Between facilitators and barriers: older women's perceptions regarding cervical and breast cancer screeningAbstract
Objective To understand the perceptions of women aged ≥ 60 years regarding cervical and breast cancer screening.
Method An exploratory descriptive study with a qualitative approach was conducted. Data collection took place in 2023 through semi-structured interviews. The interviews were recorded, fully transcribed, and subjected to content analysis.
Results Three thematic categories emerged: (Mis)understanding about screening – with perceptions related to the purpose, frequency, and completion of examinations, relevance and problems in carrying out the screening, as well as the influence of hysterectomy, absence of sexual life, and symptoms; Facilitators of adherence to screening – involving the relationship with healthcare professionals, service organization, and family history; and Aspects that hinder screening – such as physical discomfort related to the examinations, age-related characteristics, and feelings of fear, shame, and anxiety.
Conclusion The women's perceptions revealed both motivating factors and barriers to screening. Therefore, considering these unique characteristics is essential for supporting educational strategies, strengthening bonds, and promoting welcoming environments, contributing to greater adherence, comprehensiveness, and effectiveness of prevention actions aimed at the older population.
Keywords
Health of Older Adults; Women's Health; Mass Screening; Early Detection of Cancer; Qualitative Research.
Resumo
Objetivo conhecer as percepções de mulheres ≥ 60 anos de idade acerca do rastreio de cânceres de colo de útero e mama.
Método estudo exploratório e descritivo, de abordagem qualitativa. A coleta de dados ocorreu em 2023, por meio de entrevista semiestruturada. As falas foram gravadas, transcritas integralmente e submetidas à Análise de Conteúdo.
Resultados emergiram três categorias temáticas: (Des)entendimento sobre o rastreamento - com percepções relacionadas à finalidade, periodicidade e encerramento dos exames, relevância e problemas na realização, além da influência da histerectomia, ausência de vida sexual e de sintomas; Facilitadores na adesão ao rastreamento - envolvendo vínculo com profissionais de saúde, organização do serviço e histórico familiar; e Aspectos que dificultam o rastreamento - como desconfortos físicos relacionados aos exames, características próprias da idade e sentimentos de medo, vergonha e ansiedade.
Conclusão as percepções das mulheres idosas revelam tanto aspectos de motivação quanto obstáculos ao rastreamento, dessa forma, considerar essas singularidades torna-se essencial para subsidiar estratégias educativas, fortalecer o vínculo e promover ambientes acolhedores, contribuindo para maior adesão, integralidade e efetividade das ações de prevenção voltadas à população idosa.
Palavras-chave
Saúde do Idoso; Saúde da Mulher; Programas de Rastreamento; Detecção Precoce de Câncer; Pesquisa Qualitativa.
INTRODUCTION
Breast and cervical cancers constitute an important public health problem because of their high incidence and mortality, despite the existence of screening and prevention programs. In 2022, approximately 2.3 million cases of breast cancer and more than 600,000 deaths were recorded, making it the second-most-common cancer worldwide. Cervical cancer, despite having a lower incidence (662,000 cases), had proportionately high mortality, with more than 348,000 related deaths1.
This situation highlights the need for effective interventions for early diagnosis and appropriate treatment. In this context, when these strategies are inadequate, higher mortality rates can result, particularly in developing countries2.
Population aging, recognized as a global phenomenon, calls for the implementation of specific health actions addressing the needs of older people, based on available technologies and ongoing monitoring3. In addition, the prevalence of cancer tends to increase with advancing age, reinforcing the urgency of strategies targeting the older population4.
In Brazil, mammography (MMG) and cytopathology (CP) are fundamental to the effectiveness of screening programs, with evidence of reduced mortality5. However, the National Health Survey revealed that 24.2% of women in the indicated age group had never undergone mammography and 6.1% had never undergone cytopathological tests, highlighting a major public health challenge6.
Health behaviors among older people are strongly associated with socioeconomic and demographic factors7. However, there is a gap in the understanding of subjective aspects that influence adherence to preventive actions, and their analysis is essential to inform more effective intervention strategies. Therefore, the aim of the present study was to understand the perceptions of women aged ≥60 years regarding cervical and breast cancer screening.
METHOD
An exploratory descriptive study with a qualitative approach was conducted of older women living in southern Brazil, following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines8. The city studied has just over 250,000 inhabitants, and its economy is based on the poultry and pork processing agribusiness.
The women were recruited through Cidade do Idoso [City for Older People], an initiative for the older population that seeks to provide quality of life, well-being and specialized care. This location was chosen because it facilitated access to women from different areas. Participants were selected by convenience sampling, based on their availability and interest in taking part in the study.
Women aged ≥60 years who lived in the city and received primary health care were included. Women with limitations that precluded communication during the interview were excluded, such as cognitive deficits identified by the researcher, hearing impairment not compensated by a hearing aid, or severe speech impairments.
Data were collected between November and December 2023, during weekly visits according to the venue’s activity schedule. The researchers familiarized themselves with the venue and participants for one month before data collection. Individual interviews were held in a private space, using a previously prepared semi-structured guide, and were conducted by the same researcher throughout—an author of the article who is a nurse, doctoral student and women’s health specialist. The instrument comprised two parts: participants’ sociodemographic information and open-ended questions to explore their perceptions of cervical and breast cancer screening (Do you consider that your current lifestyle habits prevent the development of cervical or breast cancer?; Do you undergo the screening test/mammography?; For how much longer do you intend to undergo it?; What are the screening or Papanicolaou (cervical smear) test and mammography for?; What stops or might stop you from having these tests?; What do you consider a barrier to undergoing these tests?). A pilot study with two women was conducted to assess the clarity and adequacy of the interview guide.
The interviews were audio-recorded with participants’ consent and lasted an average of 20 minutes. To ensure anonymity, each woman was identified by the letter “I” (idosa [older woman]), followed by a number denoting the order in which the interview was conducted. This code was also used in presenting the results. Data collection ended when data saturation was reached.
All interviews were fully and faithfully transcribed in a word processor and analyzed in duplicate using content analysis, following the stages proposed by Bardin9. Pre-analysis consisted of a preliminary reading and the selection of relevant excerpts; thematic categories grouped by similarity emerged from exploration of the material, with subsequent interpretation of the findings9. Verbatim excerpts from participants’ statements were selected to illustrate the findings.
The study complied with the ethical guidelines of National Health Council Resolutions Nos. 466/2012 and 510/2016 and was approved by the Research Ethics Committee (Opinion No. 5,909,941). All participants signed the Informed Consent Form and the Consent Form for Use of Voice.
USE OF ARTIFICIAL INTELLIGENCE
OpenEvidence, OpenEvidence Inc. Purpose: Search for scientific articles; Stage: Discussion of results.
DATA AVAILABILITY
The dataset supporting the study findings is available from the corresponding author upon request.
RESULTS AND DISCUSSION
A total of 13 older women participated in the study, with a mean age of 69.5 years (±6.1 years), ranging from 64 to 86 years. Most participants self-identified as White (61.5%), had a mean of 2.7 children (±1.9), ranging from one to eight children. In addition, 53.8% lived with a partner and all participants were retired (Chart 1).
Sociodemographic characteristics of the study participants. Santa Catarina state, Brazil, 2023.
Analysis of the older women’s narratives identified three core categories concerning cervical and breast cancer screening: (Mis)understanding about screening; Facilitators of adherence to screening; and Aspects that hinder screening (Chart 2).
Analytical categories concerning cancer screening among older women. Santa Catarina state, Brazil, 2023.
(Mis)understanding about screening
The older women’s statements revealed varied and sometimes imprecise perceptions regarding the purpose of preventive examinations. The women associated screening with broad prevention encompassing different types of disease. This generalized view reflects a diffuse understanding extending to any problem involving the female reproductive system.
“I think it prevents various types [of disease], because women are more likely to have a condition, some sort of womb problem; I guess the preventive test is prevention for various things.” (I2)
“Well, it was through that [CP] that they also found I had a uterine fibroid, which I then had to have removed.” (I3)
Low cancer health literacy may influence an individual’s ability to manage risks and can negatively affect health behaviors and their outcomes10. Despite growing awareness of the importance of health literacy, little attention has been paid to this concept with regard to older adults11.
Cervical neoplasia is one of the most preventable cancers, and screening is an important pillar for reducing incidence and mortality. Thus, the adoption of preventive behaviors and knowledge of the CP test are essential for primary prevention; understanding the purpose of examinations may be one of the most important factors predicting health behaviors, particularly in screening procedures12.
In the subcategory frequency and discontinuation of screening, doubts emerged about how often examinations should be performed and when they should be discontinued. This diversity of perceptions reveals a lack of clarity in recommendations and shortcomings in communication between services and users, resulting in heterogeneous practices that may compromise both adherence and the effectiveness of screening actions.
“Well, I guess the doctors know; I don’t know how long [to continue], I’ve even heard that after 70 it isn’t necessary anymore, but I don’t know [...].” (I1)
“[...] I’ll keep doing them as long as I can, as long as I think I should; there is no [cut-off], if I live another 20 years, at 70 or 80, if I can do it, I will.” (I6)
Although cytopathological examination is recommended for women aged 25–64 years at three-year intervals, annual testing is observed throughout Brazil, according to a survey by the National Cancer Institute (INCA)13. This behavior may be influenced by health professionals, who view the recommended interval as a risk of losing their bond with users14.
With regard to MMG, differences in recommended frequency exist between the Ministry of Health (biennial) and the Brazilian Society of Mastology (annual)15,16. Recently, Brazil’s Ministry of Health updated its recommendations for screening in the Brazilian Unified Health System (SUS), which should be performed in women aged 50–74 years, without restricting access below or above these ages provided women are advised of the risks and benefits17.
The subcategory relevance and problems in undergoing examinations revealed ambivalent perceptions. Some participants reported concerns about mammography, fearing that the procedure could be harmful to their health, while others emphasized its importance, particularly after family experiences. Doubts about the effectiveness of the examinations also emerged, revealing a complex relationship between risk perception and adherence to prevention.
“Thank God, I don’t have any problems; perhaps they press [the mammography machine] there so much that I’ll leave with a problem it caused by squeezing [...].” (I4)
“Well, as for mammography, I think it would be more necessary than the preventive test, because mammography has much more [importance]. I lost a niece to breast cancer, so I have it every year too [...], because it starts in the breasts and only then goes down to the uterus [...].” (I8)
“[...] This preventive test has been around a long time, and there are so many women we know who then get cervical cancer and other things, so I don’t know how worthwhile it is [...].” (I12)
The perceptions identified in this study underscore the need for ongoing investment in health education, using diverse strategies adapted to different target audiences. In Brazil, mammography is the only screening test with proven effectiveness in reducing mortality, whereas cytopathological examination remains the most widely used method for cervical cancer screening and can reduce the incidence of invasive disease by 60% to 90%5. In 2025, new screening guidelines were approved using molecular tests to detect oncogenic HPV DNA, which are being rolled out nationally18.
The subcategory hysterectomy, absence of sexual activity and absence of symptoms revealed ambivalent perceptions about the need for preventive examinations. Some older women reported contradictory professional advice, leading to uncertainty regarding continuation of screening. Others associated the absence of pain, sexual activity or symptoms with assurance of good health, interpreting these factors as reducing the risk of complications.
“They [health professionals] said it was not really necessary, but that it was good to have the test every now and then, every two years or so, because even without a uterus something can develop. But thank God, I don’t think anything will develop.” (I3)
“Because I know my health is good, I know I’m healthy, are you with me? I don’t feel pain, I don’t have sex with anyone, I don’t catch anything from anyone, I know I’m clean.” (I4)
According to INCA data, women who have undergone total hysterectomy for causes unrelated to cervical cancer should not be included in screening5. However, women with a previous HPV-related disease require careful examination of the entire vaginal wall19.
In the Brazilian context, higher cervical cancer mortality has been observed among single and widowed women, reinforcing evidence that the absence of a sexual partner is associated with less frequent screening and late diagnosis of the neoplasm20.
Seeking screening examinations only when symptoms are present also reveals weaknesses in health-promotion and prevention actions directed at older women, although this is not exclusive to the local context21. As symptoms in neoplasms usually indicate more advanced stages of disease, this practice leads to late diagnoses that could be avoided through regular systematic use of health services22.
Lastly, this category emphasizes the complexity of women’s perceptions of preventive examinations, revealing both awareness of their importance and ambivalence generated by a lack of clear information. Thus, it is essential to develop health communication strategies that prioritize women’s education and awareness, ensuring understanding of the risks associated with failure to undergo regular examinations and reinforcing the importance of continuous and appropriate screening.
Facilitators of adherence to screening
This category encompasses reported experiences that demonstrate elements capable of encouraging older women’s participation in preventive examinations. These relational and structural factors show that adherence to screening depends not only on the availability of examinations, but also on the quality of interactions between users and professionals, how services are organized to accommodate this population, and personal or family experiences that reinforce risk perception and the need for prevention.
The subcategory relationship with the professional shows that a consistent and positive relationship with health professionals can be considered a facilitator. In this context, participants reported feelings of trust and comfort when being seen by the same professional over the years. This interpersonal bond created a welcoming environment in which older women felt respected and recognized, favoring engagement in prevention practices.
“[...] thank God, I’ve been going to the same [professional] for I don’t know how many years; he’s as old as I am now [laughter].” (I6)
“I have always been treated well every time I went; the nurses have always been great, there was no problem.” (I8)
The degree of trust in the professional, and consequent adherence to their recommendations, tends to strengthen when follow-up is maintained over time. In addition to continuity of care, well-established relationships reinforce the feeling of being recognized as an individual with legitimate concerns, which is fundamental to sustaining engagement in gynecological prevention23.
The subcategory service organization shows that adequate structuring and accessibility of the health system are fundamental determinants of adherence to examinations. Beyond simplifying bureaucratic processes, effective service organization helps create responsive pathways that facilitate welcoming care for users and the timely use of available resources.
“[...] I have most of them done at the Women’s Network; I call to book, or until last year they called me [...] as long as I can go, I will, because we don’t even pay for it, we get it for free, so why wouldn’t I go.” (I7)
“At the health center we don’t even need to go there, we schedule by phone, go there and have it done, it’s easy [CP], there’s no problem. Mammography too—we think it will take a while; I had mine in September, booked it and she said it would take a while, but within a week they called me in to have it done.” (I8)
The use of reminder systems, through messages, may increase adherence to breast and cervical cancer screening examinations24. Conversely, difficulty booking appointments has been identified as a factor associated with non-adherence to screening25. In this regard, implementation of appointment-scheduling strategies has contributed positively to the organization and efficiency of care in Primary Health Care (PHC)26, helping shorten waiting lists, optimize the use of available resources and improve users’ experience27.
Lastly, the subcategory family history shows that participants perceived this as a fundamental incentive for adherence to screening programs. More proactive and vigilant behavior towards one’s own health was evident, since family experience acts as a constant reminder of the importance of prevention.
“It is prevention that we have, isn’t it? Since my mother had this problem [breast cancer], even at our age the recommendation is to have mammography.” (I5)
Although not the only factor, the genetic component is one of the most recognized breast cancer risk factors28. Evidence indicates that women without a family history of cancer tend to receive their diagnosis at a more advanced stage of disease29.
Analysis of facilitators of screening adherence showed a combination of factors that encourage women’s continuous participation in preventive health programs. When combined, this alignment of trust, accessibility and personal motivation not only improves individual health outcomes for older women but also strengthens the health system by fostering a culture of prevention and continuous care.
Aspects that hinder screening
This category brings together elements that reveal the main barriers to adherence by participants to screening examinations, encompassing physical and emotional dimensions, as well as structural aspects of care. These findings show that difficulties in screening are not confined to the individual dimension but also result from shortcomings in the professional approach and the lack of services adapted to the specific needs of the older population.
The subcategory discomfort related to examinations and characteristics of older women showed that pain and physical discomfort experienced during screening procedures are significant barriers to adherence. Participants reported experiences marked by distress and discomfort, in which direct contact with the body was described as painful and sometimes traumatic.
These perceptions indicate the need for greater sensitivity among health professionals and adaptation of practices and technologies, to ensure comfort, respect and care that is responsive to the needs of older women during screening processes.
“I had it done several times and suffered every time [...] I don’t have much breast tissue [...] so she had to compress what little breast I have [...] it hurt so much; my breast was sore for two or three weeks.” (I4)
“[...] I had bleeding, so I went for a while without having the preventive test because I thought that every time I went, there would be pain and bleeding, and I thought it would always be like that [...] the vagina gets drier, doesn’t it, so it becomes more difficult.” (I5)
“I find it uncomfortable, all of it uncomfortable; that instrument they put in hurts us a lot [speculum] [...] once they used an instrument that was too big, and then I felt unwell afterwards.” (I11)
Although the discomfort reported by the participants was recurrent, this factor should not prevent mammography, given the benefit afforded by early detection of breast cancer. Recent studies highlight the potential of non-pharmacological methods for lessening examination-related pain, such as personalized compression protocols, adjustable cushions, music therapy and nurse-led interventions, which have shown promise for making the examination more tolerable and humane30,31.
For the CP examination, physical discomfort is an even greater limitation to adherence32. The reported pain and bleeding most often result from menopausal vulvovaginal atrophy, a condition affecting most women owing to estrogen deficiency and the consequent reduction in vaginal tissue thickness and elasticity. In this context, more sensitive and inclusive approaches are essential in both preparation for and performance of the examination, ensuring welcoming care, attentive listening, and respect for the physiological limitations of aging33.
The subcategory resulting feelings includes a series of emotions that directly influence adherence. Fear stands out as the most recurrent emotion, reflecting apprehension about the possibility of testing positive and the implications of diagnosis. This perception of cancer as synonymous with suffering and death leads to avoidance behaviors, in which not knowing appears to offer a false sense of protection.
In addition to fear, feelings of shame and embarrassment were marked, related to bodily exposure and cultural standards of modesty and appearance considered “appropriate”, which reinforce insecurities about body image and femininity in old age.
“Fear that something might happen, that something might show up; sometimes people withdraw and stay like that, you know.” (I3)
“Because if you’re not shaved, it´s as though you’re unclean, you see.” (I4)
“Ah, because it is embarrassing too, taking your clothes off.” (I9)
Emotional factors not only hinder adherence to screening examinations but also point to the need for preventive actions to consider psychological well-being as a central dimension of care34. Fear of diagnosis, shame and embarrassment related to bodily exposure demonstrate weaknesses in communication between professionals and users, requiring empathetic approaches and strategies that promote self-acceptance and appreciation of the aging body. Creating welcoming, non-judgmental environments with assured privacy is essential to reduce anxiety and fear and foster women’s trust in the screening process35.
Thus, the findings in this category reinforce the strategic role of health professionals in promoting sensitive care that recognizes older women’s individuality, minimizes discomfort and makes screening a positive and educational experience.
Although this study provides relevant insights into the perceptions of women aged 60 years or over regarding cervical and breast cancer screening, some limitations should be considered. First, the study was conducted during a specific period and within a geographically limited setting, possibly influencing participants’ views and reducing diversity. Another consideration is the qualitative nature of the study, which, although rich in detail and depth, may be subject to bias in the interpretation of statements during content analysis. In addition, applying a single data-collection method may fail to fully capture the complexity of women’s perceptions of screening, suggesting that future studies could benefit from including quantitative methods or data triangulation for a more comprehensive analysis.
CONCLUSION
The participants´ perceptions of cervical and breast cancer screening revealed a coexistence of facilitators and barriers across individual, relational and structural dimensions of care. While recognizing the importance of preventive examinations, the women´s accounts showed low health literacy, fear of diagnosis, physical discomfort, embarrassment, absence of a uterus, lack of sexual activity or of symptoms, and poor communication with health professionals, all of which contributed to experiences of discontinuity and low adherence to examinations.
Conversely, factors such as a bond with professionals, service organization and family experience of the disease emerged as strong incentives for prevention. These findings reinforce that adherence to screening should not be understood as an isolated choice, but as a social and affective process shaped by life experiences, access to services and the quality of relationships established in Primary Health Care.
Thus, investment in actions that consider the particularities of women’s aging can help expand coverage, strengthen autonomy and promote comprehensive and equitable care that is sensitive to the needs of this population.
Funding
References
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