening reminders: by text, email, letter or phone? Analyse written communication to ensure that the tone is welcoming and non-judgemental. Consider changing the standard reminder letters to a card that congratulates the woman for undergoing regular screening and reminds her that it is time to look after herself again and come back for another screening.

Think outside the square: Improve screening rates by providing better incentives to participate. For example: how can you further improve access – by providing mobile services? What can you do to better acknowledge or reward someone for undertaking screening – by providing vouchers for free manicures to women attending?

Be strategic: Health providers and professionals play a crucial role in building patients’ health literacy. Integrating health literacy practices requires health organisations to incorporate it into strategic and operational planning, service delivery, leadership and management. Efforts should also be made to: involve patients in planning and evaluating programmes, develop the health workforce’s skills, improve patients’ access to and navigation of services and the system, and improve oral and written communication.


For more information contact:
Susan Reid (
or Carla White (