Determinants of routine cervical screening participation in underserved women: a qualitative systematic review

Enhancing equity in cervical screening - initiatives to increase screening participation

PURPOSE OF REVIEW

Cervical cancer can be eliminated as a public health problem through a three-pillar approach including high coverage of human papillomavirus (HPV) vaccination and HPV-based cervical screening, and treatment of precancers and invasive cancers. However, access inequities prevent many women and people with a cervix benefitting from these life-saving advances. This review focuses on evidence-based interventions that can improve equity and scale-up of cervical screening.

RECENT FINDINGS

The transition from conventional cytology to HPV screening provides multiple opportunities to address equity and a multipronged approach can be used to identify priority groups, understand barriers and develop tailored solutions. There are proven financing mechanisms, tools, technologies and screening delivery methods to overcome screening barriers in different settings. This includes self-sampling interventions, point-of-care testing, health service integration, consumer-led co-design processes and digital screening registries.

SUMMARY

To achieve cervical cancer elimination globally, cervical screening must be delivered in an inclusive, culturally safe and context-appropriate manner. There are multiple tools and strategies that can be implemented to improve participation of never- and under-screened groups, and to enhance equity in cervical screening.

Assessment of barriers to cancer screening and interventions implemented to overcome these barriers in 27 Latin American and Caribbean countries

There is a gap in the understanding of the barriers to cancer screening participation and complying with downstream management in the Community of Latin American and Caribbean states (CELAC). Our study aimed to assess barriers across the cancer screening pathway from the health system perspective, and interventions in place to improve screening in CELAC. A standardized tool was used to collect information on the barriers across the screening pathway through engagement with the health authorities of 27 member states of CELAC. Barriers were organized in a framework adapted from the Tanahashi conceptual model and consisted of the following dimensions: availability of services, access (covering accessibility and affordability), acceptability, user-provider interaction, and effectiveness of services (which includes governance, protocols and guidelines, information system, and quality assurance). The tool also collected information of interventions in place, categorized in user-directed interventions to increase demand, user-directed interventions to increase access, provider-directed interventions, and policy and system-level interventions. All countries prioritized barriers related to the information systems, such as the population register not being accurate or complete (N = 19; 70.4%). All countries implemented some kind of intervention to improve cancer screening, group education being the most reported (N = 23; 85.2%). Training on screening delivery was the most referred provider-directed intervention (N = 19; 70.4%). The study has identified several barriers to the implementation of cancer screening in the region and interventions in place to overcome some of the barriers. Further analysis is required to evaluate the effectiveness of these interventions in achieving their objectives.

The Co-Production, Pilot and Qualitative Evaluation of a Cancer Prevention Programme With High-Risk Women Delivered on Group Walks by Cancer Champions: Shoulder to Shoulder, Walk and Talk

OBJECTIVES

Women in the criminal justice system and women who have been subject to domestic abuse are at high risk of cancer but underrepresented in health promotion research. We aimed to co-produce, pilot and evaluate a health promoting programme delivered on group walks.

DESIGN

A programme co-produced by women, based on motivational interviewing, created the opportunity for supportive conversations about cancer prevention.

METHODS

Programme development in two workshops with women with lived experience using authentic vignettes to prompt help-seeking conversations. A small pilot and a qualitative evaluation was done using framework analysis.

RESULTS

The programme appeared acceptable to women and the walk leaders. Women felt included and found it a safe space for sensitive conversations. They appeared empowered and more confident to seek help. Walk leaders expressed confidence in delivering this informal programme, which used prompts rather than delivering didactic training.

CONCLUSION

Cancer prevention for high-risk groups can be delivered in a personalised and novel way by creating informal opportunities for supportive conversations about cancer prevention. Careful co-production of the programme of walks with women, using scenarios and quotes that were authentic vignettes, ensured that these came directly from the women's lived experience and enabled women to talk about change. Our findings indicate that this approach was practical, relevant and acceptable to them with some evidence of women feeling empowered to make informed decisions about their health. We recommend that future cancer prevention programmes for underrepresented groups take an asset-based approach by utilising pre-existing community organisations to increase reach and sustainability.

PATIENT AND PUBLIC INVOLVEMENT

Women with lived experience co-designed and tested the programme. Provisional findings were fed back to the women and the women's organisation that partnered with this research.

Experiences and Challenges of African American and Sub-Saharan African Immigrant Black Women in Completing Pap Screening: a Mixed Methods Study

BACKGROUND

Understanding Black women's Papanicolaou (Pap) screening experiences can inform efforts to reduce cancer disparities. This study examined experiences among both US-born US Black women and Sub-Saharan African immigrant women.

METHOD

Using a convergent parallel mixed methods design, Black women born in the USA and in Sub-Saharan Africa age 21-65 years were recruited to participate in focus groups and complete a 25-item survey about patient-centered communication and perceived racial discrimination. Qualitative and quantitative data were integrated to provide a fuller understanding of results.

RESULTS

Of the 37 participants, 14 were US-born and 23 were Sub-Saharan African-born Black women. The mean age was 40.0 ± 11.0, and 83.8% had received at least one Pap test. Five themes regarding factors that impact screening uptake emerged from the focus groups: (1) positive and negative experiences with providers; (2) provider communication and interaction; (3) individual barriers to screening uptake, (4) implicit bias, discrimination, and stereotypical views among providers, and (5) language barrier. Survey and focus group findings diverged on several points. While focus group themes captured both positive and negative experiences with provider communication, survey results indicated that most of both US-born and Sub-Saharan African-born women experienced positive patient-centered communication with health care providers. Additionally, during focus group sessions many participants described experiences of discrimination in health care settings, but less than a third reported this in the survey.

CONCLUSION

Black women's health care experiences affect Pap screening uptake. Poor communication and perceived discrimination during health care encounters highlight areas for needed service improvement to reduce cervical cancer disparities.

Stakeholder perceptions of cervical screening accessibility and attendance in Ireland: a qualitative study

Organized cervical screening programmes are commonplace in high-income countries. To provide an equitable cervical screening service, it is important to understand who is and is not attending screening and why. Promotion of screening and service improvement is not possible without recognition and identification of the barriers and needs of communities that are less engaged with screening. This study explored stakeholder perceptions of cervical screening attendance and accessibility in Ireland. Semi-structured interviews were conducted with 12 healthcare professionals, policymakers and academics. Interviews were conducted online in 2022. Reflexive thematic analysis was used inductively to generate themes, supported by NVivo. Three themes were developed: (i) getting the right information out the right way, (ii) acceptability and accessibility of screening and (iii) trying to identify and reach the non-attenders. Participants felt public knowledge of cervical screening and human papilloma virus was low and communication strategies were not adequate. Individual, cultural, structural and service-level factors influenced the accessibility and acceptability of screening. Identifying and reaching non-attenders was considered challenging and community outreach could support those less likely to attend screening. Stakeholder perspectives were valuable in understanding the complexities of screening accessibility and attendance from individual to service-level factors. Cultural competency training, inclusive language and visual cues in waiting rooms would support engagement with some populations who may be hesitant to attend screening. Collaboration with community organizations has opportunities to promote screening and understand the needs of those less likely to attend screening.

Attitudes and Preferences Towards Screening for Dementia with a Focus on Ethnic Minority and Low Socio-Economic Groups: A Systematic Review of Research Studies Written in the English Language

Background

Increased understanding of dementia risk-reduction and early detection of Alzheimer's disease and related disorders has spurred interest in the identification of risks for dementia, underlying putative biologies, or dementia itself. Implementation of such approaches require acceptability to the public. Research prior to 2012 indicated limited acceptability for population dementia screening. The changing landscape of dementia prevention research may influence recent perceptions. Additionally, perspectives from underserved populations, such as ethnic minorities and low socio-economic groups, are lacking.

Objective

In this systematic review, we sought published studies since 2012 on attitudes and preferences of people with dementia, carers and the general public from ethnic minorities and low socio-economic groups regarding dementia screening.

Methods

This review was preregistered on PROSPERO (CRD42023384115) and followed PRISMA guidelines. Key search terms were entered into five databases. Articles were included if they focused on population or risk screening for dementia via primary/community care-based assessments, and which included majority ethnic minority or low socio-economic groups or discretely considered these groups in data analysis. Data were synthesized narratively.

Results

Seven studies reported perspectives of ethnic minorities regarding dementia screening; one study included people from low socio-economic groups. Results indicated that participants from ethnic minorities were willing to undergo dementia screening. Predictors of willingness included belief in benefits, desire to boost diversity, and to implement lifestyle changes. Unwillingness was associated with anxiety regarding results.

Conclusions

Although there seems to be high acceptability for screening in the studied groups, more research is necessary to explore the practical considerations for screening such as cultural and economic barriers, trust, and post-screening actions.

Barriers to adherence to cytology exam: a case study in low-income Colombian women

BACKGROUND

Cervical cytology is essential for the early detection of cervical cancer. However, in Colombia, only 50% of women with subsidized health insurance were screened in 2019, compared to 100% of women with contributory insurance. This disparity highlights significant barriers that must be addressed. This study aimed to identify the factors that contribute to or hinder adherence to cervical cytology screening among low-income women with subsidized health insurance in a public primary care network in Cali, Colombia, from 2014 to 2018.

METHODS

In a qualitative case study, the experience of women and health care and administrative personnel was recovered. Forty-seven women participated in seven focus group discussions. Five other women using the program participated in in-depth interviews. Finally, we interviewed eight people from the healthcare area and the health services administration. The qualitative data collected underwent content analysis, guided by the theoretical framework of Social Determinants of Health. Within this framework, five interconnected dimensions that influence adherence were incorporated.

RESULTS

Adherence is a multifactorial phenomenon, and in relation to attendance at cervical cytology, the analysis delved into the mechanisms that affect it in a low-income context. Barriers to adherence were identified across multiple dimensions, including social and economic factors, health conditions, and patient-related factors, among both adherent and non-adherent women. Among adherent women, barriers and facilitators related to the healthcare team and system, as well as patient-related factors, were identified.

CONCLUSIONS

The findings of this research can be useful in developing personalized interventions and strategies to improve adherence and screening outcomes in low-income settings. It is necessary to increase the resources of health insurance entities to establish effective communication channels with women who attend the cervical cancer prevention program.

Non-adherence to cervical cancer screening recommendations among women in Eswatini: a cross-sectional study

BACKGROUND

In 2018, Eswatini had the world's highest age-standardised cervical cancer incidence rate. Cervical cancer screening reduces women's risk of invasive cervical cancer. Data on adherence to cervical cancer screening recommendations in Eswatini are scarce. The purpose of the current study was to determine Eswatini women's self-reported adherence to cervical cancer screening recommendations, attitudes toward screening, and factors associated with non-adherence.

METHODS

A cross-sectional survey of women (n = 377) aged 25 to 59 accessing primary healthcare clinics (n = 4) in Eswatini assessed screening participation, attitudes and knowledge regarding cervical cancer screening, and socio-demographic variables. Adjusted logistic regression was used to assess factors associated with non-adherence to Eswatini cervical cancer screening recommendations.

RESULTS

One hundred and sixty-six (44%) women were classified as adherent to cervical cancer screening recommendations. Attitudinal barriers endorsed by over one-third of participants included a perceived low risk of cervical cancer (n = 161, 43%) and a view that screening is likely to be painful (n = 146, 38%). Participants had higher odds of being classified as non-adherent if they: were single compared with married (OR = 1.78, 95% CI: 1.05, 3.01, p = 0.03), perceived screening as likely painful (OR = 4.43, 95% CI: 2.62, 7.46, p < 0.001); and had not been advised by a doctor/ nurse to screen (OR = 2.82, 95% CI: 1.71, 4.64, p < 0.001). Also, a 1-year increase in age was associated with an increase in the odds of being classified as non-adherent (OR = 1.42, 95% CI: 1.39, 1.45, p = 0.01).

CONCLUSIONS

Self-reported adherence was moderate among this group of women. Tailored interventions are needed to increase participation in cervical cancer screening, especially for those women with characteristics associated with being classified as non-adherent. Primary healthcare clinic nurses (and other health providers) may contribute toward improving participation in cervical cancer screening by advising eligible women to screen and providing health education addressing negative attitudes toward screening.

Physically fit with a higher cancer risk? Influences of cervical cancer screening among a sample of physically active women ages 21-49 living in the United States

To achieve the lowest risk level for various cancers, individuals would engage in several healthy lifestyle behaviors and age-eligible cancer screenings as recommended. Nonetheless, research has largely omitted exploration of concurrent primary and secondary prevention behaviors. This study was designed to explore influences of cervical cancer screening among physically active women who reported participation in recreational sports. U.S. based women between the ages of 21-49, who had never been diagnosed with cancer, were eligible to complete a web-based survey. Logistic regression analyses were conducted using SAS 9.4. On average, women were 31 years of age (N = 394) and self-identified as Black (51.3 %). Although low overall (30.7 %), higher odds of cervical cancer screening were associated with age (OR = 1.06, 95 % CI = 1.03-1.10), employment (OR = 2.43, 95 % CI = 1.14-5.18), knowledge of cancer-related risk behaviors (OR = 4.04, 95 % CI = 1.33-12.28), routine doctor's visit (OR = 4.25, 95 % CI = 1.56-11.54), and team-based vs individual-based sport participation (OR = 1.95, 95 % CI = 1.13-3.34). Our study provides insight into the health profile of physically active women, ages 21-49, as it relates to risks for cervical cancer. Screening uptake among this diverse sample was much lower than the general population and national goals set by Healthy People 2030. Interventions should be tailored to increase knowledge of cancer-related risk behaviors, access to healthcare, and recommended cervical cancer screenings among even assumed-to-be healthy populations.