Barriers to breast and cervical cancer screening uptake among Black, Asian, and Minority Ethnic women in the United Kingdom: evidence from a mixed-methods systematic review
BMC Health Services Research volume 23, Article number: 390 (2023)
Cancer is currently the leading cause of mortality globally, with new cancer cases estimated at 19.3 million and almost 10 million deaths in 2020. Specifically, breast and cervical cancer incidence and mortality prevalence among women of the minority group or marginalised populations in Europe have continued to be a public health concern due to the low uptake of cancer screening. Thus, this study utilised a mixed-method systematic review to identify barriers to breast and cervical screening uptake among Black, Asian, and Minority Ethnic women in the United Kingdom.
Databases including PubMed, CINAHL, British Nursing Index, Web of Science, EMBASE, and Scopus databases, were systematically searched for studies on barriers to breast and cervical screening uptake among Black, Asian, and Minority Ethnic women in the United Kingdom published in English between January 2010 to July 2022. This mixed-method systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in reporting the included studies’ results. The cluster mapping approach was used to identify and classify the barriers into themes.
Thirteen eligible studies were included in this current review. Seven of the thirteen studies used quantitative cross-sectional research design, while six used qualitative cross-sectional research design. These studies were conducted across the United Kingdom. Five themes were developed from the cluster mapping, and thirty-four sub-theme barriers to the uptake of breast and cervical cancer screening among Black, Asian, and Minority Ethnic women in the United Kingdom were identified. The developed themes in relation to the barriers include; socio-demographic characteristics, health service delivery, cultural, religious & language, the gap in knowledge & awareness, and emotional, sexual & family support.
The study concluded that barriers in socio-demographic characteristics, health service delivery, cultural, religious and language, the gap in knowledge & awareness, and emotional, sexual & family support were identified as non-uptake of breast and cervical cancer screening among Black, Asian, and Minority Ethnic women in the United Kingdom. Reducing or eliminating these barriers would improve the benefits of timely breast and cervical cancer screening in the United Kingdom.
Cancer is currently the leading cause of mortality globally, with new cancer cases estimated at 19.3 million and almost 10 million deaths in 2020 [1,2,3]. These adverse statistics on cancer have serious implications for global public health, life expectancy, and labour force participation [2, 4,5,6]. Breast cancer was the leading cause of cancer incidence, contributing an estimated 2.3 million cases to the global cancer incidence in 2020; this contribution represents 11.7% of cancer worldwide . Breast cancer incidence and mortality prevalence among women varies from region to region and is more prominent in the European region than in other regions [1, 7, 8]. The disparities in the distribution of breast cancer incidence and mortality among women in Europe have been linked to late diagnosis, preventing early detection and treatment, and leading to low survivor rates [5, 9]. Cervical cancer was reported as the fourth most frequently diagnosed and leading cause of cancer mortality among women globally, with about 604,000 new cases and 342,000 deaths in the year 2020 . Although cervical cancer incidence and mortality prevalence rates are not high in the European region and other high-income countries, however, studies have recently raised concern about the rise in cervical cancer among immigrant women in Europe, leading to apparent health inequalities [10,11,12,13].
The United Kingdom has been identified as one of the regions with high rates of breast and cervical cancer incidence, morbidity, and mortality among women, which is attributed largely to inequality in the uptake of prescribed breast and cervical screenings . The English National Breast and Cervical programmes in the United Kingdom were saddled with the responsibility of preventing cancer by treating precancerous changes or ensuring diagnosis at the early stages when treatment outcomes are more successful [14, 15]. Besides the English National Breast and Cervical programmes mandates, the Department of Health's cancer outcome strategy since 2011 has made it its main focus to promote cancer screenings, particularly breast and cervical cancer, in order to increase early diagnosis and save lives [15,16,17].
Additionally, to ensure the high rate of breast and cervical cancer-related morbidity and mortality are reduced, the government introduced guidelines for an automatic invite for breast cancer screening uptake for women between the ages 50 to 70 residing in the United Kingdom every three years while women between the age of 25 to 49 years are invited for cervical cancer screening every three years and those between 50 to 64 years are invited every five years [18, 19]. Despite the government's ambitious strategies and plans to reduce the prevalence of incidence and mortality attributable to breast and cervical cancer in the United Kingdom [14,15,16], about 11,500 and 1,121 women still die yearly from breast and cervical cancer, respectively [18, 20, 21] whilst additional 50,000 and 3,791 women with breast and cervical cancer are diagnosed annually in the United Kingdom [20, 22]. Reducing these rates depends largely on women's participation in breast and cervical cancer screenings in the United Kingdom .
However, participating in the United Kingdom cancers screening programmes is influenced by several barriers, which are more prominent among the minority or underrepresented women population, often referred to as Black, Asian, and Minority Ethnic groups, and these barriers continue to contribute to the high prevalence rate of breast and cervical cancers among women in the United Kingdom [23,24,25]. Accelerating the uptake of these screenings would require identifying the barriers influencing the non-utilisation of these screening services and providing requisites programmes and plans to overcome the barriers [26,27,28]. Nevertheless, previous studies conducted on the barriers to the uptake of breast and cervical cancer screenings among Black, Asian, and Minority Ethnic group women in the United Kingdom using either primary or secondary data source; however, to the best of our knowledge, no study has been able to synthesise all the barriers for the last 12 years using a systematic review [29, 30].
Overcoming the barriers in the non-uptake of breast and cervical cancer screening among the Black, Asian, and Minority Ethnic group women in the United Kingdom requires collating all available evidence on barriers preventing the uptake of the screening, and this may be used to develop necessary interventions that may help with early detection and treatment, improved health outcomes, and ultimately accelerate the achievement of sustainable development goal 3, which seeks to ensure healthy lives and promote the well-being of all at all ages by the year 2030 . Thus, to address this, a mixed-methods systematic review was utilised toidentify the barriers to breast and cervical cancer screening uptake among Black, Asian, and Minority Ethnic women in the United Kingdom between January 2010 to July 2022 with a research question of ‘What are the barriers to the uptake of breast and cervical cancer screening among Black, Asian, and Minority Ethnic women in the United Kingdom?’.
This review was systematically conducted in accordance with the 2015 and 2020 Joanna Briggs Institute (JBI) methodology guidelines for mixed-methods systematic reviews [32, 33], and reported the findings following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) . A mixed-method systematic review is essential in providing unique insights into challenges around healthcare service delivery . This mixed-method systematic review was registered with the Prospero registration number CRD42022381510.
Data source and search strategy
The search terms were developed strategically and cross-checked by both authors (OAB & NH). To ensure that the search terms and strategy were without bias and comprehensive, a preliminary search of both Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was undertaken by scrutinising the text words in the title, abstract, and the index terms used to describe the article which is often known as keywords. The initial search showed the available literature and identified appropriate search terms for subsequent searches. The preliminary search returns a large number of relevant articles, which indicates a robust search. These same search terms were used to search other electronic databases included in this study; it is recommended that search strategies are not restricted to English, given the resources available in other languages . However, this study only included articles published in English between January 2010 and July 2022 (Appendix III). Only English language studies were considered because both authors are unable to read and write in other languages other than the English language, and only studies between 2010 to 2022 were considered because, according to Cancer Research UK, there was an increase of 11.4% and 7.7% in the number of new cases for both breast and cervical cancers respectively in the United Kingdom between 2010 to 2021 .
Electronic database search
Following the preliminary search of relevant articles from MEDLINE and CINAHL databases using relevant search terms and strategies, the same search terms and strategies were adopted for other databases searches including the British Nursing Index (BNI), Web of Science (WOS), EMBASE, and Scopus to ensure consistency of the process. This search returns numerous relevant articles. This systematic review also applied another method in retrieving relevant articles by checking the referencing list of the included articles to include additional relevant articles. Two articles were retrieved as additional to the eligible articles in this review.
The Population, Intervention, Context, Outcome, Timing and Study type (PICOTS) template components align with the review research questions. The PICOTS table was applied to develop and review the inclusion and exclusion criteria (Table 1).
Inclusion and exclusion criteria
The PICOTS table included above was applied to developing and defining the review inclusion and exclusion criteria. According to the JBI , the inclusion and exclusion criteria must be clearly stated from the initial review stage to ensure that relevant articles are included as eligible articles whilst minimising the selection bias risk. Consequently, PICOTS was fully utilised whilst searching and screening for eligible studies. Table 2 below shows the inclusion and exclusion criteria.
The title and abstracts were sifted by importing all the retrieved articles into RefWorks and eliminating duplicates. Then the remaining article's title and abstract were checked against the inclusion and exclusion criteria to identify potentially relevant studies. All articles with limited information in the abstracts were included for full-text reading in the second phase of the shifting. Detailed information about the study selection is provided in the result section of this review using the PRISMA flowchart. The selection of eligible studies was completed transparently by ensuring that all the processes involved in the study selection were well documented at every step, as recommended by Page .
The second stage of the study selection process was full-text sifting. All the articles were eligible for full-text screening after the title and abstract sifted were downloaded for reading. The article included for full-text screening that was unavailable as open access on the website was accessed using Canterbury Christ Church University’s library. Reading and selecting eligible studies were confirmed against the inclusion and exclusion criteria; some studies that required further reading were read more than once to ensure their suitability before inclusion.
Data extraction and synthesis
The extraction of relevant data was done twice to ensure no important information was left unextracted. The extraction of relevant data was based on specific details about the study of interest (Breast cancer, cervical screening, barriers associated with the uptake, Black Asian and Minority Ethnic women, United Kingdom), the method utilised in the study, and the significance of the outcome variable. Only data on Black Asian and Minority Ethnic women were extracted for articles that included other population groups of women on breast and cervical cancer screening uptake in the United Kingdom . To generate the quantitative evidence from the eligible studies a significant relationship of barriers associated with the uptake of breast and cervical cancer among Black Asian and Minority Ethnic women was considered, while direct quotes provided by the respondents in the eligible studies were extracted for qualitative evidence .
Assessment of methodological quality
 After selecting articles that met the inclusion criteria, a quality assessment of 13 published articles was conducted. Porritt  argued that it is important to conduct a quality assessment of eligible articles for a review because low-quality articles may affect the review's credibility. To reduce the risk of bias and ensure that the studies included in this review were all high-quality. The Mixed Methods Appraisal Tool (MMAT) is often utilised to evaluate and appraise qualitative, quantitative, or mixed-methods research designs. This tool assessed the eligible articles included in this review since qualitative and quantitative studies were included . The MMAT assesses the appropriateness of the study aim and design, participant recruitment, adequacy and methodology, data collection, presentation of findings, data analysis, authors’ discussions, and conclusions. Both authors independently reviewed the eligible articles and assigned a quality rating. There were no discrepancies between the two reviewers (OAB & NH) regarding the quality assessment of the articles included in this study [40, 41]. The eligible articles were appraised based on six methodological quality criteria: research questions, representativeness of the target population, rate of non-response, research measurement, and how the research questions were analysed . All the scores were summed up, and no article was dropped because the least score was 80% , as shown in Appendix 1.
Data analysis and emerging clusters
This review utilised the emerging clusters approach in synthesising the data extracted from the included studies [42,43,44]. The analysis process was in two stages. The first stage involves the identification of all barriers to breast and cervical cancer screening uptake among Black Asian and Minority Ethnic women in the United Kingdom in the included studies. The second stage involved structuring and sorting those identified barriers into clusters; this is the clustering of all the barriers in each study according to how they relate to each other leading to the identification of 5 clusters and 34 barriers . The concept of the cluster mapping approach seems sufficient since the study aims to identify the barriers associated with the uptake of breast and cervical cancer screening among Black Asian and Minority Ethnic women in the United Kingdom. Therefore, the findings were presented in narrative form using tables . To generate the quantitative evidence from the eligible studies a significant relationship of barriers associated with the uptake of breast and cervical cancer among Black Asian and Minority Ethnic women was considered for quantitative studies, while direct quotes provided by the respondents in the eligible studies were extracted for qualitative studiesevidence . Then, a detailed analysis of findings extracted from the included eligible articles was achieved by using a cluster approach; similar content was clustered into five categories as themes . The organisation, assessments, and data analysis are important because the analysis of the data extracted from the included studies should answer the study’s research questions [46, 47]. These clusterings were developed through in-depth reading and interpretation of the included articles’ results section. This increased the in-depth knowledge of the authors in the study, which improved the quality of the results presented in this study [44, 48, 49].
An initial search yielded a total of 225 studies identified from the included databases. One hundred fifty-one studies were excluded as duplicates from the search results, whilst additional 49 studies were excluded after the title, and abstract sifting of the studies does not fit into the inclusion criteria of this review, leaving 25 studies for studies for full-text sought and screening. All 25 full-text studies were retrieved, and 12 studies did not meet the study inclusion criteria of reporting barriers to breast cancer screening among Black Asian and Minority Ethnic in the United Kingdom. The 12 full-text studies screened that did not meet the review criteria were based on the following; 3 studies did not report screening [50,51,52], 3 studies were previously published review studies [53,54,55,56], 5 studies did not state any barriers [57,58,59,60], and 1 study was not on Black Asian and Minority Ethnic women  as shown in appendix II. 13 studies that met the inclusion criteria were finally included in the review for analysis, as shown in Fig. 1.
To ensure that the eligible included studies were good qualities, the MMAT was used to appraise the eligible articles based on six methodological quality criteria: research questions, representativeness of the target population, rate of non-response, research measurement, and how the research questions were analysed . All the scores were summed up, and no article was dropped because the least score was 80%, as shown in Appendix 1.
Characteristics of included studies
The characteristics of the 13 studies included in the systematic review, such as the study aim, country where the research was conducted, study design, and participant characteristics, were illustrated in Table 3. In relation to this study focus, out of the 13 studies in this review, 8 studies focused on the range of barriers to breast cancer screening among Black Asian and Minority Ethnic women in the United Kingdom [62,63,64,65,66,67,68,69], whilst 5 studies focused on the barriers to cervical cancer screening among Black Asian and Minority Ethnic women in the United Kingdom [29, 30, 70,71,72].
England was the highest country with number of studies with a total of 7 studies; 4 studies were conducted on barriers to breast cancer screening, whilst 3 studies were conducted on barriers to cervical cancer screening between January 2010 to July 2022 [30, 62, 65, 68,69,70,71]. Four studies were conducted in the United Kingdom, three on barriers to breast cancer screening and only 1 study was on cervical cancer screening [30, 63, 66, 67]. The country with the least studies was Scotland, with only 2 studies [29, 64].
There were variations in respondents interviewed in the 13 studies included in the review. The variation in the characteristics of the respondents ranges from the age of the respondents to the study sample sizes and year of residency [29, 30, 62,63,64,65,66,67,68,69,70,71,72]. However, all studies were conducted on Black Asian and Minority Ethnic women in the United Kingdom who can give information on barriers to either breast cancer or cervical cancer screening (Table 3).
Key findings in themes on barriers to breast and cervical cancer screening
Five themes were developed as barriers to breast and cervical cancer screening among Black Asian and Minority Ethnic women in the United Kingdom between January 2010 to July 2022. Thirty-four barriers (key findings) were identified from the 13 included studies; breast and cervical cancer screenings have 17 barriers each, and these barriers were categorised under five themes discussed below.
Theme 1: Socio-demographic-related barriers
Out of the 13 included studies in this review, 6 studies [63, 64, 68,69,70, 72] reported barriers related to socio-demographic factors for breast and cervical cancer screening. The barriers reported include; low socioeconomic status, educational level (Limited/no literacy), cost of travelling & other expenses for breast cancer, whilst the barriers reported for cervical cancer were older aged women (51 to 60 years), migrant women, younger and unmarried women, cost, and logistics of travelling as shown in Table 4.
Theme 2: Health service delivery-related barriers
Six studies [29, 62, 63, 66, 68, 71] out of the 13 included studies reported barriers around health service delivery to non-uptake of breast and cervical cancer screening. For breast cancer screening, barriers reported were invitation types, interpreter lack of medical knowledge, short/lack of appointment time, health professionals lack of cultural competence, and negative/unhelpful attitude of health workers, whilst barriers reported for cervical screening uptake were health workers negative attitude, distance to healthcare centres, limited/lack of appointment time as shown in Table 4.
Theme 3: Cultural, religious, and language-related barriers
Barriers relating to culture, religion and language were reported by 7 studies [62, 65,66,67, 70, 72] out of the 13 included studies. Language and communication, cultural beliefs/differences on cancer sigma, and spiritual belief were the barriers reported to the uptake of breast cancer among Black Asian and Minority Ethnic women in the United Kingdom, whilst barriers such as religious belief and language & communication were reported for cervical cancer screening uptake as shown in Table 4
Theme 4: Gap in knowledge and awareness-related barriers
Out of the 13 studies included, 10 studies [29, 30, 62, 63, 65, 67, 69,70,71,72] reported a gap in knowledge and awareness-related factors as barriers to breast and cervical cancer screening among Black Asian and Minority Ethnic women in the United Kingdom. Barriers related to breast cancer include; lack of knowledge of breast screening services & procedures, incomprehensible medical terminologies, and absence of symptoms, whilst barriers related to cervical cancer include; lack of knowledge and awareness of cervical cancer screening, lack of knowledge about medical terminologies, and absence of symptoms as shown in Table 4.
Theme 5: Emotional, sexual and family support-related barriers
Seven studies [29, 62, 63, 65, 70,71,72] of the 13 included studies reported barriers relating to emotional, sexual & family support as the reason for the non-uptake of breast and cervical cancer screening. Breast screening barriers include embarrassment & fear, anxiety & fatalism, and lack of family support, whilst barriers reported for cervical screening include embarrassment, fear & shame, fear of test procedure, sexual inactivity, work & family responsibilities, and fear of racism, as shown in Table 4.
The studies included in this mixed-methods systematic review was 13, presenting a wide range of barriers to breast cancer and cervical cancer screening uptake among Black Asian and Minority Ethnic women in the United Kingdom between January 2010 to July 2022. Although the studies included two important NCD outcome variables and were conducted in different regions within the United Kingdom, the barriers highlighted by the studies were consistent throughout the study locations in the United Kingdom. The mixed-methods systematic review extracted 34 key findings and developed 5 themes from similar key findings (clusters) from the 13 included studies.
Five synthesised findings generated in this review in relation to barriers to breast cancer and cervical cancer screening uptake among Black Asian and Minority Ethnic women in the United Kingdom were socio-demographic-related barriers, healthcare service delivery-related barriers, cultural, religious & language-related barriers, the gap in knowledge & awareness-related barriers, and emotional, and sexual & family support related barriers.
Socio-demographic related barriers
Both breast and cervical cancers are preventable diseases, provided that women of reproductive ages adhere to regular screening, which previous studies have reportedly recommended to facilitate early detection and influence better treatment outcomes for these two types of cancers [73,74,75,76]. Despite the evidence supporting the effectiveness of regular screening for both diseases, other evidence counteractively shows that women of reproductive age often face socio-demographic-related barriers preventing them from adhering to regular screening practices [77, 78].
The findings from this study ascertained the point raised above as nearly half of the studies assessed in this review specifically presented the socio-demographic-related barriers as one of the categories of barriers preventing Black Asian and Minority Ethnic women in the United Kingdom from accessing breast and cervical cancer screening services. The three key socio-demographic-related barriers highlighted for breast cancer screening include the low socioeconomic status of Black Asian and Minority Ethnic women, which is likely to be a result of women taking more household responsibilities as primary caregivers to their children which often predisposed them to some socioeconomic disadvantages like inability to be gainfully employed overtime, leading to financial independence to seek medical attention as at when due [79, 80]. Globally, the high cost of care has been reported as an important barrier preventing women from accessing screening services, especially for migrant women with no stable jobs, and this is another way in which the socioeconomic status of women hinders their ability to access breast and cervical cancer screening services .
The two other barriers revealed in this review among Black Asian and Minority Ethnic women were also linked to low socioeconomic status because of the role that socioeconomic status plays in the attainment of educational qualifications and the ability/inability to afford the cost of medical and non-medical expenses among socioeconomically disadvantaged people. Several other studies [81,82,83] conducted among women from other continents across the world identified similar socio-demographic barriers preventing women from accessing breast and cervical cancer screening services, and these studies supported the current study's findings. For instance, Park's  study among Korean women showed that socio-demographic factors like marital status, education, residency and health insurance status often predict the categories of women who uptake breast and cervical cancer screening and that women of higher socioeconomic status uptake these services more compared to women of lower socioeconomic status. Although, there are some variations in the specific socio-demographic barriers listed in this current review and Park’s  study, such as the health insurance status, marital status and residency that were not identified in the current review.
Health service delivery-related barriers
In some cases, women often overcome sociodemographic barriers to breast and cervical cancer screening but meet a brick wall at the facility where they intend to uptake the screening services . These barriers often destroy women’s resolve to seek healthcare services because healthcare services deliver-related barriers often discourage them from requesting screening services . The findings from this research showed that Black Asian and Minority Ethnic women encountered several other barriers related to healthcare service provision in their quest to access screening services for breast and cervical cancer. Adunlin’s study  reported similar findings to the current review on some of the healthcare-related barriers influencing migrant women’s breast and cervical cancer screening, and these include the knowledge gap between the medical personnel and the care seekers, which stems from either interpreters’ ability to pass accurate information to the migrant women where language barriers are predominantly existing. This aspect of Adunlin's  study coincides with the findings from this review and other systematic and scoping reviews like the ones conducted by de Cuevas , Ferdous , and Boom . All these three studies highlighted the role of healthcare-system-related barriers in preventing ethnic minoritised women from attending breast and cervical cancer screening.
In some studies with similar findings to this current review, like those of Chidyaonga-Maseko , Gele , Orji and Yamashita , other factors like cultural differences and fear of racial discrimination were identified as major push and pull factors influencing healthcare-related barriers. Marques 's research on immigrant women in Europe revealed findings that followed a similar pattern to those of the current review by linking the healthcare system barriers to some inherent factors that are peculiar to ethnic minority women across Europe (like Black Asian and Minority Ethnic women in the United Kingdom).
Previously experienced healthcare services disparities from racial and Ethnic group maybe linked to the reasons for not seeking healthcare services [90, 92,93,94]. All these factors may contribute to the healthcare-system-related barriers .
Cultural, religious & language related barriers
The acculturation process has been reported to influence healthcare-seeking behaviour as it takes time for different categories of people at different times and for different reasons because of the rigid nature of their inherent behaviour tied to their cultural and religious beliefs from their country of origin . Language, culture, and religious beliefs, in the case of Black Asian and Minority Ethnic in the United Kingdom, are not only a barrier to health-seeking behaviour but other social and cooperative engagement like employability, social engagement, women in manufacturing and construction industries, which also ping back to their ability to access healthcare services like breast and cervical cancer screening . The findings from this review show that religious beliefs, culture, and language also contribute to the barriers to taking up breast cancer and cervical cancer screening as there are possibilities that Black Asian and Minority Ethnic women in the United Kingdom have reluctancy to give up their inherent belief about their health and these cannot be easily corrected when trying to get incorporated into an entirely new system .
Marques's  study conducted among minoritised women in Europe showed a similar pattern of findings to the current review, as their study listed cultural differences as the key barriers preventing these women from accessing cervical cancer screening services. Although, their study also reported other barriers like the healthcare system-related barrier and the cultural differences, which are all accounted for in this current review findings.
These barriers could be attributed to the inability to understand or communicate due to language differences can also influence poor uptake of cancer screening procedures for breast and cervical cancer . Spiritual and religious beliefs were also identified as one of the barriers to taking up cancer screening. Spiritual and religious beliefs such that many Black Asian and Minority Ethnic communities will rather request herbs to be sent from their native country than visit a healthcare facility, and the belief in spiritual healing was also identified as barriers in this review such that the Black Asian and Minority Ethnic community prefer to believe in the supernatural intervention than to seek medical advice [91, 97]. Some believe that talking about cancer could be a form of affirmation, resulting in them attracting and developing it; therefore, they will not discuss it. Cultural belief is also a barrier to screening uptake; one of these beliefs is having sexual relationships outside of marriage and the possibility that a cervical cancer diagnosis would be seen as embarrassing by certain women .
These findings were similar to what has been reported by other studies that highlighted that wizardry, sexual relationships with multiple partners, and the use of herbs through the vagina as the cause of cervical cancer, while the necessity for spousal consent, discrimination at hospitals, lack of awareness, religious and cultural responsibilities of modesty, the gender of healthcare personnel, fear of nosocomial infections, fear of disclosure of results, and fear of publication of results as barriers to screening were the barriers reported in their studies [96, 97]. Similarly, Kirubarajan's  systematic review also identified cultural beliefs and language barriers to cervical cancer screening uptake. Another systematic review among South Asian women by de Cuevas  on breast and cervical cancer screening uptake also found cultural practices as barriers. Mafiana  also reported traditional, cultural and religious beliefs are some of the barriers to screening.
The gap in knowledge & awareness-related barriers
Knowledge and awareness are vital in influencing health-seeking behaviour, especially among women who may be dispositioned for one reason or the other, as in the case of Black Asian and Minority Ethnic women in the United Kingdom . Findings from this review show that knowledge and awareness-related barriers influence non-uptake of breast and cervical screening practices among Black Asian and Minority Ethnic women due to their inability to seek health services and make informed decisions as a result of probable poor knowledge about where to seek proper healthcare services, including how and why to seek healthcare services and other information surrounding breast and cervical screening practices.
Several studies conducted among women across the globe identified knowledge and awareness as factors hindering healthcare services among Black Asian and Minority Ethnic women [86, 101,102,103]. A study conducted by Sultana  on “Awareness About Cervical Cancer in Pakistani Women” shows that the major barrier to cervical screening is a lack of awareness and fallacy towards the screening, which correlates with the current review. However, the study identified the screening fallacy as a barrier, which dissociates from the current review. In another study conducted by Moodley  among sub-Saharan African women in South Africa and Uganda, it was ascertained that breast cancer awareness influences healthcare practices. However, the study scope targeted married women living with their partners, married women not living with their partners, urban dwellers, and rural dwellers, which were not identified in the current review.
More so, research conducted in some European countries has shown that women participating in breast and cervical cancer screening examinations have lower mortality tendency,however just a few usually undergo screening due to a knowledge gap [7, 91]. This was also true in other continents; for instance, a study conducted among minoritised women residing in Australia by Alam  who concluded that insufficient knowledge is one of the major barriers to cervical cancer screening uptake among this group of women. However, some of the studies included obese women, which does not correlate with the current review [73, 91, 105]. Research conducted among Ethnic minority backgrounds in the United Kingdom shows that inadequate awareness and knowledge about cervical screening and related tests in Ethnic minority communities increases the cervical cancer mortality rate . The study ascertained the gap in knowledge and awareness identified in this current review.
Emotional, sexual, and family support-related barriers
Support from family is crucial to managing any health condition, especially cancer management, which usually over some time and can be draining. Emotional and family support ensures that the individual is not alone in the fight . This review found that lack of family and emotional support, embarrassment, fear and shame, and fear of the test procedure are major barriers to the uptake of cervical and breast cancer screening. It has been revealed from the findings of this review that emotional support provided by family and friends could encourage the uptake of breast and cervical cancer screening.
This aspect of the findings is supported by Molina's  study on the role of family and social interactions in breast cancer screening among women of Latina origin. The point of concordance in the two studies  and this current review was on the importance of family support and recommendations in the utilisation of healthcare screening services and without, which may form a significant emotional barrier for women from ethnic minoritised groups that were the focus of the current review. Similarly, Adegboyega's  study reported slightly similar findings about those barriers related to family support with special reference to spousal approval, which is a key decider in women’s healthcare-seeking behaviour among immigrants from sub-Saharan Africa with its engraved patriarchal social structure in marital relations.
Similarly, this review also showed that many Black Asian and Minority Ethnic women often feel embarrassed when it comes to testing procedures, and they may also be afraid of being treated differently because of their skin colour or race. The issue of racial disparities as an emotional barrier to the uptake of breast and cervical screening services was documented in other studies like that of White-Means , Orji and Yamashita , where women of African descent and other Ethnic minorities in the United States of America often feel stigmatised for their skin colour and race in all ramifications and this introduced emotional barriers that prevent this category of women from seeking healthcare services related to breast and cervical cancer screening.
Findings from this study also showed that the fear of the test procedure being perceived as painful and uncomfortable has resulted in many Black Asian and Minority Ethnic women withdrawing from the screening procedure. It was also found that Black Asian and Minority Ethnic women, especially the older ones, often express their bodies as private; hence they will feel embarrassed taking the test. It was also observed that the perceived shame, with the main driver being what people would say, how they developed cancer, was a limiting factor to taking the screening test. They feel it is better not to know than for it to become a stigma. In Nyblade's  study, the Indian community discovered that seeking screening, early diagnosis, or treatment was not advised among women because of the stigma associated with receiving a cancer diagnosis, and Ginjupalli  corroborated this; in the same vein, Momenimovahed  identified pain and embarrassment as barriers to screening uptake among their respondents.
Strengths and limitations
Whale  poised that presenting key strengths and limitations of systematic review studies is an important research process that contributes to its credibility to be admitted as evidence by healthcare stakeholders and researchers alike with a perfect understanding of its flaws and thereby make informed decisions based on that. Some of the key strengths identified in this study include its extensive literature search that showed a wide range of primary studies that discussed diverse barriers to breast and cervical cancer screening uptake and solidified the reviewer’s justification for conducting this review. It is vital to note that the strengths identified for this review were as important as its credibility and weaknesses, which will show both the researcher’s lapses and those inherited (from included studies) biases. Another limitation of this review is that the study was only conducted in English; this could have excluded some important studies conducted in other languages.
Recommendations for future research
This mixed-methods systematic review was conducted to fill some gaps in knowledge and literature about barriers that prevent the uptake of breast cancer and cervical cancer screening among Black Asian and Minority Ethnic women in the United Kingdom, and in doing so, was able to discover other areas for exploration by future research. The barriers were synthesised to form healthcare-system-related and individual-related barriers that hinged on Black Asian and Minority Ethnic women’s emotions, family, knowledge, and sociocultural profiles. However, this study shows that there are gaps in the identification of the most prevalent and significant barriers among the myriads of barriers discussed in this study and therefore recommended that future research should:
Examine each barrier to link cause and effect using mixed methods research methods (with a meta-analysis approach) to show the most significantly predominant barrier influencing Black Asian and Minority Ethnic women.
Explore the peculiarities of individual subgroups among Black Asian and Minority Ethnic women to identify barriers unique to a group or those that do not exist in other groups and ascertain whether this is common among Blacks, Asians, or other minority populations. For example, some English-speaking African countries might not have language and interpreter-related barriers. So future research should focus on migrant women of black origin and migrant women of Asian origin.
Look into each of the barriers, specifically among different groups of women, since this current review has been able to bring together most of the barriers to screening uptake among Black Asian and Minority Ethnic women to link and increase the generalisability of the findings from this current review.
This review identified barriers to the uptake of breast cancer and cervical cancer screening among Black Asian and Minority Ethnic women in the United Kingdom. The study concluded that barriers were socio-demographic characteristics, healthcare service delivery, cultural, religious & language, the gap in knowledge & awareness, and emotional, sexual & family support. To reduce or eliminate these barriers, continuous campaigns and education on the importance and benefits of timely breast and cervical cancer screening should be made widely available in all public places and hospitals where Black Asian and Minority Ethnic women domicile in the United Kingdom. It also needs to be acknowledged the need for structural changes, including examining public health priorities, exploring political drivers and addressing wider healthcare bureaucracies, as barriers to screening are complex. Tackling health and cancer inequalities requires a variety of public health interventions. Although this can be perceived to be a great deal of work, it has never been more crucial for both research and practice.
Availability of data and materials
All data generated and analysed during this study are included in this manuscript as supplementary information.
World Health Organisation
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Medical Literature Analysis and Retrieval System Online
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Bolarinwa, O.A., Holt, N. Barriers to breast and cervical cancer screening uptake among Black, Asian, and Minority Ethnic women in the United Kingdom: evidence from a mixed-methods systematic review. BMC Health Serv Res 23, 390 (2023). https://doi.org/10.1186/s12913-023-09410-x
- Breast cancer
- Cervical cancer
- Screening uptake
- Black Asian and Minority Ethnic women
- United Kingdom