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The information on this page is aimed at professionals who want to understand barriers to cervical screening.
What do we mean by a ‘barrier’?
There is a broad and complex range of reasons why women and people with a cervix find cervical screening difficult. We call these reasons ‘barriers’ because they often factor into someone’s decision not to attend. Barriers can vary hugely between different groups or communities.
It is important to be aware there are lots of reasons patients may avoid cervical screening and that those reasons may not always be obvious – so assumptions can be unhelpful or even harmful. It can be helpful for all staff to understand this, including reception staff, nurses and doctors.
Barriers to cervical screening
This list of barriers isn’t exhaustive, but covers some common reasons why cervical screening can be difficult for patients. Be aware that there are lots of myths surrounding cervical screening that may also create barriers to access.
Read about:
- Embarrassment >
- Pain >
- Relevance >
- Fear of results >
- Judgement >
- Convenience >
- Physical disability >
- Trauma >
- FGM >
- Familiarity with the sample taker >
- Lack of understanding >
“I’m too embarrassed to go for cervical screening”
Feeling embarrassed is a common obstacle to cervical screening. This can be especially true if it is someone’s first test. Any gynaecological examination or test can cause this reaction, because genitals are a part of the body that may not be shared with many others – particularly healthcare professionals.
What you can do
Although cervical screening and genitals may be commonplace for you, remember that isn’t the case for your patients:
- Make sure the consultation room is as comfortable as possible. Simple things can help, such as making sure the bed doesn’t face the door or reassuring them no one unexpected will walk in.
- You can suggest a patient wears something like a long skirt or brings a piece of clothing to cover up. This may help them feel less exposed. They’ll also be given a plastic or paper sheet for modesty.
- Hang a ‘Do Not Disturb’ sign on the door, as well as asking the patient if they would prefer it to be locked or unlocked.
- Your surgery could consider cervical screening drop-in clinics, with refreshments, information stands, and an informal atmosphere. This setting can help normalise cervical screening and create a positive association.
“Screening is painful”
For some women and people with a cervix, cervical screening may be painful, which can be distressing. There are a number of reasons for this, including:
- menopausal and post-menopausal symptoms, such as vaginal dryness
- vaginismus
- anxiety – this could be caused by many things, including a previous bad experience, worry about the test or fear of results
- a tilted womb, where the cervix is sitting in a posterior or anterior position
- female genital mutilation (FGM), where the genital area has been cut
- using a speculum that is too big
- not using any or enough lubrication.
What you can do
- Try to encourage your patient to talk to you about their concerns so you can understand their fears and past experiences. If someone expresses concerns or seems nervous, acknowledge their worries.
- Use a smaller speculum. Show your patient the options so they can choose their preferred size.
- If someone has a tilted cervix, making a ball with their fists and placing them behind their lower back can make it much easier to find the cervix. Lying in the left lateral position may also help.
- If someone has vaginal dryness, prescribing an oestrogen cream in advance can help with lubrication.
- Suggest ways to cope with any kind of anxiety-linked pain, including breathing exercises, listening to music or a podcast for distraction, or having a partner or friend in the room.
“Cervical screening isn’t relevant for me”
There are a few myths that mean some women and people with a cervix think cervical screening isn’t relevant for them, including that:
- screening isn’t necessary after menopause
- they haven’t had sex for a long time
- they have been in a monogamous relationship for years.
However, we know that HPV – the main cause of cervical cancer – can be dormant in the body for years and may become active again, which cervical screening can help detect.
The media also sometimes focuses on cervical cancer as a ‘young person’s’ cancer. While 30 to 45 is the peak age for being diagnosed with cervical cancer, any woman or person with a cervix can be affected at any age.
What you can do
- Develop resources, such as posters, that specifically target this age group.
- Work with non-healthcare partners in the area that have links with this age group to increase awareness. For example, local community groups or hairdressers.
- Make sure patients have the information they need to understand cervical screening and assess their risk. You could direct them to the patient information about HPV and cervical screening on our website or print it out for patients to read at home.
“I’m scared about what my results will be”
It’s natural for patients to worry about their cervical screening results. Sometimes this is exacerbated by myths, including that cervical screening is a test cervical cancer.
What you can do
- Explain to patients that cervical screening isn’t a test for cancer – it’s a way of preventing cancer from developing.
- Let your patient know that you and other staff will be there if they have any questions when they get their results.
- Signpost your patient to our services in case they have more questions or need extra support.
“Members of my community may find out I’ve gone for cervical screening”
Anonymity, or lack of it, can be an issue in communities where there is shame about being sexually active outside of marriage. Even if a woman is married, there may be a belief in the community that only women who have had multiple partners need to go for cervical screening.
This stigma around being thought of as having sex with many people (promiscuity) means some are very frightened of being seen at their GP surgery or clinic. They may have fears about being shunned or even physically harmed as a result.
What you can do
- Be aware that your patient may not tell you this is an issue for them. It’s likely they will either avoid screening completely or may go out of their way to travel to a distant clinic where they won’t be seen.
- Make sure all patients know cervical screening is completely confidential. People have appointments at GP surgeries and clinics every day, for a variety of reasons. Nobody will know what they are there for.
“I can’t find the right time to go for a test”
It can be difficult to get to an appointment at a time that suits. This may be even worse at the moment because of COVID-19 restrictions, if your surgery is only able to offer cervical screening at certain times.
Sometimes patients have commitments, including childcare or work, which clash with available appointments. Cervical screening will understandably not usually be as much of a priority as these other commitments, so it can easily fall off someone’s to-do list.
What you can do
- If your surgery has capacity, consider organising some evening or Saturday morning drop-in clinics for patients who work long hours during the week. Making these regular can be a big advantage.
- Signpost the patient to any local clinics that offer cervical screening appointments at more flexible hours.
“My physical disability makes it hard or impossible for me to attend”
Women and people with a cervix who have a physical disability have told us their disability has made it more difficult for them to access or attend screening. Barriers can include:
- lack of wheelchair access
- problems getting onto the examination couch for the test
- previous misunderstanding, dismissal and negative experiences of cervical screening.
What you can do
- Learn about the barriers patients with a disability may face in accessing screening. Read the findings from our report >
- Check whether your surgery is able to invest in equipment, such as a hoist or adjustable couch.
- If wheelchair access or equipment at your surgery is not suitable, you may be able to refer patients to the colposcopy department at your local hospital or another surgery.
- Discuss whether it is realistic to offer home visits for those who are housebound.
“The test is intrusive and traumatic”
Anyone who’s experienced trauma, such as sexual violence or a previous negative experience with health tests, may find cervical screening distressing or triggering.
What you can do
- At the booking stage, reception staff could ask whether a patient has any concerns and if possible, allow extra time for the appointment so the nurse can explain the procedure step by step.
- Let the patient see the equipment that will be used.
- Ask the patient if they would like to insert the speculum themselves, in their own time.
- Make sure the patient knows they can ask for the test to stop at any point.
- Offer a chaperone – it may be helpful for the patient to have someone they trust with them.
- Make sure they know they can bring things that help them feel more comfortable, such as a mobile phone, tablet or book.
- Place a sign or poster in your surgery acknowledging difficulties and encouraging patients to speak with a staff member.
- Signpost patients to specialist clinics, such as My Body Back, that are trained to offer specific support to those with trauma.
“I have been affected by FGM”
Female genital mutilation (FGM) is when parts or all of the female genitals are deliberately cut, changed or removed. It can make any gynaecological examination, including cervical screening, painful or distressing for the patient.
What you can do
If you see a patient who is affected by FGM, you should follow the guidelines in your area about recording or reporting it.
- Don’t react. FGM can be a difficult thing to witness, but it is important to maintain your professional composure.
- Signpost your patient to specialist support services for further help.
- Let your patient know that they are in control. Get verbal consent, tell them each step before you do it, and make sure they know you can stop at any time.
“I might know the nurse taking the sample”
Our Public Health Engagement Coordinators have found familiarity with sample takers can be a problem in rural areas with tight-knit communities. Understandably, this can feel challenging with such an intimate test. Similarly, patients may find having screening at the same surgery as their family may feel embarrassing.
What you can do
- If you work in an area like this, it may be worth seeing if you can do a ‘swap’ with a surgery in a neighbouring location. That way, you can have a locum taking samples on certain days and advertise that fact.
“I don’t understand what I’m being invited for”
This can be an issue for a number of patients, including:
- some patients with lower literacy – in the UK, literacy is generally low and medical information can be difficult for many people
- anyone who doesn’t have English as a first language – the invitation letter may not be accessible for them and, if they are from a country that does not have a routine cervical screening programme, the concept may be unfamiliar
- some people with a learning disability – the invitation letter or explanation about cervical screening may not be accessible for them.
What you can do
Try to make sure you and other staff are aware of those who may need a different type of support to understand and cervical access screening.
- Offer interpreters in person or over the phone, translated information or translated videos.
- Offer Easy Read versions of invitation letters and other resources.
- Offer extra time during cervical screening appointments, so the sample taker can explain the test and answer any questions.
- Work with your local learning disability nursing to see what specific support they can offer patients.
- Ask what else they need to make an informed decision about cervical screening.
