Meet the people helping homeless women get vital smear tests: ‘You’ve got to hear their voices’

Serina Aboim has performed cervical screenings with RnB music on blast, jazz tunes wafting through the room, and songs from the past reminding patients of happier times. For the women facing homelessness she supports, steps like these can make an “invasive experience” like a smear test more comfortable.

“It’s about being flexible, creative and making it very led by them. You’ve got to hear their voices,” says Aboim, who is the clinical service lead at the homeless and high intensity user service at the Guy’s and St Thomas’ NHS Foundation Trust. 

There are around 3,000 new cases of cervical cancer every year in the UK, and more than 99% are associated with a common infection called human papillomavirus (HPV). Cervical screenings, alongside the HPV vaccination, greatly reduce the risk of cancer – but many women are missing out.

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Research shows that two of the main risk factors in developing cervical cancer are non-engagement with regular screenings and socioeconomic deprivation. It means women experiencing homelessness are particularly vulnerable and often face multiple barriers to smear tests.

Without a fixed address, women and people with cervixes might not receive GP letters saying they are due a screening – or they may not be registered with a GP at all. They might find it difficult to stick to appointment times, or be unable to afford the cost of transport.

They may be facing addiction or trauma associated with abuse. Experiences of violence and abuse are believed to be “near universal” for women sleeping rough, and the smear test may be re-traumatising.

Patients might not have had a good experience with cervical screening in the past. Some people might feel discriminated against, or have a disability which makes the test more daunting. They may face language barriers or cultural differences, or have no understanding of the screening.

“It’s an intimate examination,” says Claire Joels, advanced nurse practitioner at Great Chapel Street Medical Centre, a specialist service for people experiencing homelessness in Westminster. “And if someone hasn’t had a shower for a while, if they’re rough sleeping, then they might not want to have to undress or have anyone go near them.”

But services like Great Chapel Street and the homeless service at Guy’s and St Thomas’ are setting out to make women feel more comfortable.

The teams go to women’s day centres, hostels and youth services to support women who need help accessing healthcare. They make cervical screenings a normal part of health discussions, alongside talking about breast screenings, reproductive health and menopause.

They often support women to register with a GP, book appointments, cover the cost of transport, or go with them to their cervical screening. If women are fearful of their GP surgery, they can have the cervical screening at one of the day centres or hostels. 

Great Chapel Street has showers, as do many of the day centres, and patients are given the opportunity to clean themselves before their appointment.

“It’s often a very slow approach. It’s rare that I meet someone and they will be like: ‘Sure, let’s do it now,'” Joels says. “If they haven’t had a smear before, or if they don’t know anything about it, it’s giving them a lot of information and the reasoning behind it, showing them how we’re going to do it, letting them touch and feel the brush, and demystifying it.”

Joels worked with one woman who had anxiety about the cervical screening and she agreed to have the smear test done after months of conversations. The woman found out there were changes to her cells and she needed intervention, or it could have turned into cancer.

“There are frequently no symptoms whatsoever, especially for precancerous changes,” Joels says. “The only way to know is through this test.”

Helen Hyndman, a nurse who runs the service ‘Ask Eve’ for the Eve Appeal, explains that HPV is a very common virus which “most people” will contract at some point in their lives.

“It’s spread through close skin-to-skin contact during any type of sexual contact. That could be penetrative sex, oral sex, touching genital areas, sharing sex toys,” she says.

“Cervical screening isn’t for somebody who has symptoms. It’s for people who don’t have symptoms. It’s a preventative test. HPV infects the cells of the cervix, and that can cause abnormal cell changes which are not cancerous, but we want to know about them so that we can monitor or treat them, to prevent them developing into cancer.”

Hyndman suggests people request a double appointment so they don’t feel rushed. They can also ask for their nurse to be female. There are different sized speculums, and people can ask for more water-based lubricant to help the speculum slide in more easily. Hydman encourages women to listen to music, podcasts or do deep breathing exercises if they are anxious.

“If women are going for their screening and don’t feel able to have it done when they get there, that’s absolutely fine,” Hydman adds. “They can say that they don’t feel able to have it done, and they can always make another appointment. There’s no pressure at all. It’s important they feel in control.”

Joels says there have been pilots around self-swabbing which can be less invasive for women who are concerned about smear tests. You can also ask for someone to go into the appointment with you.

Imogen Sagon, health navigator at the Marylebone Project, says that she attended “many smears” in her capacity as a support worker for women facing homelessness before she attended her own cervical screening. She runs the health beds alongside Great Chapel Street.

“People, especially women with more complex needs, often don’t want to go to the GP. It takes too long. They can ask insensitive questions. I’ve experienced that personally, where I was with a resident and they asked why they were on methadone,” Sagon says.

“I feel like there is a general lack of awareness from health professionals about what might be a sensitive situation. People avoid the GP for many reasons. Often, the only time that people get any health intervention is when they’re in crisis.”

Sagon explains that when working with people with complex needs, it can often “feel like you’re going from one crisis to another” and they might not be in a headspace to be able to have a conversation about routine screenings. 

“Often, the women we support aren’t ever ready, but making sure you’re still on top of that as a key worker is really important. It’s something that the NHS is trying to focus on, because the rates for screening for people experiencing homelessness are so much lower than the general population,” Sagon says.

People facing homelessness are more likely to die young, with an average age of death 47 and even lower for homeless women at 43. Often, these deaths would have been preventable.

“It’s something we’ve noticed in the health beds – missed screenings, and then people coming in and having warning markers for cancer and other issues could have been caught a lot earlier and could have been dealt with before this final stage,” Sagon says.

She adds that such specialist services such as those offered at Great Chapel Street are “pretty uncommon” and that “gender specific services are rarer than they should be”.

Aboim agrees there can be a “postcode lottery” as “each area of London has a different service”. The homeless and high intensity user service at the Guy’s and St Thomas’ NHS Foundation Trust covers Lambeth, Southwark and Lewisham.

“If you’re rough sleeping in one of those boroughs and you get placed in one of those hostels, then you have access to our service,” Aboim says. More broadly across the country, specialist health services for people facing homelessness can be limited.

Hydman suggests that for those who cannot access specialist services, or who do not want to attend a cervical screening at their GP surgery or a sexual health clinic, it is worth seeing if you can be referred to your local hospital, which may have more options available.

It’s also important to check if you could be eligible for the HPV vaccine. It is offered to children in secondary school, but it’s also available for people under the age of 25 on the NHS, as well as specific groups under 45 including men who have sex with men, sex workers and those who are immunosuppressed. Others can pay to have it done privately.

“I would like to see more accessible information, awareness raising, and information for women and people with cervixes about how they can overcome barriers,” Hydman says. “And I would like people to know we are there to support them through the process and help them with whatever they need to feel that they can go through with their test.”

Find out how to get support from an Ask Eve nurse here. There’s more information about getting cervical screenings on the NHS website and find out if you could be eligible for an HPV vaccine here.

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