The Social Ecology of Cervical Cancer: The Challenges to Pap Smear Screening

doi:10.4236/ijcm.2013.412A1004

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International Journal of Clinical Medicine, 2013, 4, 16-20

Published Online December 2013 (http://www.scirp.org/journal/ijcm)

http://dx.doi.org/10.4236/ijcm.2013.412A1004

Open Access IJCM

The Social Ecology of Cervical Cancer: The Challenges to

Pap Smear Screening

Annekathryn Goodman

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, USA.

Email: [email protected]

Received October 13th, 2013; revised November 12th, 2013; accepted December 10th, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In

ABSTRACT

Cervical cancer is a preventable disease. The risk factors for the development of cervical cancer include both biologic

factors and social factors. In the United States, the leading risk factor for the development of cervical cancer is not hav-

ing a Pap smear for five years prior to the diagnosis of cancer. In low and middle income countries, cervical cancer in-

cidence and mortality are directly related to the lack of both screening programs and cancer treatment facilities. This

paper examines the social ecology of cervical cancer. The literature is reviewed on social and cultural barriers to access

to health care and its effect of cervical cancer rates and outcomes.

Keywords: Cervical Cancer; Pap Smear; Screening; Social Ecology

1. Introduction

Cervical cancer is a preventable cancer. It has a long

preinvasive phase that can be easily detected by an accu-

rate screening test, the Pap smear. Pap smear screening

has become so successful that the American Society of

Cytologists and Cervical Pathologists (ASCCP) 2012

guidelines recommend a reduction in screening fre-

quency to every three years [1]. Despite this highly suc-

cessful test along with the use of HPV testing, which

increases the screening sensitivity, women still present

cervical cancer in high-income countries (HICs) such as

the United States and the European Union [2].

In low and middle income countries (LMICs), screen-

ing programs with Pap smear screening are challenged

by a lack of medical infrastructure. As a result, low cost

solutions using visual inspection with acetic acid (VIA)

have become a successful triage program for cervical dis-

ease since the mid 1990’s.

Yet in LMICs, cervical cancer is the leading cause of

cancer death in women. In HICs, cervical cancer is di-

rectly related to not getting a Pap smear and to not com-

ing in for a pelvic examination. The reasons for not ac-

cessing screening opportunities whether by VIA in

LMICs or by Pap smear and HPV testing in HICs is

complex and nuanced by socioeconomic status, culture,

and the structural violence of healthcare bureaucracies.

This paper examines the social challenges to women in

North America that delay or prevent a life saving, inex-

pensive screening test. The problem is examined at five

different levels: intrapersonal, interpersonal, organiza-

tional, community and societal which are also summa-

rized in Table 1. The paper concludes with a brief sum-

mary of the international literature.

2. The Magnitude of the Public Health Issue

In the United States, there were 12,610 new cases of cer-

vical cancer and 4290 deaths in 2011. Two thirds of cer-

vical cancer cases occur in the underserved populations

of the United States including those living in rural com-

munities and the poor [3]. In particular, the rates of cer-

vical cancer among Latina women and African American

women were 14.7 per 100,000 and 13 per 100,000 re-

spectively compar ed to 8.6 per 100,000 for white women

[4].

2.1. Factors Related to Delay of Screening at the

Intrapersonal Level

The factors that impact health from an intrapersonal level

include both psychological and biological issues. These

The Social Ecology of Cervical Cancer: The Challenges to Pap Smear Screening 17

Table 1. Challenges to Pap smear screening the social ecology levels.

General Influences Barriers to Cervical Cancer Screening

Personality Depression, anxiety

Comprehension Ability to navigate healthcare system

Intrapersonal level

Genetics Less common high-risk subtype HPV

Family Family history cervical cancer

Home environment Embarrassment

Culture Fatalistic beliefs

Interpersonal level

Social mores Smoking

Employment Unemployment

School Lack of health care awareness Organizational level

Health Insurance Lack of healthcare coverage

Race, Ethnicity Minority status, discrimination

Socioeconomic status Low socioeconomic status Community level

Public resources Citizenship status

Healthcare facilities Delay of services

Economics Poverty

Educational system Utilization of healthcare

Society level

Government policy Lack of financial support

include factors that make up personality, ability to un-

derstand health issues, ability to navigate the healthcare

system, and genetics.

Women who suffer from psychiatric disorders will be

less likely to undergo cancer screening [5]. The conse-

quences include delay in diagnosis and treatment. How-

ever one study demonstrated that depression and anxiety

correlated with a reduction in cervical cancer screening

and diagnostic delays of abnormal Pap smears [5]. An-

other systematic review of nineteen studies on mental

illness and screening confirmed the presence of dispari-

ties in screening rates for this vulnerable population [6].

A fascinating study analyzed the distribution of HPV

oncogenic subtype by ethnicity and poverty. There was a

significantly lower proportion of preinvasive disease

related to the most common HPV subtypes (HPV 16 and

18) among African American and Hispanic women in

poverty based areas [7]. This suggests that for poor, mi-

nority women, the current 16/18 HPV vaccine may not

be eff ective for prevention of cervical cancer.

2.2. Screening Barriers at the Interpersonal

Level

In the social ecology health model, the interperso nal lev-

el includes the influences of the family, the home envi-

ronment, and the culture and mores of the peer group.

Despite universal healthcare and an aggressive cervical

cancer-screening program in Canada, Chinese-Canadian

women have had a higher incidence of cervical cancer

and a higher death rate [8]. An analysis of Chinese

women who live in North America revealed a reluctance

to undergo Pap smear screening because of embarrass-

ment. These women considered Pap smear testing to be

linked to sexual promiscuity [9].

In the United States, Latinas have an increased rate of

cervical cancer compared to white women. Cultural

norms are important to understand. Latina women who

never underwent Pap smear screening frequently held

fatalistic beliefs [4]. A program of planned behavior

training to increase perceived behavior control was use-

ful to increase Pap smear screening in this population

[10].

In Canada, there has been an increase in cervical can-

cer rates among the First Nation population. An analysis

of lifestyle risk factors and screening shows no differ-

ence in Pap screening suggesting that the increase is due

to an interpersonal ecology level shift dues to smoking

[11].

An analysis of attitudes towards screening and com-

pliance with Pap smear screening did not show a change

based on a family history of cervical cancer [12].

2.3. Challenges at the Organizational Level

The organizational level of social ecology includes

healthcare barriers that can occur through employment

challenges, the school environment, and healthcare in-

Open Access IJCM

The Social Ecology of Cervical Cancer: The Challenges to Pap Smear Screening

surance. In the absence of universal healthcare in the

United States, insurance coverage becomes one of the

factors associated with delays in screening for cervical

cancer. Screening was strongly associated with health

insurance among African American women in South

Eastern United States [12].

In an analysis of the New Jersey State Cancer Registry,

lack of health insurance was linked to significantly h igh-

er death rates from cancer compared people with private

insurance [13]. Cervical cancer five-year survival rates

for the 2002 to 2004 period were 68% versus 73% for

uninsured versus privately insured [13]. A national health

interview survey of cancer survivors analyzed the rates

of screening for other cancers compared to healthy con-

trols. Women who had survived one cancer were less

likely to undergo cervical cancer screening compared to

the general population and were between 8% and 20%

below the screening go als of “Healthy People 2010” [14].

The reasons for lack of screening were unclear and the

authors recommended information campaigns to address

this screening deficit.

Interventions at an organizational level can be effec-

tive for vulnerable groups. A program using lay health

workers to educate and navigate Mexican-American wo-

men led to an in crease in Pap smear screening in this po-

pulation [15]. Another similar intervention recruited fe-

male family members among Arab, African American,

and Latina women to increase willingness to get screen ed

[16].

2.4. Challenges at the Community Level

The community level includes factors that affect health-

care that derive from issues of race, socio-economic sta-

tus, the resources of available public resources, and the

“built environment”. Minorities by race and ethnicity

experience a disproportionate incidence of cervical can-

cer compared to whites. In African American women, the

rate of cervical cancer escalates with age [3]. Looking at

changes in disparities from 1979 to 2009, the cervical

cancer incidence equalized for younger African Ameri-

can women compared to whites but the disparities per-

sisted for older black women [17]. Delay in definitive

therapy for cervical cancer occurs among women with

lower income and educational background. Analysis of

delays pointed to financial barriers, delay on the part of

the doctor, and inability to navigate the healthcare system

[18].

In Georgia, there were geographic differences in inci-

dence and death rates for cancer that appeared to be di-

rectly linked to proximity to health centers and socio-

economic status [19]. The mortality to incidence ratio

(MIR) is higher among black women at 0.423 compared

to white women with a MIR of 0.279 [19].

Another study looking at screening among African

immigrant women in Minnesota analyzed health behav-

iors through a survey [20]. Age and education were not

associated with getting Pap smears. The most important

factor was duration of living in the United States. This

data suggests that unlike African American women, the

barriers to Pap smear screening for immigrant women

have more to do with learning the system of a new coun-

try.

Native American women reported reluctance to use

health care facilities for cancer screening because of

perceived discrimination [21]. Other factors of impor-

tance for these women included a high school education,

unemployment, and a history of diabetes.

2.5. Cervical Cancer Screening Disparities at the

Society Level

The societal influences of healthcare usage and outcomes

include the infrastructure of healthcare, the presence of

health facilities, economics, the educational system, and

government policy.

The incidence of cervical cancer in the United States

varies by geography and region. This partially reflects

areas of deep poverty such as Appalachia, the Deep Sou-

th, and the Mexican-Texan border. For example, the in-

cidence of cervical cancer and the cancer death rate is

higher among white women in Appalachia than among

white women who do not live in Appalachia (9.6 and 3.1

per 100,000 and 7.7 and 2.3 per 100,000 respectively)

[22]. There are disparities in medical infrastructure utili-

zation. Follow-up of abnormal results and utilization of

treatment services are significantly delayed for ethnic

minorities and poor women compared to white women

[23].

3. Cervical Cancer Screening Challenges

around the World

In Malaysia, the incidence of cervical cancer is increas-

ing [24]. However, semi-structured interviews of patients

with cancer revealed that the majority of people had nev-

er heard of cancer screening tests. Analysis of the barri-

ers to cervical cancer screening revealed a lack of public

education suggesting an organizatio nal level deficit. This

was combined with a personal and community belief

system that was suspicious of medical testing [24].

Cervical cancer screening rates have been increasing

in Korea from 40% in 1998 to 52.5% in 2010. However

demographic data reveal that screening is related to so-

cioeconomic status through educational level and house-

hold income [25]. This data suggests that the main bar-

rier to screening in Korea is at the organizational lev el in

the social ecology model. This same pattern by socio-

economic status for cervical cancer was identified look-

ing at cancer registry data in Iran [26].

Open Access IJCM

The Social Ecology of Cervical Cancer: The Challenges to Pap Smear Screening 19

In Argentina and Latin America in general, cervical

cancer is the second most common cancer in women. An

analysis of Pap smear screening showed an increase in

screening from 51.6% in 2005 to 60.5% in 2009 [27].

However, most of the increase in Pap smears screening

has been among the high-income women. An evaluation

of eight provinces in Argentina revealed either a stable or

an increasing inequality by income and education gradi-

ents among medium-income women. This suggests that

the world economic crisis has differentially impacted the

medium-income group.

In the European Union, all the countries of the EU

have universal healthcare. Disparities in screening are

still seen. For instance, in the United Kingdom, cervical

cancer screening rates were significantly lower in women

with learning disabilities [28]. This barrier is at the in-

trapersonal level and would require the establishment of

a navigation system within the medical infrastructure to

address this population a risk. In Italy, education and

occupation were associated with high levels of cervical

cancer screening compared to unemployed women [29].

4. Conclusion

The barriers to cervical cancer screening are complex

and intimately linked to social, cultural, and societal

forces.

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