Interpretation
Our results support the current literature base regarding the uptake of cervical cancer screening in young women. Young women face unique barriers and facilitators in comparison to older groups, necessitating age-specific interventions. Our studies highlighted age-specific barriers such as concern about privacy from parents, transportation difficulties, and continuity of care after moving away for school. In addition, as this is typically the first invasive procedure that young women undergo, there were concerns about pain, discomfort, and the intimacy of the pelvic exam. The young women who participated in these studies had helpful suggestions regarding age-specific interventions, such as emailed reminders in comparison to written reminders, or screening provided on college campuses. Our literature also aligns with the greater research base regarding young people and low preventative service use in general, as many young people do not have a consistent family physician.50,51
When comparing results across internationally, we noticed that many themes were universally represented across income levels. There were accessibility concerns, cost concerns, and knowledge gaps in both lower and higher income countries. However, it is important to note that screening rates differ across the globe, and even within the same country for lower income and minority populations. As financial constraints were cited as a frequent barrier in our included studies, it is not surprising that women from lower socioeconomic backgrounds have lower screening rates.52,53 In addition, women from minority populations may have more strained relationships with the health system due to discrimination, lack of cultural competence, and the historic failure of medical systems to be equitable towards minority groups.54,55 This is particularly relevant to cervical screening, as the patient’s individual relationship with the health system was noted as an important barrier or facilitator towards screening. To increase cervical screening rates, it is important that we improve health system interactions overall to be more equitable.
Additionally, we noted that cultural barriers were discussed in several studies, including sex-negative beliefs.23,30,34,36Several studies highlighted a fear of hymen breakage with the pelvic exam, which has the societal stigma against virginity loss.21,23,24,31 This concept was not only studied in Asia and Africa, but also included two studies from the United States.23,31 It is important to educate about the concept of virginity as a social construct and improve sexual education for girls. In higher-income countries, language barriers, health literacy, and cultural beliefs were also noted as barriers among recent immigrants. Recent literature has shown that the “healthy immigrant effect” tends to taper off after several decades in a new country, with immigrants at higher risk of poor health outcomes and underuse of health services.56,57 Specific to cervical cancer, immigrant and minority populations in developed countries are at higher risk, often due to low screening rates.58,59 Thus, interventions that target cervical screening uptake should have an intersectional approach in addressing these issues, rather than a “one size fits all” approach.
Further research is required to characterize which interventions are the most effective for different age groups, including a diverse range of ethnicities, sexual orientations, educational backgrounds, and income levels. Moreover, we were surprised that none of the studies specifically targetted the beliefs of non-heterosexual or non-cisnormative participants, as this has been documented as a growing public health concern and source of misinformation.62-65 Studies regarding transgender men were eligible for study inclusion, but yielded no search results based on our protocol. Further specific investigation is required to understand this topic, from both the perspective of the patient and the physician.