A LASER FOCUSED APPROACH TO IMPROVING HEALTH INEQUALITIES How community outreach is working to improve uptake of cervical screening

Earlier this year, The Ferret revealed that in 2020-21 in Scotland, 440,000 people eligible for cervical screening had not had a smear test in the last three to five years.

If compared to the average percentage of smear tests that show a positive result for Human Papillomavirus (HPV), some 37,000 of these 440,000 untested people could have the virus – and statistically, 340 of these, may be potentially cancerous.

The reasons that people don’t attend screenings when requested are many. Last autumn, Trudy went to her usual GP practice twice two weeks apart and the practice nurse was unable to take the sample with the tools she had at her disposal.

“It caused me a lot of pain and drew blood each time. I’ve instead been referred to a specialist service instead and am waiting on an appointment. Apparently, the nurse has to refer a handful of women on to the hospital or sexual health clinic each month, as it’s not super unusual for them not to fit the speculums available at GP practices. It was a horrible experience and I’d been putting it off for a number of years. I’m 29 now and hadn’t gone for my smear before because I was too nervous and then the pandemic gave me a very good excuse to put it off for longer.”

In the Sandyford sexual health clinic, a specialist service called My Body Back offers cervical screening along with other services like contraceptive care, STI testing and maternity care specifically for people who’ve experienced sexual violence. Designed by survivors, alongside psychologists and healthcare providers, it’s based out of Sandyford Clinic. Appointments last a full hour, with oneon-one time with specially trained female psychologists to talk about concerns and try some grounding techniques before the test begins.

But cultural factors can also contribute to reticence to attend tests. Cervical screening

By Rhiannon J Davies Illustration by Laura Wade

uptake has been shown to be lower in particular ethnic or community groups. In 2020, research into the Roma population in Sheffield found that the cervical screening uptake was between 40-53 percent, well below the citywide average of 73.5 percent. It was found that a longstanding distrust of the role of the state in relation to health underpinned many of the reasons given for not attending.

Recognising these barriers, charity Jo’s Cervical Cancer Trust worked with the South Sector Health Improvement Team of the Health and Social Care Partnership in Glasgow to develop several interventions that would target groups in Govanhill where screening rates are low.

In 2018, uptake of smear tests at Practice A located in Govanhill Health Centre, was approximately 69 percent. So a drop-in clinic was planned, particularly targeting those overdue for a screening. Farhat Khan, a health improvement practitioner in the South Locality Health Improvement Team worked on the project in collaboration with the doctors surgeries based in the Govanhill Health Centre. She said: “My colleague (speaking Slovakian) and I (speaking Urdu) made phone calls to invite people along. The reasons we heard for why people hadn’t come before were barriers like fear, embarrassment, lack of English language skills, bad experiences in the past and a lack of priority.”

On the day, a curtained off stand was set up in the waiting room. Staff wore pink, gave out goody bags and the place was decorated with bunting and balloons. Around 20 women either attended the clinic or booked a subsequent appointment because of the intervention, from a range of ethnically diverse backgrounds. A video that explains what happens with the test was also created in community languages including Romanes (historically an unwritten) language spoken by the Roma community.

This improved uptake has raised awareness for the patients at this practice, as well as increasing knowledge among non clinical staff about the barriers some women face. This model has been repeated at other practices. Having interpreters and bi-lingual healthcare workers made a big difference, along with using a range of different communications methods. However, not enough time was made available and not everyone who showed an interest was able to be seen at that time.

Recognising the particular barriers that Roma women may face, a member of the public engagement team at Jo’s Cervical Cancer Trust worked alongside a group of Romanian Roma women at Govanhill community centre, The Space. NHS Health Improvement staff trained two translators as peer educators, with a focus on group work, facilitator skills and cervical cancer awareness training.

These interventions were trialled pre-pandemic, and when Covid-19 hit, this put a pause to many programmes and projects. Even now, GP services have different priorities, meaning some of the more specialised work has been lost. However, the health improvement team has recently secured some funding to hold another event at The Space.

Farhat explained that this kind of laser focused targeted approach has been applied to other areas too: “For example, we know that bowel screening has particularly low uptake with South Asian men, so my colleague has been out speaking to men’s groups, as well as visiting the Glasgow Central Mosque and the Glasgow Gurdwara. We’ve also been using this opportunity to promote awareness of cervical and breast screening.”

The health improvement team aren’t involved in clinical delivery but instead work to: ‘improve the health and wellbeing of individuals or communities through enabling and encouraging healthy choices as well as addressing underlying determinants of health such as poverty and lack of educational opportunities’.

For Farhat, the community approach of projects like these is key: “I work with the community and just tell people about the benefits versus the risks, so that people can come to an informed choice about whether to participate in the screening programmes… Key to our work is our connections with local community organisations, because if you don't have that, you don’t get to hear what the issues are.”