Cervical cancer incidence and mortality rates have halved in Australia since the introduction in 1991 of the National Cervical Screening Program (NCSP).
Although Australia could be one of the first countries in the world to eliminate cervical cancer, incidence rates among Aboriginal and Torres Strait Islander women remain more than twice those of non-Indigenous women and mortality is three times higher.
This article is based on a newly-published article in the Australian and New Zealand Journal of Public Health; Health care provider perspectives on cervical screening for Aboriginal and Torres Strait Islander women: a qualitative study.
Cervical screening in Australia is delivered predominantly through primary health care, including general practice, community and women’s health centres, family planning or sexual health clinics and Indigenous health services provided by Aboriginal Community Controlled Health Services, or government-run services specifically for Aboriginal and Torres Strait Islander communities.
In 2018-19, 54% of Aboriginal and Torres Strait Islander clients seen by Indigenous health services were female.
To date there has been little research exploring perspectives of health care providers on the delivery of cervical screening, especially of those who work with Aboriginal and Torres Strait Islander women.
The study is based on research conducted from April 2018 to January 2019, as part of the Screening Matters project, conducted in five primary health care centres (PHCC) across Queensland, New South Wales and the Northern Territory. Screening Matters sought to understand the perspectives of Aboriginal and Torres Strait Islander women and health care professionals on cervical screening.
Interviews were conducted over the phone or in-person by an Aboriginal and Torres Strait Islander woman and topics included clientele, information systems, workforce, education, and client access.
The barriers and enablers
Many factors act as barriers or facilitators for health practitioners in delivering cervical screening for Aboriginal and Torres Strait Islander women. These include health service and system factors (e.g., culturally appropriate program and service delivery, availability of workforce and resources, appointment wait times), health practitioner factors (e.g., attitudes, communication among providers and with clients, cultural differences), and community consultation and engagement.
There are also many factors that shape women’s decisions to participate (or not) in cervical screening, including feelings of shame, fear and distrust, privacy concerns and competing life priorities.
Enablers of screening include culturally safe resources and services, flexible service provision, the availability of female and/or Indigenous health practitioners, and positive relationships with health services and staff.
Health care professionals (HCPs) were conscious of the fear, shame, embarrassment and discomfort that women may feel regarding cervical screening.
I have had people say to me ‘no, I’m never doing a pap smear again. A nurse held me down and made me have one when I was 18 and it was such a dreadful experience.
HCPs appreciate that many women need time to mentally and physically prepare for cervical screening and acknowledged that this may stem from some women’s experiences of trauma.
I do understand that domestic violence and sexual abuse, and all those factors, do influence their general sense of self-care. And women do see the pap as being invasive. And I totally agree.
HCPs widely acknowledged that cervical screening is ‘women’s business’ and were sensitive to women’s cultural needs for privacy and confidentiality.
None of the male GPs do pap smears here – it’s not culturally appropriate.
Cause (it’s an) Indigenous community, everybody knows everybody and they think, ah, you’re (going to) talk about them and there’s that stigma…it’s really personal, you can tell with their body language.
Most HCPs spoke about limited staff time and availability for women’s health issues as major service barriers, making prioritising cervical screening particularly challenging.
For me, when I put it (cervical screening) into the mix with all the other responsibilities, it’s not that it’s not essential, it’s just that so many other things are essential as well.
Information and education about cervical screening were provided to women in a range of ways, including structured health promotion activities, resources and materials, and via social media. HCPs viewed women’s groups as an important way to reach women and disseminate messages widely.
If you want to get a message to different groups, one of the best ways for us to do it is to actually do the education to the women who are running the women’s groups.
HCPs emphasised the critical role of trusting and respectful provider-client relationships in supporting women to participate in screening, which provided a foundation for open communication channels about screening, and supporting women’s control over decisions to screen when they were ready to do so.
You give them the information; they say yes or no, they’re completely competent to make that decision; you respect it, you ask for permission to check in regularly, and I ask them even how often it’s okay for me to check in…
Generally, HCPs who spoke about self-collection considered it a valuable option, which could provide women with greater choice and control, particularly those who may otherwise decline screening.
The findings of this research indicate that a multi-faceted approach is required, in which HCPs are sensitive and responsive to Aboriginal and Torres Strait Islander women’s needs and cultivate a culturally safe and accessible place for cervical screening to occur. This includes the availability of self-collection alongside primary health care centre systems, and a workforce that supports the needs of HCPs and women.
This approach will work towards addressing long-standing and unacceptable barriers to cervical screening for Aboriginal and Torres Strait Islander women.
The article published in the Australian and New Zealand Journal of Public Health is co-authored by Rachael Jaenke, Tamara Butler, John Condon, Gail Garvey, Julia Brotherton, Joan Cunningham, Kate Anderson, Allison Tong, Suzanne Moore and Lisa Whop.