Politics and patriarchy: Barriers to health screening for socially disadvantaged women
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School of Nursing and Midwifery, College of Health and Science, University of Western Sydney, Sydney NSW
Health screening and early detection of cancer results in significantly better health outcomes and lower mortality, however barriers to such screening are multiple and complex. This paper specifically addresses barriers to women's health screening for socially disadvantaged women in an economically and service disadvantaged area. In this qualitative study, women's healthcare workers and consumers of women's health screening were interviewed and data related to issues for women who had special needs were analysed. Findings indicate there is a lack of access to appropriate services for socially disadvantaged women which affects their screening uptake rates. This study also highlights the difficulties socially disadvantaged women encountered when they were able to access these services which also influenced their decisions regarding subsequent health screening. Implications for nurses and other health care professionals are manifold and include advocating for greater access to services and more sensitive care in the delivery of health screening services for socially disadvantaged women.
nursing; women’s health screening; qualitative research; feminist methods; social disadvantage; health promotion
Health screening and early detection of cancer results in significantly better health outcomes and lower mortality (Australian Institute of Health and Welfare (AIHW), 2007a; AIHW, 2007b). Most deaths due to cervical and breast cancer are avoidable due to screening, early detection and timely treatment. Despite this, in recent years participation rates in some National screening programs have decreased (AIHW, 2007b).
New South Wales (NSW) has the lowest percentage of all states in Australia for participation in the National Cervical Screening Program despite having the highest number of new cases and deaths from cervical cancer (AIHW, 2007b). More specifically, the regional area targeted for this study has notably lower participation rates for breast and cervical cancer screening than NSW as a whole (Sydney South West Area Health Service (SSWAHS), 2005).
Previous studies have identified that women from lower socioeconomic areas, and those who belong to minority cultural groups, have physical disabilities, or have been sexually abused, are less likely to attend women's health screening and are therefore at greater risk of poorer health outcomes than women who utilise health screening services (Chevarley, Thierry, Gill, Ryerson & Nosek, 2006; Durham & Pollard, 2010; Farley, Golding & Minkoff, 2002; Feig, 2006; Reath & Carey, 2008; Robohm & Buttenheim, 1996; Smeltzer, Sharts-Hopko, Ott, Zimmerman & Duffin, 2007; Wagner, 2009; Wang, Fang, Tan, Liu & Ma, 2010; Yankaskas et al., 2010).
The regional area targeted for the purpose of this study is considerably more socioeconomically disadvantaged than most other areas in NSW, with high unemployment and a high proportion of welfare dependent families (SSWAHS, 2005; Australian Bureau of Statistics (ABS), 2006a; ABS, 2006b). Furthermore, this regional area is ethnically diverse with around half of the population being immigrants, and only 40% speaking English at home (ABS, 2006a).
Additional social disadvantage in this area is evidenced by statistics that show that people with disabilities in this regional area account for almost 16% of the population (ABS, 2006a). Also indigenous people, who have a greater incidence of cancers and poorer outcomes than non-Indigenous people (Reath & Carey, 2008), account for around 1% of the total population for the regional area (ABS, 2006a). Further, there were 334 sexual assaults reported in 2007 for this disadvantaged regional area (not including indecent assaults, acts of indecency and other sexual offences which accounted for an additional 370 cases) (Goh & Moffatt, 2008) however, as not all sex crimes are reported, actual figures for these assaults may be much higher.
This paper stems from a broader qualitative study that recruited women's healthcare workers and women's health consumers from the above-mentioned regional area for the purpose of exploring their perceptions and attitudes to women's health screening. A previous publication from this study (XXXX, 2010) highlighted women's preferences regarding the type of service they can access for women's health screening. This current paper explores the accounts of women's healthcare workers and consumers of women's health screening to illuminate perceived barriers to such services for women from minority cultural groups, those who have physical disabilities, and women who have been sexually abused. Whilst it is acknowledged that women's health screening services can incorporate screening for an extensive amount of conditions/diseases, this study refers to cervical screening (Papanicolaou (pap) tests) and mammography due to the emphasis participants placed on these procedures throughout their narratives.
Previous studies (for example see Chevarley et al., 2006, and Smeltzer, 2006) have identified that women with disabilities are less likely than able-bodied women to access health screening. Additionally, women with disabilities have been found to have a higher mortality rate due to breast cancer and are often diagnosed at a more advanced stage than able-bodied women (McCarthy et al., 2006). Whilst McCarthy et al. (2006) do not attribute this to any one cause, they do raise questions related to access to particular treatment options that suggest inequities in health care options offered to women with physical disabilities.
There are multiple barriers to health screening for women with physical disabilities identified in the literature. Survey data that included responses from 1055 women with disabilities, found that the most common reasons for this population not participating in breast screening included a lack of perceived problems, fear of or actual pain associated with mammograms, financial cost and lack of referral by physicians (Yankaskas et al., 2010). Transport and lack of disabled access to healthcare facilities were cited as barriers to accessing mammography by women with more severe disabilities (Yankaskas et al, 2010). This is consistent with previous literature that identified physical barriers as obstructions to health screening by Morrison et al., (2008) and Smeltzer et al., (2007).
Women from minority cultural groups also identified a lack of transport as a barrier to health screening (Durham & Pollard, 2010; Hodgins, Millar & Barry, 2006; Reath & Carey, 2008; Wagner, 2009). Further reasons given for the lack of uptake of women's health screening for women from cultural minorities are knowledge deficits related to the importance of health screening, as well as where and how to access these services (Reath & Carey, 2008; Wagner, 2009; Wang et al., 2010, Wall, Nunezrocha, Salinas-Martinez, Baraniuk & Day, 2010), lack of trust in the healthcare provider (Reath & Carey, 2008; Wagner, 2009), lack of culturally sensitive care (Hodgins et al., 2006, Wang et al., 2010), communication and language difficulties (Durham & Pollard, 2010; Wagner, 2009; Wang et al., 2010), the financial cost of screening (Durham & Pollard, 2010; Hodgins et al., 2006; Reath & Carey, 2008; Wagner, 2009) and fear of pain (Wang et al., 2010).
Pain is further reported to be a trigger for negative feelings during gynaecological examinations in women who have suffered sexual abuse (Leeners et al., 2007). Quantitative studies that have examined the gynaecological sequelae of sexual abuse acknowledge there is considerable psychological distress associated with gynaecological care for these women, and this contributes to lower uptake rates of women's health screening (Farley et al., 2002; Leeners et al., 2007; Robohm & Buttenheim, 1996). In order to alleviate some of this distress, women who have experienced sexual abuse often seek women centred care and prefer women to perform health screening procedures (Leeners et al., 2007; Peters, 2010).
Most research to date has employed quantitative methods to study women's health care attitudes and practices. A qualitative study utilising feminist principles to explore women's health screening practices for socially disadvantaged women has the potential to provide valuable insights and in depth information to nurses and other health care professionals regarding barriers to health screening for these women.
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