A synthesis of qualitative research on cervical cancer screening behaviour: Women?s perceptions of the barriers and motivators to screen and the implications for policy and practice, CHERE Working Paper 2006/7

Cervical cancer is one of the most preventable and treatable cancers. It has been estimated that up to 90% of the most common type of cervical cancer may be prevented if cell changes are detected and treated early. Early detection is undertaken using a Pap test. In most Western countries, including Australia, and in many less developed countries, screening for cervical cancer is provided to women in the form of an organised program. These programs typically provide Pap tests free or at low cost, at the point of delivery. However, as most cancers occur in women who have never or rarely screened, increasing the rate of screening remains an important issue. Numerous studies have identified the variables associated with women rarely or never screening. Older, poorer women, women living in rural communities and those from non-European ethnic backgrounds (in Australia, especially those who do not speak English) are much less likely to screen than their younger, richer, urban-dwelling, English-speaking sisters. This type of information can be used to target women less likely to screen but does not address what women perceive to be the major barriers to their having a Pap test or what messages might be most effective in convincing them to have the test. A number of qualitative studies have examined these issues. In this project, the results of such studies have been synthesised in an attempt to answer two questions: 1. Why don?t some women have Pap tests? 2. What would work to encourage women who currently do not screen to change their behaviour? This synthesis adopted the meta-ethnographic approach as described in Campbell et al (2003). The results from 16 papers were appraised in terms of the quality of the research undertaken as well as results and conclusions. The results indicate that the majority of women have heard of or know about the Pap test. However, many were misinformed about the details of the test and its implications. Women may not think a Pap test is relevant for them for a number of reasons: many believe that it detects cancer (rather than cervical abnormalities which may or may not be pre-cancerous lesions). This may lead to under-screening if a woman is afraid of cancer or believes that screening is only necessary if and when symptoms appear. Women may also not screen if their cultural and/or religious beliefs connect cervical cancer with sexually transmitted infections acquired as the result of pre-marital or extra-marital sexual contact (ie promiscuity). Common barriers to accessing Pap tests included the direct cost of the test and various opportunity costs in terms of time and availability of childcare. The lack of availability of female health care providers was also an important barrier. The synthesis has indicated that there are some standard preferences and barriers which cross cultural, demographic and socio-economic lines that could be considered by practitioners and policy makers attempting to improve services and increase screening uptake. Practitioners can encourage women to screen by emphasising the curable nature of cervical lesions, being honest about the relationship between sexual activity and cervical cancer and explicitly recommending a Pap test. There is also a need for more individually tailored approaches to target specific ethnic groups. An understanding of community-specific beliefs is invaluable to health professionals if they are to provide cultural sensitive and appropriate services.