Age, ethnicity, health beliefs factor in Pap smear uptake in Singapore
It appears that women who tend to avoid Pap smear screening in Singapore are those who are younger, of Malay ethnicity and who lack confidence in the effectiveness of the procedure as a prevention measure against cervical cancer, a study reports.
“This study provides relevant and up-to-date insights into factors that influence women’s decisions to go for Pap smears,” the investigators said. The results prompt the need to implement age- and culturally sensitive cervical cancer screening promotional approaches for Singaporean women through addressing any false knowledge regarding Pap smears.
The present descriptive cross‐sectional study involved 268 women recruited from a local maternity hospital via convenience sampling. The majority (77.9 percent) were 21–34 years in age, and 83.4 percent were Singaporeans—37.5 percent Chinese, 41.6 percent Malay, 11.2 percent Indian and 9.7 percent other ethnicities. Muslims comprised more than half (53.9 percent) of the sample, while Buddhists accounted for 22.5 percent.
All women completed a questionnaire that examined factors influencing Pap smear uptake. On Pearson’s chi-square or Fisher’s exact test, Pap smear uptake showed significant correlations with age, ethnicity, religion and with the following variables from the perceived benefit/barrier subcategories: effectiveness of Pap smear in detecting cervical cancer, the desire to discover health problems early and considering the procedure to be painful. [J Adv Nurs 2018;doi:10.1111/jan.13769]
The final logistic regression model, which included all significant health belief variables and adjusted for all pertinent demographic variables, performed well in differentiating between women who had ever and never gone for a Pap smear (p<0.001).
Misconceptions an important barrier
Consistent with reports from previous studies, the present data shed light on the physical and attitudinal barriers that women may face in undergoing Pap smears. [Med Princ Pract 2009;18:35-42; J Womens Health 2009;18:1825-1832; Ann Acad Med Singapore 2015;44:326]
With respect to demographic factors, the investigators pointed out that older women are less likely to be deterred by embarrassment associated with Pap smears compared with younger women, who tend to also believe that the Human Papillomavirus vaccine eliminates cervical cancer risk, making it unnecessary to undergo screening.
Malay women are similarly less likely to adhere to the cervical cancer screening guidelines than the Chinese due to the stigma tied to the Pap smear as a test for sexually transmitted diseases and carrying the connotation of being ‘unclean’ and ‘embarrassing’. [Afr J Reprod Health 2006;10:91-103]
Meanwhile, reports say that a minority of Muslim women falsely interpret the Islamic law as not permitting disease prevention due to their belief that sickness and healing can only occur in accordance to God’s will. Some Muslim women even state that it is their cultural norms (eg, subservience and modesty) that hinder them to undergo screening. [BMC Womens Health 2015;15:1-13; Health Care Women Int 2012;33:45-74]
When it comes to health belief factors, the investigators noted that while the motivation to be healthy and the desire to take action for one’s own health favourably affect health screening practices, the fatalistic attitudes of Singapore women toward cancer diagnosis may have influenced their participation in Pap smears. “Some women felt that life and death were predestined and hence, there was no need to go for screening.” [Asian Pac J Cancer Prev 2016;17:3887]
The investigators acknowledged that sample in this study was not consistent with the ethnic distribution of Singapore’s population. This can be attributed to the difference in the levels of public healthcare obstetric service consumption Singaporean women, wherein a higher percentage of Malay women choose to deliver their babies in public hospitals while the Chinese have a preference for private hospitals.
Moreover, the use of convenience sampling in this study limited the recruitment of participants to women who were admitted to the postnatal wards, thus preventing the generalization of findings to the population level.
Despite the study limitations, the present data have important implications. “[H]ealthcare professionals have a crucial role in being a key provider of information to women and in fostering suitable and comfortable environments for increasing Pap smear uptake,” the investigators said.
“Efforts should be targeted at improving the awareness of cervical cancer screening so that women have better knowledge of the benefits of going for Pap smears and the need for regular adherence to the cervical cancer screening guidelines.”