PACIFIC JOURNAL OF REPRODUCTIVE HEALTH
Cervical Screening in South Tarawa, Kiribati: Understandings, Attitudes and Barriers to Access
cervical screening, Kiribati, pap smear, cervical cancer.
Cervical cancer affects hundreds of thousands of women worldwide ever year,1 and disproportionately affects developing countries.2 Cervical cancer is a major public health issue in Kiribati, and a significant cause of morbidity and mortality among women. It is one of the leading causes of cancer death amongst I-Kiribati women.3 This persists despite the efficacy of cervical screening in reducing cervical cancer morbidity and mortality.
The Republic of Kiribati is one of the most geographically isolated places in the world. It is categorised as a least developed country, and faces a number of major challenges, including high infant, child and maternal mortality rates, low life expectancy, and a lack of resources and infrastructure to meet the needs of the population.
Cervical cancer is one of many health problems experienced by I-Kiribati, but one which has seen minimal improvement in incidence and mortality over the last several years. It has a population of 110,000 people, but in 2016 there were only 2,368 visits to health centres and clinics for pap smears.4
Globally, research has been conducted into cervical screening to identify key barriers to access. Research has identified several barriers, including a lack of suitable, free services with skilled practitioners and the necessity of taking time off work or arranging childcare,5 as well as embarrassment, fear of the procedure and a lack of knowledge around screening.6,7
For many women, it may be inappropriate for someone other than a husband or partner to have access to intimate parts of the body, as occurs in cervical screening.8 A perceived link to sexual activity can mean there is shame and stigma associated with an abnormal result, and make participating in cervical screening difficult.9 Barriers to cervical screening access are often exacerbated for marginalised women, particularly women with disabilities, those living in rural or isolated areas, and those who have experienced sexual abuse.10
Attempts have been made in Kiribati to address several of these known barriers through the provision of free clinics in local communities, as well as through education and health promotion through community visits, posters, pamphlets and radio messaging. However, there is a lack of empirical research into barriers to cervical screening for I-Kiribati women, and current efforts have necessarily been based on anecdotal evidence. There is a need for local research, to identify solutions which are relevant and meaningful for the community.
Research was conducted among men and women in South Tarawa, Kiribati. South Tarawa is the largest urban population in Kiribati, home to around half the total population. The research used a mixed-methods approach to explore understandings, attitudes and barriers to cervical screening. A community survey was conducted, followed by focus groups to explore understandings, attitudes and barriers in more depth. The research was conducted in collaboration with Kiribati Family Health Association (KFHA), a major cervical screening provider in Kiribati.
The research was conducted in line with Massey University’s Code of Ethical Conduct for Research, Teaching and Evaluations Involving Human Participants,11 which is accredited by the Health Research Council of New Zealand.
Data was collected from a total of 90 individuals, made up of 26 men and 63 women. Two thirds of participants were aged between 18 and 39 (Table 1).
The survey explored exposure to information about cervical screening, knowledge of cervical screening, uptake of cervical screening, reasons for attending and not attending cervical screening and potential objections from male family members. The surveys were conducted in the local language, I-Kiribati.
The survey was tested with nurses at KFHA before being administered by trained volunteers. Participants were recruited through door-to-door visits. The results of the surveys were entered electronically to be analysed. Graphs were generated to illustrate results.
Three focus groups were conducted, one male group (6 participants), and two female groups (4 and 5 participants), giving a total of 15 focus group participants.
Focus groups were led by skilled facilitators. Informed consent was obtained and ground rules were established. Questions covered knowledge and attitudes around cervical screening and cancer, including family members’ attitudes, and explored barriers and facilitators to cervical screening. The focus groups were conducted in I-Kiribati.
Both audio recordings and notes were produced at each focus group. The recordings and notes were used by a skilled translator to generate transcripts in English. Responses were analysed manually for common themes. These were grouped within the categories of attitudes, knowledge, drivers, barriers and facilitators.
Knowledge around pap smears was low for both genders, and lower for males than females. Many respondents did not know what a pap smear was or were unsure (Figure 1).
Many females (39%) did not know where to go for a pap smear. Half of participants were not sure how often women should have pap smears, while only 5% gave the response that is currently recommended in Kiribati of 3 years, and a significant number (17%) suggested that they should attend when they experienced symptoms (Table 2).
Exposure to information on cervical screening was also low, with 51% of participants indicating they had not received any information on pap smears before. For those that had received any information on cervical screening, the primary source of this information was from volunteers coming into the community (45% of all respondents) (Table 3).
Only a small proportion of female respondents (32%) had ever had a pap smear. For those who had ever had a pap smear, the length of time since their last smear varied widely, although 44% had had a pap smear within the past three years in line with clinical recommendations (Table 4).
Respondents were asked what they thought the main reason for women undergoing cervical screening was. The key reasons identified were experiencing health problems or symptoms (41%), being invited or encouraged to attend (31%), and to prevent cervical cancer (24%) (Figure 2).
When asked about the drivers of cervical screening attendance, focus group participants generally suggested that it was to test for cervical cancer, although other ideas included maintaining the health of women and their families, or detecting general cervical health issues.
Male participant: “For the wife to stay healthy, so they can have a long happiness in their family lives.”
Female participant: “I really want to live-long so that also encourages me to go for pap smears.”
Female participant: “It is a “must” for women to inform them if they have problems with their cervical parts or not.”
Respondents were asked to select possible reasons why women might not attend a pap smear. Responses were varied, but the most frequently reported reasons were being scared of the test (21%) and embarrassed (24%) (Table 5).
Focus group responses elaborated on these barriers, including why women might not return for their results or for future pap smears. Feeling shy or embarrassed, access issues (particularly in relation to transport costs and for those with disabilities), and fear of results were identified by male focus group participants.
Male participant: “Some of the women refuse to because they are too shy to be seen.”
Male participant: “Migration to other islands where a woman will surely miss her expected time for Pap smear.”
Male participant: “Some will think that it is better not to know rather than knowing it. If she discovers [an abnormal result] it will worsen the situation she in. So she will prefer not knowing it and spend her time happy with her friends until she finally dies from that.”
Female focus groups participants also identified several barriers to participation. These included shyness, feeling scared of the test or results, believing they were healthy, and a lack of knowledge around cervical screening and cancer.
Female participant: “Feeling and looking healthy means for some people, they don’t need to go for pap smears.”
Female participant: “In some cases, women feel scared of pap smears as they don’t really know how a pap smear is done on women.”
Participants were also asked to identify reasons why men might not want female partners or family members to attend. Survey responses varied, but the most frequently reported reasons were thinking that they are fine (20%) and think it is not appropriate to do (13%) (Table 5).
Focus group discussions expanded on the reasons why males might not want female family members to participate in cervical screening. Jealousy was established as a key barrier, particularly in relation to not understanding what was involved in the procedure.
Male participant: “In our custom it is too difficult for men to allow their wife to have a cervical cancer test if they are not really sure of how does it is operated on their women.”
Female participant: “Jealous. Since a pap smear is done on women’s genital parts, the husband will feel jealous of the male nurses. If not the husband, the mother in law will.”
A lack of faith in the effectiveness of the medical system was also established as a barrier, as was the belief that if women appeared and felt healthy they did not need to attend screening.
Male participant: “Men won’t allow their wife to go for Pap smears if they are not feeling confident about those who will do it.”
Female participant: “People think you are healthy so there’s no point for you to go for pap smears. They don’t know what a pap smear is.”
Focus group participants discussed factors that would facilitate women attending cervical screening. Practical tools such as reminders were established as facilitators, as well as combining cervical screening with other services such as family planning. Participants also discussed the responsibility lying with the smear-taker to follow up with women. The role of radio advertising had a mixed response, with some believing it was a useful tool, but others expressing concerns about privacy.
Male participant: “Better to write a date and reminder somewhere you can’t lose it. One good idea is to write a date and notice of your next pap smear on a big board.”
Female participant: “I really suggest KFHA should be responsible in reminding women about their next time to come back for pap smear… I think this kind of role is in the heart of its establishment so KFHA has to take up this challenge.”
The role of males in supporting their family members was also discussed as an important facilitator. This was not limited to reminders, but also included the need to be supportive and encourage women to attend screening and treatment.
Male participant: “Loving your wife, means you have to allow your wife to go for a pap smear. This proves your concern about your wife to stay healthy.”
Male participant: “Sometimes in cases where the daughter is having cervical cancer then, then there’s a need to talk to parents so that they support their daughters to seek help.”
Mobile services and community outreach were identified as a useful facilitator to access. This included both service delivery and health promotion. Tapping into other community events was also identified as a good way to connect with people.
Male participant: “It’s better if there’s a service that will visit households especially.”
Female participant: “Reminding people through awareness programs. These can be done by KFHA youth volunteers through reaching out community and reminding women about their appointment.”
Male participant: “It would be a good idea if hosting some sort of gathering, for example hosting festival, where drink and food are provided. In that way it can be expected that many people will come.”
Trust in the effectiveness of available treatment was also identified as a facilitator.
Female participant: “Women’s experiences of being cured or helped by taking up their treatment given from hospital, would encourage them to feel confident in getting more treatment and would likely go back…whenever they are needed.”
Table 1: Survey Participant Demographics | ||||
Age group | Female | Male | Not specified | |
Under 18 | 2 | 0 | ||
18-24 | 8 | 6 | ||
25-29 | 11 | 3 | ||
30-34 | 10 | 5 | 1 | |
35-39 | 11 | 3 | ||
40-44 | 5 | 2 | ||
45-49 | 5 | 5 | ||
50-54 | 2 | 1 | ||
55-59 | 3 | 1 | ||
60+ | 4 | 0 | ||
Not specified | 2 | 0 | ||
Total | 63 | 26 | 1 | 90 |
Table 2: Knowledge around cervical screening | ||||||||
Do you know what a pap smear is?
| FEMALES ONLY: Where would you go for a pap smear/where did you go for your last one? | How often do you think someone should have a smear? | ||||||
Females | Males | Females | Males | Females | Males | |||
Yes | 18 | 5 | KFHA static clinic | 4 | Every few months | 5 | 3 | |
No | 24 | 10 | KFHA mobile/ after hours clinic | 5 | Every year | 11 | 1 | |
Not sure | 21 | 11 | Tungaru Hospital | 8 | Every 2 years | 3 | 2 | |
Not sure | 10 | Every 3 years | 4 | 0 | ||||
When there are symptoms | 11 | 2 | ||||||
Not sure | 26 | 11 | ||||||
63 | 26 | 27 | N/A | 60 | 19 |
Table 3: Exposure to information on cervical screening | |||||
Have you received any information on pap smears before? | If yes, where did you receive this information?
| ||||
Females | Males | Females | Males | ||
Yes | 25 | 4 | Posters | 2 | 1 |
No | 30 | 14 | Pamphlets | 2 | 0 |
Not sure | 8 | 5 | KFHA staff/ volunteers in the community | 13 | 5 |
From a doctor, nurse or midwife | 5 | 1 | |||
Radio | 8 | 1 | |||
Other | 9 | 4 | |||
Total | 63 | 23 | 39 | 12 |
Table 4: Uptake of cervical screening | |||
FEMALES ONLY: Have you ever had a pap smear before? | FEMALES ONLY: If yes, roughly when was your last pap smear?
| ||
Yes | 21 | Less than 1 year ago | 7 |
No | 38 | 1-3 years ago | 4 |
Not sure | 4 | 3-5 years ago | 5 |
5-10 years ago | 1 | ||
More than 10 years ago | 4 | ||
Not sure | 4 | ||
Total | 63 | 25 |
Table 5: Barriers to uptake of cervical screening | |||||
Why might someone not for a pap smear? | Why might a male family member not want a woman to go for a pap smear? | ||||
Female | Male | Female | Male | ||
Too busy with work | 6 | 2 | They are busy with work | 4 | 1 |
Feel healthy/fine | 7 | 4 | They are busy with the family | 3 | 4 |
Scared of test | 13 | 5 | Think they are healthy/fine | 10 | 6 |
Scared of what result might be | 7 | 3 | Scared of what result might be | 6 | 2 |
Too far to travel | 5 | 3 | It is too far to travel | 2 | 3 |
Don’t think it would make you better | 3 | 3 | Don’t think it would make her better | 5 | 2 |
Partner/family do not approve | 5 | 2 | Religious beliefs | 2 | 1 |
Religious beliefs | 0 | 1 | Don’t think it is appropriate to do | 8 | 2 |
Embarrassed | 16 | 4 | Not sure | 14 | 7 |
Don’t think it is appropriate to do | 6 | 3 | Other | 8 | 2 |
Not sure | 12 | 6 | |||
Other | 5 | 1 | |||
Total | 85 | 37 | 62 | 30 |
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- World Health Organisation. Comprehensive cancer control: A guide to essential practice (2nd Edition ed.). Geneva, Switzerland: World Health Organisation, 2014.
- Ministry of Health and Medical Services. Kiribati Annual Health Bulletin. South Tarawa, Kiribati: Ministry of Health and Medical Services, 2016.
- Ministry of Health and Medical Services. Kiribati Annual Health Bulletin. South Tarawa, Kiribati: Ministry of Health and Medical Services. 2016.
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- Massey University [Internet]. Code of ethical conduct for research, teaching and evaluations involving human participants. [cited 30 May 2017]. Available from https://www.massey.ac.nz/massey/research/research-ethics/human-ethics/code-ethical-conduct.cfm
- Naidu, S. L., Heller, G., Qalomaiwasa, G., Naidu, S., & Gyaneshwar, R. Knowledge, attitude, practice and barriers regarding cervical cancer and its screening using Pap smear, in rual women of Ba, Lautoka and Nadi, Fiji. Pacific Journal of Reproductive Health 2015; 1(2): 50-59.
- Jameson, A., Sligo, F., & Comrie, M. Barriers to Pacific women’s use of cervical screening services. Australian and New Zealand Journal of Public Health 1999; 23(1): 89-92.