Holistic Care: Increasing Cervical Cancer Screening among Aboriginal Women

Cervical cancer is cancer of the cervix, which is located at the opening of the uterus. The two most common types of cervical cancer are squamous cell carcinoma and adenocarcinoma. These types of cervical cancers usually develop from precancerous changes in the cervix, which can be detected in early screening methods (Canadian Cancer Society, 2018). Cervical cancer is among one of the most preventable cancers with the use of the screening method, Pap test. In the Canadian Cancer Statistics report (2018), it states that more than 70% of cervical cancers diagnosed in females aged 18-39 years were diagnosed at stage I, which reflects early detection through cervical cancer screening programs. In addition, in Ontario, the regular use of Pap screening has decreased both incidence and mortality by 60% over the last 30 years (Marr et al., 2016). This is also further demonstrated in Figure 1, where you can see the dropping rates of deaths due to cervical cancer.

Figure 1. This line chart shows the changes in cervical cancer death rates from 1975 to 2011. Rates dropped most years between 1975 and 2007, but stayed the same between 2008 and 2011 (National Center for Chronic Disease Prevention and Health Promotion, 2014)

A Pap test is a simple screening test that can detect cell changes in the cervix that may lead to cancer before women feel any symptoms. The Pap test is done in a healthcare provider’s office using an instrument called a speculum. This speculum is inserted into a woman’s vagina so that her cervix can be seen. A sample of the cells taken from the surface of the cervix is collected and sent to a laboratory to be examined (Cancer Care Ontario, 2018). The Ontario Cervical Screening program, which is similar to that of other provinces, recommends women ages 21-69 have a Pap test every 3 years (CCO, 2018).

However even with this knowledge of early detection of cervical cancer, the burden of cervical cancer in Indigenous populations worldwide is still very high due to under-screening (Marr et al., 2016). Marr and her colleagues (2016) state that cervical cancer is the most common cancer in First Nations women living in the Northwest Territories, and in an Albertan community, the incidence of cervical cancer was 20 times higher than in the province as a whole (p. 2). This is also shown among Indigenous women from the United States, Australia, and New Zealand. A large contributing factor to these statistics may be low screening or attendance for follow-up appointments among Indigenous populations. Spence, Goggin, and Franco (2007) determined that screening is the key to cervical cancer prevention through early detection and that new cervical cancer diagnoses worldwide are in women with inadequate or no screening or follow-up.

To help promote cervical cancer screening programs among Aboriginal women, a multilevel health approach can be used to identify the barriers and find ways to address this complex issue. Both Goodman (2013) and Marr et al. (2016) used the social ecological model to help approach the issue of low cervical cancer screening among this population. The social ecological model (SEM) defined by UNICEF (2014) is a theory-based framework for understanding the multifaceted and interactive effects of personal and environmental factors that determine behaviours (p. 1). There are five nested, hierarchical levels of SEM: individual, interpersonal, community, organization, and policy/enabling environment (Figure 2 and Table 1).

Figure 2. The social ecology model (UNICEF, 2014)

Table 1. A Description of the SEM levels (UNICEF, 2014).

Goodman (2013) used the SEM to identify challenges at each level that affected women from following through with the Pap smear screening. She found that for example, at the intrapersonal level, women who are suffering mental health issues are less likely to undergo cancer screening and that depression and anxiety are correlated with a reduction in cervical cancer screening (p. 17). Goodman (2013) also identified some challenges at the community level that derive from issues of race and socioeconomic status. Native American women reported reluctance to use health care facilities for cancer screening because of perceived discrimination (p. 18).

Marr et al. (2016) used a collaborative research team that partnered with First Nations communities in Northwest Ontario to explore feasible, community-based intervention strategies for cervical cancer screening. They interviewed health care professionals stationed in the partner communities and identified key recommendations to increase cervical cancer screening participation among Indigenous women (p. 3). They identified seven key themes through the interviews and determined that it would have to be a multilevel process to increase screening recruitment. The seven themes were: explain the value of cervical cancer screening; motivate through specific educational strategies and capacity building; embed cervical cancer screening into community events; health care providers need a trusting rapport with women; integrate cervical cancer screening recruitment into existing health care services; create a dialogue on cervical cancer screening in day-to-day activities; and incorporate First Nations gender perspective on body and preferred screening techniques to enhance privacy and comfort (Maar et al., 2016). These seven themes can be placed into three global concepts of a multilevel process. The first concept is to target women and their families, second is to promote preventive care with current and local health care services, and lastly the third concept is to motivate individual behaviour change with community-based strategies (Figure 3).

Figure 3. (a) Thematic network for “targeting women at the individual level and through the family”- the innermost circle, individual and family level, of the social-ecological model. (b) Thematic network for “promoting preventive care within current, local health care practice”- the second level, organizational level, of the social-ecological model. (c) Thematic network for “motivating with culturally appropriate, community-based strategies”- the third level, community level, of the social-ecological model (Maar et al., 2016).

Maar et al. (2016) felt that adopting a holistic approach to health promotion with focus on the First Nations women and their roles as nurturers of life and caretakers of their families’ and their communities’ health would provide a positive influence on increasing cervical cancer screening.

In conclusion, the barriers and challenges for Aboriginal women in cervical cancer screening is complex and linked to social, cultural, and societal forces. There is no single health promotion strategy that would help increase preventative cancer screening among Aboriginal women, but rather a multi-pronged and multi-leveled approach is essential to reach more women. This is why the social ecological model is so powerful as it allows for individual focus at each level in the hierarchy to identify pitfalls and solution to those issues. It is important for cervical screening services to be flexible, personal, friendly, and respectful of Aboriginal women. An important consideration to be more culturally sensitive is the prospect of the use a non-invasive screening approach, such as the human papillomavirus (HPV) test. The HPV test has a sensitivity of more than 95% and can be performed based on self-collection, which adds to the convenience and privacy as a screening method. The HPV test is not currently used as a primary screening method for cervical cancer in Canada, but it is available in individual cases.

References: https://lynnnguyen17.wixsite.com/eportfolio/multilevel