Why aren't ethnic minority women getting their smear tests?
If the thought of a complete stranger perched between your legs while using a brush to collect a sample of cells from your cervix doesn’t fill you with joy, you’re not alone.
According to the most recent data from the Department for Heath and Social Care, nearly a third of those eligible for a smear test (also known as a cervical screening or pap smear) hadn’t been screened as of March 2021.
Because cervical screenings (along with HPV vaccinations) are the main way to prevent cervical cancer, this poses a problem for our healthcare service, and has prompted the launch of a new government campaign created to boost uptake of the procedure.
Hesitancy towards smear tests is far from a new phenomenon and is prevalent among all sub-sets of women and people with a cervix. It’s widely acknowledged, however, that those from Black and Asian backgrounds are less likely to attend cervical screenings than white women.
In 2011 research from Jo’s Cervical Cancer Trust found that ethnic minority women were more likely to say they’d never attended a screening than white women (12% vs 8%) while just 70% of Asian women knew what cervical screenings were for compared to 91% of white women.
The latter comparison highlights one of the major culprits responsible for resistance to smear tests among ethnic minorities – a tenuous grasp on the facts and potential health implications relating to smear tests and cervical cancer.
This was evidenced in a 2015 study which looked at the barriers to cervical cancer screening among ethnic minority women, and states that participants ‘felt that there was a lack of awareness about cervical cancer in their community.’
Fear, embarrassment, shame, lack of time and low perceived risk of cervical cancer were also identified as barriers.
‘Believe it or not [in some cultures] there is a stigma attached to going for a smear test,’ says consultant obstetrician and gynaecologist Dr Shree Datta. ‘In some communities, the same way we say, “I’m going to the dentist” is the same way somebody would say “I’m going to get my smear done”. In others, there are [negative] connotations that are associated with going for a smear. The latter is probably more specific to BAME (Black, Asian, minority ethnic) women.’
As a British Muslim of Bengali heritage, Nilly Dahlia intimately understands the stigma associated with smear tests, and how the conflation of different obstacles can prevent somebody from arranging their screening.
‘Smear tests aren’t spoken about enough in our culture,’ she tells Metro.co.uk. ‘It’s like a shameful thing to talk about and to expose yourself in that way, so women feel embarrassed to talk about it.
‘In the Bengali household it’s traditional for women to stay at home with the kids while their husband goes to work. So when they get invited to have a smear test they can’t find the time to go because they can’t leave their kids with anyone.’
The 34-year-old mum-of-three admits she’s never had a smear test, which she says is partly because she’s been pregnant multiple times since turning 25 (the age people become eligible for a screening) and partly due to fear of the procedure.
‘I’ve read about what happens when people get bad results and it’s quite frightening so I sometimes think I’m just going to take myself away from that whole equation, even though I know that’s a really bad approach,’ she notes.
‘Also, it can be scary. My sister-in-law who does go always says she bleeds and that really puts me off because I feel like if she’s going to be bleed will I bleed as well? And are they not gentle? We hear more of the horror stories about the smear test than anything else.’
For Black women, similar notions of the respectability stigma also contribute to a lower uptake in smear tests, particularly for those from African backgrounds who – according to a 2014 study – were more likely to be overdue for screenings than Caribbean women.
Consultant obstetrician and gynaecologist Dr Christine Ekechi, who led the study, tells Metro.co.uk: ‘We found numerous reasons including difficulty in scheduling appointments, a lot of myths around who is more likely to have HPV and therefore cervical cancer and an association with cervical screenings and promiscuity. Or indeed it was felt that if you were married you didn’t need to have a cervical screening.
‘But the conclusion of the study was that there was definitely an influence of culture and religion as an overlay as to why some people had the wrong information.’
Lucy Akao was four years late to attend her first screening. Originally from Uganda, she admits that she was scared of what the result might be, and that going to the hospital to get yourself checked for anything is discouraged in her community.
She shares: ‘That’s not a normal thing in minority households because the moment you mention it people say, “Why are you going to a doctor? God is your protector, so in case of anything just pray”.’
She agrees that culturally conservative attitudes play a significant part in Black and Asian women’s reluctance to attend their smear tests, saying: ‘We are taught to preserve ourselves and preserve certain parts of ourselves so we get scared because we feel like we’re opening ourselves up to someone.
Smear tests aren’t spoken about enough in our culture
‘We feel like it takes away our dignity, we feel embarrassed about it. Speaking to someone and saying, “I went to the doctors and this is what they did to me” is really embarrassing because it’s not something that is talked about.’
In some instances, when smear tests are open for discussion among family and friends, it’s misinformation or fear-mongering that can result in refusal to get checked.
Esther Mukundgi, who is of Congolese heritage, remembers being told that having a smear test would mean she’d no longer be a virgin, despite her never having sex.
‘From my experience I found that whenever the conversation would come up about smear tests or even using tampons, the response was “You don’t need to do it until you’ve had sex because you will lose your virginity”,’ she reveals.
Aside from the differing cultural perceptions, factors such as language barriers, lower educational attainment and migrating to the UK from other countries can also contribute to the lower numbers of ethnic minority women who opt not to get tested. All of these were highlighted in a 2015 study, which found that ethnic minority women were significantly less likely to attend screenings than white women (44–71% vs 12%). Consideration of these accessibility factors paints a clearer picture as to why ethnic groups may be less engaged with the NHS cervical screening programme which was first established in 1988.
How then, can healthcare providers ensure that pertinent information is accessible to marginalised ethnic groups, correct misguided beliefs about smear tests and raise awareness of cervical cancer?
‘Personally I think it’s about using different channels to give the correct information about cervical screening,’ says Dr Christine. ‘So yes, there are the official channels like billboards and going to the GP, but people also get their health information from their friends and family so we have to think more about how we disseminate information through the non-traditional channels.’
For Nilly, counteracting outdated and sometimes dangerous viewpoints is something she’s now committing to.
‘I feel like for people in my generation, it’s our duty to go for our smear tests and break that taboo so we have the knowledge to pass on to our kids,’ she says. ‘I’ve got two daughters and if I don’t teach them to go for it then that’s my fault and if anything were to happen to them I feel like it would be on me.
‘It’s up to us to shift this whole mentality for the next generation onwards.’
You, me & HPV
This week, Metro.co.uk is looking at HPV and its related cancers from a range of perspectives.
By and large HPV isn’t something to worry about – but it is something to be aware of.
HPV is something that eight in 10 of us will encounter at some stage of our lives. It’s spread through skin-to-skin contact, not just penetrative sex. There is even some evidence to suggest it can spread through deep kissing.
It isn’t tested for in a standard sexual health screening, so it’s near impossible to know when or where a person might have contracted it or who they might have passed it onto.
For most people, their bodies will fight the virus off in around one to two years without any lasting effects. For some people however, it can make them more vulnerable to cancers of the cervix, anus, head and neck, penis, vagina and vulva.
Over this week, we’ll be exploring the human issues that come with HPV and its related cancers.
For more health information, please visit Jo’s Cervical Cancer Trust, The Eve Appeal, the No Man campaign and The Anal Cancer Foundation.
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