Immigrant women and cervical cancer screening uptake: a multilevel analysis

Trends in cervical cancer screening in Norway 2012-2017: a comparison study of non-immigrant and immigrant women

AIMS

Immigrant women in Norway have lower cervical cancer screening participation than non-immigrant women. Our aim in this study was to assess whether the observed increase in screening participation during 2012-2017 was different between Norwegian-born women and immigrant women.

METHODS

Data were collected from three national registries. The study included 1,409,561 women, categorized according to country of birth and immigrant background: (i) Norway, Norwegian parents; (ii) Norway, immigrant parent(s); (iii) Europe, excluding Norway; (iv) Africa; (v) Asia, including Turkey; and (vi) other countries. Trends and differences between groups were analyzed using Poisson regression analyses with adjustments for variables other studies have found to influence screening participation. Trends were assessed by including half-years as a continuous variable in the models and reported as prevalence ratios with 95% confidence intervals.

RESULTS

Screening participation increased in all groups, but was not statistically significant among women from Africa in the adjusted model. The highest increase was among Norwegian women, with a 2.2% increase per year. Interaction tests showed significantly smaller increases in screening among women born in Europe (p interaction < 0.0001), Africa (p interaction < 0.0001), Asia (p interaction < 0.0001), and countries in the "Other" category (p interaction = 0.004). There was also a smaller increase among Norwegian-born women with one or more immigrant parent(s), but this was not significant (p interaction = 0.178).

CONCLUSIONS

The gap in screening participation and the increasing differences in trends suggest that healthcare services do not reach all women in Norway to the same extent. One should attempt to improve this while working toward further increasing screening participation for all.

Predictors of non-adherence to cervical cancer screening among immigrant women in Ontario, Canada

Cervical cancer is one of the most common types of cancer among women and is largely preventable with regular screening using Papanicolau (Pap) tests. In Canada, all provinces have regular screening programs, although with slightly differing recommendations. Previous research has found that immigrant women, who are a large proportion of the Canadian population, are at higher risk of being under-screened, or non-adherent to the recommended screening frequency. Using data from the 2017 Canadian Community Health Survey, this study examined: (1) the extent to which immigration status and time since immigration are associated with Pap test adherence in Ontario, and (2) predictors of Pap test adherence for immigrants and Canadian born populations in Ontario, Canada's most populous province, with a focus on the role of racial or ethnic identity among immigrants. Estimates of 3-year test adherence were 71.3 % (95 %CI: 66.9-75.7) among immigrant women and 75.4 % (95 %CI: 73.1-77.1) among non-immigrant women. Recent immigrants (6-10 years in Canada) had lower adherence (63.5 %, 95 %CI: 48.0-80.0). Logistic regression models found that immigrant women had lower adherence than Canadian-born women, controlling for age, household income, education, and having a primary care physician. Subgroup analysis found that South Asian immigrant women were least likely to be adherent. These results support targeted programming to increase screening adherence among recent immigrants and raise concerns regarding potential barriers to screening. Data that allow better disaggregation of racial and ethnic identities are important for better understanding the potential implications of these patterns for racial inequities in health.

Incidence, factors, and disparities related to cancer among Black individuals in Canada: A scoping review

BACKGROUND

In Canada, two of five individuals will be diagnosed with cancer in their lifetime and one in four will die from this disease. Given the disparities observed in health research among Black individuals, we conducted a scoping review to analyze the state of cancer research in Canadian Black communities regarding prevalence, incidence, screening, mortality, and related factors to observe advances and identify gaps and disparities.

METHODS

A comprehensive search strategy was developed and executed in December 2021 across 10 databases (e.g., Embase). Of 3451 studies generated by the search, 19 were retained for extraction and included in this study.

RESULTS

Studies were focused on a variety of cancer types among Black individuals including anal, breast, cervical, colorectal, gastric, lung, and prostate cancers. They included data on incidence, stage of cancer at diagnosis, type of care received, diagnostic interval length, and screening. A few studies also demonstrated racial disparities among Black individuals. This research reveals disparities in screening, incidence, and quality of care among Black individuals in Canada.

CONCLUSIONS

Given the gaps observed in cancer studies among Black individuals, federal and provincial governments and universities should consider creating special funds to generate research on this important health issue.

PLAIN LANGUAGE SUMMARY

Important gaps were observed on research on cancer among Black communities in Canada. Studies included in the scoping review highlights disparities in screening, incidence, and quality of care among Black individuals in Canada.

Awareness of cervical cancer and its associated socio-demographic factors among Yemeni immigrant women in Malaysia

BACKGROUND

Studies have revealed that a higher proportion of women affected by cervical cancer are from some minority groups of immigrant women. Hence, this study was conducted to assess Yemeni immigrant women's awareness of cervical cancer and its associated socio-demographic factors.

METHODS

A cross-sectional study was conducted among 370 Yemeni women in Selangor and Kuala Lumpur, Malaysia. Data on the awareness of symptoms/signs, risk factors, and screening programme were collected using Cervical Cancer Awareness Measurement (Cervical CAM) questionnaire.

RESULTS

More than 74% of the study participants were unable to recall any warning symptoms/signs, and 73% were unable to recall any risk factors. The factors associated with the awareness of symptoms and risk factors were age (95% CI 4.22-5.22, p = 0.039), marital status (95% CI 4.05-7.87, p = 0.021), employment (95% CI 3.89-5.77, p = 0.046) and the number of children (95% CI 5.33-6.54, p = 0.041).

CONCLUSION

The findings underline the need for public awareness campaigns to improve public awareness of cancer symptoms and risk factors among underserved communities.

Factors associated with cervical cancer screening behaviors among young married female (aged 20-29) immigrants in South Korea

OBJECTIVE

To identify factors that affect the participation of female immigrants in their 20s in the national cervical cancer screening programs.

METHODS

Data were obtained from the National Health Insurance Services from 2016 to 2017. A total of 17,730 women who agreed to undergo cervical cancer screening during 2016-2017 were included in the study.

RESULTS

Of the 17,730 women, 8,149 (46%) participated in cervical cancer screening, whereas, 9,581 (54%) did not. Logistic regression analysis of factors related to cervical cancer screening showed that the odds ratio (OR) of screening was higher in short duration of stay (OR, 1.18; 95% confidence interval [CI], 1.03-1.35), Chinese nationality (OR, 1.43; 95% CI, 1.28-1.59), unemployment (OR, 1; 95% CI, reference), participation in general health screening (OR, 4.16; 95% CI, 3.24-5.33), and comorbidities (OR, 1.16; 95% CI, 1.09-1.24) when compared to the other populations. The highest OR was associated with participation in general health screening.

CONCLUSION

Appropriate programs should be developed to increase participation of socially vulnerable groups in cervical cancer screening. Such programs will improve awareness regarding cervical cancer screening and reduce disparities in healthcare.

Effect of culturally tailored education on attendance at mammography and the Papanicolaou test

Objectives

To determine the effectiveness of culturally tailored education on attendance at breast and cervical cancer screening among ethnic minority women.

Data Sources

Systematic database searches in Ovid MEDLINE, ProQuest, PubMed, PsycINFO, and Cochrane CENTRAL.

Study Design

Randomized controlled trials (RCTs) of culturally tailored educational interventions to ethnic minority women in Western countries were investigated for a meta‐analysis. RCTs that assessed attendance at mammography or the Papanicolaou test (Pap test) were eligible for inclusion.

Data Collection Methods

Study characteristics and results were extracted separately. Independent raters assessed risk of bias by using Cochrane Collaboration's tool.

Principal Findings

Seven RCTs (n = 4246) were included in the meta‐analysis of mammography attendance, and four RCTs (n = 1750) were included in the meta‐analysis of Pap test attendance. The effect of culturally tailored educational interventions on attendance at mammography was an increase of 18 percent (RR = 1.18, 95% CI, 1.09‐1.28, P < .001), with low heterogeneity (I² = 30.0, P = .237), and a 54 percent increase at the Pap test (RR = 1.54, 95% CI, 1.14‐2.09, P = .005), with substantial heterogeneity (I² = 75.9%, P = .001).

Conclusions

Interpreted within the limitations set by the low number of studies and substantial heterogeneity for the Pap test, findings from the current meta‐analyses indicate that culturally tailored educational interventions may increase attendance of ethnic minority women at breast and cervical cancer screenings. There is a need for more studies, in particular RCTs conducted outside the United States, to determine if such findings are similar in other countries.

Group Versus Individual Culturally Tailored and Theory-Based Education to Promote Cervical Cancer Screening Among the Underserved Hispanics: A Cluster Randomized Trial

Purpose:

To determine whether group education is as effective as individual education in improving cervical cancer screening uptake along the US–Mexico border.

Design:

Cluster randomized controlled study.

Setting:

El Paso and Hudspeth Counties, Texas.

Participants:

Three hundred women aged 21 to 65 years, uninsured, due for a Pap test, no prior history of cervical cancer or hysterectomy.

Intervention:

Theory-based, culturally appropriate program comprised of outreach, educational session, navigation services, and no-cost cervical cancer testing.

Measures:

Baseline, immediate postintervention, and 4-month follow-up surveys measured knowledge and theoretical constructs from the Health Belief Model, Theory of Reasoned Action, and the Social Cognitive Theory.

Analysis:

Relative risk regression analyses to assess the effects of educational delivery mode on the uptake of screening. Mixed effect models to analyze changes in psychosocial variables.

Results:

One hundred and fifty women assigned to each educational group; 99% Hispanic. Of all, 85.7% completed the follow-up survey. Differences in screening rate at follow-up were analyzed by education type. Overall screening rate at follow-up was 73.2%, no significant difference by education type (individual: 77.6%, group: 68.9% P = .124). Significant increases among group education at follow-up for knowledge, perceived susceptibility, perceived seriousness, and subjective norms and significant decrease for perceived benefits.

Conclusion:

This study provides evidence to support the effectiveness of group education to promote cervical cancer screening among vulnerable Hispanic women and offers an additional method to address cervical cancer disparities.

Factors Associated with Cervical Cancer Screening among Married Female Immigrants with Korean Husbands in South Korea

Background. The purpose of this study was to identify factors associated with the national cervical cancer screening behaviors of married female immigrants living in South Korea. Methods. The present study dataset was collected by the National Health Insurance Services in 2014⁻2015. A final study population of 15,935 was considered eligible for inclusion in this study if they met the criteria for participation in the national cervical cancer screening program in 2014⁻2015. Results. Of the 15,935 subjects, 7837 (49%) participated in cervical cancer screening. Based on the results of the logistic regression analysis of the association between cervical cancer screening behaviors and related factors, the odds ratio (OR) for participation in cervical cancer screening among individuals older than 50 years was the highest (OR: 2.13; 95% confidence interval (CI): 1.82⁻2.51), and the OR increased as their duration of stay in South Korea decreased. The OR of Chinese women for cervical cancer screening participation was higher than that of non-Chinese women (OR: 1.83; 95% CI: 1.69⁻1.99). The OR value was 29.4 (95% CI: 25.9⁻33.3) among those who participated in the general health screening compared with those who did not participate. Conclusions. To improve awareness about cervical cancer screening and reduce disparities in access to healthcare, appropriate programs should be developed to promote cervical cancer screening participation to socially vulnerable classes. Continuous social attention is needed to address these issues and encourage participation in general health screening to improve the rate of cervical cancer screening.

Barriers to cervical cancer screening faced by immigrants: a registry-based study of 1.4 million women in Norway

Background

Immigrants from certain low- and middle-income countries are more prone to cancers attributed to viral infections in early life. Cervical cancer is caused by human papillomavirus but is highly preventable by regular screening. We assessed participation among immigrants in a population-based cervical screening programme and identified factors that predicted non-adherence within different immigrant groups.

Methods

We used data from several nationwide registries. The study population consisted of 208 626 (15%) immigrants and 1 157 223 (85%) native Norwegians. Non-adherence was defined as no eligible screening test in 2008–12. We estimated prevalence ratios with 95% confidence intervals (CIs) for factors associated with non-adherence by modified Poisson regression.

Results

In total, 52% of immigrants were not screened. All immigrants showed 1.72 times higher non-adherence rates (95% CI 1.71–1.73) compared with native Norwegian women when adjusted for age and parity. The proportion of non-adherent immigrants varied substantially by region of origin and country of origin. Being unemployed or not in the workforce, being unmarried, having low income and having a male general practitioner was associated with non-adherence regardless of region of origin. Living <10 years in Norway was an evident determinant of non-adherence among most but not all immigrant groups.

Conclusions

An increasing proportion of immigrants and low screening participation among them pose new public health challenges in Europe. Immigrants are diverse in terms of their sociodemographic attributes and screening participation. Tailored information and service delivery may be necessary to increase cancer screening among immigrants.

Differences in cervical cancer screening between immigrants and nonimmigrants in Norway: a primary healthcare register-based study

Supplemental Digital Content is available in the text.

The prevalence of cervical cancer is high among some groups of immigrants. Although there is evidence of low participation in cervical cancer screening programs among immigrants, studies have been subject to selection bias and accounted for few immigrant groups. The aim of this study was to compare the proportion of several groups of immigrants versus nonimmigrants attending the cervical cancer-screening program in Norway. In addition, we aimed to study predictors for attendance to the screening program. Register-based study using merged data from four national registries. All Norwegian-born women (1 168 832) and immigrant women (152 800) of screening age for cervical cancer (25–69 years) registered in Norway in 2008 were included. We grouped the immigrants by world’s geographic region and carried out descriptive analyses and constructed several logistic regression models. The main outcome variable was whether the woman was registered with a Pap smear in 2008 or not. Immigrants had lower rates of participation compared with Norwegian-born women; Western Europe [adjusted odds ratio (OR), 95% confidence interval (CI): 0.84, 0.81–0.88], Eastern Europe (OR 0.64, 95% CI: 0.60–0.67), Asia (OR 0.74, 95% CI: 0.71–0.77), Africa (OR 0.61, 95% CI: 0.56–0.67) and South America (OR 0.87, 95% CI: 0.79–0.96). Younger age, higher income, residence in rural areas, and having a female general practitioner (GP) were associated with Pap smear. Longer residential time in Norway and having a nonimmigrant GP were associated with screening for some immigrant groups. Appropriate interventions targeting both immigrants and GPs need to be developed and evaluated.

Cervical cancer screening in Montreal: Building evidence to support primary care and policy interventions

In Canada, over 40% of invasive cervical cancers occur among women who have never been screened. Although 12% of Canadian women have never been screened, this number can be as high as 43% among certain social groups. Little is published on factors associated with screening uptake and inequalities among women residing in Quebec. Four waves of the Canadian Community Health Survey (2003, 2005, 2008, 2012, N = 6393) were utilized to assess lifetime screening and screening in the previous 3 years among women residing in Montreal. Chi-squared statistics were calculated, Poisson regression was utilized to model prevalence ratios, and prevalence differences were calculated. In total, 13.6% of women had never been screened and 12.1% had not been screened in the previous 3 years. Immigrant status was the strongest predictor of never being screened [recent vs non-immigrant: Prevalence Ratio (PR), 3.9 (95% Confidence Interval (CI): 2.9-5.4)] and not having a primary care physician (PCP) was the strongest predictors of not being screened recently [PR = 3.0 (95% CI: 2.3-3.9)]. The two most common reasons for not being screened were not "know[ing] it was necessary" and not "get[ting] around to it." These results provide a description of sub-populations which might benefit from cervical screening interventions: immigrants and women without a PCP. Interventions targeting access to PCPs, expanding training of non-physicians to conduct screening, organized screening, or autoadministered screening test may mitigate inequalities. Future work should assess their acceptability and feasibility, and evaluate the impact of these types of primary care and policy interventions.

Cervical and Breast Cancer Screening After CARES: A Community Program for Immigrant and Marginalized Women

INTRODUCTION

Marginalized populations such as immigrants and refugees are less likely to receive cancer screening. Cancer Awareness: Ready for Education and Screening (CARES), a multifaceted community-based program in Toronto, Canada, aimed to improve breast and cervical screening among marginalized women. This matched cohort study assessed the impact of CARES on cervical and mammography screening among under-screened/never screened (UNS) attendees.

METHODS

Provincial administrative data collected from 1998 to 2014 and provided in 2015 were used to match CARES participants who were age eligible for screening to three controls matched for age, geography, and pre-education screening status. Dates of post-education Pap and mammography screening up to June 30, 2014 were determined. Analysis in 2016 compared screening uptake and time to screening for UNS participants and controls.

RESULTS

From May 15, 2012 to October 31, 2013, a total of 1,993 women attended 145 educational sessions provided in 20 languages. Thirty-five percent (118/331) and 48% (99/206) of CARES participants who were age eligible for Pap and mammography, respectively, were UNS on the education date. Subsequently, 26% and 36% had Pap and mammography, respectively, versus 9% and 14% of UNS controls. ORs for screening within 8 months of follow-up among UNS CARES participants versus their matched controls were 5.1 (95% CI=2.4, 10.9) for Pap and 4.2 (95%=CI 2.3, 7.8) for mammography. Hazard ratios for Pap and mammography were 3.6 (95% CI=2.1, 6.1) and 3.2 (95% CI=2.0, 5.3), respectively.

CONCLUSIONS

CARES' multifaceted intervention was successful in increasing Pap and mammography screening in this multiethnic under-screened population.

Determinants of Uptake of Cervical Cancer Screening Services at a No-cost Reproductive Health Clinic Managed by Nurse-Midwives

BACKGROUND

The incidence of cervical cancer (CC) has been rising in sub-Saharan Africa, and health authorities in this region have responded by increasing the availability of cheap or no-cost CC screening services (CCSS), public health education, and others. However, the efforts have not yet resulted into the expected uptake of CCSS.

OBJECTIVE

The aim of this study was to examine the determinants of uptake of CCSS at a no-cost reproductive health clinic managed by nurse-midwives.

METHODS

A descriptive design and a structured interview questionnaire were used to collect data from 236 women attending the reproductive health clinic. Logistic regression statistics were used to examine the determinants of uptake of CCSS.

RESULTS

The mean age of participants was 28.7 years, and only 29% had received CC screening. The significant determinants of uptake of CCSS were concern about the gender of the healthcare professional (HCP) (odds ratio [OR], 5.03; P = .001), age older than 25 years (OR, 3.09; P = .005), contraceptive use (OR, 0.28; P = .02), encouragement by HCPs (OR, 0.16; P = .00), and perceived quality of CCSS (OR, 0.08; P = .00).

CONCLUSIONS

Gender of the HCP and encouragement or reminders by the HCP influence uptake of CCSS. Because nurse-midwives have successfully led strategies to promote other integrated reproductive health services, they can also play a key role in enhancing uptake of CCSS in resource-poor settings.

IMPLICATIONS FOR PRACTICE

Interventions to enhance service quality and deliberate policies requiring HCP to recommend encourage and remind clients may help to enhance uptake of CCSS in resource-poor settings.

Participation and risk of high grade cytological lesions among immigrants and Italian-born women in an organized cervical cancer screening program in Central Italy

Few studies analyzed the risk for high-grade squamous intraepithelial lesions or worse (HSIL+) among immigrants and natives attending organized cervical cancer (CC) screening programs (SP). We evaluated participation and diagnosis of HSIL+ by country of birth with logistic models. Overall 540,779 invitation letters were delivered to target women of Florence SP in three screening rounds (years 2000-2002, 2003-2005, 2006-2008). The probability of attending screening was lower for immigrants than natives, but the difference decreased from 35% (1st round) to 20% (2nd-3rd round) for women born in high migration pressure (HMP) countries. The risk of HSIL+ was double than natives for HMP-born women from countries with high prevalence of human papillomavirus, even adjusting for age and previous history of Pap test. This is an important public health problem due to an increasing proportion over time of immigrant women with a lower attendance and greater risk for CC.

"I want to save my life": Conceptions of cervical and breast cancer screening among urban immigrant women of South Asian and Chinese origin

Background

Breast and cervical cancer screening rates remain low among immigrant women and those of low socioeconomic status. The Cancer Awareness: Ready for Education and Screening (CARES) project ran a peer-led multi-lingual educational program between 2012 and 2014 to reach under and never-screened women in Central Toronto, where breast and cervical cancer screening rates remain low.

The objective of this qualitative study was to better understand how Chinese and South Asian immigrants – the largest and most under-screened immigrant groups according to national and provincial statistics - conceive of breast and cervical cancer screening. We explored their experiences with screening to date. We explicitly inquired about their perceptions of the health care system, their screening experiences with family physicians and strategies that would support screening in their communities.

Methods

We conducted 22 individual interviews and two focus groups in Bengali and Mandarin with participants who had attended CARES educational sessions. Transcripts were coded through an iterative constant comparative and interpretative approach.

Results

Themes fell into five major, overlapping domains: risk perception and concepts of preventative health and screening; health system engagement and the embedded experience with screening; fear of cancer and procedural pain; self-efficacy, obligation, and willingness to be screened; newcomer barriers and competing priorities. These domains all overlap, and contribute to screening behaviours. Immigrant women experienced a number of barriers to screening related to ‘navigating newness’, including transportation, language barriers, arrangements for time off work and childcare. Fear of screening and fear of cancer took many forms; painful or traumatic encounters with screening were described. Female gender of the provider was paramount for both groups. Newly screened South Asian women were reassured by their first encounter with screening. Some Chinese women preferred the anonymous screening options available in China. Women generally endorsed a willingness to be screened, and even offered to organize women in their community hubs to access screening.

Conclusions

The experience of South Asian and Chinese immigrant women suggests that under and never-screened newcomers may be effectively integrated into screening programs through existing primary care networks, cultural-group specific outreach, and expanding access to convenient community -based screening.

Cancer screening behaviours among South Asian immigrants in the UK, US and Canada: a scoping study

South Asian (SA) immigrants settled in the United Kingdom (UK) and North America [United States (US) and Canada] have low screening rates for breast, cervical and colorectal cancers. Incidence rates of these cancers increase among SA immigrants after migration, becoming similar to rates in non-Asian native populations. However, there are disparities in cancer screening, with low cancer screening uptake in this population. We conducted a scoping study using Arksey & O'Malley's framework to examine cancer screening literature on SA immigrants residing in the UK, US and Canada. Eight electronic databases, key journals and reference lists were searched for English language studies and reports. Of 1465 identified references, 70 studies from 1994 to November 2014 were included: 63% on breast or cervical cancer screening or both; 10% examined colorectal cancer screening only; 16% explored health promotion/service provision; 8% studied breast, cervical and colorectal cancer screening; and 3% examined breast and colorectal cancer screening. A thematic analysis uncovered four dominant themes: (i) beliefs and attitudes towards cancer and screening included centrality of family, holistic healthcare, fatalism, screening as unnecessary and emotion-laden perceptions; (ii) lack of knowledge of cancer and screening related to not having heard about cancer and its causes, or lack of awareness of screening, its rationale and/or how to access services; (iii) barriers to access including individual and structural barriers; and (iv) gender differences in screening uptake and their associated factors. Findings offer insights that can be used to develop culturally sensitive interventions to minimise barriers and increase cancer screening uptake in these communities, while recognising the diversity within the SA culture. Further research is required to address the gap in colorectal cancer screening literature to more fully understand SA immigrants' perspectives, as well as research to better understand gender-specific factors that influence screening uptake.

Sociodemographic correlates of 25-hydroxyvitamin D test utilization in Calgary, Alberta

BACKGROUND

Increasing laboratory test utilization is a major challenge facing clinical laboratories. However, in most instances we lack population level information on the patient groups to which increased testing is directed. Much recent work has been published on the sociodemographic correlates of 25-hydroxyvitamin D deficiency. An unanswered question, however, is whether testing is preferentially directed towards individuals with a higher likelihood of deficiency. In this paper we examine this question by combining laboratory information system data on testing rates with Census Canada data.

METHODS

We examined 1,436 census dissemination areas within the city of Calgary, Alberta, Canada. For each census dissemination area we determined age and sex-specific 25-hydroxyvitamin D testing rates over a one year period. We then compared these testing rates with the following sociodemographic variables obtained from Census Canada: first nations status, education level, household income, visible minority status, and recent immigrant status.

RESULTS

Overall, 6.9% of males in the city of Calgary were tested during the study period. Females were 1.7 times more likely to be tested than males. Testing rate increased with increasing age, with 16.8% of individuals 66 years and over tested during the one-year study period. Individuals having at least some university education were less likely to be tested (RR = 0.60; p < 0.0001). Interestingly, although visible minorities were over twice as likely to be tested as compared to non-visual minorities (RR = 2.25; p < 0.0001), recent immigrants, a group known to exhibit low 25 hydroxyvitamin D levels, were significantly less likely to be tested than non-recent immigrants (RR = 0.72; p = 0.0174). While median household income was modestly associated with increased testing (RR = 1.02; p < 0.0001), First Nations status and non-English speaking were not significant predictors of 25-hydroxyvitamin D testing.

CONCLUSIONS

Testing for 25-hydroxyvitamin D is in part directed toward populations at higher risk of deficiency (visible minorities) and at higher risk of osteoporosis (older females), but a particularly high risk group (recent immigrants) is being tested at a lower rate than other patient groups.

Chinese female immigrants english-speaking ability and breast and cervical cancer early detection practices in the New York metropolitan area

BACKGROUND

Breast and cervical cancers are significant causes of mortality and morbidity for Asian women, and poor English-speaking ability is a barrier to cancer prevention practices.

MATERIALS AND METHODS

This project tested relationships among English-speaking ability and early detection practices regarding to breast and cervical cancer among female Chinese immigrants. A descriptive cross-sectional survey was used.

RESULTS

175 female Chinese immigrants completed the survey in the breast cancer prevention section, and 35 of them also completed the cervical cancer prevention section. Some 63% of them had heard about the clinical breast exam (CBE), but only 54% had had a CBE. While 46% of the participants were aware of their need for a Pap smear, only 31% had heard about it and had undergone a pelvic exam.

CONCLUSIONS

English-speaking ability was strongly associated with immigrant women's knowledge of female cancer early detection. Culturally and linguistic issues should be considered as the first step to access immigrant population in designing future education intervention.

Reproductive health behaviour of Muslim immigrant women in Canada

Purpose

– Reproductive health is critically important for women and yet minority women in Canada are less likely to use preventive health care services. The purpose of this paper is to increase understanding of the health behaviours of this minority population and, in particular, identify barriers to accessing reproductive health care services.

Design/methodology/approach

– This study qualitatively analysed data from focus group discussions with 22 Muslim immigrant women in Ottawa, Canada.

Findings

– The theme of modesty emerged as one of the main barriers in the health seeking behaviour of Muslim immigrant women when it comes to reproductive health and, therefore, the gender of the physician was very important. Focus group participants also discussed a preference for family physicians from the same ethnic and cultural background. Adaptation, or the need to be flexible if there was no alternative to a male doctor, emerged as a theme throughout the focus groups. Emergencies were frequently cited as a reason to adapt.

Practical implications

– The findings reveal that while religious rules do play a predominant role in the health behaviour of Muslim immigrant women, communication by health care providers, government and health agencies can offer strategies to increase the uptake of preventive reproductive care.

Originality/value

– This study offers unique insights into the very personal experience of reproductive health care through rich, qualitative data. Given the impact of culture and religion on perceptions and practices, in particular related to reproductive health, this study contributes to more effective communication strategies with Muslim women.

Using organizational network analysis to plan cancer screening programs for vulnerable populations

OBJECTIVES

We examined relationships among organizations in a cancer screening network to inform the development of interventions to improve cancer screening for South Asians living in the Peel region of Ontario.

METHODS

From April to July 2012, we surveyed decision-makers, program managers, and program staff in 22 organizations in the South Asian cancer screening network in the Peel region. We used a network analytic approach to evaluate density (range = 0%-100%, number of ties among organizations in the network expressed as a percentage of all possible ties), centralization (range = 0-1, the extent of variability in centrality), and node characteristics for the communication, collaboration, and referral networks.

RESULTS

Density was similar across communication (15%), collaboration (17%), and referral (19%) networks. Centralization was greater in the collaboration network (0.30) than the communication network (0.24), and degree centralization was greater in the inbound (0.42) than the outbound (0.37) referral network. Diverse organizations were central to the networks.

CONCLUSIONS

Certain organizations were unexpectedly important to the South Asian cancer screening network. Program planning was informed by identifying opportunities to strengthen linkages between key organizations and to leverage existing ties.

Sociodemographic inequalities in sexual activity and cervical cancer screening: implications for the success of human papillomavirus vaccination

BACKGROUND

Papanicolaou smear screening has significantly reduced cervical cancer morbidity and mortality. However, inequalities still persist across different socioeconomic status (SES) groups. These inequalities have been associated with differential participation in screening. However, even with equal participation to screening, some women may still have greater risk of cervical cancer because of sexual behavior. We aim to identify the sociodemographic characteristics of women who reported greater sexual activity and/or screening underuse.

METHODS

We used data from (i) the Canadian Community Health Survey-2005, a population-based survey of 130,000 Canadians, and (ii) a multicenter study including 952 women screened for cervical cancer.

RESULTS

Aboriginals and women with lower SES reported greater sexual activity and lower screening participation, which may produce synergetic effects toward higher cervical cancer risk. Women who did not complete high school and aboriginals were, respectively, 3.6 and 2.5 times more likely to report sexual debut before 15 years old compared with women with university degree and Caucasians. Women who did not complete high school were 2.2 times more likely to have never been screened compared with women with university degree. East and South Asian women were, respectively, 4.3 and 3.1 times more likely to have never been screened than Canadian-born women but reported lower levels of sexual activity and were adherent to screening guidelines when screened at least once.

CONCLUSIONS

The success of human papillomavirus vaccination at reducing cervical cancer and inequalities will depend on achieving high coverage among high-risk subpopulations.

IMPACT

These groups must be monitored closely, and if need be, targeted for additional interventions.

Migration and maternity: insights of context, health policy, and research evidence on experiences and outcomes from a three country preliminary study across Germany, Canada, and the United kingdom

A group from Germany, Canada, and the United Kingdom undertook country-specific scoping reviews and stakeholder consultations before joining to holistically compare migration and maternity in all three countries. We examined four interlinking dimensions to understand how international migrant/minority maternal health might be improved upon using transnational research: (a) wider sociopolitical context, (b) health policy arena, (c) constellation, outcomes, and experiences of maternity services, and (d) existing research contexts. There was clear evidence that the constellation and delivery of services may undermine good experiences and outcomes. Interventions to improve access and quality of care remain small scale, short term, and lacking in rigorous evaluation.

Using geographic methods to inform cancer screening interventions for South Asians in Ontario, Canada

Background

Literature suggests that South Asians in Ontario, Canada are under-screened for breast, cervical and colorectal cancer. Accordingly, we are involved in a community-engaged multi-phase study aimed at increasing cancer screening for this vulnerable group. In the work described in this manuscript, we aimed to use visual displays of spatial analyses to identify the most appropriate small geographic areas in which to pilot targeted cancer screening interventions for Ontario’s South Asian community.

Methods

We used Geographic Information Systems (GIS), including Local Indicators of Spatial Association (LISA) using GeoDa software, and population-level administrative data to create multi-layered maps of: i) rates of appropriate cancer screening, ii) the percentage of residents of South Asian ethnicity, and iii) the locations of primary care practices and community health centres by census tract in the Peel Region of Ontario (population: 1.2 million). The maps were shared with partner health service and community service organizations at an intervention development workgroup meeting to examine face validity.

Results

The lowest rates of appropriate cancer screening for census tracts across the region were 51.1% for cervical cancer, 48.5% for breast cancer, and 42.5% for colorectal cancer. We found marked variation both in screening rates and in the proportion of South Asians residents by census tract but lower screening rates in the region were consistently associated with larger South Asian populations. The LISA analysis identified a high-risk area consisting of multiple neighbouring census tracts with relatively low screening rates for all three cancer types and with a relatively large South Asian population. Partner organizations recognized and validated the geographic location highlighted by the LISA analysis. Many primary care practices are located in this high-risk area, with one community health centre located very nearby.

Conclusions

In this populous region of Ontario, South Asians are more likely to reside in areas with lower rates of appropriate breast, cervical and colorectal cancer screening. We have identified a high-risk area appropriate for both patient- and provider-focused interventions. Geographic Information Systems, in particular LISA analyses, can be invaluable when working with health service and community organizations to define areas with the greatest need for interventions to reduce health inequities.

Using concept mapping in the knowledge-to-action process to compare stakeholder opinions on barriers to use of cancer screening among South Asians

BACKGROUND

Using the knowledge-to-action (KTA) process, this study examined barriers to use of evidence-based interventions to improve early detection of cancer among South Asians from the perspective of multiple stakeholders.

METHODS

In 2011, we used concept mapping with South Asian residents, and representatives from health service and community service organizations in the region of Peel Ontario. As part of concept mapping procedures, brainstorming sessions were conducted with stakeholders (n = 53) to identify barriers to cancer screening among South Asians. Participants (n = 46) sorted barriers into groups, and rated barriers from lowest (1) to highest (6) in terms of importance for use of mammograms, Pap tests and fecal occult blood tests, and how feasible it would be to address them. Multi-dimensional scaling, cluster analysis, and descriptive statistics were used to analyze the data.

RESULTS

A total of 45 unique barriers to use of mammograms, Pap tests, and fecal occult blood tests among South Asians were classified into seven clusters using concept mapping procedures: patient's beliefs, fears, lack of social support; health system; limited knowledge among residents; limited knowledge among physicians; health education programs; ethno-cultural discordance with the health system; and cost. Overall, the top three ranked clusters of barriers were 'limited knowledge among residents,' 'ethno-cultural discordance,' and 'health education programs' across surveys. Only residents ranked 'cost' second in importance for fecal occult blood testing, and stakeholders from health service organizations ranked 'limited knowledge among physicians' third for the feasibility survey. Stakeholders from health services organizations ranked 'limited knowledge among physicians' fourth for all other surveys, but this cluster consistently ranked lowest among residents.

CONCLUSION

The limited reach of cancer control programs to racial and ethnic minority groups is a critical implementation issue that requires attention. Opinions of community service and health service organizations on why this deficit in implementation occurs are fundamental to understanding the solutions because these are the settings in which evidence-based interventions are implemented. Using concept mapping within a KTA process can facilitate the engagement of multiple stakeholders in the utilization of study results and in identifying next steps for action.

Human papilloma virus vaccination programs reduce health inequity in most scenarios: a simulation study

BACKGROUND

The global and within-country epidemiology of cervical cancer exemplifies health inequity. Public health programs may reduce absolute risk but increase inequity; inequity may be further compounded by screening programs. In this context, we aimed to explore what the impact of human papillomavirus (HPV) vaccine might have on health equity allowing for uncertainty surrounding the long-term effect of HPV vaccination programs.

METHODS

A simple static multi-way sensitivity analysis was carried out to compare the relative risk, comparing after to before implementation of a vaccination program, of infections which would cause invasive cervical cancer if neither prevented nor detected, using plausible ranges of vaccine effectiveness, vaccination coverage, screening sensitivity, screening uptake and changes in uptake.

RESULTS

We considered a total number of 3,793,902 scenarios. In 63.9% of scenarios considered, vaccination would lead to a better outcome for a population or subgroup with that combination of parameters. Regardless of vaccine effectiveness and coverage, most simulations led to lower rates of disease.

CONCLUSIONS

If vaccination coverage and screening uptake are high, then communities are always better off with a vaccination program. The findings highlight the importance of achieving and maintaining high immunization coverage and screening uptake in high risk groups in the interest of health equity.

Cervical cancer screening among vulnerable women: factors affecting guideline adherence at a community health centre in Toronto, Ont

OBJECTIVE

To see if refugee women at a community health centre (CHC) in Toronto, Ont, are appropriately screened for cervical cancer and if there are any demographic characteristics that affect whether they are screened.

DESIGN

Chart review.

SETTING

A CHC in downtown Toronto.

PARTICIPANTS

A total of 357 eligible refugee women attending the CHC.

MAIN OUTCOME MEASURES

Papanicolaou test received or documented reason for no Pap test.

RESULTS

Ninety-two percent of women in the study sample were either appropriately screened for cervical cancer or had been approached for screening. Eighty percent of women were appropriately screened. Demographic variables including pregnancy, being uninsured, not speaking English, recent migration to Canada, and being a visible minority did not affect receipt of a Pap test after migration in multivariate analyses. Not speaking English was associated with a delay to receiving a first Pap test after migration.

CONCLUSION

The clients at our centre are demographically similar to women who are typically overlooked for Pap tests in the greater Toronto area. Despite belonging to a high-risk population, refugee women in this multidisciplinary CHC were screened for cervical cancer at a higher rate than the local population.

Influencia del lugar de origen en la utilización de pruebas de cribado de cáncer ginecológico en España

OBJETIVO: Analizar la asociación entre el área geográfica de procedencia en el uso de las citologías y la mamografía. MÉTODOS: Los datos analizados proceden Encuesta Nacional de Salud de España-2006 dirigida a población mayor de 16 años. La Encuesta incluye 13.422 mujeres. Las variables dependientes fueron realización de una mamografía y de una citología vaginal, ambos en los últimos 12 meses. La medida de asociación fue el odds ratio con intervalo de confianza al 95% calculado por regresión logística. RESULTADOS: Tomando como referencia la población española, la probabilidad de realizarse una mamografías entre las mujeres procedentes de África fue 0,36 (IC95% 0,21;0,62) veces menor; Europa del Este 0,40 (IC95% 0,22;0,74) veces menor; Europa Occidental, EEUU y Canadá, 0,60 (IC95% 0,43; 0,84) veces menor y América Central / Sur 0,64 (IC95% 0,52;0,81) veces menor. En relación a la prevención de cáncer de cervix, probabilidad de realizarse una citología entre las mujeres Europa del Este fue 0,38 (IC95% 0,28;0,50) veces menor que la población española, África 0,47 (IC95%:0,33;0,67) veces menor y Europa Occidental, EEUU y Canadá 0,61 (IC95% 0,46;0,81) veces menor. Dichas asociaciones fueron independientes de la edad, indicadores socioeconómicos, estado de salud y cobertura sanitaria. CONCLUSIONES: Las mujeres inmigrantes hacen menor uso de los programas de cribado que las mujeres autóctonas. Este dato podría reflejar dificultades de acceso a los programas preventivos.

Canadian oncogenic human papillomavirus cervical infection prevalence: systematic review and meta-analysis

BACKGROUND

Oncogenic human papillomavirus (HPV) infection prevalence is required to determine optimal vaccination strategies. We systematically reviewed the prevalence of oncogenic cervical HPV infection among Canadian females prior to immunization.

METHODS

We included studies reporting DNA-confirmed oncogenic HPV prevalence estimates among Canadian females identified through searching electronic databases (e.g., MEDLINE) and public health websites. Two independent reviewers screened literature results, abstracted data and appraised study quality. Prevalence estimates were meta-analyzed among routine screening populations, HPV-positive, and by cytology/histology results.

RESULTS

Thirty studies plus 21 companion reports were included after screening 837 citations and 120 full-text articles. Many of the studies did not address non-response bias (74%) or use a representative sampling strategy (53%). Age-specific prevalence was highest among females aged < 20 years and slowly declined with increasing age. Across all populations, the highest prevalence estimates from the meta-analyses were observed for HPV types 16 (routine screening populations, 8 studies: 8.6% [95% confidence interval 6.5-10.7%]; HPV-infected, 9 studies: 43.5% [28.7-58.2%]; confirmed cervical cancer, 3 studies: 48.8% [34.0-63.6%]) and 18 (routine screening populations, 8 studies: 3.3% [1.5-5.1%]; HPV-infected, 9 studies: 13.6% [6.1-21.1%], confirmed cervical cancer, 4 studies: 17.1% [6.4-27.9%].

CONCLUSION

Our results support vaccinating females < 20 years of age, along with targeted vaccination of some groups (e.g., under-screened populations). The highest prevalence occurred among HPV types 16 and 18, contributing a combined cervical cancer prevalence of 65.9%. Further cancer protection is expected from cross-protection of non-vaccine HPV types. Poor study quality and heterogeneity suggests that high-quality studies are needed.

Cervical screening participation and risk among Swedish-born and immigrant women in Sweden

Cervical cancer is one of the most common cancers among women worldwide, although cervical screening has reduced the incidence in many high-income countries. Low screening uptake among immigrant women may reflect differences in risk of cervical cancer. We investigated the degree of participation in cervical screening among immigrant and Swedish-born women and their concurrent risk of cervical cancer based on individual information on Pap smears taken both from organized and opportunistic screening. Mean degree of participation in cervical screening was estimated for women between 23 and 60 years from 1993 to 2005, stratified by birth region and age at migration. In Poisson regression models, we estimated relative risks (RRs), incidence rates and incidence rate ratios of cervical cancer for women adhering or not to the cervical screening program. We also assessed effect of adherence to screening on the risk of cervical cancer among immigrant groups compared to Swedish-born women. The degree of participation was 62% and 49% among Swedish-born and immigrant women, respectively, with large variations between immigrant groups. Participation was lowest among those immigrating at older ages. Swedish-born and immigrant women who where nonadherent to the cervical screening program had a fivefold excess risk of cervical cancer compared to adherent women. After adjustment for screening adherence, excess RRs of cervical cancer were statistically significant only for women from Norway and the Baltic States. Participation to screening is lower among immigrant than Swedish-born women, and adherence to the recommended screening intervals strongly prevents cervical cancer.

Predictors of low cervical cancer screening among immigrant women in Ontario, Canada

BACKGROUND

Disparities in cervical cancer screening are known to exist in Ontario, Canada for foreign-born women. The relative importance of various barriers to screening may vary across ethnic groups. This study aimed to determine how predictors of low cervical cancer screening, reflective of sociodemographics, the health care system, and migration, varied by region of origin for Ontario's immigrant women.

METHODS

Using a validated billing code algorithm, we determined the proportion of women who were not screened during the three-year period of 2006-2008 among 455,864 identified immigrant women living in Ontario's urban centres. We created eight identical multivariate Poisson models, stratified by eight regions of origin for immigrant women. In these models, we adjusted for various sociodemographic, health care-related and migration-related variables. We then used the resulting adjusted relative risks to calculate population-attributable fractions for each variable by region of origin.

RESULTS

Region of origin was not a significant source of effect modification for lack of recent cervical cancer screening. Certain variables were significantly associated with lack of screening across all or nearly all world regions. These consisted of not being in the 35-49 year age group, residence in the lowest-income neighbourhoods, not being in a primary care patient enrolment model, a provider from the same region, and not having a female provider. For all women, the highest population-attributable risk was seen for not having a female provider, with values ranging from 16.8% [95% CI 14.6-19.1%] among women from the Middle East and North Africa to 27.4% [95% CI 26.2-28.6%] for women from East Asia and the Pacific.

CONCLUSIONS

To increase screening rates across immigrant groups, efforts should be made to ensure that women have access to a regular source of primary care, and ideally access to a female health professional. Efforts should also be made to increase the enrolment of immigrant women in new primary care patient enrolment models.

Defining socially-based spatial boundaries in the region of Peel, Ontario, Canada

Background

The purpose of the project was to delineate a series of contiguous neighbourhood-based "Data Zones" within the Region of Peel (Ontario) for the purpose of health data analysis and dissemination. Zones were to be built on Census Tracts (N = 205) and obey a series of requirements defined by the Region of Peel. This paper explores a method that combines statistical analysis with ground-truthing, consultation, and the use of a decision tree.

Data

Census Tract data for Peel were derived from the 2006 Canadian Census Master file.

Methods

Following correlation analysis to reduce the data set, Principal Component Analysis was applied to the data set to reduce the complexity and derive an index. The Getis-Ord Gi*statistic was then applied to look for statistically significant clusters of like Census Tracts. A detailed decision tree for the amalgamation of remaining zones and ground-truthing with Peel staff verified the resulting zones.

Results

A total of 15 Data Zones that are similar with respect to socioeconomic and sociodemographic attributes and that met criteria defined by Peel were derived for the region.

Conclusion

The approach used in this analysis, which was bolstered by a series of checks and balances throughout the process, gives statistical validity to the defined zones and resulted in a robust series of Data Zones for use by Peel Public Health. We conclude by offering insight into alternative uses of the methodology, and limitations.

Young Asian Americans' knowledge and perceptions of cervical cancer and the human papillomavirus

Cervical cancer is a major health disparity among Asian Americans, with cervical cancer rates of Vietnamese women being significantly higher than for the general US female population and low screening rates reported for Asian American females. Focus groups and interviews were conducted with young Vietnamese, Filipino, and Korean adults (ages 18-29) to collect information on knowledge, perceptions and sources of information regarding cervical cancer, Pap tests and the human papillomavirus. 16 Korean, 18 Vietnamese, and 18 Filipino (50% female) adults participated in the study. Many participants had never heard of HPV, cervical cancer and Pap testing. Cervical cancer screening rates were low for Korean and Vietnamese females and were influenced by moral beliefs and lack of awareness. Culturally relevant education materials that consider specific Asian ethnicity and language are needed to increase awareness of cervical cancer, Pap testing, and HPV among Asian American young adults.

Cervical cancer screening among urban immigrants by region of origin: a population-based cohort study

OBJECTIVES

We compared the prevalence of appropriate cervical cancer screening among screening-eligible immigrant women from major geographic regions of the world and native-born women.

METHODS

We determined the proportion of women who were screened during the three-year period of 2006-2008 among 2.9 million screening-eligible women living in urban centres in Ontario, Canada. In multivariate analyses, we adjusted for numerous variables including age, neighbourhood-level income, and prenatal visits during the study period.

RESULTS

61.3% of women were up-to-date on cervical cancer screening. Screening rates were lowest among women from South Asia when compared to the referent group (Canadian-born women and immigrants who arrived before 1985) (adjusted rate ratio 0.81, 95% CI [0.80-0.82] among women aged 18-49 years, adjusted rate ratio 0.67 [0.65-0.69] among women aged 50-66 years). Of the older South Asian women living in the lowest-income neighbourhoods and not in a primary care enrollment model, 21.9% had been appropriately screened. In contrast, among Canadian-born women living in the highest-income neighbourhoods and in a primary care enrollment model, 79.0% had been appropriately screened.

CONCLUSION

Efforts to reduce cervical cancer screening disparities should focus on women living in the lowest-income neighbourhoods and women from South Asia.

Barriers to acceptance of self-sampling for human papillomavirus across ethnolinguistic groups of women

OBJECTIVES

Immigrant and low socio-economic (SES) women in North America underutilize Papanicolaou screening. Vaginal swab self-sampling for oncogenic human papillomavirus (HPV) has the potential to increase cervical cancer screening participation. The purpose of this qualitative study was to understand the perceptions of lower SES and immigrant women regarding self-sampling for HPV.

METHODS

Eleven focus-group interviews were conducted: one with Canadian-born English-speaking lower SES women, and two groups each with Arabic, Cantonese, Dari (Afghani), Somali and Spanish (Latino)-speaking women (one group conducted in English, the other in the native language) recently immigrated to Canada. Five to nine women aged 35 to 65 years and married with children participated in each group.

RESULTS

Themes included 1) who might use self-sampling and why; 2) aversion to self-sampling and reasons to prefer physician; 3) ways to improve the appeal of self-sampling. Women generally perceived benefits of self-sampling and a small number felt they might use the method, but all groups had some reservations. Reasons included: uncertainty over performing the sampling correctly; fear of hurting themselves; concern about obtaining appropriate material; and concerns about test accuracy. Women preferred testing by a health care professional because they were accustomed to pelvic examinations, it was more convenient, or they trusted the results.

CONCLUSIONS

Perceptions of self-sampling for HPV were similar across cultures and pertained to issues of confidence in self-sampling and need for physician involvement in care. These findings can inform programs and studies planning to employ self-sampling as a screening modality for cervical cancer.

Access to primary and preventive care among foreign-born adults in Canada and the United States

OBJECTIVE

To conduct cross-country comparisons and assess the effect of foreign birth on access to primary and preventive care in Canada and the United States.

DATA SOURCES

Secondary data from the 2002 to 2003 Joint Canada-United States Survey of Health.

STUDY DESIGN

Descriptive and comparative analyses were conducted, and logistic regression models were used to assess the effect of immigrant status and country of residence on access to care. Outcomes included measures of health care systems and processes, utilization, and patient perceptions.

PRINCIPAL FINDINGS

In adjusted analyses, immigrants in Canada fared worse than nonimmigrants regarding having timely Pap tests; in the United States, immigrants fared worse for having a regular doctor and an annual consultation with a health professional. Immigrants in Canada had better access to care than immigrants in the United States; most of these differences were explained by differences in socioeconomic status and insurance coverage across the two countries. However, U.S. immigrants were more likely to have timely Pap tests than Canadian immigrants, even after adjusting for potential confounders.

CONCLUSIONS

In both countries, foreign-born populations had worse access to care than their native-born counterparts for some indicators but not others. However, few differences in access to care were found when direct cross-country comparisons were made between immigrants in Canada versus the United States, after accounting for sociodemographic differences.

Intraclass correlation estimates for cancer screening outcomes: estimates and applications in the design of group-randomized cancer screening studies

BACKGROUND

Screening has become one of our best tools for early detection and prevention of cancer. The group-randomized trial is the most rigorous experimental design for evaluating multilevel interventions. However, identifying the proper sample size for a group-randomized trial requires reliable estimates of intraclass correlation (ICC) for screening outcomes, which are not available to researchers. We present crude and adjusted ICC estimates for cancer screening outcomes for various levels of aggregation (physician, clinic, and county) and provide an example of how these ICC estimates may be used in the design of a future trial.

METHODS

Investigators working in the area of cancer screening were contacted and asked to provide crude and adjusted ICC estimates using the analysis of variance method estimator.

RESULTS

Of the 29 investigators identified, estimates were obtained from 10 investigators who had relevant data. ICC estimates were calculated from 13 different studies, with more than half of the studies collecting information on colorectal screening. In the majority of cases, ICC estimates could be adjusted for age, education, and other demographic characteristics, leading to a reduction in the ICC. ICC estimates varied considerably by cancer site and level of aggregation of the groups.

CONCLUSIONS

Previously, only two articles had published ICCs for cancer screening outcomes. We have complied more than 130 crude and adjusted ICC estimates covering breast, cervical, colon, and prostate screening and have detailed them by level of aggregation, screening measure, and study characteristics. We have also demonstrated their use in planning a future trial and the need for the evaluation of the proposed interval estimator for binary outcomes under conditions typically seen in GRTs.

Low rates of cervical cancer screening among urban immigrants: a population-based study in Ontario, Canada

OBJECTIVE

Women who are immigrants or socioeconomically disadvantaged have been found to have significantly lower cervical cancer screening rates than their peers in Toronto, Ontario, Canada. The objective of this study was to examine rates of appropriate cervical cancer screening among women living in Ontario, Canada, using recent registration with Ontario's universal health insurance plan as an indicator of immigrant status.

METHODS

This retrospective cohort study included 2,273,995 screening-eligible women aged 25 to 69 years, who resided in Ontario's metropolitan areas during the calendar years 2003, 2004, and 2005. A validated algorithm was applied to the Ontario-wide physicians' claims database to determine which women had undergone cervical cancer screening with a Pap test during the 3-year period.

RESULTS

Appropriate cervical cancer screening occurred for 61.1% of women. Despite adjustment for physician contact and pregnancy rates, cervical cancer screening rates were especially low among: women aged 50 to 69 years; women living in low-income areas; and women who had registered with Ontario's universal health insurance plan within the preceding 10 years, a group consisting largely of recent immigrants. Women with all 3 of these characteristics had a screening rate of 31.0% compared with 70.5% among women with none of these characteristics.

CONCLUSION

Within a system of universal health insurance, appropriate cervical cancer screening is significantly lower among women who are older, living in low-income areas, or recent immigrants. Efforts to reduce disparities in cervical cancer screening should focus on women with these characteristics.

Do geodemographic typologies explain variations in uptake in colorectal cancer screening? An assessment using routine screening data in the south of England

BACKGROUND

Uptake of colorectal cancer (CRC) screening in UK is less than 60%. Geodemographic typologies are useful in describing patterns of individual preventive health behaviour but little is known of their value in assessing uptake of CRC screening, or how this compares to traditional measures of area deprivation.

METHODS

We used data on CRC screening uptake in the South Central, South-East Coast and South-West England National Health Service regions in multilevel logistic regression to describe the effects of individual composition and contextual factors (area deprivation and geodemographic segments) on non-response to screening invitation. The relative impact of geodemographic segmentation and the index of multiple deprivation (IMD) 2007 was compared. The potential population impact of a targeted increase in uptake in specific geodemographic segments was examined.

RESULTS

About 88 891 eligible adults were invited to be screened from 2006 to 2008. Uptake rate was 57.3% (CI: 57.0-57.7) and was lower amongst younger persons, men, residents of more deprived areas and people in specific geodemographic segments. Age and gender were significant determinants of uptake and contextual factors explained an additional 3% of the variation. Geodemographic segmentation reduced this residual contextual variation in uptake more than the IMD 2007 (72% vs. 53% reduction). The three geodemographic types that best predicted non-response were characterized by both ethnic mix and a higher than average proportion of single pensioner households renting council properties. Achieving average uptake in the 2.3% of the study population in these geodemographic segments would only increase the total population uptake rate by 0.5% (57.3-57.8%).

CONCLUSION

Variation in the CRC screening uptake in Southern England is principally explained by characteristics of individuals but contextual factors also have a small but significant effect. This effect is captured in greater detail by geodemographic segmentation than by IMD 2007. This information could be used to inform the design of interventions aiming to improve uptake.

The role of health insurance in explaining immigrant versus non-immigrant disparities in access to health care: comparing the United States to Canada

Using a cross-national comparative approach, we examined the influence of health insurance on U.S. immigrant versus non-immigrant disparities in access to primary health care. With data from the 2002/2003 Joint Canada/United States Survey of Health, we gathered evidence using three approaches: 1) we compared health care access among insured and uninsured immigrants and non-immigrants within the U.S.; 2) we contrasted these results with health care access disparities between immigrants and non-immigrants in Canada, a country with universal health care; and 3) we conducted a novel direct comparison of health care access among insured and uninsured U.S. immigrants with Canadian immigrants (all of whom are insured). Outcomes investigated were self-reported unmet medical needs and lack of a regular doctor. Logistic regression models controlled for age, sex, nonwhite status, marital status, education, employment, and self-rated health. In the U.S., odds of unmet medical needs of insured immigrants were similar to those of insured non-immigrants but far greater for uninsured immigrants. The effect of health insurance was even more striking for lack of regular doctor. Within Canada, disparities between immigrants and non-immigrants were similar in magnitude to disparities seen among insured Americans. For both outcomes, direct comparisons of U.S. and Canada revealed significant differences between uninsured American immigrants and Canadian immigrants, but not between insured Americans and Canadians, stratified by nativity. Findings suggest health care insurance is a critical cause of differences between immigrants and non-immigrants in access to primary care, lending robust support for the expansion of health insurance coverage in the U.S. This study also highlights the usefulness of cross-national comparisons for establishing alternative counterfactuals in studies of disparities in health and health care.

Providing family planning and reproductive healthcare to Canadian immigrants: perceptions of healthcare providers

Cultural impacts on health experiences and behaviours are profound in the area of reproductive health and family planning. Explored through interviews with family planning healthcare professionals, this paper evaluates their experiences in providing family planning and reproductive healthcare to immigrants in the Greater Toronto and Hamilton area of Ontario, Canada. Results reveal the complexity of delivering care to members of this group, particularly when dealing with language barriers, situations when professional and non-professional interpreters are used, and instances where healthcare professionals realize that they themselves have misconceptions and misunderstandings about other cultures. The paper concludes by discussing future research options and implications for the delivery of reproductive health family planning services to this population.