ArticlePDF Available

Knowledge of cervical cancer and attendance at cervical cancer screening: a survey of Black women in London

Authors:

Abstract and Figures

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. 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. 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. Women 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. 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.
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 1878, 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 didnt 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 Englands 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 Healths
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 dont need to
have test s; I have never heard of cervical screening; I am
too young to be invited (1824 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 2549 years and had
not been screened in the last 3 years or if they were 4964
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 06). 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 1624
year olds each older age group was progressively more
likely to cite a correct symptom: 2534 years (OR =
2.54, CI: 1.55-4.18), 3544 years (OR = 2.76, CI: 1.66-
4.57), 4564 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 2564 years, who
had not had a hysterectomy, n = 652), 75% had been
screened in the last 3 years and 16% in the last 35years.
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 2534 year olds and 25% of 3544 year
olds compared to 13% of 4564 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 didnt 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 Healths 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 didnt 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 didnt 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,
20022006. 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, 54:7893.
6. Currin LG, Jack RH, Linklater KM, Mak V, Moller H, Davies EA: Inequalities in
the incidence of cervical cancer in South East England 20012005: 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 201213). 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, 58:441445.
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, 11:564571.
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,
18:251261.
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, 365:12461255.
15. Guthrie LC, Butler SC, Ward MM: Time perspective and socioeconomic
status: a link to socioeconomic disparities in health? Soc Sci Med 2009,
68:21452151.
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,
38:167174.
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, 16:199204.
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, 48:30013008.
19. Waller J, McCaffery K, Wardle J: Beliefs about the risk factors for cervical
cancer in a British population sample. Prev Med 2004, 38:745753.
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, 15:9196.
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, 17:9196.
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, 97:15281540.
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,
8:347358.
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,
59:10141018.
26. Bynum SA, Guillaume DA, Brandt HM, Fletcher FE: Does knowledge
influence pap test screening among young African-American women?
J Cancer Educ 2014, 29:478481.
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
... The Cervical Cancer Awareness Measure covers questions regarding awareness of the symptoms and risk factors of CC, the public knowledge on National Cervical Screening and HPV vaccination programme, and demographic information. Questions on uptake of CS and any possible barriers were taken from another two studies and added to the research tool [13,14] after relevant permissions were sought and obtained. Psychometric evaluation of the tool was then conducted. ...
... Pain and weight loss are general symptoms of most cancers; participants might have acquired information on these symptoms from other cancer information campaigns. Health promotional messages in England were focused on increasing the knowledge of the three earliest CC symptoms: post-menopausal vaginal bleeding, post-coital bleeding and persistent foul smelling vaginal discharge [2,14]. There is a need to increase the knowledge of these three symptoms in Malta, to help in their early recognition by the public and thus early referral to a health professional. ...
... There is a need to increase the knowledge of these three symptoms in Malta, to help in their early recognition by the public and thus early referral to a health professional. Knowledge of CC symptoms increased with increasing level of education which was a common finding in the literature [2,14] and may be attributed to people with higher level of education having a higher health literacy [17]. The most recalled unprompted CC risk factor (43.24%) was sexual promiscuity which was again confirmed in the prompted questions. ...
Article
Objectives: This study comes at an opportune time due to recent introduction of the National Cervical Cancer Screening programme in Malta. It aims to assess the knowledge of 25-64 year-old females on cervical cancer and attitudes towards screening. Study design: A cross-sectional, telephone-based, quantitative survey conducted in 2017. Methods: The survey tool was based on the Cervical Cancer Awareness Measure questionnaire and was carried out among a random stratified sample of females of 25-64 years, resident in Malta. Multivariate logistic regression models were applied. Results: 407 females (85% response rate) were interviewed. Knowledge of cervical cancer risk factors and symptoms was found to be significantly higher in women with a higher level of education (p < 0.001). Cervical screening was attended every 3 years by 69% of respondents. Regular attendees were more likely to have children (p = 0.001), have experienced cancer in a close family member (p = 0.002), and were between 35-44 and 45-54 years old (p < 0.001). The main reasons for non-attendance were embarrassment, fear of the test and fear of the result. Conclusion: This research provides a better understanding of who are the vulnerable groups with respect to cervical cancer knowledge and screening attendance. Improving health literacy and implementing health promotion campaigns will improve early symptom recognition, risk factor knowledge and attendance for screening.
... Women who have less educational attainment (high school or less), are uninsured, or do not have a primary care provider have the lowest screening rates [11]. Studies have shown that limited knowledge, fear of screening result, short duration of residence in the U.S., embarrassment, cultural, and religious factors (e.g., fatalism, religiosity etc.) [12,13] are barriers to cervical cancer screening uptake. Barriers associated with the healthcare system and access to care have also been identified including discomfort with the screening procedure [2], cost, inadequate (or lack of) health insurance [8,14], lack of access to screening services, negative past health care experiences, poor patient-provider relationships, and mistrust of the health care system [15]. ...
... In addition, the period of adjustments, adaptations, and acculturation may affect access and use of preventive health care services including cervical cancer screening [24]. Lack of primary care providers, lack of access to screening, and being underinsured or uninsured are common barriers to screening among SAI women [12,13,30]. ...
Article
Full-text available
Although regular cervical cancer screening can prevent cervical cancer, screening utilization remains low among immigrant population including sub-Saharan African immigrants (SAIs). Acculturation is a complex process, which can lead to adoption of positive or negative health behaviors from the dominant culture. Acculturation strategies are the varying ways in which individuals seek to go about their acculturation by either maintaining or rejecting their own cultural values ip or accepting or rejecting the host culture’s cultural values. Cervical cancer screening behaviors among SAI women may be influenced by their acculturation strategies. We conducted a secondary analysis of data to examine the relationship between acculturation strategies and Pap screening among 99 SAI women recruited from community settings. Data were collected on Pap screening behavior and acculturation strategy. Traditionalists and Integrationists were the dominant acculturation strategies; 32.3% women were Traditionalists and 67.7% Integrationists. From the logistic regression models, Integrationists had seven times the odds of having ever been screened compared to Traditionalists (OR = 7.08, 95% CI = 1.54–28.91). Cervical cancer screening interventions should prioritize Traditionalists for cancer screening. Acculturation strategies may be used to tailor cancer prevention and control for SAIs. More research among a larger SAI women sample is warranted to further our understanding of Pap screening patterns and acculturation strategies.
... Similarly, we found that memory was a significant predictor of regular attendance. This is consistent with other research, where forgetting to make an appointment was a main reason for non-attendance in a survey study of Dutch women [22], and not getting round to making an appointment was a commonly reported barrier in a study of Black women in London [23]. ...
Article
Full-text available
Background Cervical screening saves approximately 5000 lives annually in England. However, screening rates have been falling continuously, and coverage in London is particularly low (64.7%). While demographic predictors of uptake have been well researched, there has been less thorough investigation of the individual barriers and facilitators which predict cervical screening attendance. Understanding modifiable factors influencing attendance can guide the design of effective interventions to increase cervical screening uptake. The aim of this study was to understand the demographic, and individual factors associated with self-reported attendance at cervical screening in London. Methods The study used an online survey of 500 women in London (June-July 2017). The survey included self-reported measures of past attendance, demographic variables (including age, household income, ethnicity), past experience variables, and individual variables (list of potential barriers and facilitators developed based on the Theoretical Domains Framework and existing literature, which included: environmental context and resources, perceived risk, anticipated pain/embarrassment). Participants were categorised into regular attenders and non-regular attenders. Backwards stepwise logistic regression investigated the barriers and facilitators predicting past attendance. Demographic variables with significant differences between regular and non-regular attenders were added to the final regression model. Results Of women who had previously been invited ( n = 461, age range: 25–65), 34.5% ( n = 159) were classified as non-regular attenders, and 65.5% ( n = 302) as regular attenders. The individual barriers and facilitators predicting attendance were: cervical screening priority, memory, environmental context and resources, and intention. The only demographic variables related to regular attendance were relationship status (married/civil partnership having higher rates than single) and higher household income. Relationship status was not significant when adjusting for barriers and facilitators. Those who have ever been sexually active or who have had an STI in the past were significantly more likely to be regular attenders. Conclusions The study shows the importance of individual barriers and facilitators in predicting self-reported cervical screening attendance. Household income was the only significant demographic variable when combined with the individual variables. Interventions targeting priority, memory, and practical barriers affecting environmental context may be expected to be effective an increasing attendance.
... As reported previously, only a minority had encountered a degree of unpleasantness or physical pain during screening [40,42]; however, a woman's screening experience is crucial in determining the likelihood that she will return for the next appointment [43,44], and this was expressed by some of the women in our study. In contrast to earlier findings [49,51,54,69], although all the women in our study were Christians and from different cultural backgrounds, issues related to religious background and ethnicity were not particularly prominent factors to screening participation; instead, most women had positive attitudes towards screening. ...
Article
Full-text available
Globally, cervical cancer constitutes a substantial public health concern. Evidence recommends regular cervical cancer screening (CCS) for early detection of “precancerous lesions.”Understanding the factors influencing screening participation among various groups is imperative for improving screening protocols and coverage. This study aimed to explore barriers and facilitators to CCS participation in women of Nigerian, Ghanaian, Cameroonian, and Kenyan origin in Finland. We utilized a qualitative design and conducted eight focus group discussions (FGDs) in English, with women aged 27–45 years (n = 30). The FGDs were tape-recorded, transcribed verbatim, and analyzed utilizing the inductive content analysis approach. The main barriers to CCS participation included limited language proficiency, lack of screening awareness, misunderstanding of screening’s purpose, and miscomprehension of the CCS results. Facilitators were free-of-charge screening, reproductive health services utilization, and women’s understanding of CCS’s importance for early detection of cervical cancer. In conclusion, among women, the main barriers to CCS participation were language difficulties and lack of screening information. Enhancing screening participation amongst these migrant populations would benefit from appropriate information about the CCS. Those women with limited language skills and not utilizing reproductive health services need more attention from healthcare authorities about screening importance. Culturally tailored screening intervention programs might also be helpful.
Chapter
Cervical cancer consumes many lives around the world. Many of these lives could be saved if more women were screened for cervical cancer. This study explored the potential of digital nudging through short electronic messages as a means of increasing women’s participation in cervical screening programs. A questionnaire-based study was designed to explore Norwegian women’s perceptions towards five different types of nudges, with a total of 280 respondents. The results show that women were generally positive towards text message nudging. The type of nudge had a significant effect on the respondents’ perceptions. Messages that invited to an explicit appointment was perceived most positively, and incentives nudges were perceived least positively. About 87% of the participants expressed that it was desirable to receive such invitations via text messages although younger participants were more positive towards digital text messages than older participants. The results may be useful in designing more effective campaigns for increased participation in cervical cancer screening programmes.
Article
More people in the UK are living with cancer than ever before. With an increasingly ethnically diverse population, greater emphasis must be placed on understanding factors influencing cancer outcomes. This review seeks to explore UK-specific variations in engagement with cancer services in minority ethnic groups and describe successful interventions. The authors wish to highlight that, despite improvement to engagement and education strategies, inequalities still persist and work to improve cancer outcomes across our communities still needs to be prioritised. There are many reasons why cancer healthcare inequities exist for minority communities, reported on a spectrum ranging from cultural beliefs and awareness, through to racism. Strategies that successfully enhanced engagement included language support; culturally-sensitive reminders; community-based health workers and targeted outreach. Focusing on the diverse city of Leicester the authors describe how healthcare providers, researchers and community champions have worked collectively, delivering targeted community-based strategies to improve awareness and access to cancer services.
Article
Objectives: This pilot study aimed to evaluate the acceptability of a codesigned, culturally tailored, faith-based online intervention to increase uptake of breast, colorectal and cervical screening in Scottish Muslim women. The intervention was codesigned with Scottish Muslim women (n=10) and underpinned by the reframe, reprioritise and reform model and the behaviour change wheel. Setting: The study was conducted online, using Zoom, due to the COVID-19 pandemic. Participants: Participants (n=18) taking part in the intervention and subsequently in its evaluation, were Muslim women residing in Scotland, recruited through purposive and snowball sampling from a mosque and community organisations. Participants were aged between 25 years and 54 years and of Asian and Arab ethnicity. Design: The study's codesigned intervention included (1) a peer-led discussion of barriers to screening, (2) a health education session led by a healthcare provider, (3) videos of Muslim women's experiences of cancer or screening, and (4) a religious perspective on cancer screening delivered by a female religious scholar (alimah). The intervention was delivered twice online in March 2021, followed 1 week later by two focus groups, consisting of the same participants, respectively, to discuss participants' experiences of the intervention. Focus group transcripts were analysed thematically. Results: Participants accepted the content and delivery of the intervention and were positive about their experience of the intervention. Participants reported their knowledge of screening had increased and shared positive views towards cancer screening. They valued the multidimensional delivery of the intervention, appreciated the faith-based perspective, and in particular liked the personal stories and input from a healthcare provider. Conclusion: Participatory and community-centred approaches can play an important role in tackling health inequalities in cancer and its screening. Despite limitations, the intervention showed potential and was positively received by participants. Feasibility testing is needed to investigate effectiveness on a larger scale in a full trial.
Article
Objective: Cervical cancer is predominantly a cancer of younger women, and improvements in oncological outcomes have led to an increase in cervical cancer survivors living with the long-term effects of treatment. Understanding the recovery process after treatment is essential to increase awareness of the short- and long-term needs of survivors. The aim of this study was to qualitatively explore the recovery process and return to daily activity of cervical cancers survivors from a biopsychosocial perspective. Methods: Participants were 21 women treated for cervical cancer between the ages of 18 and 60 years, living in the United Kingdom. Interviews were undertaken face to face and via the telephone using a semi-structured interview schedule. Results: Data analysis revealed themes which represented participants' experience and perceptions of treatment as a paradox; emotional needs after treatment; and a journey of adversarial growth. A key finding from this analysis was the nuanced experiences between treatment modalities, with physical changes perceived to be more disruptive following radical treatments, whilst psychological repercussions were significant regardless of treatment type. Conclusion: This study provides novel insight into the varied recovery experiences of those treated with surgery and/or chemoradiotherapy for cervical cancer, which can be used to improve the survivorship experience.
Article
Full-text available
BACKGROUND: Cervical cancer is one of the leading causes of death in women worldwide. Women living with Human Immunodeficiency virus are at higher risk of acquire cervical cancer. Despite the importance of screening, the proportion of willingness for screening among these women is low in Ethiopia. Therefore, this study aimed to determine the magnitude of willingness for cervical cancer screening and its associated factors among women living with HIV. METHODS: A facility-based cross-sectional study was conducted from March 14 to May 8, 2018. 341 women were selected by using systematic sampling method among adult HIV positive women attending treatment at Jinka General Hospital. The data were collected using an interviewer-administered questionnaire. Bivariate and multivariable logistic regression analyses were used to determine the presence and the strength of association between dependent and independent variables by using odds ratio with 95% confidence interval. RESULTS: The status of willingness for cervical cancer screening was 56.9% (95%CI; 51.6%, 62.1%). Women aged 40 years and above (AOR=2.58; 95% CI = 1.21-5.45), having two or less number of children (AOR=2.49; 95% CI =1.3-4.78), having awareness about cervical cancer screening (AOR = 4.85; 95% CI = 2.56-9.17), high perceived susceptibility (AOR=5.02;95%CI=2.74-9.18) and low perceived barrier (AOR=9.87; 95% CI = 5.34-18.31) were found to increase willingness for cervical cancer screening. CONCLUSIONS: The finding of this study has important indications which call for a wide ranged public health approach directed to cervical cancer and its screening among HIV-positive women. The willingness, knowledge and awareness for cervical cancer screening is low. This calls for the need to create awareness and educate HIV-positive women about the availability of screening and usefulness of utilizing the screening service by using different mass media. Being young , having two or fewer number of living children, awareness about cervical cancer screening, perceived susceptibility, and perceived barriers were predictors of willingness for cervical cancer screening.
Article
Full-text available
Aims To identify and synthesise peer-reviewed, published literature reporting perceived barriers and facilitators associated with cervical cancer screening attendance in EU member states with organised population-based screening programmes. Methods Quantitative and qualitative studies reporting perceived barriers/facilitators to attendance for cervical cancer screening were searched for in databases Embase, HMIC, Medline and PsycInfo. Data were extracted and deductively coded to the Theoretical Domains Framework domains and inductive thematic analysis within domains was employed to identify specific barriers or facilitators to attendance for cervical cancer screening. Results 38 studies were included for data extraction. Five theoretical domains [‘Emotion’ (89% of the included studies), ‘Social influences’ (79%), ‘Knowledge’ (76%), ‘Environmental Context and Resources’ (74%) and ‘Beliefs about Consequences’ (68%)] were identified as key domains influencing cervical cancer screening attendance. Conclusion Five theoretical domains were identified as prominent influences on cervical cancer screening attendance in EU member states with organised population-based screening programmes. Further research is needed to identify the relative importance of different influences for different sub-populations and to identify the influences that are most appropriate and feasible to address in future interventions.
Article
Full-text available
To explore barriers to early presentation and diagnosis with breast cancer among black women. Systematic review. We searched multiple bibliographic databases (January 1991-February 2013) for primary research, published in English, conducted in developed countries and investigating barriers to early presentation and diagnosis with symptomatic breast cancer among black women (≥18 years). Studies were excluded if they did not report separate findings by ethnic group or gender, only reported differences in time to presentation/diagnosis, or reported on interventions and barriers to cancer screening. We followed Cochrane and PRISMA guidance to identify relevant research. Findings were integrated through thematic synthesis. Designs of quantitative studies made meta-analysis impossible. We identified 18 studies (6183 participants). Delay was multifactorial, individual and complex. Factors contributing to delay included: poor symptom and risk factor knowledge; fear of detecting breast abnormality; fear of cancer treatments; fear of partner abandonment; embarrassment disclosing symptoms to healthcare professionals; taboo and stigmatism. Presentation appears quicker following disclosure. Influence of fatalism and religiosity on delay is unclear from evidence in these studies. We compared older studies (≥10 years) with newer ones (<10 years) to determine changes over time. In older studies, delaying factors included: inaccessibility of healthcare services; competing priorities and concerns about partner abandonment. Partner abandonment was studied in older studies but not in newer ones. Comparisons of healthy women and cancer populations revealed differences between how people perceive they would behave, and actually behave, on finding breast abnormality. Strategies to improve early presentation and diagnosis with breast cancer among black women need to address symptom recognition and interpretation of risk, as well as fears of the consequences of cancer. The review is limited by the paucity of studies conducted outside the USA and limited detail reported by published studies preventing comparison between ethnic groups.
Article
Full-text available
The aim of the study was to develop and validate measures of awareness of symptoms and risk factors for ovarian and cervical cancer (Ovarian and Cervical Cancer Awareness Measures). Potentially relevant items were extracted from the literature and generated by experts. Four validation studies were carried out to establish reliability and validity. Women aged 21-67 years (n=146) and ovarian and cervical cancer experts (n=32) were included in the studies. Internal reliability was assessed psychometrically. Test-retest reliability was assessed over a 1-week interval. To establish construct validity, Cancer Awareness Measure (CAM) scores of cancer experts were compared with equally well-educated comparison groups. Sensitivity to change was tested by randomly assigning participants to read either a leaflet giving information about ovarian/cervical cancer or a leaflet with control information, and then completing the ovarian/cervical CAM. Internal reliability (Cronbach's α=0.88 for the ovarian CAM and α=0.84 for the cervical CAM) and test-retest reliability (r=0.84 and r=0.77 for the ovarian and cervical CAMs, respectively) were both high. Validity was demonstrated with cancer experts achieving higher scores than controls [ovarian CAM: t(36)= -5.6, p<0.001; cervical CAM: t(38)= -3.7, p=0.001], and volunteers who were randomised to read a cancer leaflet scored higher than those who received a control leaflet [ovarian CAM: t(49)=7.5, p<0.001; cervical CAM: t(48)= -5.5, p<0.001]. This study demonstrates the psychometric properties of the ovarian and cervical CAMs and supports their utility in assessing ovarian and cervical cancer awareness in the general population.
Article
The aim of the study was to develop and validate measures of awareness of symptoms and risk factors for ovarian and cervical cancer (Ovarian and Cervical Cancer Awareness Measures).
Article
Objectives To explore barriers to cervical screening attendance in a population-based sample, and to compare barriers endorsed by women who were up-to-date with screening versus those who were overdue. We also tested the hypothesis that women who were overdue for screening would be more generally disillusioned with public services, as indexed by reported voting behaviour in elections.Setting A population-based survey of women in England.Methods Face-to-face interviews were carried out with 580 women aged 26-64 years, and recruited using stratified random probability sampling as part of an omnibus survey. Questions assessed self-reported cervical screening attendance, barriers to screening, voting behaviour and demographic characteristics.Results Eighty-five per cent of women were up-to-date with screening and 15% were overdue, including 2.6% who had never had a smear test. The most commonly endorsed barriers were embarrassment (29%), intending to go but not getting round to it (21%), fear of pain (14%) and worry about what the test might find (12%). Only four barriers showed significant independent associations with screening status: difficulty making an appointment, not getting round to going, not being sexually active and not trusting the test. We found support for our hypothesis that women who do not attend for screening are less likely to vote in elections, even when controlling for barrier endorsement and demographic factors.Conclusions Practical barriers were more predictive of screening uptake than emotional factors such as embarrassment. This has clear implications for service provision and future interventions to increase uptake. The association between voting behaviour and screening uptake lends support to the hypothesis that falling screening coverage may be indicative of a broader phenomenon of disillusionment, and further research in this area is warranted.
Article
OBJECTIVE: To investigate the relation between women's reported use of breast and cervical screening and sociodemographic characteristics. DESIGN: Cross sectional multipurpose survey. SETTING: Private households, Great Britain. Population 3185 women aged 40-74 interviewed in the National Statistics Omnibus Survey 2005-7. MAIN OUTCOME MEASURES: Ever had a mammogram, ever had a cervical smear, and, for each, timing of most recent screen. RESULTS: 91% (95% confidence interval 90% to 92%) of women aged 40-74 years reported ever having had a cervical smear, and 93% (92% to 94%) of those aged 53-74 years reported ever having had a mammogram; 3% (2% to 4%) of women aged 53-74 years had never had either breast or cervical screening. Women were significantly more likely to have had a mammogram if they lived in households with cars (compared with no car: one car, odds ratio 1.67, 95% confidence interval 1.06 to 2.62; two or more cars, odds ratio 2.65, 1.34 to 5.26), and in owner occupied housing (compared with rented housing: own with mortgage, odds ratio 2.12, 1.12 to 4.00; own outright, odds ratio 2.19, 1.39 to 3.43), but no significant differences by ethnicity, education, occupation, or region were found. For cervical screening, ethnicity was the most important predictor; white British women were significantly more likely to have had a cervical smear than were women of other ethnicity (odds ratio 2.20, 1.41 to 3.42). Uptake of cervical screening was greater among more educated women but was not significantly associated with cars, housing tenure, or region. CONCLUSIONS: Most (84%) eligible women report having had both breast and cervical screening, but 3% report never having had either. Some inequalities exist in the reported use of screening, which differ by screening type; indicators of wealth were important for breast screening and ethnicity for cervical screening. The routine collection within general practice of additional sociodemographic information would aid monitoring of inequalities in screening coverage and inform policies to correct them.
Article
Pap test screening among African-American women has substantially increased. However, African-American women continue to bear the burden of cervical cancer as compared to White women. The objective of this study was to assess the influence of Pap test knowledge on cervical screening history among young African-American women. Between January and April 2009, 320 women from historically black colleges and universities located in the southeastern United States who met study inclusion criteria completed an anonymous self-report questionnaire to assess their awareness, knowledge, and behaviors related to human papillomavirus and cervical cancer prevention and control. Seventy-six percent of women reported ever having a Pap test, 54 % reported having a Pap test less than 1 year ago, and 25 % reported ever having an abnormal Pap test result. The overall mean score on the six-point Pap test knowledge scale was 4.46 ± 1.02. Women who reported having an abnormal Pap test (4.96 ± 0.82) had significantly higher Pap test knowledge compared to those never having an abnormal result (4.49 ± 1.04), p < 0.01. No other differences were found. Efforts to improve Pap test knowledge among all women, including those with no prior abnormal Pap test history, are critical to cervical cancer prevention and control over the life course. Such efforts should include creating information that is relevant to the population and enables informed decision making about cervical health.
Article
To describe some of the factors that act as barriers to effective uptake of breast and cervical cancer screening services among black minority ethnic (BME) groups living in Brent and Harrow in the UK. A series of focus groups among African Caribbean, African, Gujarati, Pakistani, Greek and Arabic groups were held to discover their perceptions of cancer screening, the barriers to effective uptake and some strategies for intervention. This consisted of 135 participants: 85 women and 50 men. Analysis of focus group data has revealed poor knowledge, underlying health and cultural beliefs, attitudes, language and unhelpful attitudes of health professionals to be important barriers. In terms of strategies for effective intervention, the most popular strategy for improving uptake of screening services was community-based cancer awareness education that is sensitive to religious and cultural needs. There is a need to provide community-based education to increase the uptake of screening services among BME groups. It is essential to plan concurrently to educate GPs and other health professionals in cultural beliefs and customs, language needs, racial awareness and communication skills.
Article
To consider the recent evidence which examines factors that are associated with uptake of cervical and breast screening in the British South Asian community and to consider the effectiveness of interventions to improve uptake in this group. A search strategy was developed and key databases were searched to identify primary research studies that examined the uptake of cervical and breast screening in British women of South Asian origin. Studies published prior to 1996 were excluded from the review. Seventy-eight studies were identified and ten were included in the review. Observational studies demonstrated mixed results on the effect of ethnicity on uptake of screening. Controlling for confounders attenuated the effect in all studies and removed its effect entirely in some. Investigation of low uptake in qualitative and quantitative research indicates that South Asian women were more likely to have incorrect addresses and language or cultural barriers to screening than other women. Few interventional studies were identified and all varied in their design. The success of interventions was mixed and the lack of control groups in some studies made it difficult to draw conclusions on their effectiveness. There is a poor uptake of cervical and breast screening by South Asian women compared with the general population in Britain. Evidence is inconclusive as to whether this is due to a residual effect of ethnicity following control for socio-demographic and local health service variables. Currently there is a lack of robust experimental studies on which to base interventions intended to increase uptake in this population.