Socioecological perspectives on cervical cancer and cervical cancer screening among Asian American women

Empowering Low-Income Asian American Women to Conduct Human Papillomavirus Self-Sampling Test: A Community-Engaged and Culturally Tailored Intervention

BACKGROUND

Asian American women face disproportionate burden of cervical cancer (CC) than non-Hispanic white women in the U.S. The goal of this study was to assess the feasibility and impact of a culturally tailored intervention to promote Human papillomavirus (HPV) self-sampling test among hard-to-reach Asian American women.

METHODS

We adopted the community-based participatory research (CBPR) approach to conduct this efficacy study. A total of 156 female participants (56 Chinese, 50 Korean, and 50 Vietnamese) were recruited from community-based organizations (CBOs) in the greater Philadelphia metropolitan area. The intervention components included HPV-related education, HPV self-sampling test kit and instructions, group discussions, and patient navigations, all available in Asian languages. We examined several outcomes, including the completion of HPV self-sampling, HPV-related knowledge, perceived social support, self-efficacy, and comfort with the self-sampling test at post-intervention assessment.

RESULTS

The majority of Asian American women had low annual household income (62.3% earned less than $20,000) and low educational attainment (61.3% without a college degree). We found significant increase in participants' knowledge on HPV (baseline: 2.83, post: 4.89, P <.001), social support (baseline: 3.91, post: 4.09, P < .001), self-efficacy (baseline: 3.05, post: 3.59, P < .001), and comfortable with HPV self-sample test (baseline: 3.62, post: 4.06, P < .001).

CONCLUSION

To the best of our knowledge, this is the first intervention study that promoted HPV self-sampling test among Asian American women. Our findings showed that CBPR culturally tailored intervention of self-sampling was highly effective in empowering low-income Asian American women to conduct HPV self-sampling tests.

Barriers and Challenges to Cervical Cancer Screening, Follow-Up, and Prevention Measures among Korean Immigrant Women in Hawaii

OBJECTIVE

Despite being the fastest-growing population in the United States, Asian American women have one of the lowest cancer screening rates and the least attention given to cancer-related research. Cervical cancer screening disparities among Korean immigrant women (KIWs) in Hawaii have been reported.

METHODS

The qualitative ethnographic study was to explore the health barriers and challenges of cervical cancer prevention among KIWs in Hawaii. The Social Ecological Model was used to guide the study. Data were collected using individual structured interviews with 20 KIWs aged 21-65 years. The data were coded and analyzed to identify themes in exploring health barriers.

RESULTS

The findings revealed that participants (a) lacked knowledge about the U.S. health-care system; (b) lacked access; (c) had limited resources regarding cervical cancer screening communicated in Korean; (d) lacked an understanding of cultural and psychosocial beliefs on preventive care; (e) lacked female and Korean-speaking providers; and (f) experienced language barriers and limited coverage of health insurance.

CONCLUSIONS

A multicomponent intervention combining individual and community-based, Internet-accessible, culturally, and linguistically appropriate approaches may enhance effective cervical cancer screening rates and positive health outcomes among KIWs in Hawaii.

Comparisons of Papanicolaou Utilization and Cervical Cancer Detection between Rural and Urban Women in Taiwan

Using the claims data of one million insured residents in Taiwan from 1996–2013, this study identified 12,126 women in an urban city (Taichung) and 7229 women in a rural county (Yunlin), aged 20 and above. We compared Papanicolaou (Pap) test uses and cervical cancer detection rates between urban and rural women. Results showed that the Pap screening rate was slightly higher in rural women than in urban women (86.1 vs. 81.3 percent). The cervical cancer incidence was much greater for women without Pap test than women with the test (35.8 vs. 9.00 per 1000 in rural women and 20.3 vs. 7.00 per 1000 in urban women). Nested case-control analysis showed that Pap test receivers had an adjusted odds ratio (OR) of 0.35 (95% CI = 0.25–0.51) to be diagnosed with cervical cancer as compared to those who did not receive the test. The rural women had an adjusted OR of 1.46 (95% CI = 1.03–2.06) to be diagnosed with cervical cancer as compared to urban women. In conclusion, women in rural area are at higher cancer risk than city women. Women who do not undergo Pap tests deserve timely intervention of Pap test to prevent the onset of cancer, particularly in rural women with low income.

Qualitative Evidence Synthesis on Self-Collection for Human Papillomavirus-Based Cervical Screening: Protocol for Systematic Review

Background

Cervical cancer is the fourth most common cancer affecting women worldwide. In the 1980s, it was found that the sexually transmitted disease human papillomavirus causes over 90% of all cervical cancer cases. Since that discovery, diagnostic technologies have been developed for the detection of human papillomavirus DNA in cervical samples. However, significant sociocultural and structural barriers remain. Considerable strides have taken place in recent years to address these barriers, such as the self-collection for human papillomavirus–based cervical screening method.

Objective

The purpose of this review is to synthesize qualitative evidence around the self-collection method and identify strategies to increase acceptability and feasibility in different settings. This qualitative synthesis will be used to better understand how to conceptualize and implement more effective, accessible, and socially and culturally acceptable cervical screening programs and policies globally.

Methods

A systematic search will be conducted in Global Health, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ProQuest, ScienceDirect, EMBASE, EMCARE, Medline (OVID), Scopus, and Web of Science. Published and peer-reviewed articles will be included. Two reviewers will independently screen and assess the studies. The data will be coded and analyzed using a thematic synthesis process. The socioecological model will be used to organize emergent themes at the micro and macro levels. The results will be presented in narrative and tabular form.

Results

The article search and data extraction were completed in May 2020. The data were analyzed in June 2020. The review will be submitted for publication in Fall 2020.

Conclusions

This review will present the global evidence of the perspectives and experiences of various key stakeholders and how these perspectives and experiences impact their decision-making process to perform or accept self-collection for human papillomavirus–based cervical screening. The review will provide guidance to implementation researchers as well as implications for future research.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42019109073; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=109073

International Registered Report Identifier (IRRID)

DERR1-10.2196/21093

Community-Based Cervical Cancer Education: Changes in Knowledge and Beliefs Among Vietnamese American Women

Low cervical cancer screening rates among Vietnamese American women have been attributed, in part, to inadequate knowledge about cervical cancer and health beliefs that hinder screening. A community-based educational program was developed to improve knowledge and attitudes toward cervical cancer screening in this underserved population. It was hypothesized that the program would result in increases in knowledge, as well as enhanced health beliefs and self-efficacy toward obtaining cervical cancer screening. Using a group-randomized design, 1488 women from 30 Vietnamese community-based organizations were assigned to either the intervention (n = 816) or control (n = 672) conditions. The intervention group received cervical cancer education delivered by bilingual community health educators. Intervention content addressed individual beliefs and expectancies regarding cervical cancer screening (e.g., perceived risk of developing cervical cancer; perceived benefits and barriers to screening; social and cultural norms regarding screening). The control group received general health education, including information about cancer screening. Knowledge and health beliefs were assessed at baseline and post-intervention. Among women in the intervention group, overall knowledge about cervical cancer and screening guidelines increased from pre- to post-program (30% vs. 88%, p < 0.001), perceived benefits of screening increased (3.50 vs. 4.49, p < 0.001), and perceived barriers to screening decreased (3.13 vs. 2.25, p < 0.001). Changes in knowledge and health beliefs were not observed among women in the control group. A community-based educational program can help increase knowledge about cervical cancer and screening, promote positive changes in women's beliefs about the benefits of cervical cancer screening, and reduce perceived barriers to screening. Such programs may play an important role in addressing health disparities and informing underserved populations about recommended screening tests.

"My husband says this: If you are alive, you can be someone…": Facilitators and barriers to cervical cancer screening among women living with HIV in India

PURPOSE

Women living with human immunodeficiency virus (WLWH) have a higher risk of cervical cancer than women without HIV. In addition, women in India experience a high burden of death from cervical cancer. This qualitative study evaluated individual and interpersonal factors influencing cervical cancer screening among WLWH in Surat, India.

METHODS

In-depth interviews were conducted with 25 WLWH and 15 stakeholders in Surat, India. Data were analyzed using directed content analysis to identify individual and intrapersonal barriers and facilitators.

RESULTS

WLWH lacked knowledge and reported being afraid of cervical cancer and cervical cancer screening but were interested in learning more about it. Interpersonal factors influencing cervical cancer screening included receipt or lack of instrumental and emotional family support, interactions with healthcare providers, and receipt or lack of information about cervical cancer and the Pap test from healthcare providers.

CONCLUSION

Widespread public education is necessary to increase awareness of cervical cancer and cervical cancer screening and to encourage family members to support women who wish to obtain screening. Patient- and provider-focused interventions may facilitate the process of providing cervical cancer care to WLWH who are obtaining care in busy public healthcare systems in India.

Demographics, self-efficacy, benefits/barriers, stages of adopting pap testing among Korean American women

Korean American women (KAW) experience the third highest incidence rate of cervical cancer among nine major Asian Americans. This study examined cervical cancer screening among KAW using constructs from the transtheoretical model (TTM). Using a cross-sectional survey design, 102 KAW aged 21-65 years of age were recruited through convenience sampling. Twenty-seven per cent of participants reported of never receiving a Pap smear. Women who were older and married were more likely to report being in the action/maintenance stages; women who perceived themselves to be in poor health were less likely to be in the action/maintenance stages. Higher self-efficacy and lower perception of barriers were significantly associated with more advanced TTM stages. The perceived benefits were not statistically different across TTM stages of change. A special attention should be given to young and unmarried KAW to increase screening participation. Impact statement What is already known on this subject? The utilisation of Pap test among Korean American women (KAW) was low. Using the transtheoretical model (TTM) approach has the potential to increase a screening adherence. What do the results of this study add? This is the first study to examine the association between TTM constructs related to Pap testing among KAW. Younger and unmarried women reported the lowest levels of screening attitudes or behaviours; and tailored efforts may be beneficial in increasing the screening among these women. What are the implications of these findings for clinical practice and/or further research? Increasing the self-efficacy and decreasing the barriers to obtaining Pap screening are critical to move Korean women to the advanced TTM stages. Further investigation is needed with KAW to fully understand the relationships between TTM constructs.

Perceived barriers to early detection of breast cancer in Wakiso District, Uganda using a socioecological approach

BACKGROUND

Early detection of breast cancer is known to improve its prognosis. However, women in most low and middle income countries, including Uganda, do not detect it early hence present at an advanced stage. This study investigated the perceived barriers to early detection of breast cancer in Wakiso district, Uganda using a multilevel approach focused through a socioecological framework.

METHODS

Using qualitative methods, participants were purposively selected to take part in the study. 5 semi-structured interviews were conducted among the community members while two focus groups were conducted amongst women's group and community health workers (CHWs) in Ssisa sub county, Wakiso district. In addition, 7 key informant interviews with health professionals, policy makers and public health researchers were carried out.

RESULTS

Findings from the study revealed that barriers to early detection of breast cancer are multifaceted and complex, cutting across individual, interpersonal, organizational, community and policy barriers. The major themes that emerged from the study included: knowledge, attitudes, beliefs and practices (KABP); health system and policy constraints; and structural barriers. Prominent barriers associated with KABP were low knowledge, apathy, fear and poor health seeking behaviours. Barriers within the health systems and policy arenas were mostly centred around competing health care burdens within the country, lack of a cancer policy and weak primary health care capacity in Wakiso district. Distance, poverty and limited access to media were identified as the most prominent structural barriers.

CONCLUSION

Barriers to early detection of breast cancer are complex and go beyond individual behaviours. These barriers interact across multiple levels of influence such as organizational, community and policy. The findings of this study could provide opportunities for investment in multi-level interventions.

Using the socioecological model to explore factors affecting health-seeking behaviours of older Korean immigrants

AIMS AND OBJECTIVES

The purpose of this study was to explore multilevel factors affecting older Korean immigrants' health-seeking behaviours.

BACKGROUND

Although studies have documented significant issues related to healthcare access and utilisation issues among older immigrants, a noted limitation of current research is its failure to explore multiple factors related to their health-seeking behaviours.

DESIGN

A qualitative study using interview data from two previous studies.

METHODS

We performed a qualitative analysis of focus groups and individual interviews using inductive coding methods. The socioecological model provided a useful framework to guide this study. The sample included 17 community-dwelling older Korean immigrants aged ≥65 years living in the metropolitan area of Seattle, WA, USA.

RESULTS

Findings revealed various factors at the individual (e.g., perception of health and illness, mistrust, cultural values and norms, length of residency in the United States, language barriers and ageing experiences), interpersonal (e.g., peers, family and primary care physicians), community (e.g., ethnic community centres and organisations, home care helpers and interpretation services) and policy (e.g., lack of affordability and health benefits coverage) levels. Each of these factors played a role as either a barrier to or facilitator of older Korean immigrants' health-seeking behaviours. Several factors, such as language barriers and lack of available information, were intertwined.

CONCLUSIONS

Findings indicate the importance of considering four major areas when designing culturally appropriate, community-based interventions for older immigrants. Also, utilising peers or trusted human resources in the community is critical to the design and implementation of health promotion interventions for older immigrants.

IMPLICATIONS FOR PRACTICE

Examining intrapersonal, interpersonal, community, and policy level factors that affect older immigrants' health-seeking behaviours informs the design of community-based health promotion interventions for older immigrants.

Assessing perceived benefits/barriers and self-efficacy for cervical cancer screening among Korean American women

A large proportion of Korean American women (KAW) do not receive regular cervical cancer screening. Self-report data from 102 KAW were analyzed by multiple linear regressions. As compared to women in action/maintenance, women in precontemplation/relapse stages were less likely to agree that a Pap test is important for health and were more likely to endorse barriers to testing (cost, not having a female doctor, preference for Korean medicine). Women in precontemplation/relapse stages also reported lower scores on self-efficacy items (travel large distances, pain perceptions, financial costs, and time). Differences in specific aspects may be informative for interventions to improve screening rates among KAW.

Cervical Cancer Screening Among Arab Women in the United States: An Integrative Review

PROBLEM IDENTIFICATION

Arab American women are an ethnic minority and immigrant population in the United States with unique and nuanced sociocultural factors that influence preventive health behaviors. The aims of this article are to evaluate and synthesize the existing evidence on cervical cancer screening behaviors, as well as determine factors that influence these behaviors, among Arab American women.
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LITERATURE SEARCH

Extensive literature searches were performed using PubMed, CINAHL®, Scopus, Embase, and Cochrane databases; articles published through October 2015 were sought. 
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DATA EVALUATION

Of 17 articles, 14 explicitly identified Arab and/or Muslim women and cervical cancer screening in either the title or the abstract; the remaining three focused on cancer attitudes and behaviors in Arab Americans in general but measured cervical cancer screening. Eleven articles reported different aspects of one intervention. Because of methodologic heterogeneity, the current authors synthesized results narratively.
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SYNTHESIS

Key factors influencing cervical cancer screening were identified as the following.

CONCLUSIONS

Cervical cancer screening rates among Arab American women are comparable to other ethnic minorities and lower than non-Hispanic White women. Findings are inconsistent regarding factors influencing cervical cancer screening behaviors in this underrepresented group. 
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IMPLICATIONS FOR RESEARCH

Significant need exists for more research to better understand cervical cancer prevention behaviors in this group to inform culturally relevant interventions. Healthcare providers play a crucial role in increasing cervical cancer screening awareness and recommendations for Arab American women.

Disparities in cervical cancer survival among Asian-American women

PURPOSE

We compared overall survival and influencing factors between Asian-American women as a whole and by subgroup with white women with cervical cancer.

METHODS

Cervical cancer data were from the Surveillance, Epidemiology, and End Results registry; socioeconomic information was from the Area Health Resource File. We used standard tests to compare characteristics between groups; the Kaplan-Meier method with log-rank test to assess overall survival and compare it between groups; and Cox proportional hazards models to determine the effect of race and other covariates on overall survival (with and/or without age stratification).

RESULTS

Being 3.3 years older than white women at diagnosis (P < .001), Asian-American women were more likely to be in a spousal relationship, had more progressive disease, and were better off socioeconomically. Women of Filipino, Japanese, and Korean origin had similar clinical characteristics compared to white women. Asian-American women had higher 36- and 60-month survival rates (P = .004 and P = .013, respectively), higher overall survival rates (P = .049), and longer overall survival durations after adjusting for age and other covariates (hazard ratio = 0.77, 95% confidence interval: 0.68-0.86). Overall survival differed across age strata between the two racial groups. With the exception of women of Japanese or Korean origin, Asian-American women grouped by geographic origin had better overall survival than white women.

CONCLUSIONS

Although Asian-American women, except those of Japanese or Korean origin, had better overall survival than white women, their older age at cervical cancer diagnosis suggests that they have less access to screening programs.