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Anaman, Judith Akworkor, King, Julie, & Correa-Velez, Ignacio(2017)Barriers and facilitators of cervical cancer screening practices amongAfrican immigrant women living in Brisbane, Australia.European Journal of Oncology Nursing, 31, pp. 22-29.

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https://doi.org/10.1016/j.ejon.2017.09.005

Barriers and Facilitators of Cervical Cancer Screening Practices among African Immigrant Women Living in Brisbane, Australia

Anaman-Torgbor, J. A., King, J. and Correa-Velez, I. School of Public Health and Social Work, Queensland University of Technology (Accepted for Publication in European Journal of Oncology Nursing, 24 September 2017)

Background

Cervical cancer is a common type of cancer that affects women worldwide. While

cervical cancer is gradually becoming a rare disease in many developed countries, this is not the

case in developing countries [1]. Estimates in 2015 indicate that about 444,546 new cases of

cervical cancer and 230,158 related deaths occurred in less developed regions compared to

83,078 new cases and 35,495 deaths in the more developed regions [2]. Of the 20 countries with

the highest incidence of cervical cancer worldwide, 16 are African countries including Malawi,

Mozambique, Zambia, Zimbabwe and Tanzania [3]. In Australia for instance, opportunistic

cervical screening started in the 1960s, and organized or programmed screening was established

in 1991 [4] and it is now coordinated nationally. Invitations to screen are organized and

managed at state level and the screening test used in Australia by the National Cervical

Screening Program (NSCP) is the cytology from the Papanicolaou smear or ‘Pap test’, which

involves the collection of cells from the transformation zone of the cervix. The cells are

transferred on to a glass slide for cytology. The screening program targets sexually active

women for screening at 2-yearly intervals from age 18 to 20 years up to 69 to 70 years [5].

While cervical cancer cases and deaths are low in Australia by international standards [6], in

Zimbabwe, it is the most common cancer among black women [7]. Additionally, available data

show that the disease burden is greater in the less developed regions [2].

Cervical screening coverage is very low or non-existent in most African and Asian

countries [8-10]. The low coverage of cervical screening services in developing countries has

been attributed to individual and structural barriers. Individual barriers include lack of

knowledge about cervical cancer and screening practices, perceptions and attitudes specific to

cultural and religious beliefs [11, 12]. Structural barriers include unavailability of screening

programs, limited human, material and financial resources, poor healthcare infrastructure and

competing health priorities [13, 14]. These are major factors influencing women’s health-

seeking behaviour and the decisions to participate in cervical screening programs.

In 2015, the world witnessed the highest level of forced displacement since World War II

(65.3 million) [15] and the highest ever recorded number of international migrants (244 million)

with almost half being women and many from the African region [16]. With no or limited

access to quality and regular prevention services, most women migrating from Africa are more

likely to be unfamiliar with preventive cervical screening practices. Therefore are more likely to

perceive participation in regular cervical screening as an element foreign to their local culture

and may be at risk of under screening or not being screened at all. Previous studies among

immigrant women in Australia have reported low levels of cervical screening participation [17,

18], leading to increased risk of late diagnosis of the disease.

The African community in Australia is growing. For instance, the number of new

immigrants from Sub-Saharan African who migrated to Australia between 2006 and 2011

increased from 36,514 to 56,962 (28,345 males and 28,623 females) [19]. Women from refugee

backgrounds have survived persecution and serious human rights violations, including sexual

violence, torture, female circumcision and sexual slavery [20]. Many non-refugee migrant

women have also suffered high levels of psychological distress due to separation from family

[21] and challenges faced in their new environment [22].

To date there is very little research that has examined African immigrant women’s

cervical screening needs and challenges. Women from African backgrounds face socio- cultural

barriers [11, 23] and are more likely to have access to limited information on how to

successfully navigate the healthcare system in their new place of residence. This decreases their

access to and understanding of health services and ultimately their wellbeing. The purpose of

this study is to better understand barriers to, and facilitators of cervical screening practices

among African women from refugee and non-refugee backgrounds living in Brisbane. The

findings can contribute to the implementation of culturally sensitive screening programs to

improve cervical screening participation among the women from this population.

Materials and Methods

Study Design

We conducted semi-structured interviews with 19 African immigrant women (10 refugee

and 9 non-refugee) living in Brisbane. The interviews provided rich textual descriptions of

barriers to and facilitators of cervical cancer screening in participants’ communities. The

interviews were conducted between February and April 2014 and were audio-recorded with the

consent of the women. Ethical approval was obtained from the Queensland University of

Technology (QUT) Human Research Ethics Committee (HREC) (Approval No. 1300000580).

Administrative approval was informally obtained from all the African churches visited by the

investigator and written informed consent was obtained from all the participating women. This

study was part of a broader mixed-method study that investigated cervical screening practices

among 254 African immigrant women living in Brisbane.

Participants and Sampling Process

Criterion sampling was employed to sample women from different locations across the

Greater Brisbane metropolitan area including African churches, shopping centres where

African-born women congregate and African community gatherings such as end of year

activities and women’s forums. Women were included in the study if they were African-born,

between the ages of 21 to 65 years, had migrated to Australia in the past 15 years, were an

Australian citizen or permanent resident, were able to speak and understand English, and able to

give written consent to participate in the study. In addition, women were included based on

their personal experiences in using Pap smear services, their role in and knowledge of their own

communities, and their willingness to share this knowledge with the principal investigator.

Nineteen women accepted the invitation to participate in the qualitative component of the study.

Saturation was reached before all interviews had been completed, i.e. no new themes emerged

from the last few interviews [24]. Attempts were made to include women with diverse

backgrounds from different countries in Africa in order to capture the diversity within the

African community.

Data Collection Instrument and Procedures

The principal investigator, using a semi-structured, open-ended questionnaire guide,

conducted all the interviews. The interview guide was developed from the existing literature

[25, 26] and previously conducted quantitative survey. It included items exploring knowledge

about cervical cancer, cervical screening experiences, perspectives, beliefs, and barriers to

screening practices in more depth. For instance the women were asked the following “What do

you believe causes cervical cancer?” “What do you know about cervical screening services in

Australia?” “What are the cervical screening needs, challenges, and barriers facing women from

your ethnic community in Brisbane?” The guide was pre-tested among 10 women to provide

feedback on the wording and clarity of the questions. These 10 women were excluded from the

final analysis.

Out of the 19 interviews, eight were conducted at the women’s homes, seven were at

work places and four took place at church premises (this included a female pastor and three

female leaders in African churches). The interviews took an average of 45-60 minutes. As an

African woman and a cultural insider, the principal investigator successfully gained women’s

trust, building rapport, and confidence throughout the interview process.

Data Analysis

Data from the interviews were captured using a voice recorder, transcribed verbatim and

manually analysed using interpretative thematic analysis [27]. The data were coded using

structural coding, applying conceptual phrases representing a topic of inquiry to segments of the

data that relate to specific research questions used to frame the interviews [28]. Focusing on

individual responses to each question, the researcher examined commonalities, differences and

relationships among concepts [29]. Patterns of themes appearing in the data were identified and

clustered into groups, which formed the basis for the thematic categories [30]. The thematic

categories were organised into coherent broader areas under the research questions. Quotations

in the transcripts that best illustrated themes were also identified and used to present and discuss

the findings. A summary of the themes from the semi-structures interview is presented in Table

1.

Table 1: Themes and Sub-themes from Semi-structured Interviews

THEMES

SUB-THEMES

Theme 1: Lack of understanding about cervical screening

• Lack of Knowledge about Cervical Cancer • Lack of Knowledge about the Screening

Test Theme 2: Barriers to Regular Cervical Screening

• Cultural and religious beliefs • Barriers Relating to the Healthcare

System

THEMES

SUB-THEMES

Theme 3: Facilitators of Regular Cervical Screening

• Recommendation of testing by health

professionals • Effective reminder system

Rigor

The researcher has endeavored to capture participants’ views and interpretations in all their

original, complexities, and depth without distorting the meanings. All the audio recordings were

replayed on the field prior to verbatim transcription. All the research team reviewed the

transcripts to ensure that participants’ views were truthfully represented. The analysis focused

on maximizing the use of direct quotations as part of interpretative rigor.

Results

Participants Characteristics

The participants came from a range of countries in Africa including Liberia, Sierra Leone,

South Sudan, Zimbabwe, Ghana, Nigeria, Botswana, Ethiopia and Kenya. All the women were

Christians and their mean age was 33.9 years (range: 21 to 51 years). Seven women had never

given birth and 12 had borne one or more children (six had one child, three had between two

and four children and three had five children). All women had some form of formal education

with the majority (n=15) having a university degree and four having a certificate or a diploma

qualification. Fifteen women had undergone a Pap smear at least once in Australia.

Lack of understanding about cervical screening

The study found several barriers to cervical screening among the participants. The barriers

relating to individual factors included: lack of knowledge about cervical cancer, and the

screening test, absence of warning signs of cervical cancer, embarrassment, fear, concern about

the gender of the service provider, lack of privacy, lack of information about Pap smear test,

low perception of risk and the idea that a Pap smear was not necessary. Other barriers were

related to cultural and religious beliefs and the healthcare system. In general, the findings did

not show any major differences between refugee and non-refugee women regarding knowledge

about cervical cancer and cervical screening practices.

Lack of Knowledge about Cervical Cancer

Although the women shared some information about cervical cancer most of them have

limited knowledge about the disease. Almost all of them did not have adequate knowledge

about cervical cancer and one woman admitted she did not know what cervical cancer was. The

majority of the women heard about cervical cancer for the first time after they relocated to

Australia. They did not know about the disease prior to coming to Australia:

“Cervical cancer I believe is the cancer that affects the cervix or the vagina area it’s not an STI but am not sure how exactly it is transmitted or how you go getting it” (27 y/o non-refugee from Zimbabwe).

Another woman’s response when she was asked about what causes cervical cancer: “May be infections, I am not sure, we are not doctors to read or know more about what cause it but I hear people say probably is from female circumcision and the infection from the circumcision which stays in the body and leads to cervical cancer. Most often the circumcision is not done in a hygienic way and the infection from that causes cervical cancer and fibroid” (34 y/o refugee from Liberia)

Knowledge about the cause of cervical cancer for instance was uncommon among the

both refugee and non-refugee women, even among those who had healthcare qualifications. The

health professionals shared common beliefs regarding the indeterminacy of the cause of cervical

cancer. None of the participant referred to Human Papillomavirus (HPV) as the causative

organism of cervical cancer. Instead, they believed the cause is unknown or that cervical cancer

has no single cause:

“I really do not know. I wish I knew what causes cervical cancer but obviously some sort of infection happens and that ends up causing cancer. Whether it’s through multiple sexual partners or whether its diet or unhygienic practices or some people say the things you use to wash your vagina or even using tampons but I really do not know” (35 y/o non-refugee from Botswana).

Other women saw the cause of cervical cancer from a cultural and religious perspective.

To these women, the cause of all diseases including cervical cancer was associated with the

supernatural and depending on the capacity in which they find themselves, whether they are

speaking from a traditional Shona woman’s perspective or from a religious point of view. Either

way, they believe diseases are associated with the supernatural:

“I know is that any kind of diseases like my Pastors told me any kind of disease typically, cancer comes from bitterness or fear that manifest itself in the body. That is my Christian point of view. As a Shona woman, probably someone was

curse by someone at one time. Whether that specifically results in cervical cancer I am not sure back home I have never really heard of anyone with cervical cancer but I have heard of someone who was sick and the thought it was because somebody somewhere long time ago did some kind of cultural spell on them or someone kind of cursed them. But I would think people would generally think in the Shona culture if they were sick of cervical cancer it would have something to do with black magic or kind of black magic, (27 y/o non-refugee from Zimbabwe).

The lack of knowledge about the cause of cervical cancer is common and a major barrier

identified among this sub-population.

Lack of Knowledge about the Screening Test

Even though 15 out of the 19 women had undergone Pap smear testing at least once in

Australia, most of them could not make any connection between the Pap smear testing and

cervical cancer. They admitted not having knowledge about the Pap smear test and the

cervical screening program in Australia. For instance one woman indicated that the Pap

smear test was meant to detect cancer of the vagina, syphilis and HIV/AIDS:

“Pap smear generally is a test that you go in to have a check-up they take fluid from the under part to test for diseases that is not seen it could be HIV, syphilis it could be anything. Once they take the fluid they check for all these things it tells them what you have” (29 y/o refugee from Liberia)

It was found that the majority of the women accessed health facilities for other health

conditions and health professionals presented the Pap smear to them without being

accompanied by adequate information about the test. Other barriers identified included

absence of symptoms, fear, lack of privacy, low perception of risk and the perception that

there is no cure for cancer. Some women believed cervical cancer was a death sentence and

because of this perception and fear of being diagnosed with the disease, the women shared

the view that they would rather die without being told that they have cervical cancer.

Barriers to Regular Cervical Screening

Cultural and religious beliefs

Cultural beliefs including gender norms emerged as major barriers to cervical

screening. The fact that the test is done around the vagina area was a major challenge for the

women. They expressed that the vagina area is a “sacred” area and should not be seen or

touched by any other person apart from their sexual partners. In addition, depending on the

level of acculturation, most of the women were not comfortable with the position in which

the test is done:

“It is just the way how people are brought up and it also depends on how people understand and interpreted things in my ethnic community when a woman is giving birth they kneel down and not the other way like in the hospital so they are not comfortable with the position in which the test is done” (48 y/o refugee from Sudan)

The study also found that it is possible some women have experienced female

circumcision, which is a common cultural practice in some African communities and these

circumcised women may find it challenging exposing their genitals to others for the fear

stigmatization. This might prevent these women from undergoing Pap smear testing possibly

thinking people will question them if they saw their scarred genitals:

“Female circumcision is very common practice in the Liberia not just the Krahn ethnic group, I am not sure now but in the past because I used to hear about it a lot when I was a child but I am not sure if t they are still doing it. I think it can make the women not to do the test if they have been circumcised because they don’t want anybody to see it”(29 y/o refugee from Liberia).

Most women expressed dissatisfaction about the screening participation because male

healthcare service providers saw them. The women saw the Pap smear testing to be very

intimate and such a level of intimacy could only be shared with their sexual partners.

According to the women, it is uncomfortable and embarrassing for them to be examined

naked by another man.

“The only time that I find it embarrassing and hard for me was when it was done at the hospital by a male doctor. Initially I did not know that it was a male who was going to do it so it was so hard and I was on the spot and there was no way I could say I do not need it to be done again” (47 y/o refugee from Sudan).

All the participants were Christians, however, they shared some knowledge about the

experiences of Muslim women. They identified that Islam was strict in terms of faith-based

practices such as not permitting females to be examined by male health professionals. As

reported by some women, the challenge Muslim women faced, was the difficulty in finding a

female service provider who they believe would understand their background and share

similar beliefs. They thought that this could deter Muslim women from screening. The

women believed the preference for a female health professional during vaginal examination

was usually due to cultural beliefs and individual choice among Christians. However, the

women thought their Christian religion might not let young women talk openly about a Pap

smear because church members might see them as not being virgins or as being sexually

promiscuous:

“I think the Christian religion might not let them talk about it because if you say you went for Pap smear then that means you are not a virgin so religion might make them not to be so open to say I did it but then they will do it despite” (27 y/o non-refugee from Zimbabwe).

Barriers Relating to the Healthcare System

The women were asked about the education/information they received at the health

facility regarding the Pap smear test and cervical cancer. This was to ascertain whether these

women received any information prior to testing, whether the education/information provided

was above the women’s understanding, or whether the means of communicating the

information was not appropriate. The women were presented with the test at health facilities

when they went seeking gynecological or obstetric care and it was inferred that most of the

women underwent the Pap smear without adequately understanding or internalizing the

reasons and benefits of testing. They complied with the testing procedure, perceiving it as a

formality at post-natal clinics. Although some women were provided with brochures in the

English language, most women stated that the information received was inadequate in

enhancing their knowledge. One participant shared the following:

“They did not say anything much, he just said, have you done Pap smear before and I said no and he said ok I will do this and that, I did not get much information about it but they gave me a flyer/brochure to read. I did it my first time because then I was suffering from pain during my period so I just decided to do something and I went to the GP where I had to go through all the test including Pap smear and it was not pleasant I had never done such tests before around my cervix or vagina so it was a bit unpleasant but the second one was good I did it after having my baby and was not a big issue for me” (33 y/o refugee from Ethiopia).

From the women’s perspective, the use of brochures was not appropriate because they wanted a

direct and verbal health education messages from their GP. Some women could not read and/or

understand and process the information contained in the brochures. Without a proper

understanding of the test and its benefits women may not be motivated to use the services. It

was also found that standardized information on cervical cancer and cervical screening practices

specifically was not communicated to these women and therefore women received different and

insufficient information about cervical cancer and screening. In the absence of standardized

culturally appropriate information being properly communicated to these women, they may not

be empowered to keep up with the regular screening practices as required.

Facilitators of regular cervical screening

The recommendation of the screening test by health professionals was a key facilitator

for the women. Most of the women spoke very highly of their GPs. They perceived their

health professional as an “authority” and were keen to follow their instructions:

“My GP encouraged me, she asked me have you done Pap smear before and I said no and she said well it’s important to do it then she explained why it’s done then I accepted to do it because I have never done it before…” (48 y/o refugee from Sudan).

Additionally, it was found that among the three women who believed that the Pap

smear testing was routine, the provision of information, good rapport, and adequate

reassurance from their service providers prior to testing contributed to their level of comfort:

“I think the testing was ok, in the beginning I used to be scared because the doctor will open me up open my cervix. But now my doctor will say I am going to open you up and get just a swab and that explanation eases my fear but that was long time ago, now I am comfortable with the test and I think the doctors can play a very important role in making you comfortable and when you know and understand the reasons for that test (Pap smear) then its ok going through that. She is a woman and I am not really concern about the gender of the GP I think it’s just about building a rapport with the patient” (35 y/o non-refugee from Botswana).

The women said that if they were educated about cervical cancer, its causes, how to

prevent it, the signs and symptoms, the risk factors, they would have been more likely to

internalize positive behaviour towards the disease and screening practices. One participant

from Ghana admitted having experienced Pap smear testing but could not establish a link

between the Pap smear testing and cervical cancer. Another participant from a refugee

background also requested that basic information about the disease and Pap smear test be

aligned and communicated to him or her regularly:

“Seriously I do not know much about cervical cancer, I do not also know the implications of having abnormal Pap smear and all that stuff, whether abnormal Pap smear result will lead to cervical cancer or whatever is associated with it, that kind of information is what should be getting across, to say that …. look

these are the various diseases a woman can get as long as she is sexually active and to prevent that from happening you got to do Pap smear at this regular intervals so that the disease can be detected early. I believe the information should be if you don’t do this Pap smear the possible diseases that you may get. If you sell Pap smear alone to them then the question will be and so what if I do Pap smear what is the implication if I don’t do it…. so all those things need to be communicate across” (36 y/o non-refugee from Ghana).

The first information should be the introduction, like what cervical cancer is, just an explanation for us to understand what cervical cancer is and that terminology what does it mean because it’s very important because they might go to a doctor and the doctor may say they should do a Pap smear test to check if they have cervical cancer and when they hear the name cervical cancer then they can remember the terminology. Then the second step is to educate them on the symptoms because if they know of the symptoms they can remember and say for instance…….I think something is wrong somewhere. These refugees because they have gone through a lot of hardships even if they are not feeling well they keep saying everything is ok, it shall be well and they do not like going to the hospital but when they see a symptom which is persisting then they will know and report” (47 y/o refugee from Sudan)

Importantly, it emerged that the resilience shown by women from refugee backgrounds

that had endured many adverse situations during their refugee journey contributed to their

reluctance to seek medical attention when needed. It is therefore paramount that these women

receive relevant information that will motivate them to participate regularly in preventive

screening activities. A clear understanding of the benefits of the screening test may help to

achieve this purpose.

The participants expressed a need for more effective reminder systems that would

prompt the women to be tested. As mothers taking care of their families in addition to

working and studying, they reported forgetting about their personal health issues such as Pap

smear testing. With competing priorities, it is important there is a system in place that

prompts women to be screened for cervical cancer. The current cervical screening program

in Australia regularly sends letters to remind women about their cervical screening. Sending

out invitation letters, however, was perceived to be inadequate. Most of the women disclosed

that they had not received any such letters, and the few who had received them did not see

this as an effective strategy:

“I think it’s more of a reminder problem if I do get that reminder from my GP on my phone to say for instance “your Pap smear is due when do you want to come for your Pap smear” because I know this is something you know you should have

but for some reason one can stretch the 2 years to 4 years but if I get that reminder from your GP to say that your Pap smear is due I think I will get it done” (32 y/o non-refugee from Zimbabwe)

The majority of women stated a preference for female service providers. Eleven out of the

19 women expressed the desire to be attended to by a female service provider because they felt

more comfortable:

“ I am more comfortable with a female GP than a male even though that person is a GP but to go so intimate with me it’s only my husband who can do that not a GP” (42 y/o refugee from Liberia).

This suggests that giving women the option to decide the gender of the Pap smear

service provider may increase the incentive for women and therefore ultimately improve

participation in screening activities.

Discussion

The study findings show that the lack of knowledge about cervical cancer and the

screening test is a major barrier to cervical screening participation among this group of

African immigrant women. Other barriers identified included: concern about the gender of

the service provider, absence of warning signs of cervical cancer, embarrassment, fear, lack

of privacy, lack of standardized information, and the idea that a Pap smear was not necessary.

Similar findings have also been reported in other studies conducted among African women in

their country of birth and adopted country [11, 23, 31, 32]. Marlow, Waller [31] identified

barriers including fear, embarrassment, shame, lack of convenient clinic time, absence of

symptoms, and low perception of risk among women from ethnic minority backgrounds

(Indian, Pakistani, Caribbean, African and Caribbean) in the United Kingdom. In Ethiopia,

barriers reported by Birhanu, Abdissa [11] among women aged 21–70 years included lack of

awareness about cervical cancer and the absence of information about warning signs. In

Zimbabwe, Mupepi, Sampselle [23] also identified lack of awareness about the test, partner’s

disapproval, embarrassment, pain, gender of the service provider, the absence of information

about warning signs and fear as barriers among rural women between 14 and 49 years of age.

In a study involving a large national sample of Australians (5,190 participants), Pitts,

Heywood [33] found that a higher proportion of their study participants (66.0%) associated

HPV with cervical cancer where as in this current study none of the participants associated

cervical cancer with HPV. The different levels of knowledge about cervical cancer among the

Australian population are indication of the diversity of its population and the need for

targeted health education interventions to increase awareness and knowledge about cervical

cancer and the screening test. It is important to note that emotional barriers such as fear,

embarrassment, concern about the gender of the service provider and lack of privacy were

seen as important to the participants. Such emotional barriers can inhibit participation in

preventive screening activities and it is therefore important to consider the provision of

psychosocial support for the purpose of motivating the women. The psychosocial support

may help them to overcome emotional barriers and get them to open up and discuss issues

related to sexual and cervical screening practices. This, ultimately, may help increase their

participation in screening activities. Using models such as person-centred care [34] could

help to focus cervical screening service delivery to address individual needs. Similarly,

improving relationships and communication between service providers and clients, and

improving health professionals’ cultural competence may help to promote culturally safe

service delivery.

A study among African immigrant women in Washington D. C. reported lack of

knowledge among the women [35] and another study conducted in New South Wales also

identified embarrassment and lack of knowledge as barriers to participation in preventive

cervical screening among African immigrant women [32]. The similarity between this current

study and some of the above studies’ findings reflects the shared experiences of African-born

women both at home and abroad. Notably, most of these studies identified the lack of

knowledge about cervical cancer and screening as a common barrier. This is of concern

especially for the studies conducted in developed regions such as the USA and Australia

where organised cervical screening programs have been successful, suggesting that these

programs are not reaching the population of African immigrant women. It is important to

recognise that the lack of knowledge about the disease and the test may impact negatively on

a women’s decision to participate in preventive cervical screening. The evidence provided by

this study confirms the need for continuous education interventions targeted at increasing

awareness about the disease and the test among African-born women.

It was concluded that the women were not comfortable regarding physical environment

and privacy and having a female health professional performing the Pap smear test increased

their comfort level. Most of the women felt embarrassed mainly because male service

providers were doing the testing. A similar concern has been noted among Australian-born

women aged 40 and above, who reported that the gender of the cervical screening service

provider was a key factor in making a decision to have a Pap smear test, and 77% of the 144

women studied preferred female service providers [36]. A literature review by Women’s

Health Goulburn North East (WHGNE) [37] found that the gender of the service provider

was a barrier in Australian Aboriginal communities. Furthermore, the Queensland Health

Policy for authorized Pap smear providers also recognizes gender of health practitioners as a

barrier to cervical screening participation [38].

Additionally, the women in this current study saw Pap smear testing as an “intimate

procedure” and believed that such a level of intimacy should only be shared with their

husbands or sexual partners. This perspective was also observed among Chinese Australians

who expressed that they would never undergo Pap smear testing, stating as their reason that

their vaginal area should not be seen by another person except their husband or sexual partner

[39]. Similarly, women living in the Stockholm region in Sweden who declined to participate

in cervical screening stated that feelings of vulnerability and the intimate character of the

screening process were common reasons for declining the test [40]. This emphasises that

having male health professionals providing cervical screening services has the potential to

deter women across different settings and backgrounds from undertaking the test. Lofters,

Moineddin [41] found that women from nearly all world regions who had access to at least

one female service provider were the most likely to be screened. This suggests that giving

women the option to decide the gender of the Pap smear service provider may increase the

incentive for women and therefore ultimately improve participation in screening activities.

This could be further investigated for African communities.

The proposed review of the National Cervical Screening Program in Australia is

considering HPV testing using self-collection of the specimen, where women will be required

to take a sample of cells from their cervix using a tampon or cotton-tipped swab for testing

[42] . It is anticipated that self-collection of the sample will provide some level of privacy to

women and help reduce the barrier of fear of exposing the genital area to another person or

male service providers. Women’s acceptance of the proposed self-collection method,

however, needs to be investigated further (in particular among immigrant women). It is also

important that women’s opinion should be canvassed regarding the self-collection of samples

for the HPV testing being considered for the new National Cervical Screening Program in

Australia. More health education interventions are therefore needed to create awareness about

this new proposal, especially among those sub-populations who are particularly concerned

about being examined by male health professionals. This may encourage them to participate

in screening.

This study has highlighted that information about cervical cancer and screening tests

was not adequately or appropriately communicated to the women prior to testing. The women

indicated that they respond better to verbal information than printed material such as

brochures/leaflets. It is possible that many women did not understand the brochures/leaflets

previously given to them during screening because they were in English or used terms that

were not familiar to the women. This may explain why they could not make a connection

between cervical cancer and the Pap smear. The absence of a standardised and culturally

appropriate information about cervical cancer and the screening test for African immigrant

women, and the lack of adequate education by health professionals prior to testing may have

contributed to the low level of knowledge about the disease and the lack of understanding

about the test.

In Peru, a direct clinical observation of health professionals that aimed to explore the

type of health education provided to women about cervical cancer and the Pap smear test,

revealed that only one-third of the interaction included some type of health education related

to cervical cancer and prevention [43]. Most of the limited health education included only a

general mention of the disease: severity of cervical cancer constituted 3.8% of the general

information provided, information about HPV was 2.2%, and information about the Pap

smear test detecting cervical cancer accounted for 11.9% [43]. The study by Bayer,

Nussbaum [43] documented how health education messages about cervical cancer prevention

provided to patients were insufficient or non-existent. Additionally, a qualitative study

exploring private medical practitioners implementing cervical screening in South Africa

found that practitioners did not educate patients about cervical cancer, its predisposing factors

or the Pap smear test [44] because they believed their major role as a GPs was to identify and

treat diseases [45]. This might not necessarily be the case in Australia, however, an

examination of the type of health education messages on cervical cancer provided by health

professionals to immigrant women, especially those from non-English speaking backgrounds,

is needed. The observation may identify information gaps and assist in developing well-

tailored health education packages appropriate for this sub-population.

This study has a number of limitations. First, the sample size is small and limited to a

single urban location. As a qualitative study, the findings cannot be generalized to the overall

population of African immigrant women in Australia. Second, some sub-populations were

excluded, such as those African immigrant women who could not read or speak English. The

views in this study did not include those of women from the Muslim community. This is an

important limitation as these women are more likely to face language and communication

barriers when accessing cervical screening services. The study acknowledges the over-

representation of educated women in the sample and that the results may not be a true

reflection of the experiences of other African immigrant women. However, the low level of

knowledge about cervical cancer and screening observed among this well-educated group of

women is of concern. This suggests the need for continuous health interventions to increase

health literacy and awareness of cervical cancer and screening in the women’s communities.

Conclusion

This research with African immigrant women in Australia showed that lack of

knowledge about cervical cancer and participants’ belief systems were the major barriers to

screening. The women’s understanding of the causation of cervical cancer was inadequate

and largely shaped by their cultural and religious beliefs, which were generally inconsistent

with medical knowledge. One consequence was an incorrect perception of the need for and

benefits of Pap smear screening, with a consequential risk that cervical cancer could go

undetected among the participants. The absence of standard information packaged and

effectively communicated to the women was notable. In addition, the research demonstrated

that the barriers experienced include other culturally-based factors that led to discomfort with

the physical process of screening and the interaction with medical staff.

Implications of findings

As one of the first studies to examine preventive cervical screening behaviours among

African immigrant women in Australia, this study has broadened the understanding about the

screening behaviours and challenges of immigrant women from the African community. In

terms of knowledge gaps, the study found a clear need for African immigrant women to have

basic standardised information regarding the disease and the screening test such as the causes,

prevention, and warning signs of cervical cancer, the purpose and benefits of Pap smear

testing, and the screening guidelines in Australia. Information on screening activities must be

tailored to educate the sub-population to addresses the women’s misperceptions about

cervical cancer causation and screening practices. It is also important to enhance cultural

competence among health professionals providing cervical screening services in African

communities in order to build their capacity to apply service delivery models that will honor

group cultures and provide culturally appropriate approaches to cervical cancer and cervical

screening practices.

Conflict of Interest

The authors declare that there is no conflict of interest.

Informed Consent

All procedures followed were in accordance with the ethical standards of the

responsible committee on human experimentation (Queensland University of Technology

(QUT) Human Research Ethics Committee (HREC). Informed consent was obtained from

all patients for being included in the study. The data for analysis did not include any

identifying information on the participants.

Page 18 of 18

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