Perceptions of Cervical Cancer Screening, Screening Behavior, and Post-Migration Living Difficulties Among Bhutanese-Nepali Refugee Women in the United States

The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review

A majority of individuals with limited English proficiency (LEP) in the U.S. are foreign-born, creating a complex intersection of language, socio-economic, and policy barriers to healthcare access and achieving good outcomes. Mapping the research literature is key to addressing how LEP intersects with healthcare. This scoping review followed PRISMA-ScR guidelines and included PubMed/MEDLINE, CINAHL, Sociological Abstracts, EconLit, and Academic Search Premier. Study selection included quantitative studies since 2000 with outcomes specified for adults with LEP residing in the U.S. related to healthcare service access or defined health outcomes, including healthcare costs. A total of 137 articles met the inclusion criteria. Major outcomes included ambulatory care, hospitalization, screening, specific conditions, and general health. Overall, the literature identified differential access to and utilization of healthcare across multiple modalities with poorer outcomes among LEP populations compared with English-proficient populations. Current research includes inconsistent definitions for LEP populations, primarily cross-sectional studies, small sample sizes, and homogeneous language and regional samples. Current regulations and practices are insufficient to address the barriers that LEP individuals face to healthcare access and outcomes. Changes to EMRs and other data collection to consistently include LEP status and more methodologically rigorous studies are needed to address healthcare disparities for LEP individuals.

The Relationship between Healthcare Providers and Preventive Practices: Narratives on Access to Cancer Screening

Cancer screening programs are public health interventions beneficial to early diagnoses and timely treatments. Despite the investment of health policies in this area, many people in the recommended age groups do not participate. While the literature is mainly focused on obstacles and factors enabling access to health services, a gap from the point of view of the target population concerns healthcare providers. Within the "Miriade" research-action project, this study aims to explore the dimensions that mediate the relationship between healthcare providers and preventive practices through the narrations of 52 referents and healthcare providers involved in breast, cervical and colorectal cancer screening. We conducted ad hoc narrative interviews and used theory-driven analysis based on Penchansky and Thomas' conceptualization and Saurman's integration of six dimensions of healthcare access: affordability, availability, accessibility, accommodation, acceptability and awareness. The results show that 21 thematic categories were representative of the access dimensions, and 5 thematic categories were not; thus, we have classified the latter as the dimension of affection. The results suggest trajectories through which psychological clinical intervention might be constructed concerning health, shared health decisions and access to cancer screening.

Willingness of a Multiethnic Immigrant Population to Donate Biospecimens for Research Purposes

This cross-sectional study explores the willingness to donate biospecimens for research purposes among six refugee communities in North Texas (spanning Myanmar, Central Africa, Somalia, Nepal, Arabic speaking countries, and others). Participants were asked four questions about biospecimen donation: (1) previously asked to donate, (2) ever agreed to donate, (3) willingness to donate for future research, and (4) what samples they would be willing to donate. Most participants (77%) were willing to donate biosamples for medical research; 58% were willing to donate samples. Fewer refugees from Somalia were willing to donate compared to immigrants from Myanmar, Central Africa, and Nepal (p < 0.01). Participants in the older age group (40 + years) were 3.2 times more likely to be willing for donation of biospecimens than the younger ones (OR 3.22, 95% CI 1.22, 8.55). Findings suggest refugees' willingness to participate in biospecimen donation which support intentional inclusion of multicultural populations into medical research.

Cervical screening uptake: A cross-sectional study of self-reported screening attitudes, behaviours and barriers to participation among South Asian immigrant women living in Australia

Introduction:

Cervical cancer remains a major cause of morbidity and mortality among women from low and lower middle-income countries, as well as underserved population subgroups in high-income countries. Migration from South Asia to Australia has increased over the last decade, and immigrant women from this region have been reported as a subgroup, with less than optimal cervical screening participation in Australia. This study examined cervical screening uptake and associated behavioural attitudes among South Asian immigrant women living in Queensland Australia.

Methods:

A cross-sectional, Internet-based survey was used to collect data from a convenience sample of 148 South Asian women living in Queensland. The main outcome measure was receipt of cervical screening test ever (yes/no) and its recency (within 2 years/more than 2 years). The survey also examined participants’ views on barriers towards screening and ways to enhance it.

Results:

Of 148 women who completed the survey, 55.4% (n = 82) reported ever having a cervical screening test before and 43.9% (n = 65) reported having it in previous two years. Not having a previous cervical screening test was significantly associated with duration of stay in Australia for less than five years, not having access to a regular general practitioner (GP), not being employed, having low cervical cancer knowledge level and not knowing if cervical screening test is painful or not. Most commonly reported barriers to screening uptake included considering oneself not at risk, lack of time and lack of information. The most favoured strategy among participants was encouragement by GP and awareness through social media advertisements.

Conclusion:

This study provided insights into factors that need consideration when developing future targeted interventions.

Pap Smear and Mammogram Screening Rates in a Refugee and General OB/GYN Clinic: A Retrospective Review

Although multiple studies have shown that resettled refugee women are less likely to receive preventative cancer screenings like pap smears and mammograms, a small number have demonstrated the opposite. This retrospective chart review, conducted between January 2017 and October 2018, compares pap smear and mammogram rates of patients seen in a refugee-specific OB/GYN clinic with patients from the general OB/GYN clinic at the same institution. Data from 298 patients (149 refugee and 149 general clinic patients matched by age and date-of-visit) were analyzed. Pap smear screening rates were 90.60% in the refugee group and 73.83% in the general group [p < 0.009, aOR 3.46 (1.36-8.81)], while mammogram screening rates were 36.84% and 38.60%, respectively (p = 0.46). The provision of holistic services meeting refugee women's unique needs can effectively increase pap smear screening rates.

Cervical Cancer Screening Among Immigrant and Refugee Women: Scoping-Review and Directions for Future Research

The purpose of this study is to explore existing research on determinants of cervical cancer screening among immigrants and refugees in the U.S. A scoping review was conducted on 77 studies targeting immigrant and/or refugee women in the U.S., investigating factors related to cervical cancer screening. Sixty-three percent of studies were conducted in the past ten years, and included 122,345 women. Studies predominately explored knowledge, beliefs and barriers related to cervical cancer and screening. Common beliefs included fear of cancer, treatment and death. Participants perceived pap smears to be associated with embarrassment, pain and fear. Barriers to screening were reported in three categories: psychosocial (shame and embarrassment), communication (inability to speak in English), and barriers related to access (lack of insurance or primary care provider). Study findings indicate research focused at the individual-level and future research should focus on exploring multilevel influences on cancer screening uptake.

Patterns and Trends of Cancer Screening in Canada: Results From a Contemporary National Survey

BACKGROUND

The aim of this study was to assess the patterns and trends of colorectal, breast, and cervical cancer screening within a contemporary cohort of Canadian adults.

METHODS

Canadian Community Health Survey datasets (2007-2016) were accessed and 3 cohorts were defined: (1) a colorectal cancer (CRC) screening cohort, defined as men and women aged 50 to 74 years with complete information about CRC screening tests and their timing; (2) a breast cancer screening cohort, defined as women aged 40 to 74 years with complete information about mammography and its timing; and (3) a cervical cancer screening cohort, defined as women aged 25 to 69 years with complete information about the Papanicolaou (Pap) test and its timing. Multivariable logistic regression analysis was then performed to evaluate factors associated with not having timely screening tests at the time of survey completion.

RESULTS

A total of 99,820 participants were considered eligible for the CRC screening cohort, 59,724 for the breast cancer screening cohort, and 46,767 for the cervical cancer screening cohort. Among eligible participants, 43% did not have timely recommended screening tests for CRC, 35% did not have timely mammography (this number decreased to 26% when limiting the eligible group to ages 50-74 years), and 25% did not have a timely Pap test. Lower income was associated with not having a timely recommended screening tests for all 3 cohorts (odds ratios [95% CI]: 1.86 [1.76-1.97], 1.89 [1.76-2.04], and 1.96 [1.79-2.14], respectively). Likewise, persons self-identifying as a visible minority were less likely to have timely recommended screening tests in all 3 cohorts (odds ratios for White race vs visible minority [95% CI]: 0.87 [0.83-0.92], 0.85 [0.80-0.91], and 0.66 [0.61-0.70], respectively).

CONCLUSIONS

More than one-third of eligible individuals are missing timely screening tests for CRC. Moreover, at least one-quarter of eligible women are missing their recommended breast and cervical cancer screening tests. More efforts from federal and provincial health authorities are needed to deal with socioeconomic disparities in access to cancer screening.

An integrative literature review of barriers and facilitators to cervical cancer screening among refugee women in the United States

Refugee women experience disproportionally high cervical cancer-related mortality. In this integrative review, we identify and discuss factors related to cervical cancer screening among refugee women in the US according to the Social Ecological Model. Two qualitative and three quantitative studies met inclusion criteria. Individual-level factors include English-language ability, availability, and individual knowledge, attitudes, and beliefs. Interpersonal-level factors include interactions with family/friends, provider, and community health worker. Community-, organization-, and policy-level factors include sociocultural values, transportation, ability to navigate the healthcare system, and health insurance. We discuss findings in the context of related reviews and applicability to other global settings.

Uptake of cancer screenings among a multiethnic refugee population in North Texas, 2014-2018

Background

Refugees are less likely than US born populations to receive cancer screenings. Building Bridges is a community health worker prevention program designed to increase refugee’s cancer screening uptake. The purpose of this cross sectional analysis was to assess differences in uptake of cervical, breast, liver, and colorectal screens across six cultural groups.

Methods

Data was abstracted in 2018 for this analysis. Participants were categorized into six cultural groups (Myanmar, Central Africa, Bhutan, Somalia, Arabic Speaking Countries, and Other) to assess differences in sociodemographic measures and screening uptake. Uptake proportions were calculated for each cancer type (cervical, breast, liver, and colon) among eligible participants, by gender and cultural group. Differences in uptake across groups were assessed using stratified analysis and logistic regression. Prevalence odds ratios (POR) and 95% confidence intervals (CIs) were calculated for each group to assess the association between screening completion and cultural group.

Findings

874 refugees were asked about cancer screening history. The majority of participants were either ‘never had been screened’ or ‘not up-to-date’ for every cancer screening. Among age eligible, 82% had no prior pap exam within the past 3 years, 81% had no prior mammogram within the past year, 69% didn’t know their Hepatitis B status and 87% never had a colon cancer screening. Overall, higher uptake of all types of cancer screenings was observed in Myanmar and Bhutanese groups, except colon cancer screening which was higher among Central African Region and Arabic Speaking participants.

Conclusion

Screening uptake varied by ethnic group and screening type. The program reached an under and never screened population, however, the proportion of refugees who received a cancer screening remained low compared to the US population. Diversity within refugee communities requires adaptation to specific cultural and linguistic needs to include new Americans in cancer elimination efforts.

A systematic review of barriers and enablers to South Asian women's attendance for asymptomatic screening of breast and cervical cancers in emigrant countries

OBJECTIVES

The aim of this review was to identify the cultural, social, structural and behavioural factors that influence asymptomatic breast and cervical cancer screening attendance in South Asian populations, in order to improve uptake and propose priorities for further research.

DESIGN

A systematic review of the literature for inductive, comparative, prospective and intervention studies. We searched the following databases: MEDLINE/In-Process, Web of Science, EMBASE, SCOPUS, CENTRAL, CDSR, CINAHL, PsycINFO and PsycARTICLES from database inception to 23 January 2018. The review included studies on the cultural, social, structural and behavioural factors that influence asymptomatic breast and cervical cancer screening attendance and cervical smear testing (Papanicolaou test) in South Asian populations and those published in the English language. The framework analysis method was used and themes were drawn out following the thematic analysis method.

SETTINGS

Asymptomatic breast or cervical screening.

PARTICIPANTS

South Asian women, including Bangladeshi, Indian, Pakistani, Sri Lankan, Bhutanese, Maldivian and Nepali populations.

RESULTS

51 included studies were published between 1991 and 2018. Sample sizes ranged from 25 to 38 733 and participants had a mean age of 18 to 83 years. Our review showed that South Asian women generally had lower screening rates than host country women. South Asian women had poorer knowledge of cancer and cancer prevention and experienced more barriers to screening. Cultural practices and assumptions influenced understandings of cancer and prevention, emphasising the importance of host country cultures and healthcare systems.

CONCLUSIONS

High-quality research on screening attendance is required using prospective designs, where objectively validated attendance is predicted from cultural understandings, beliefs, norms and practices, thus informing policy on targeting relevant public health messages to the South Asian communities about screening for cancer.

PROSPERO REGISTRATION NUMBER

CSD 42015025284.

The Personal Social Networks of Resettled Bhutanese Refugees During Pregnancy in the United States: A Social Network Analysis

Women comprise 50% of the refugee population, 25% of whom are of reproductive age. Female refugees are at risk for experiencing significant hardships associated with the refugee experience, including after resettlement. For refugee women, the strength of their personal social networks can play an important role in mitigating the stress of resettlement and can be an influential source of support during specific health events, such as pregnancy. A personal social network analysis was conducted among 45 resettled Bhutanese refugee women who had given birth within the past 2 years in the Akron Metropolitan Area of Northeast Ohio. Data were collected using in-depth interviews conducted in Nepali over a 6-month period in 2016. Size, demographic characteristics of ties, frequency of communication, length of relationship, and strength of connection were the social network measures used to describe the personal networks of participants. A qualitative analysis was also conducted to assess what matters were commonly discussed within networks and how supportive participants perceived their networks to be. Overall, participants reported an average of 3 close personal connections during their pregnancy. The networks were comprised primarily of female family members whom the participant knew prior to resettlement in the U.S. Participants reported their networks as "very close" and perceived their connections to be supportive of them during their pregnancies. These results may be used to guide future research, as well as public health programming, that seeks to improve the pregnancy experiences of resettled refugee women.

We Should Know Ourselves: Burmese and Bhutanese Refugee Women's Perspectives on Cervical Cancer Screening

Refugee women are at increased risk for cervical cancer and have low rates of cervical cancer screening both in their countries of origin and in the U.S. Using the Behavioral Model for Vulnerable Populations as a conceptual framework, we conducted eight focus groups with Burmese and Bhutanese refugee women to gather information about factors influencing cervical cancer screening (31 Burmese and 27 Bhutanese participants). Less than one-third (28%) reported being screened for cervical cancer before coming to the U.S. and only 45% reported being screened after resettling in the U.S. Participants had limited knowledge about cervical cancer and the need for screening, and faced multiple barriers including competing priorities and cost. However, trusted providers and interpreters were seen as means of facilitating screening. Cervical cancer screening among Bhutanese and Burmese refugee women could be improved with culturally tailored health education and increased access to female providers and trained interpreters.