Available via license: CC BY 4.0
Content may be subject to copyright.
RES E AR C H A R T I C L E Open Access
Knowledge of cervical cancer and attendance at
cervical cancer screening: a survey of Black
women in London
Christine Ekechi
1
, Adeola Olaitan
2
, Rosie Ellis
3
, Jacob Koris
4
, Adaugo Amajuoyi
3
and Laura AV Marlow
5*
Abstract
Background: Women from ethnic minority backgrounds are less likely to attend cervical screening, but further
understanding of ethnic inequalities in cervical screening uptake is yet to be established. This study aimed to
explore the socio-demographic and ethnicity-related predictors of cervical cancer knowledge, cervical screening
attendance and reasons for non-attendance among Black women in London.
Methods: A questionnaire was completed by women attending Black and ethnic hair and beauty specialists in
London between February and April 2013. A stratified sampling frame was used to identify Black hair specialists in
London subdivisions with >10% Black population (including UK and foreign-born). Fifty-nine salons participated.
Knowledge of cervical cancer risk factors and symptoms, self-reported screening attendance and reasons for
non-attendance at cervical screening were assessed.
Results: Questionnaires were completed by 937 Black women aged 18–78, describing themselves as being
predominantly from African or Caribbean backgrounds (response rate 26.5%). Higher educational qualifications
(p < .001) and being born in the UK (p = .011) were associated with greater risk factor knowledge. Older age was
associated with greater symptom knowledge (p < .001). Being younger, single, African (compared to Caribbean) and
attending religious services more frequently were associated with being overdue for screening. Wome n who had
migrated to the UK more than 10 years ago were less likely to be overdue than those born in the UK. Of those
overdue for screening who endorsed a barrier (67/133), ‘I meant to go but didn’t get round to it’ (28%), fear of the
test procedure (18%) and low risk perception (18%) were the most common barriers.
Conclusions: Ethnicity, migration and religiosity play a role in predicting cervical screening attendance among
women from Black backgrounds. African women, those born in the UK and those who regularly attend church are
most likely to put off attending. Additional research is needed to explore the attitudes, experiences and beliefs that
explain why these groups might differ.
Keywords: Cervical screening, Knowledge, Awareness, Race, Ethnicity
Background
Cervical cancer is the fourth most common cancer in
women worldwide with a significant burden of mortality,
particularly in developing countries [1]. In developed
countries such as the US and UK incidence of cervical
cancer is much lower, but disparities by socio-economic
status, race and ethnicity remain [2-5]. These disparities
are likely due to varia tion in risk factors for cervical can-
cer which include exposure to human papillomavirus ,
smoking status and non-attendance at cervical screening
[6]. In England, an organised cervical screening programme
dramatically reduces risk of cer vical cancer, yet around
20% of women a re not considered to be adequately
screened [7].
A recent study that assessed a range of socio-economic
variables, showed ethnicity was the most important socio-
demographic predictor of having never attended cervical
screening, with non-white women more than twice a s
* Correspondence: l.marlow@ucl.ac.uk
5
Cancer Research UK Health Behaviour Research Centre, Department of
Epidemiology & Public Health, University College London, Gower Street,
London WC1E 6BT, England
Full list of author information is available at the end of the article
© 2014 Ekechi et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Ekechi et al. BMC Public Health 2014, 14:1096
http://www.biomedcentral.com/1471-2458/14/1096
likely to have never attended [8]. The term ethnicity re-
fers to “th e group t o which people belong… as a result
of certain shared characteristics including geographical
and ancestral origins, but particularly cultural traditions
and languages” [9]. A m ulti-faceted concept, ethnicity
encompasses a range of factors such a s m igration his -
tory,languageandreligion.Todatetheinfluencethat
these factors have on cer vical screening uptake ha s not
been explored. Qualitative studies suggest lower know-
ledge o f cervical cancer among minority groups could
explain low engagement with cance r pre vention ser-
vices, [10] but this has not been explored quantitatively.
Identifying ethnic groups with poor knowledge of cer-
vical cancer and low engagement with cancer prevention
services would highlight where interventions to reduce in-
equalities need to be directed. A number of studies have
examined factors associated with screening uptake in Brit-
ish South Asian women, [11] but to our knowledge there
are no studies exploring cervical cancer knowledge or
screening behaviour among Black women in the UK. In
2011, the Black population in England was approximately
1.8 million, including predominantly those from African
and Caribbean backgrounds (UK-born and foreign-born)
[12]. Women from African and Caribbean backgrounds
are often grouped together for research purposes, but
there is evidence of variation between these ethnic sub-
groups in other behavioural risk factors for cervical cancer
(smoking status and sexual behaviour [13,14]). Differences
in cervical screening uptake have not been explored.
We conducted a community-based sur vey of Black
womeninLondon.Ourobjectiveswerei)toexplore
socio-demographic and ethnicity-related factors associated
with cer vical cancer knowledge and non-attendance at
cervical screening and ii) consider self-reported reasons
for non-attendance at screening.
Methods
A questionnaire, examining knowledge and attitudes to
cervical cancer screening was distributed to Black and
ethnic hair and beauty specialists in London. We decided
to focus data collection in London because census data
(2011) show that more than half of England’s Black popu-
lation reside in London [12]. We planned to include all
women over 18 years old, UK-born and foreign-born who
classified themselves as African, Caribbean, any other
Black/African/Caribbean background, mixed White and
Black Carribbean, mixed White and Black African (in re-
sponse to the 2011 census question on ethnic group). We
felt that recruiting through hair and beauty salons serving
the Black community would help us identify women from
our target population including those who may not rou-
tinely access healthcare. Similar methods have been used
for community-ba sed re cruitment of ethnic minority
groups in the United States [15].
Recruitment
The aim was to di stribute 6000 questionnaires through
100 establishments over a t welve week period. Initially,
a stratified sampling frame was dev eloped a s follows ,
1) London boroughs
a
with a greater than 10% proportion
of residents from Black backgrounds (including UK and
foreign born) were selected, 2) The number of salons to
be recruited within each borough was determined accord-
ing to the size of the Black population in that borough, 3)
A list of hair and beauty salons catering to the Black com-
munity within each of the selected boroughs were identi-
fied using an internet search (122 salons were identi fied ).
We intended to target 100 Salons across 18 boroughs,
between 3 and 10 salons per borough (see Additional
file 1). Where listed establishments had moved location or
were unwilling to participate in the study, alternative local
salons within the same borough were approached. Many
of the salons on the original internet-based recruitment
list were unavailable so a secondary recruitment method
was based on identifying local high streets (focal points
for business, particularly shops) in each borough and visit-
ing these to look for salons. In some instances hair salons
who agreed to participate would suggest other salons that
might be interested in taking part. For logistical reasons,
recruitment ceased after the allocated recruitment period
(12 weeks) despite not reaching our original target of 100
salons.
Questionnaires were distributed between February and
April 2013. Each participating salon was visited (by RE
and/or AA) and left with 60 self-administered question-
naires to distribute to all women who attended over a one
week period (7 days inclusive). Salons were given key rings
to offer their clients as a thank you for participating. Some
hair salons were visited on more than one occasion if at first
visit it was apparent that the initial response rate was low.
Questionnaires were completed anonymously, were sealed
in an envelope provided and deposited in a secure box.
All women over the age of 18 who described themselves
as being from a Black background were eligible for the
study. Although women are not invited to cervical screen-
ing in England until they are 25 years old, we felt it was
appropriate to assess knowledge of cervical cancer among
women in a wider age range.
Measures
A self-administered structured questionnaire was devel-
oped based on previous research on cervical cancer know-
ledge and screening (Additional file 2). Socio-demographic
and ethnicity-related variables were assessed using items
from the 2001 Census. We assessed ethnicity, country of
birth, length of time in the UK, language spoken at home,
religion and religiosity. We also assessed education level,
marital status and smoking status. Education was recoded
into low (no formal qualifications or General Certificate of
Ekechi et al. BMC Public Health 2014, 14:1096 Page 2 of 9
http://www.biomedcentral.com/1471-2458/14/1096
Secondary Education), medium (vocational qualifications
or A-levels) or high (a university degree).
Knowledge questions were taken from the Cervical
Cancer Awareness Measure (Cervical CAM) a validated
tool to meas ure awareness of cer vical cancer [16]. Two
open questions from the Cer vical C A M were used to
examine knowledge of cer vical cancer risk factors and
symptoms. Participants freely listed risk factors and
symptoms, and their responses were coded in accordance
with a predefined list of target risk-factors and symptoms
identified in the scientific literature and forming the
National Health Ser vice (NHS) Department of Health’s
‘Key Messages’ on cer vical cancer. Only corre ct risk
factors and symptoms were coded.
To assess attendance at cervical screening women
were asked “Which of these statements , if any, describes
whether you have had cer vical screening (smears)?” with
the following respon se options: I have had a test within
the las t 3 years; My la st test wa s 3 to 5 years ago; My
last test wa s more than 5 years ago; I have never been
invited to have a test; I have been invited but have never
had a te st; I have had a hysterectomy so I don’t need to
have test s; I have never heard of cervical screening; I am
too young to be invited (18–24 years); None of the
above. Women who had never had a smear test, or did
not a ttend their last screening were asked to indicate
why by selecting from a predefined list. The cervical
screening attendance question and the predefined list
of barriers had been used previously in a population-
representative sur vey [17].
Analysis
Data were analyse d using SPSS v.20. Overall risk factor
knowledge and symptom knowledge scores were calcula ted
by allocating a score of ‘1’ for each cited item that corre-
sponded with the pre-defined list. Participants who did not
cite any items on this list were allocated a score of ‘0’.The
same method was used in a previous study [18]. We have
reported the means for these scores, but because the data
were highly skewed participants were recoded into two
groups, those who ‘cited’ vs ‘did not cite’ at least 1 correct
risk factor/symptom. We used logistic regression to explore
associations between each socio-demographic/ethnicity-
related variable and citing a correct risk factor/symptom.
Logistic regression was also used to explore predictors of
being overdue for screening. Women were considered
‘overdue’ for screening if they were 25–49 years and had
not been screened in the last 3 years or if they were 49–64
and had not been screened in the last 5 years. Odds ratios
(OR) and 95% confidence intervals (CI) are reported.
Results
A total of 3540 questionnaires were distributed through
59 Salons and 937 were returned (response rate - 26.5%).
Blank questionnaires were excluded (n = 40), as were
those with no completed demographic information
provided (n = 21). Missing demographic data for the
remaining 876 women was approximately 5% for most
variables, but slightly higher for birthplace and migra-
tion year (8% and 10%). Participants were only ex-
cluded from analyses involving variables where their
data was missing.
Sample characteristics
Sample characteristics are shown in Table 1. Over half
the women described themselves as Caribbean (56%)
and a quarter as African (25%), with the rest describing
their background as mixed White and Black Caribbean
(5%), mixed White and Black African (3%) or other Black
(4%). Most spoke English as their main language (97%).
Most were born in the UK (61%), but many of these
women had a least one parent born outside the UK
(84%). A third of women were born outside of the UK,
but most of t hese women had been living in the UK for
more than 10 years. The majority were Christian (77%),
with 41% attending religious service at least once a
month. Almost half were single (48%) and 50% had a
high level of educational qualifications.
Knowledge of cervical cancer symptoms and risk factors
Just over half of women cited at least one cervical cancer
risk factor (55%, n = 481) and 58% (n = 509) cited at least
one cervical cancer symptom. While 41% of women
cited both a risk factor and a symptom, 28% could not
cite either. The percentage of women citing each risk
factor/symptom is shown in Table 2.
The most commonly cited risk factors were, having
many sexual partners (15%), smoking (12%) and not go-
ing for smear tests (10%). Only 4% cited infection with
human papillomavirus, but 29% cited at least one risk
factor relating to sexual behaviour (having multiple sex-
ual partners, sex at a young age, unprotected sex, HPV
or other STIs). On average women cited 0.61 correct
risk factors (range 0– 6). Citing at least one correct risk
factor was not associated with ethnicity, length of time
in the UK, religion or religiosity, however women who
were born in the UK were more likely to cite a risk fac-
tor than women born outside the UK (OR = 1.46, CI:
1.09-1.96). Women with a high level of education were
more likely to cite a risk factor than those with a low
level of education (OR = 2.22, CI: 1.46-3.35). Age and
marital status were not significantly associated with risk
factor knowledge. In adjusted analyses , including educa-
tion and being born in the UK, both variables remained
significant.
The most commonly cited symptoms were vaginal
bleeding in-between periods and unusual vaginal dis-
charge (cited by 32% and 25% of women respe ctively).
Ekechi et al. BMC Public Health 2014, 14:1096 Page 3 of 9
http://www.biomedcentral.com/1471-2458/14/1096
Table 1 Sample characteristics
Whole sample (n = 876) Screen eligible (n = 652)
N%*N%*
Marital status
Single 417 47.6 295 45.1
Married 214 24.4 184 28.4
Cohabiting 95 10.8 77 11.8
Divorced/separated/widowed 106 12.1 94 14.4
Education
Low level 131 15.0 100 15.3
Medium level 240 27.4 162 24.8
High level 436 49.8 348 53.4
Other 30 3.4 25 3.8
Ethnicity
Caribbean 488 55.7 380 58.3
African 216 24.7 166 25.5
Mixed white and Black Caribbean 39 4.5 33 5.1
Mixed white and Black African 25 2.9 20 3.1
Any other Black background 33 3.8 28 4.3
Other mixed background 13 1.5 9 1.4
Other 18 2.1 11 1.7
Birthplace
UK-born and parents UK-born 83 9.5 46 7.1
UK-born, 1 parent UK-born 204 23.3 159 24.4
UK born, no parents UK-born 244 27.9 205 31.4
Not UK-born 275 31.4 221 33.9
Year moved to UK
1956-1972 49 5.5 35 5.4
1973-1990 69 7.9 62 9.5
1991-2002 95 10.8 77 11.8
2003-2013 44 5.0 34 5.2
Religion
Christian 678 77.4 498 76.4
Muslim 27 3.1 23 3.5
No religion 103 11.8 84 12.9
Other 27 3.1 25 3.8
Religious service attendance
Rarely or never 238 27.2 181 27.8
Few times a year 239 27.3 180 27.6
1-3 times a month 103 11.8 75 11.5
At least once a week 251 28.7 192 29.4
Smoking Status
I have never smoked 508 58.0 379 58.1
I used to smoke 210 24.0 162 24.8
I currently smoke 137 15.6 101 15.5
*Unaccounted percentage is missing data.
Ekechi et al. BMC Public Health 2014, 14:1096 Page 4 of 9
http://www.biomedcentral.com/1471-2458/14/1096
Less than 1% of women cited heavier/longer periods or
vaginal bleeding after the menopause. On average
women cited 0.95 symptoms (range 0-5). Age was the
only variable significantly a ssociated with citing at lea st
one correct symptom (p < .001). Compared to 16–24
year olds each older age group was progressively more
likely to cite a correct symptom: 25–34 years (OR =
2.54, CI: 1.55-4.18), 35–44 years (OR = 2.76, CI: 1.66-
4.57), 45–64 years (OR = 4.52, CI: 2.73-7.49). Women
over 65 years were no more likely to cite a correct
symptom than the youngest group (p > .05). Symptom
knowledge was not associated with ethnicity, being
born in the U K , religion or religiosity or education.
Marital status was associated with citing a c orrect
symptom, but this wa s no longer the ca se when adjust-
ing for age.
Attendance at screening
Of the eligible population (those aged 25–64 years, who
had not had a hysterectomy, n = 652), 75% had been
screened in the last 3 years and 16% in the last 3–5years.
Sample characteristics for the screen eligible women
are shown in Table 1. Most women were last screened at
their GP surgery (75%), but health centres (10%), hospitals
(7%) and private clinics (2%) were used by some women.
Overall, 20.4% of women were overdue for screening
(n = 133). In univariable analyses (see Table 3) women
were more likely to be overdue screening if they were
younger (23% of 25–34 year olds and 25% of 35–44 year
olds compared to 13% of 45–64 year olds, p = .007 and
.003 res pectively) and single (27% compared with 15%
of married/cohabiting women, p = .001). Women who
considered themselves to be African were more likely to
be overdue (26% compared with 18% of those who consid-
ered themselves to be Caribbean, p = .024). Women who
had migrat ed to the UK more than 10 years ago were
less likely to be overdue for screening than women born
in th e UK (12% compa red with 23%, p = .003). Women
who attended religious services at lea st once a week
were more likely to be overdue tha n those who rarely or
never attended (27% compared w ith 17%, p = .020). Edu-
cation level and religion were not significantly associ-
ated with screening status. Women w ho cited at least
one symptom were less likely to be overdue for screen-
ing (OR = 0.58, CI: 0.40-0.85). In a mu ltivariable model
all variables remained significant except for ethnicity
and symptom knowledge (see Table 3).
Reasons for non-attendance in those overdue for
screening
Of the 133 women who were overdue for screening, half
selected at least one reason for not attending from the
list provided (n = 67, see Table 4). Younger women (χ
2
(2) = 6.54, p = .038), single women (χ
2
(2) = 8.05, p = .018)
and those with the highest le vel of education (χ
2
(2) =
12.06, p = .002) were more likely to provide reasons for
non-attendance, but the re were no differences by ethni-
city, birthplace, or religiosity. Of those who selected a
reason for never being screened or delaying screening, ‘I
meant to go but didn’t get round to it’ (28%), fear of the
test procedure (18%) and low risk perception (18%) were
the most common responses. Table 4 shows the reasons
women endorsed by ethnicity, birthplace and religiosity,
but numbers were too small to analy se this statistically.
Discussion
We explored socio-demographic predictors of cervical
cancer knowledge and cervical screening behaviour among
Black women living in London.
For cervical cancer knowledge, education level was the
most important predictor of citing a risk factor, while
age was the most important predictor of citing a symp-
tom, consistent with other studies in the cervical cancer
context [18,19]. To the most part, none of the ethnicity-
related variables were associated with knowledge, with
Table 2 Cervical cancer risk factor and symptoms
knowledge (n = 876)
N%*
Risk factors for cervical cancer
Having many sexual partners 132 15.1
Smoking 102 11.6
Not going for regular smear tests 89 10.2
Unprotected sex 57 6.5
Infection, STI/STD or virus 48 5.5
Starting to have sex at a young age 44 5.0
Infection with Human papillomavirus 38 4.3
Long term use of the contraceptive pill 17 1.9
Having many children 5 0.6
Having a weakened immune system 3 0.3
Symptoms of cervical cancer
Vaginal bleeding between periods 282 32.2
Abnormal discharge 219 25.0
Persistent pelvic/abdominal pain 145 16.6
Pain/discomfort during sex 78 8.9
Vaginal bleeding during/after sex 56 6.4
Persistant lower back pain 13 1.5
Blood in stool/urine 13 1.5
Unexplained weight loss 12 1.4
Heavier/longer periods than normal 6 0.7
Vaginal bleeding after the menopause 4 0.5
*Percentage of entire sample; Women were able to select more than one
risk factor/symptom.
Note: Risk factors/Symptoms identified in the NHS Department of Health’s ‘Key
Messages’ on cervical cancer [18].
Ekechi et al. BMC Public Health 2014, 14:1096 Page 5 of 9
http://www.biomedcentral.com/1471-2458/14/1096
the e xception being migration status. In general, t he
most commonly reported risk factors (ma ny s exual
partners and smoking) an d symptoms (unusual vagin al
bleeding and persistent unusual discharge) in our study
and the population-representative study were the same
[18]. Interestingly , persistent pain was more commonly
cited a s a symptom in our study (17% compared with
1%) and this could be a cause for concern if it means
symptoms in the absence of pain are not taken ser-
iously by women from Black backgrounds. Previous
work in the context of breast cancer suggests some
African American women feel confused over whether
pain is a symptom of cancer [20] and this warrants further
investigation.
Table 3 Associations between socio-demographic variables and being overdue for screening
Univariable analyses Multivariable analyses
1
Overdue n (%) OR [95% CI] OR [95% CI]
Age Group
25-34 54 (23.3) 1.98 [1.21-3.25]** 1.35 [0.75-2.42]
35-44 50 (24.9) 2.16 [1.32-3.58]** 1.92 [1.09-3.37]*
45-64 29 (13.3) 1.00
Marital Status
Single 79 (26.9) 2.03 [1.33-3.10]** 2.11 [1.32-3.37]**
Married/Cohabiting 40 (15.3) 1.00
Divorced/separated/widowed 81 (13.8) 0.89 [0.45-1.74] 0.98 [0.45-2.14]
Education
Low level 15 (15.0) 0.67
Medium level 37 (22.8) 1.13 [0.37-1.24]
High level 72 (20.7) 1.00 [0.72-1.77]
Ethnicity
Caribbean 74 (17.9) 1.00
African 48 (25.9) 1.61 [1.06-2.44]* 1.59 [0.97-2.60]
Other 9 (19.6) 1.12 [0.52-2.42] 1.29 [0.57-2.92]
Birthplace
Born in the UK 95 (23.2) 1.00
Migrated <10 years ago 11 (32.4) 1.59 [0.75-3.37] 1.01 [0.44-2.29]
Migrated >10 years ago 21 (12.1) 0.46 [0.28-0.76]** 0.42 [0.24-0.75]**
Religion
Christian 109 (21.9) 1.00
Muslim 6 (26.1) 1.26 [0.48-3.26]
No religion 11 (13.1) 0.54 [.275-1.05]
Religious service attendance
Rarely or never 60 (16.6) 1.00
Few times a year 36 (20.0) 1.26 [0.74-2.15] 1.27 [0.72-2.26]
1-3 times a month 11 (14.9) 0.88 [0.42-1.86] 1.04 [0.48-2.28]
At least once a week 51 (26.6) 1.82 [1.10-3.02]* 2.05 [1.16-3.54]*
Risk factor knowledge score
0 78 (22.5) 1.00
1+ 55 (18.0) 0.76 [0.51-1.11]
Symptom knowledge score
0 68 (25.8) 1.00
1+ 65 (16.8) 0.58 [0.40-0.85]** 0.72 [0.47-1.09]
1
Includes: age group, marital status, ethnicity, birthplace, religious service attendance, Symptom knowledge score.
*p < .05; **p < .01.
Ekechi et al. BMC Public Health 2014, 14:1096 Page 6 of 9
http://www.biomedcentral.com/1471-2458/14/1096
We also explored non-attendance at cervical screen-
ing. Younger age and being single were associated with
being overdue for screening, consistent with other stud-
ies [17,21,22]. Many of the ethnicity-related variab les
were also a ssociated with being overdue for screening.
The percentage of those who were overdue for cervical
screening was higher in those who had recently migrated
to the UK (32%), but much lower in those who had been
in the UK for more than 10 years (12%). This is consist-
ent with studies in the US that have shown immigrants
are less likely to have been screened but this inequality
decreases with acculturation (length of time in the new
country) [23,24]. There were also differences between
subgroups of the Black population, with women from
African backgrounds more likely to be overdue for
screening than Caribbean women. This is interestin g
when considered in the context of other cervical cancer
risk factors (smoking and having multiple sexual part-
ners) which suggest that African women may be at lower
risk of cervical cancer than Caribbean women [13,14].
Agyemang et al. [25] argued that health researchers
should consider diversity within Black populations be-
cause differences in beliefs and behaviours exist, yet
there remains a paucity of research exploring differences
in cancer beliefs between African and Caribbean women
in the UK.
Non-attenders reported not getting round to screen-
ing, difficulty making an appointment, fear of the test
procedure and fear of a bad result a s barriers to screen-
ing. African women who were overdue screening were
more likely to endorse fear of the test and embarrass-
ment and to believe they were not at risk of cervical can-
cer. Small numbers mean we could not run statistical
analyses on this data so this needs further exploration.
Similar to other studies with Black women we found an
association between sympto m knowledge and screening
behaviour [26] which could suggest interventions designed
to increase awareness might consequently have a positive
influence on behaviour. Alternatively, cervical screening
could be acting as an opportunity for women to learn
about cervical cancer risk factors and symptoms.
Strengths and limitations
To our knowledge this is the first study to explore cervical
cancer knowledge and screening behaviour with a focus
on Black women living in London. We took a novel ap-
proach to recruitment, targeting a specific ethnic group
by approaching women in the community. We felt that
targeting women through hairdressers, a non-health care
setting would help us recruit those who do not always en-
gage with health care. Using this method, we successfully
recruited a large number of women with a good range on
the ethnicity-related variables. We used questions from
validated measures used in previous population-based sur-
veys, although we did not pilot our sur vey before imple-
menting the study.
This study has some limitations. The response rate was
low (26.5%), so we cannot assume our findings are gener-
alisable to the entire population of women from Black eth-
nic backgrounds living in London. In comparison to 2011
Table 4 Reasons for non-attendance among women overdue for screening (number endorsed, per cent in brackets)
Ethnicity Birthplace Religiosity*
Overall
(n = 67)
Caribbean
(n = 35)
African
(n = 29)
UK born
(n = 20)
Not UK born
(n = 47)
None/low
(n = 18)
Medium
(n = 21)
High
(n = 27)
Practical barriers
I meant to go but didn’t get around to it 19 (28.4) 11 (31.4) 8 (27.6) 11 (23.4) 8 (40.0) 6 (33.3) 5 (23.8) 7 (25.9)
It is difficult to get an appointment at a time that suits me 11 (16.4) 9 (25.7) 1 (3.4) 11 (23.4) 0 (0) 3 (16.7) 4 (19.0) 4 (14.8)
Too busy/inconvenient 9 (13.4) 5 (14.3) 4 (13.8) 5 (10.6) 4 (20.0) 4 (22.2) 1 (4.8) 4 (14.8)
Emotional Barriers
Fear of the test procedure 12 (17.9) 3 (8.6) 9 (31.0) 9 (19.1) 3 (15.0) 1 (5.6) 5 (23.8) 6 (22.2)
Fear of a ‘bad’ result 10 (14.9) 5 (14.3) 5 (17.2) 6 (12.8) 4 (20.0) 3 (16.7) 4 (19.0) 3 (11.1)
Bad experience of cervical screening in the past 6 (9.0) 3 (8.6) 3 (10.3) 6 (12.8) 0 (0) 4 (22.2) 1 (4.8) 1 (3.7)
Embarrassment 6 (9.0) 2 (5.7) 4 (13.8) 5 (10.6) 1 (5.0) 1 (5.6) 2 (9.5) 3 (11.1)
Beliefs about screening
I do not believe I am at risk 12 (17.9) 4 (11.4) 7 (24.1) 9 (19.1) 3 (15.0) 5 (27.8) 1 (4.8) 6 (22.2)
I do not believe the test is needed 4 (6.0) 0 (0) 3 (10.3) 2 (4.3) 2 (10.0) 2 (11.1) 1 (4.8) 1 (3.7)
Other
I have never been invited for screening 9 (13.4) 4 (11.4) 5 (17.2) 5 (10.6) 4 (20.0) 1 (5.6) 3 (14.3) 5 (18.5)
I didn’t understand the screening invitation letter 1 (1.5) 1 (2.9) 0 1 (2.1) 0 (0) 1 (5.6) 0 (0) 0 (0)
*None/low: Rarely or never; Medium: 1-3 times a month/A few times a year; High: At least once a month.
Ekechi et al. BMC Public Health 2014, 14:1096 Page 7 of 9
http://www.biomedcentral.com/1471-2458/14/1096
census statistics for the London boroughs we sampled
from, we recruited more Black Caribbean women (58% vs
29%) and fewer African women (25% vs 45%), with fewer
women born outside the UK (31% vs 46% - figure for
women of all ages). One reason for this could be that the
survey was completed in written English, thereby exclud-
ing women who cannot read English, who are more
likely to born outside of the UK and be from African
backgrounds. Around half of our sample had degree-
level qualifications and this is also higher than
population-level figures: 40% for men and women from
Black African and 26% from Black Caribbean back-
grounds. Five -yearly screening uptake in our stu dy wa s
91%, which is higher than the national figure (80%) and
we ac knowledge that this suggests non-attenders were
under-represented. Howe ver, more women were over-
due for screening in this study than in a recent
population-representative sur vey which used ‘gold-
standard’ re cruitment methods [17]. It is also possible
that by relying on self-reported screening attendance
our findings are subject to social desirability bia s , des-
pite our attempts to minimise this by ensuring anonym-
ity. These limitations have important implications and
suggest that the overall percentages we report should be
interpreted with caution.
Our decision to focus recruitment in London means we
cannot necessarily extrapolate our findings to Black com-
munities in other parts of the UK, both rural and urban.
Recruiting through hair salons means women who do not
attend salons frequently or at all, perhaps the more so-
cially isolated or those from lower socio-economic back-
grounds, are less likely to be included. We also relied on
salon staff to distribute and collect the questionnaire (the
denominator for the response rate is the number of ques-
tionnaires distributed to salons rather than the number of
women approached). Difficulties with identifying and en-
gaging salons meant we had to adapt our methodology
and ultimately did not reach our initial recruitment target.
We feel our experience may have important implications
for other researchers considering a similar community-
based approach to survey recruitment and have provided
more detail about our experience (see Additional file 3).
Conclusions
This study suggests that ethnicity, migration and religios-
ity play a role in predicting cervical screening attendance
among Black women in London. Although previous work
had suggested ethnic inequalities in cervical screening up-
take between white and non-white women, [8] this is the
first study to suggest that among Black women those from
African backgrounds, and those who attend religious ser-
vice on a frequent basis could be the most likely to delay
attending cervical screening. More research is needed to
explore the attitudes, experiences and beliefs that might
explain why these groups differ.
Details of ethical approval
The study was approved by the UCL research ethics com-
mittee (ref :0496/011).
Endnote
a
Boroughs are subdivisions of greater London, each gov-
erned by a different council. London has 32 boroughs, each
with a population of approximately 150,000-363,000 [27].
Additional files
Additional file 1: Sampling frame.
Additional file 2: Questionnaire: Attitudes to cervical screening
among women attending specialist black hairdressers in London.
Additional file 3: Difficulties with recruitment.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AO, LM and CE conceived of and designed the study. JK, RE and AA
collected the data. LM analysed the data. CE and LM interpreted the data
and drafted the manuscript. All authors contributed to critically revising the
manuscript and approving the final version.
Acknowledgements
We would like to thank all the salons that participated for their help with the
recruitment and Jo ’s Cervical Cancer Trust for contributing the trolley token
key-rings which were used as an incentive. Remaining study costs were
covered by the UCL charity account. LM is funded by Cancer Research UK.
CE and AO are employed by the NHS. At the time of the study RE, JK and
AA were medical students studying at UCLH. Funders played no role in the
study.
Funding
The study was funded by the UCL charity account.
Author details
1
Department of Obstetrics & Gynaecology, Imperial College Healthcare Trust,
London W12 0HS, England.
2
University College London Hospital, 2nd floor
North, 250 Euston Road, London NW1 2PG, England.
3
University College
London Medical School, 21 University Street, London WC1E 6DE, England.
4
Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, England.
5
Cancer Research UK Health Behaviour Research Centre, Department of
Epidemiology & Public Health, University College London, Gower Street,
London WC1E 6BT, England.
Received: 19 June 2014 Accepted: 15 October 2014
Published: 22 October 2014
References
1. IARC: GLOBOCAN 2012: estimated cancer incidence, mortality abndf
prevalence worldwide in 2012. 2012. http://globocan.iarc.fr/Pages/
fact_sheets_cancer.aspx.
2. CDC: Cervical cancer rates by race and ethncity. http://www.cdc.gov/
cancer/cervical/statistics/race.htm.
3. Shack L, Jordan C, Thomson CS, Mak V, Moller H: Variation in incidence of
breast, lung and cervical cancer and malignant melanoma of skin by
socioeconomic group in England. BMC Cancer 2008, 8:271.
4. NCIN: Cancer incidence and survival by major ethnic group, England,
2002–2006. http://publications.cancerresearchuk.org/downloads/product/
CS_REPORT_INCSURV_ETHNIC.pdf.
Ekechi et al. BMC Public Health 2014, 14:1096 Page 8 of 9
http://www.biomedcentral.com/1471-2458/14/1096
5. Ward E, Jemal A, Cokkinides V, Singh GK, Cardinez C, Ghafoor A, Thum M:
Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer
J Clin 2004, 54:78–93.
6. Currin LG, Jack RH, Linklater KM, Mak V, Moller H, Davies EA: Inequalities in
the incidence of cervical cancer in South East England 2001–2005: an
investigation of population risk factors. BMC Public Health 2009, 9:62.
7. Screening and Immunisations team H&SCIC: NHS Cervical Screening
Programme Statistical Bulletin (England 2012–13). http://www.
cancerscreening.nhs.uk/cervical/statistics-bulletin.html.
8. Moser K, Patnick J, Beral V: Inequalities in reported use of breast and
cervical screening in Great Britain: analysis of cross sectional survey
data. BMJ 2009, 338:b2025.
9. Bhopal R: Glossary of terms relating to ethnicity and race: for reflection
and debate. J Epidemiol Community Health 2004, 58:441–445.
10. Thomas VN, Saleem T, Abraham R: Barriers to effective uptake of cancer
screening among Black and minority ethnic groups. Int J Palliat Nurs
2005, 11:564–571.
11. Sokal R: A critical review of the literature on the uptake of cervical and
breast screening in British South Asian women. Qual Prim Care 2010,
18:251–261.
12. Office for National Statistics: 2011 Census: KS201EW Ethnic group, local
authorities in England and Wales. http://www.ons.gov.uk/ons/rel/census/
2011-census/key-statistics-for-local-authorities-in-england-and-wales/rft-
table-ks201ew.xls.
13. Sproston K, Mindell J: Health Survey for England 2004. The Health of Minority
Ethnic Groups. London: The Information Centre; 2006.
14. Fenton KA, Mercer CH, McManus S, Erens B, Wellings K, Macdowall W, Byron CL,
Copas AJ, Nanchahal K, Field J, Johnson AM: Ethnic variations in sexual
behaviour in Great Britain and risk of sexually transmitted infections: a
probability survey. Lancet 2005, 365:1246–1255.
15. Guthrie LC, Butler SC, Ward MM: Time perspective and socioeconomic
status: a link to socioeconomic disparities in health? Soc Sci Med 2009,
68:2145–2151.
16. Simon AE, Wardle J, Grimmett C, Power E, Corker E, Menon U, Matheson L,
Waller J: Ovarian and cervical cancer awareness: development of two
validated measurement tools. J Fam Plann Reprod Health Care 2012,
38:167–174.
17. Waller J, Bartoszek M, Marlow L, Wardle J: Barriers to cervical cancer
screening attendance in England: a population-based survey.
J Med
Screen 2009, 16:199– 204.
18. Low EL, Simon AE, Lyons J, Romney-Alexander D, Waller J: What do British
women know about cervical cancer symptoms and risk factors? Eur J
Cancer 2012, 48:3001–3008.
19. Waller J, McCaffery K, Wardle J: Beliefs about the risk factors for cervical
cancer in a British population sample. Prev Med 2004, 38:745–753.
20. Jones CE, Maben J, Jack RH, Davies EA, Forbes LJ, Lucas G, Ream G: A
systematic review of barriers to early presentation and diagnosis with
breast cancer among black women. BMJ Open 2014, 4:e004076.
21. Marlow LA, Waller J, Wardle J: Sociodemographic predictors of HPV
testing and vaccination acceptability: results from a population-
representative sample of British women. J Med Screen 2008, 15:91–96.
22. Lancucki L, Fender M, Koukari A, Lynge E, Mai V, Onysko J, Ronco G,
Tornberg S, Vessey M, Patnick J: A fall-off in cervical screening coverage of
younger women in developed countries. J Med Screen 2010, 17:91–96.
23. Swan J, Breen N, Coates RJ, Rimer BK, Lee NC: Progress in cancer screening
practices in the United States: results from the 2000 National Health
Interview Survey. Cancer 2003, 97:1528–1540.
24. Brown WM, Consedine NS, Magai C: Time spent in the United States and
breast cancer screening behaviors among ethnically diverse immigrant
women: evidence for acculturation? J Immigr Minor Health 2006,
8:347–358.
25. Agyemang C, Bhopal R, Bruijnzeels M: Negro, Black, Black African, African
Caribbean, African American or what? Labelling African origin populations
in the health arena in the 21st century. J Epidemiol Community Health 2005,
59:1014–1018.
26. Bynum SA, Guillaume DA, Brandt HM, Fletcher FE: Does knowledge
influence pap test screening among young African-American women?
J Cancer Educ 2014, 29:478–481.
27. GLA Intelligence: 2011 Census first results: London boroughs’ populations
by age by sex. 2012, Update CIS2012-01. https://londondatastore-upload.s3.
amazonaws.com/9i0%3D2011-census-first-results.pdf.
doi:10.1186/1471-2458-14-1096
Cite this article as: Ekechi et al.: Knowledge of cervical cancer and
attendance at cervical cancer screening: a survey of Black women in
London. BMC Public Health 2014 14:1096.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit
Ekechi et al. BMC Public Health 2014, 14:1096 Page 9 of 9
http://www.biomedcentral.com/1471-2458/14/1096
