Cervical screening: Perceptions and barriers to uptake among Somali women in Camden

Summary

Objectives

To explore barriers to, and ways to improve, uptake of cervical screening among Somali women in Camden, London.

Study design

A qualitative research study using focus group discussions and in-depth interviews.

Methods

A qualitative study (comprising seven focus groups and eight in-depth interviews) was conducted with 50 first-generation Somali women aged 25–64 years. Both the groups and the interviews explored participants' understanding of the purpose of cervical screening, and the various risk factors for cervical cancer, as well as their opinions on barriers to screening and suggestions for overcoming those barriers.

Results

Knowledge about the purpose of cervical screening was limited among Somali women. There was also a lack of understanding of risk factors for cervical cancer, and many of the women held fatalistic attitudes, associated with the idea of ‘God's will’, about this cancer and other aspects of health. Another culturally specific barrier was embarrassment associated with female circumcision, i.e. female genital mutilation. Other barriers suggested by the participants were: lack of knowledge about the need for cervical screening, practical problems such as appointment times and childcare needs, language difficulties, fear of the test and negative past experiences. Possible solutions suggested by the participants included the provision of education and information about cervical screening in the Somali language by Somali community workers. They also suggested that healthcare staff should be trained about Somali culture, particularly regarding female circumcision, and that general practitioners should more proactively encourage Somali women to attend screening.

Conclusions

Language difficulties and specific cultural issues are key barriers to first-generation Somali women attending cervical screening. Providing education and information orally, as well as improving access to a more culturally appropriate screening service, could lead to improved uptake among this group.

Introduction

Cervical cancer is a global health problem¹ and the most common cause of cancer death in women in Somalia.² Cervical screening is not undertaken in Somalia; indeed, there are no Somali words for ‘smear test’ or ‘cancer’. In the UK, early detection through screening, with subsequent treatment of cervical abnormalities, is thought to prevent around 75% of cervical cancers and saves over 4500 lives each year.³ Despite these clear benefits, comprehensive population coverage for the programme has been difficult to achieve in the UK, particularly among black and minority ethnic (BME) groups.⁴

Camden is a relatively deprived inner-city borough of London with a population of approximately 245,000 people, of whom 27% are from BME groups. Civil war in Somalia has caused many Somalis to come to live in Britain since the 1990s.⁵ In Camden, the number of Somalis registered with general practitioners (GPs) has increased by 23% in the last 3 years, and Somalis now form the borough's second largest group born outside the UK (after Bangladeshis).

Like many London boroughs, Camden has consistently not achieved the national target of 80% cervical screening coverage. A recent study in Manchester found that 37% of Somali-born women had never been screened.⁶ Camden's Exeter database of registered general practice patients suggests that only 61% of Somali-born women of target screening age have been screened in the last 5 years compared with 71% of women in the general population. However, these data may be incomplete, as place of birth and ethnicity is not always recorded. Furthermore, the data do not include British-born Somali women.

Previous research suggests that lack of knowledge about cervical screening is the most significant barrier to screening among BME women.7, 8, 9, 10 Fear, embarrassment, fatalism and lack of time are also cited as obstacles.7, 8, 10 Research has also found that the inaccessibility of screening services, particularly for older ethnic minority women, is a major contributing factor to poor attendance.¹¹ Additionally, lack of childcare provision, inappropriate timing of surgeries, inflexibity in rescheduling appointments, and lack of female or proactive practitioners have been identified as barriers to uptake amongst women from all ethnic backgrounds.7, 12, 13, 14 In a recent study exploring the perception of preventative medicine amongst Somali refugee women in New York, only half had heard of cervical screening.¹⁵

Although the reasons for non-attendance for cervical screening by women from BME groups have been studied extensively, none of the published research on cervical screening has focused specifically on Somali women. Somalis are less well established in the UK than many other Black African communities, and face considerable language difficulties. In addition, their Islamic faith and the common practice of female circumcision, i.e. female genital mutilation (FGM), could lead to different perceptions of cervical screening than those of other BME groups. This research was therefore undertaken to explore the barriers to uptake of cervical screening in this group and to identify strategies for overcoming these barriers.