Trauma-informed care in cervical screening

Catherine Reilly explores how CervicalCheck is improving screening access for under-served populations, including women affected by trauma

Trauma-informed care is a “powerful equity tool” in cervical screening, states Dr Rachael Comer (PhD), Education and Training Manager in CervicalCheck’s screening training unit (STU).

‘Equity’ is the overarching priority in Ireland’s Cervical Cancer Elimination Plan, which recognises that some population groups are less likely to access screening and human papillomavirus (HPV) vaccination.

In Ireland, cervical screening is offered to women aged 25 to 65 (approximately 1.3 million individuals). CervicalCheck’s screening coverage is high at 75 per cent, according to the Programme’s 2022/23 report. Nevertheless, this means one-quarter of eligible women did not access screening in the preceding five years. Currently, around 40 per cent of cervical cancers occur in women who have never had screening.

The elimination plan commits to adopting strategies and designing specific interventions targeted at underserved populations to ensure equitable access to services – encompassing HPV vaccination, cervical screening, and timely diagnosis and treatment of precancer abnormalities and cervical cancer.

The plan’s vision is that cervical cancer will be a rare disease “in every community” by 2040. “This means threading work to achieve equity through all our projects and promoting a ‘whole-of-society’ approach,” it outlines. The priority actions include a feasibility study on HPV self-sampling, which could help improve uptake among women who face barriers to screening (see panel p5).

Trauma-informed care

Trauma-informed care/practice is a framework for how services are delivered – based on the knowledge and understanding of how trauma can affect people’s lives. It means that services are aware and sensitive to a person’s history of trauma and how this might affect their behaviour and the services they need.

Trauma can result from any situation where someone felt scared, unsafe, disrespected, or powerless, including sexual abuse or assault. A Central Statistics Office report in 2023 found that 52 per cent of women in Ireland had experienced some form of sexual violence – defined as “a range of non-consensual experiences, from non-contact experiences to non-consensual sexual intercourse”.

Cervical screening may “trigger or retraumatise” women with lived experience of sexual violence, coercive control and marginalisation, Dr Comer told the Medical Independent (MI). This may also result in avoidance of screening. “By acknowledging and addressing these realities, trauma-informed care really reduces emotional, psychological, and structural barriers to screening.”

Trauma-informed care in screening encompasses many aspects – from identifying the signs and symptoms of trauma to making women feel empowered and ensuring they are consented throughout the procedure. It includes women’s interaction with administration and clinical staff. By applying trauma-informed principles, sample-takers can help to reduce fear and anxiety; improve comfort and trust; and support access for people who may have avoided screening in the past.

This topic is embedded within the national cervical screening education programme, according to Dr Comer. This aims to ensure all sample-takers receive training on how to recognise, respond to and reduce the risk of re-traumatisation during screening. In 2025, the STU launched a clinical update on trauma-informed care, which is available to sample-takers on the CervicalCheck e-learning platform. The Programme encourages all sample-takers to access this clinical update to strengthen their understanding and confidence in providing compassionate, trauma-informed care.

As part of its work in this sphere, the STU has collaborated with services including prisons and sexual assault treatment units (SATUs) to develop trauma-informed screening. Until 2023, women at Limerick Female Prison had to be escorted to a GP practice by prison staff to access cervical screening. Ms Edel Muldowney, Chief Nurse Officer at the prison, led efforts to develop on-site screening. This work was supported by the STU and led to the establishment of a trauma-informed cervical screening service at the prison. The initiative also involves education for women about HPV, cervical screening, and HPV vaccination.

Often these women would have experienced violence and had mistrust of healthcare services, noted Dr Comer. “Crucially the model recognised this heightened vulnerability associated with intimate examination and custodial settings.”

An audit has demonstrated a 200 per cent increase in screening uptake following the service’s establishment. The HPV prevalence was found to be double that of the general population, underlining the importance of timely and accessible screening. These findings demonstrated how trauma-informed screening can “really significantly meet unmet needs in marginalised groups”.

“And importantly, on-site delivery can promote continuity of care, because they have really good relationships with these nurses. The nurses know them and are well-trained to care for their needs, with results management and follow-up, and so on.”

SATUs

To date, three of the six SATUs nationally have established a cervical screening service (Donegal SATU; Rotunda SATU; Waterford SATU). The Galway SATU is also due to commence a service shortly. Staff at the Donegal SATU identified that many women attending the service were either delayed in accessing or had never attended cervical screening. The women highlighted barriers such as embarrassment, shame, guilt, or fear of disclosure. In 2017, Advanced Nurse Practitioner, Ms Connie McGilloway, led the establishment of a screening service which is offered at a follow-up clinic. Some 72 eligible women participated in screening between 2018 and 2023, with 17 women (24 per cent) referred to colposcopy services. The service also has a support structure in place for women referred to colposcopy.

Time pressures, especially in settings such as general practice, can present challenges to the delivery of trauma-informed care. However, Dr Comer emphasised that staff want to do their best for patients. She said there are ways of ensuring women’s needs are met – such as offering a rebooking for the procedure if a longer time slot is required and when the woman is not ready to proceed on the day.

Older age groups

Trauma-informed care is one strand of CervicalCheck’s work to improve screening access and delivery. It has also placed a concerted focus on improving uptake among women over 50, who are less likely to attend screening than younger age-groups.

“Around one in four women over 50 don’t attend for screening and most of these women won’t have received a HPV vaccine, which means they are high risk if they are not being screened,” stated Dr Comer.

Inadequate screening participation at age 50–64 years has been identified as a significant risk factor for cervical cancer for women in their 60s and 70s in a population-based case control study (Castañón et al).

However, some women may believe screening is unnecessary after menopause, while others face barriers such as limited GP access, physical challenges, or trauma histories.

The establishment of cervical screening in ambulatory gynaecology units has been identified as an avenue to improve access. A high proportion of women attending the units are aged over 50. Following collaboration between CervicalCheck and the National Women and Infants Health Programme (NWIHP), 13 of the 20 units now have a nurse-led cervical screening service, with a further three in development. 

This work has involved engaging with advanced and candidate advanced nurse practitioners, consultants, and clinical nurse managers to assess readiness and training needs; and providing tailored educational and clinical support for nurse-led models.

During 2025, CervicalCheck also collaborated with the six regional complex menopause clinics to embed screening awareness during triage. This aims to ensure staff routinely discuss screening status, and offer support to women who wish to access screening in settings such as general practice/primary care, ambulatory gynaecology and SATUs.

CervicalCheck is also embarking on the pilot phase of a new quality improvement initiative focusing on women aged 50 to 65 years. In the pilot, which initially involves 35 GPs, women overdue for cervical screening by six months will receive a text message reminder, while women who have never attended for cervical screening will receive a direct phone call from the sample-taker, who may be a practice nurse or GP. This targeted approach aims to optimise engagement while supporting informed, person-centred decision-making.

“This doesn’t replace the national call-recall programme, but it strengthens it by attending an extra personalised layer of engagement,” said Dr Comer.