Introduction 

In September 2025, we were tasked with retrieving articles on barriers to breast cancer care in Nicaragua, as part of a research team working with Dr. Nouvet in the School of Health Studies at Western University. While we engaged in this task, we found articles which detailed challenges in cervical cancer detection and treatment in the region, drawing our attention to the complex nature of healthcare-seeking patterns among stigmatized diseases. 

Despite being largely preventable, cervical cancer remains a significant global health concern. Misinformation and limited access to care continue to shape disease outcomes. Worldwide, cervical cancer is uniquely burdened by misinformation and stigma related to its causes and prevention, particularly surrounding human papillomavirus (HPV) transmission, sexual health, and the perceived morality associated with the disease (Rees et al., 2017). In Canada, widespread screening and HPV vaccine uptake initiatives have reduced incidence to among the lowest globally (Canadian Partnership Against Cancer, n.d.). However, in Nicaragua, cervical cancer remains one of the leading causes of cancer-related death among women, with a rate six times higher than that observed in high-income countries (Fernandez-Deaza et al., 2024). This stark disparity reflects deep-rooted inequities in access and quality of care, health education, and social support. 

Misinformation and stigma persist despite overwhelming scientific evidence that persistent infection with high-risk types of human papillomavirus (HPV), most notably HPV-16 and HPV-18, causes approximately 70% of cervical cancer cases globally (National Cancer Institute, 2024; Bosch et al., 2002). While most HPV infections resolve spontaneously, long-term infection with high-risk strains can lead to precancerous cellular changes that are detectable and treatable through routine screening (National Cancer Institute, 2024). When screening is inaccessible or avoided due to stigma, these lesions may progress to invasive cancer. 

In what follows, we explore how misinformation, stigma, and community-level barriers to care intersect in Nicaragua, influencing health-seeking behaviours and highlighting the urgent need for community-centred interventions. 

In Nicaragua, a medley of systemic and community barriers results in inaccessibility and misconceptions regarding HPV prevention, cervical cancer screening, and cervical cancer treatment. Health system fragmentation, workforce shortage, and screening challenges are prevalent systemic barriers. This blog focuses on the role of community-level barriers and their impact on patient willingness to seek screening, treatment, and care. Such barriers are essential to consider, as they shape communal perceptions, which in turn influence health-seeking behaviours. 

The Weight of Stigma and Misconception 

In many Nicaraguan communities, pap smears and cervical cancer diagnoses are associated with sexual promiscuity, leading to damaging stigma and discrimination (Rees et al., 2017). In more conservative populations, pursuing a pap smear or HPV testing can lead to shame and social isolation. In a study conducted by Rees et al., it was found that 54% of the population believed that girls who receive pap smears will be more likely to have sexual relations (2017). This belief was more prominent among rural women (63%) than urban women (44%), but it is evident that this stigma is widespread (Rees et al., 2017). 

Even though women who are married, elderly, or have children are also affected, cervical cancer’s association with HPV causes it to be viewed as a shameful or “dirty” disease. Such normative ways of framing cervical cancer in Nicaragua lead many women to fear judgment and isolation from their community, ultimately discouraging openness within the community throughout diagnosis and treatment (Ress et al., 2017). Impacted individuals are often unable to seek support from their communities in fear of isolation, resulting in their diagnoses being kept a secret and retreating from their social lives (Rees et al., 2017). 

These misconceptions have further implications. More conservative communities may discourage young women and girls from receiving HPV vaccinations or regular pap smears to prevent sexual behaviour. In a study of nearly 1.7 million women, the efficacy of early HPV vaccination reduced cervical cancer incidence by nearly 90% when compared with incidence in women who had not been vaccinated (National Cancer Institute, 2020). It is also understood that regular Pap screening tests can reduce cervical cancer diagnosis by up to 96% (Dasgupta, 203). 

Studies have found that women often experience the consequences of stigma related to abnormal cervical cancer screening results and HPV, often considering these results as being embarrassing, disgusting, or something that should be hidden from others (Morse et al., 2023). Associating cervical cancer with promiscuity poses serious consequences in terms of a patient's willingness to seek treatment and support from their communities. In many instances, social isolation can result in reduced patient morale, which can further complicate the ability to recover from cancer. The result of these stigmas and misconceptions is a breakable cycle, filled with silence, misinformation, and preventable suffering. The result of such beliefs is expressed by an urban woman in Nicaragua, who described living with cervical cancer as “living alone” (Rees et al., 2017). 

The Barrier of Intimacy and Access 

Beyond stigma, the intimate nature of cervical cancer screening itself creates barriers. Many women worldwide express discomfort undergoing pap smears, particularly when this exam is performed by male clinicians (Arabaci and Ozsoy, 2012; McFadden et al., 2022; Wong et al., 2008). This pattern has also been observed in Nicaragua (Rees et al., 2017). In Rees et al.’s study, over 70% of women expressed feeling uncomfortable receiving a pap test from a male provider, yet the option to choose a female clinician in the context of Nicaragua is often limited to private clinics, a service that remains unaffordable for most women. Limited autonomy in choosing providers discourages women from seeking screenings (Ibid). In conservative communities, exposing intimate areas during a medical exam may also feel embarrassing or even frightening (Ibid). 

For many women, the idea of exposing intimate areas to a male clinician is not only uncomfortable but can also feel embarrassing or culturally inappropriate. When women do decide to seek care from a male clinician, being met with judgment or limited knowledge can reinforce negative feelings surrounding screening. These scenarios further deter patients from seeking potentially life-saving screenings and have profound consequences. Existing literature suggests hesitancy may be due to prevailing conservative beliefs and intimacy associated with gynaecological exams, but further research is necessary to understand why Nicaraguan women feel uncomfortable with male providers (Rees et al., 2017). 

Gaps in Knowledge and Education 

A widespread lack of education regarding cervical cancer and its symptoms further compounds the barriers outlined above. In a study conducted in one region of Nicaragua, only half of the 634 women surveyed, only half recognized the pap smear as a preventative measure of cervical cancer, and fewer than 20% could name even one symptom of the disease (Claeys et al., 2017). Such gaps in knowledge directly contribute to low screening rates. Many women avoided screening out of fear, negligence, or the belief that it was unnecessary without symptoms (Ibid). Such misconceptions reinforce a reactive, rather than preventative, approach to healthcare, leading to delayed diagnoses and poorer outcomes. Emphasizing the preventive nature of Pap smears is essential for addressing misinformation and promoting cervical cancer awareness and prevention.​ 

Moving Toward Health Equity 

Cervical cancer in Nicaragua represents a medical and social crisis. It is a gendered disease that disproportionately affects women, many of whom are primary caregivers, economic contributors, and central figures within their households. When women experience cervical cancer, the impact extends beyond individual health and risks family stability, children’s wellbeing, and the broader functionality of the community. 

Yet, this preventable cancer continues to thrive due to a complex intersection of social stigma, limited autonomy in care, misinformation, and systemic inequity. To protect both women and the families who depend on them, the region must ensure women have access to HPV screening, pap tests, gynaecological consultations, and follow-up care when results indicate abnormal cervical cytology or precancerous lesions that may indicate elevated cancer risk. Vaccination plays a critical role in reducing disease burden. As of January 13, 2025, 69,920 Nicaraguan girls have been immunized against HPV; this represents about 52% of the country’s immunisation target (Prensa Latina, 2025). As vaccine efforts continue, meaningful change is made towards protecting as many lives as possible 

​ Beyond vaccination, preventing cervical cancer in Nicaragua, as elsewhere, hinges on ensuring women have control and comfort in choosing their providers, ensuring that providers are receiving culturally competent education, and enhancing community education to demystify cervical cancer and normalize prevention. By acknowledging the gendered implications of this disease and addressing both social and structural barriers, health systems across Nicaragua can foster earlier detection, reduce stigma, and ultimately save more lives. Delivering and developing the equipment, education, and infrastructure necessary for prevention and care allows for investment in the health of women, families, and communities. 

This issue reinforces why medicine must extend beyond diagnosis and include advocacy, trust-building, and community partnership. Sustained investment in cervical cancer prevention represents a broader commitment to gender equity and community health, foundations that align closely with our aspirations as future physicians and global health advocates. 

References  

Arabaci, Z., & Ozsoy, S. (2012). The pap-smear test experience of women in Turkey: A qualitative study. Asian Pacific Journal of Cancer Prevention, 13(11), 5687–5690. https://doi.org/10.7314/apjcp.2012.13.11.5687 

Bosch, F. X., Lorincz, A., Munoz, N., Meijer, C. J., & Shah, K. V. (2002). The causal relation between human papillomavirus and cervical cancer. Journal of Clinical Pathology, 55(4), 244–265. https://doi.org/10.1136/jcp.55.4.244 

Cervical cancer causes, risk factors, and prevention. NCI. (2024). https://www.cancer.gov/types/cervical/causes-risk-prevention 

Cervical cancer. PAHO/WHO | Pan American Health Organization. (n.d.). https://www.paho.org/en/topics/cervical-cancer 

Claeys, P., Gonzalez, C., Gonzalez, M., Page, H., Bello, R. E., & Temmerman, M. (2002). Determinants of cervical cancer screening in a poor area: Results of a population‐based survey in Rivas, Nicaragua. Tropical Medicine & International Health, 7(11), 935–941. https://doi.org/10.1046/j.1365-3156.2002.00953.x 

Daniel, D., Wickerham, A., Fitzgerald, E. A., & Kue, J. (2022). Interventions to eliminate cervical cancer in Nicaragua: An integrative review of the literature. Hispanic Health Care International, 21(2), 104–113. https://doi.org/10.1177/15404153221081280 

Dasgupta, S. (2023). The efficiency of cervical PAP and comparison of conventional pap smear and liquid-based cytology: A Review. Cureus. https://doi.org/10.7759/cureus.48343 

Eliminating cervical cancer. Canadian Partnership Against Cancer. (n.d.). https://www.partnershipagainstcancer.ca/topics/eliminating-cervical-cancer/  

Fernández-Deaza, G., Serrano, B., Roura, E., Castillo, J. S., Caicedo-Martínez, M., Bruni, L., & Murillo, R. (2024). Cervical cancer screening coverage in the Americas Region: A synthetic analysis. The Lancet Regional Health - Americas, 30, 100689. https://doi.org/10.1016/j.lana.2024.100689  

McFadden, N. T., Wilkerson, A. H., & Carmack, H. J. (2022). “I feel like it’s one of those things that everyone feels the same way about, no one wants to discuss it”: A qualitative examination of Female College Students’ Pap Smear Experience. Health Behavior Research, 5(3). https://doi.org/10.4148/2572-1836.1138 

Morse, R. M., Brown, J., Gage, J. C., Prieto, B. A., Jurczuk, M., Matos, A., Vásquez Vásquez, J., Reátegui, R. R., Meza-Sanchez, G., Córdova, L. A., Gravitt, P. E., Tracy, J. K., Paz-Soldan, V. A., Carhuaza, I., Carrillo Jara, L. E., del Carmen Caruhapoma, M., Del Carpio-Morgan, M., Daza Grandez, H., Figueredo Escudero, M., … Zevallos, K. (2023). “Easy women get it”: Pre-existing stigma associated with HPV and cervical cancer in a low-resource setting prior to implementation of an HPV screen-and-treat program. BMC Public Health, 23(1). https://doi.org/10.1186/s12889-023-17324-w 

National Vaccination campaign against HPV advances in Nicaragua - Prensa Latina. Prensa Latina - Latin American News Agency. (2025, April 3). https://www.plenglish.com/news/2025/04/03/national-vaccination-campaign-against-hpv-advances-in-nicaragua/  

Rees, H. D., Lombardo, A. R., Tangoren, C. G., Meyers, S. J., Muppala, V. R., & Niccolai, L. M. (2017). Knowledge and beliefs regarding cervical cancer screening and HPV vaccination among urban and rural women in León, Nicaragua. PeerJ, 5. https://doi.org/10.7717/peerj.3871 

Study confirms HPV vaccine prevents cervical cancer. Study Confirms HPV Vaccine Prevents Cervical Cancer - NCI. (2020, October 14). https://www.cancer.gov/news-events/cancer-currents-blog/2020/hpv-vaccine-prevents-cervical-cancer-sweden-study 

Wong, L. P., Wong, Y. L., Low, W. Y., Khoo, E. M., & Shuib, R. (2008). Cervical cancer screening attitudes and beliefs of Malaysian women who have never had a PAP SMEAR: A qualitative study. International Journal of Behavioral Medicine, 15(4), 289–292. https://doi.org/10.1080/10705500802365490 

World Health Organization. (n.d.). Nicaragua. World Health Organization. https://data.who.int/countries/558  

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