International Journal of Clinical Medicine, 2013, 4, 16-20
Published Online December 2013 (
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.
Received October 13th, 2013; revised November 12th, 2013; accepted December 10th, 2013
Copyright © 2013 Annekathryn Goodman. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In
accordance of the Creative Commons Attribution License all Copyrights © 2013 are reserved for SCIRP and the owner of the intel-
lectual property Annekathryn Goodman. All Copyright © 2013 are guarded by law and by SCIRP as a guardian.
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
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
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
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
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
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
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-
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
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
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