Elsevier

Women's Health Issues

Volume 23, Issue 5, September–October 2013, Pages e319-e325
Women's Health Issues

Original article
A Qualitative Study of Provider Perspectives of Structural Barriers to Cervical Cancer Screening Among First Nations Women

https://doi.org/10.1016/j.whi.2013.06.005Get rights and content

Abstract

Objective

In Canada, opportunistic screening programs have successfully reduced mortality from cervical cancer; however, minority or disadvantaged groups, as well as women in northern and rural areas, are inadequately recruited by this approach. Hence, we set out to examine the structural barriers that prevent First Nations women's participation in cervical cancer screening.

Methods

Using a participatory action research approach and semistructured interview guides, we conducted in-depth interviews with 18 experienced health care professionals, 12 of whom were also community members. These individuals included nurses, nurse practitioners, community health representatives, social workers and physicians who provide care to women in our First Nations partner communities. In the current report, we explored perceived barriers to cervical cancer screening through the lens of service providers.

Results

Structural barriers to cervical cancer screening for First Nations women included shortage of appropriate health care providers, lack of a recall-based screening system, geographic and transportation barriers; health literacy and socioeconomic inequalities, generational effects, and the colonial legacy.

Conclusion

Existing, opportunistic cervical cancer screening programs do not perform well for First Nations women who experience significant screening-related health inequalities that are largely influenced by structural barriers. Sustainable screening interventions in First Nations communities require approaches that resolve these structural barriers, explore new ways of screening, and provide education for both women and health care providers. Many of the structural barriers are rooted in colonial history. Given the negative impact of the consequences of colonization on indigenous women worldwide, many of our findings strongly resonate with marginalized populations in other countries.

Introduction

In Canada, provincial screening programs have successfully reduced cervical cancer mortality from 7.3 per 100,000 women in 1969 to 2.2 per 100,000 women in 2000 (Health Canada, 2004). Cervical carcinomas are caused by high-risk types of the human papillomavirus (HPV). Not all women infected with high-risk types of the HPV develop a carcinoma or precursor lesion; however, those with persistent infections are at elevated risk. Currently, the primary method of cervical cancer screening is the Papanicolaou (Pap) test, which detects cell morphological changes indicative of a precursor or invasive lesion (Papanicolaou, 1942).

Most Canadian provinces have not implemented recall-based screening, where a cancer registry identifies eligible women. Instead, most jurisdictions have opportunistic screening programs, which rely on the primary health care provider inviting their patients to participate. There is increasing evidence that this screening approach is inadequate in recruiting marginalized and rural groups who are commonly underserved by primary health care providers.

Two Canadian provinces—British Columbia and Nova Scotia—provide recall-based cervical cancer screening. In British Columbia, their Cervical Cancer Screening Program has greatly increased average screening rates (Band et al., 1992, Hislop et al., 1996). However, the benefits are not realized for Aboriginal1 women who are estimated to have Pap test rates of only 50% compared with 85% for all ever-screened women (Band et al., 1992, Hislop et al., 1996). In Nova Scotia, Aboriginal women were similarly (1.6-fold) less likely to have had a recent Pap (Johnston, Boyd, & MacIsaac, 2004).

Aboriginal women have 2 to 20 times the risk of being diagnosed with cervical cancer, depending on the Canadian province. In Ontario, cervical cancer incidence is 1.73-fold higher among First Nations compared with the general population with similar differences noted for the mortality rate (Marret & Chaudhry, 2003). In Manitoba, Aboriginal women were found to have 1.8 and 3.6 times the rate of in situ and invasive cervical cancer, respectively, and this rate has been increasing (Gillis et al., 1991, Morgan and Laing, 1981, Young and Choi, 1985, Young and Frank, 1983). In an Albertan community, cervical cancer was found 20 times more often in First Nations women than in other Canadian women (Colquhoun et al.,2010). Accordingly, the death rate from cervical cancer among First Nations women significantly exceeded the rate among women from the mainstream population: the Relative Risk for women aged 20 to 64 was 5.95-fold higher during the study period from 1953 to 1984 (Band et al., 1992).

Similar disparities are found internationally. Indigenous women in Australia are 2.4 times more likely to develop cervical cancer, with a mortality rate five times the Australian average (Shannon, Franco, Powles, Leng, & Pashayan, 2011). In New Zealand (McLeod et al., 2010), Māori women have poorer cancer specific survival than non-Māori women (mortality hazard ratio, 2.07). Cervical cancer incidence in American Indians and Alaska Natives is also significantly elevated (relative risk, 1.25; 95% confidence interval, 1.11–1.39; Espey et al., 2007).

The causes of these disparities are still poorly understood, but likely involve the multiple social barriers experienced by low-income, multicultural populations (Sorensen et al., 2003). Research on the “intersecting roles of multiple sources of disparities” and the origin of observed health inequalities is urgently needed to improve cervical cancer screening among Aboriginal women (Sorensen et al., 2003).

To elucidate the factors that influence participation in cervical screening by Aboriginal women, we conducted qualitative research with 18 key informants possessing extensive experience in providing sexual health–related services to First Nations women in Ontario, Canada. We particularly focused on the structural barriers to cervical cancer screening in this population. This research is part of a larger study, entitled “Engaging First Nations Women in Cervical Cancer Screening: Assessing Factors Related to Screening and Uptake of Self-sampling.” This study is designed to identify viable, culturally acceptable cervical cancer screening approaches, with the long-term goal of increasing screening and reducing cervical cancer among Aboriginal women.

Section snippets

Methods

Our project is based on participatory action research (PAR) methodology involving research partnerships with 11 First Nations communities in rural Northwest Ontario. These communities are culturally and politically aligned with the Anishinaabek Nation Northern Superior Chiefs and the Robinson Superior Treaty. They lie within a 500 km radius of Thunder Bay, the major urban and medical center of Northwest Ontario. Communities range in population size from 70 to 840 individuals and share many

Shortage of Appropriate Health Care Providers

Participants identified a shortage of health care providers who are trained to do Pap tests as a barrier to cervical cancer screening in rural areas. In addition, participants believed that many First Nations women are shy about their bodies, particularly in medical examinations, and are consequently very uncomfortable with pelvic examinations when performed by male providers:

The girls are always looking for female doctors or nurse practitioners, because they're more comfortable. Like, my

Discussion

Aboriginal women experience significant health inequalities in cancer screening that are, based on our research, less influenced by personal risk behaviors and more by broader societal forces (Blankenship et al., 2006, Spence et al., 2007). These structural factors are centered in sociohistoric and environmental conditions that influence women's health behaviors, deter women from cervical cancer screening, and are exacerbated by health system limitations. Similarly, a recent systematic review (

Acknowledgments

The authors gratefully acknowledge the participation of Northern Superior First Nations communities in Northwest Ontario for facilitating this research and for reviewing this paper prior to publication. Marion Maar is corresponding author for the qualitative part of the study while Ingeborg Zehbe is corresponding author for the clinical part involving cervical cancer biology and HPV. We thank Lisa Boesch for transcription and support in preparing the manuscript.

Marion Maar, PhD, is a Medical Anthropologist and Associate Professor at the Northern Ontario School of Medicine. She researches Aboriginal health and health services with an emphasis on chronic illnesses and their relationship with broader societal, colonial and multigenerational issues.

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  • Cited by (0)

    Marion Maar, PhD, is a Medical Anthropologist and Associate Professor at the Northern Ontario School of Medicine. She researches Aboriginal health and health services with an emphasis on chronic illnesses and their relationship with broader societal, colonial and multigenerational issues.

    Ann Burchell, PhD, is an epidemiologist at the Ontario HIV Treatment Network and the Dalla Lana School of Public Health, University of Toronto. She researches the epidemiology and prevention of sexually transmitted infections (STIs) and their outcomes, including human papillomavirus and related cancers.

    Julian Little, PhD, is an epidemiologist with particular experience relating to cancer, birth defects and public health genomics. Part of his work has focused on the management of women with low-grade cervical cytological abnormalities, including the potential value of human papillomavirus testing.

    Gina Ogilvie, MD, DrPH, is the Medical Director for Clinical Prevention Services at the BC Centre for Disease Control and an Associate Professor in Faculty of Medicine. Her research focuses on sexually transmitted infections, human papillomavirus, HIV in women and care for marginalized populations.

    Alberto Severini, MD, is a virologist at the National Microbiology Laboratory of Canada and his laboratory is engaged in reference testing and surveillance of numerous viral agents. His work has focussed on the molecular epidemiology of human papillomavirus and on HPV genotyping methods.

    Jinghao Mary Yang, BASc, is a candidate in the doctor of medicine program at the University of Toronto. She has an interest in indigenous women's health research and practice.

    Ingeborg Zehbe, PhD, is a cancer biologist. Her work focuses on cervical cancer and its primary cause human papillomavirus (HPV). She conducts basic research in HPV, is involved in developing non-invasive treatment options and translating HPV testing to cervical cancer screening.

    Funded by the Canadian Institutes of Health Research (CIHR Operating Grant # 257682 to IZ) and Indigenous Health Research Development Program Student Mentorship Program (MM and MY).

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