Toolkit for engaging Under-screened and Never-screened women in the National Cervical Screening Program

Women from CALD backgrounds, including women who have experienced female genital cutting

Page last updated: 15 December 2019 (this page is generated automatically and reflects updates to other content within the website)

Cross-cultural understanding
Barriers to screening
Engagement strategies
Questions to ask yourself before a consultation about cervical screening with women from a CALD background
Women who have experienced female genital cutting
Working with interpreters
Healthcare provider resources
Recording information on county of birth and language preference
Healthcare provider training
Consumer resources

Barriers for women from CALD backgrounds

  • Lack of knowledge of the availability, purpose, importance and benefits of cervical screening
  • Belief that cervical screening is unnecessary without symptoms
  • Misunderstandings in regards to causes of cancer (i.e. cancer is contagious, cancer is a punishment for past behaviour/moral conduct, cervical cancer is caused by promiscuity, cancer = death)
  • Negative cultural perceptions about cancer – for example fatalistic and superstitious attitudes (i.e. cancer is the will of God, cancer is incurable, cancer is predetermined). This may leave some women to perceive cervical screening as unnecessary
  • Beliefs in traditional, non-western medicine
  • Stigma and taboos around discussing sexual topics
  • Fear, shame and stigma associated with cancer
  • Fear, modesty and embarrassment around the test
  • Language, communication and literacy difficulties
  • Availability of female healthcare providers
  • Availability of female interpreters
  • Availability of a healthcare provider who speaks their language
  • Women may have difficulties accessing and navigating the Australian healthcare system (particularly, newly arrived women)
  • Women may have other competing priorities such as employment, housing and family (particularly, newly arrived women)
  • Women may have multiple complex health problems such as chronic diseases and/or physical and mental health consequences of trauma, violence and sexual abuse (particularly, women who have newly arrived as refugees)
  • Distrust of healthcare providers due to experiences from their originating country
  • Resistance to usage of local health systems due to perceptions or experiences of culturally insensitive services
  • Logistical concerns – lack of transport, difficulties getting to the appointment, organising childcare if necessary
  • Cost to see a healthcare provider if bulk-billing is not available
Women from CALD backgrounds are less likely than women from the general population to participate in cervical screening. The reasons for this are related to cultural beliefs, a lack of understanding of the screening program and the Australian health system and language barriers.

Women who have experienced female genital cutting (FGC) may face additional barriers to screening associated with psychological trauma, pain (real or anticipated) and embarrassment. Women who have experienced type 3 FGC (where the labia have been sewn together to make the vaginal opening smaller)

may physically be unable to have a speculum examination and may be eligible for self-collection. (See Self-collection section) also who have genetic abnormally/dysmorphia of vagina where the opening is too small to introduce smallest speculum.
As women from CALD backgrounds come from diverse cultures and have diverse beliefs, it is important for healthcare providers to deliver culturally safe, appropriate and inclusive services.

Cross-cultural understanding

When working with women from CALD backgrounds, it’s important to consider their linguistic and cultural needs when discussing cervical screening.

Assessing your patient’s individual culture is necessary to assist you in caring for her in a culturally-sensitive way. Cultural factors can be dynamic and are specific to each person. Factors include: race, gender, religion and ethnicity.

It’s important to recognise the complexity of your patient’s cultural background in addition to other issues that may impact on her life, such as migration, settlement and socioeconomic status. If you need to know more about a woman’s beliefs or values, just ask.

If you are working in a mainstream health service, collaborating with women’s ethno-specific/multicultural health and welfare agencies will help you to share information and best practice ideas and to link your client to these services for further multilingual information about their health. Bilingual and bicultural health educators have expertise and skills in providing education for migrant and refugee women, and in promoting health services in general.

Barriers to screening

In addition to the general barriers women may face in participating in cervical screening, the following barriers have been identified as common for women from CALD backgrounds.

Engagement strategies

The following strategies have been shown to be effective in engaging women from CALD backgrounds in cervical screening.

Emotional / cultural

Lack of knowledge about -

Personal relevance

Practical

Embarrassment about the procedure

The purpose of a Cervical Screening Test

Not believing cervical cancer is a risk

Time constraints, including availability of child care

Fear - of tests, of being diagnosed with cancer, of further tests or of cancer treatment

The role of screening in prevention

Not considering screening to be a priority

Intending to have a test, but not getting around to doing it or forgetting when the test is due

Reluctance to screen after a negative past experience such as previous pain or discomfort

The risks of cervical cancer

Limited previous experience of prevention or screening programs

Concerns about cost

Past history of sexual abuse or sexual violence

Who needs to be tested

Being asymptomatic

Language issues

Confidentiality concerns

The accuracy of the test

Perception that HPV vaccinated women do not require screening

Lack of transport

Cultural issues (related to circumstances, beliefs, background and inequities in society)

Cancer and/or a belief that cancer = death

Perception that screening is not required for women who have sex with women, or for transgender men

Physical, social or practical barriers associated with a disability

 

 

 

Weight-related barriers (obesity)

 

 

 

Personal preference for choice of healthcare provider

Questions to ask yourself before a consultation about cervical screening with women from a culturally diverse background

  • Do I need a qualified interpreter? Do I need to access a female interpreter?
  • Has my patient understood the procedure of cervical screening? Should I ask her to repeat to me what I have explained before she gives consent?
  • Are flexible, longer and multiple appointment times available for my patient? If this is not possible, do I know where to refer my patient for outreach sexual and reproductive health education and information?
  • Do I know where to access multilingual health information (such as written information, DVDs, CDs, posters, charts and 3D models) to give my patient more information?
  • Consider what information is necessary to guide your consultation:
    • Country of birth and time of arrival to Australia
    • Previous cervical screening experiences
    • Is the woman from a country with prevalent practices of female genital cutting?
    • Would the woman prefer a female practitioner?
    • Should I explain the concept of confidentiality to the woman who may be concerned about her husband or family knowing why she has visited the doctor?

Women who have experienced female genital cutting

Barriers for women who have experienced female genital cutting
  • Psychological trauma of female genital cutting
  • Pain due to scar tissue and infection. Women may anticipate that the Cervical Screening Test will be painful/uncomfortable/difficult
  • Lack of knowledge of the availability, importance and benefits of cancer screening
  • Negative cultural perceptions about cancer – for example fatalistic and superstitious attitudes (i.e. cancer is the will of God). These attitudes may lead some women to perceive cervical screening as unnecessary
  • Embarrassment associated with female genital cutting (i.e. anticipating the healthcare provider to have a shocked reaction)
  • Language, communication and literacy difficulties
  • Fear of the test
  • Availability of female healthcare providers
  • Women may have difficulties accessing and navigating the Australian healthcare system (particularly, newly arrived women)
  • Women may have other competing priorities such as employment, housing and family (particularly, newly arrived women)
Female genital cutting is practiced in 29 countries around the world and is most prevalent in Africa (particularly Somalia, Guinea, Djibouti, Egypt, Eritrea, Mali, Sierra Leone, and Sudan), although it is also practiced in some parts of the Middle East and Asia.

Women are increasingly migrating to Australia from countries where female genital cutting is practiced. It is estimated that there are approximately 120,000 migrant women in Australia who have undergone the practice in their countries of birth. Often these countries do not have organised cervical screening programs.

In Australia, there is a low uptake of preventative health services by African women and it is known that women from culturally and linguistically backgrounds are less likely to participate in cervical screening.

Barriers to cervical screening for women who have experienced female genital cutting

In addition to the general barriers women may face in participating in cervical screening, and those faced by women from CALD backgrounds, the following barriers have been identified as common for women who have experienced female genital cutting.

Strategies to engage women who have experienced female genital cutting

The following strategies have been shown to be effective in engaging women who have experienced female genital cutting in cervical screening.

Strategy

Detail

Appropriate communication

Provide time to explain the procedure and allow women to ask any questions, including that they have the right to request a female provider.
Use simple language and pictures where appropriate/available. Women may not be familiar with basic health topics and concepts. Provide written information in simple plain language (English or other language), but be aware that not all women are literate and/or may prefer to receive information in oral form. Use a telephone interpreter if required.
Be non-judgemental and empathetic to the women’s situation. Many women are proud to have undergone FGC, but are aware that in Australia it is a judged procedure.
Offer culturally-appropriate resources such as translated fact sheets for women.
Provide suitable, trained female interpreters, as it may not be appropriate to use a family member, friend, or even an interpreter from the same community.

Cultural training

Offer cultural safety training for all health service staff.
Provide specific training for healthcare providers around how and when to ask about female genital cutting (i.e. country of birth is a good indicator; use simple language; be sensitive; use value neutral non-judgemental language).
Develop a practice guide for healthcare providers which includes examples of how to ask women about female genital cutting and tips to support them to screen.

Make the procedure as comfortable as possible

Offer women the opportunity to perform the test in a different position (e.g. on their side rather than their back).
Consider use of a smaller speculum.
In some cases it may be appropriate to offer self-collection.

Patient records

Record interpreter requirements and female genital cutting status in medical records for future consultations.

Choice or cervical screening provider

Ensure female cervical screening providers are available.
Refer patients to a cervical screening provider who speaks their language (preferably female) or to a service that may be more acceptable (i.e. a healthcare service for migrant and refugee women).



How to Engage Women from Culturally and Linguistically Diverse Backgrounds About Cervical Screening – Chapter 1




Working with an Interpreter – Chapter 2




Discussing Cervical Cancer and Screening – Chapter 3




Explaining the Screening Pathway – Chapter 4




Working with interpreters

These resources will help you to assess whether an interpreter is required, and to book and brief interpreters.

Assessing the need for an interpreter - provides practical information on when and how to offer an interpreter. (2 pages) – Centre for Culture, Ethnicity & Health

    Engaging an interpreter is recommended when a patient:
    • Requests one
    • Speaks English as a second language and is in a stressful, complex or unfamiliar situation
    • Is difficult to understand
    • Responds only in a limited way
    • Relies on family or friends to interpret
    • Wishes to communicate in his or her preferred language, or
    • Cannot grasp or respond to questions in English.
  • Booking and briefing an interpreter - provides basic information about engaging and briefing interpreters. Includes administrative information and questions to consider. (2 pages) - Centre for Culture, Ethnicity & Health
Additional time should be allowed for consultations with interpreters and female interpreters should be engaged for cervical screening consultations. Please ensure there is a space for the interpreter to position themselves behind a screen or curtain while the Cervical Screening Test is being performed.

Although working with professional interpreters is advised, if none are available in the required language, women may wish to have a trusted friend or family member who can speak English at their consultation/s, or a phone interpreter could be arranged.

Healthcare provider resources

  • Speaking with clients who have low English proficiency – tip sheet. Includes information on preparing for your conversation, issues to be conscious of during the conversation and how to check information has been understood. (2 pages) – Centre for Culture, Ethnicity & Health
  • Using the teach-back technique – advice for communicating with clients with low health literacy. (2 pages) - Centre for Culture, Ethnicity & Health
      Basic steps involve:
      1. Explaining one concept of a diagnosis or treatment plan to the client
      2. Assessing the client’s recall and understanding by asking the client to explain what you said
      3. Repeating the process until the client can demonstrate they have satisfactorily understood the information
      4. Introducing the next concept
    • Female genital cutting and cervical screening resource card - a guide for practitioners – includes descriptions and diagrams of the types of FGC and gives suggestions for supporting women and sample questions you could include in a consultation (2 pages)
    • See Health literacy for strategies to help improve patients’ health literacy.
    • If you require an interpreter please contact the Translating and Interpreter Service (TIS) on 131 450 or visit their website

Recording information on country of birth and language preference


Health services should work toward systematically identifying and recording both the country of birth and language preference of all patients. This background information can be an important indication of clinical risk factors and can assist healthcare providers in providing relevant care.

Asking and recording a patient’s preferred language and whether an interpreter is required will assist health services to plan for consultations and in making accessible health information available.

Collecting data on the cervical screening participation of women from CALD backgrounds will enable a greater understanding of their screening behaviour and inform targeted strategies to increase their participation in screening at a local, state and national level.
Collecting self-identified status data from Aboriginal and/or Torres Strait Islander patients and patients from culturally and linguistically diverse (CALD) backgrounds

Healthcare provider training

Various training programs are available to assist healthcare providers working with CALD communities to improve their cultural competency. Topics include improving cultural awareness and understanding and working with interpreters.
National options include:
  • Introduction to Cultural Competence – introductory on-line learning module. - Centre for Culture, Ethnicity and Health
  • Common Threads - Gendered cross-cultural training in sexual and reproductive health for healthcare providers and community workers who work with immigrant and refugee women – 2-day workshop available nationally - Multicultural Centre for Women’s Health
Contact the relevant peak bodies in your state/territory for additional training options.

Consumer resources

  • 5. Consumer resources – includes a range of downloadable resources which can support conversations about cervical screening.