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

Sociodemographic characteristics associated with cervical cancer screening participation by send-to-all and opt-in HPV self-sampling: Who benefits? Results from a randomized controlled trial among long-term non-attending women in Norway

With the objective to investigate associations between sociodemographic characteristics and participation in interventions designed to increase participation in cervical cancer screening among under-screened women, we randomized a random sample of 6000 women in Norway aged 35-69 years who had not attended cervical screening for ≥10 years to receive either (i) a reminder to attend regular screening (control), (ii) an offer to order a self-sampling kit (opt-in), or (iii) a self-sampling kit unsolicited (send-to-all). We analyzed how sociodemographic characteristics were associated with screening participation within and between screening arms. In the send-to-all arm, increased screening participation ranged from 17.1% (95% confidence interval [95% CI] = 10.3% to 23.8%) to 30.0% (95% CI = 21.5% to 38.6%) between sociodemographic groups. In the opt-in arm, we observed smaller, and at times, non-significant increases within the range 0.7% (95% CI = -5.8% to 7.3%) to 19.1% (95% CI = 11.6% to 26.7%). In send-to-all versus control comparisons, there was greater increase in participation for women in the workforce versus not (6.1%, 95% CI = 1.6% to 10.6%), with higher versus lower income (7.6%, 95% CI = 2.2% to 13.1%), and with university versus primary education (8.5%, 95% CI = 2.4% to 14.6%). In opt-in versus control comparisons, there was greater increase in participation for women in the workforce versus not (4.6%, 95% CI = 0.7% to 8.5%), with higher versus lower income (6.3%, 95% CI = 1.5% to 11.1%), but lower increase for Eastern European versus Norwegian background (-12.7%, 95% CI = -19.7% to -5.7%). Self-sampling increased cervical screening participation across all sociodemographic levels, but inequalities in participation should be considered when introducing self-sampling, especially with the goal to reach long-term non-attending women.

A systematic review of the cost-effectiveness of interventions to increase cervical cancer screening among underserved women in Europe

BACKGROUND

This study aimed to conduct a systematic review of the cost-effectiveness studies of interventions to increase cervical cancer screening uptake rates in underserved women in Europe.

METHODS

A search of Embase, Medline, Global Health, PsychINFO, and NHS Economic Evaluation Database was conducted for studies published between January 2000 and September 2022. Studies were eligible if they analysed the cost-effectiveness of any interventions to improve participation in cervical cancer screening among underserved women of any age eligible to participate in cervical cancer screening in European countries, in any language. Study characteristics and cost-effectiveness results were summarised. Study quality was assessed using the Drummond Checklist, and methodological choices were further compared.

RESULTS

The searches yielded 962 unique studies, with 17 of these (from twelve European countries) meeting the eligibility criteria for data extraction. All studies focused on underscreened women as an overarching group, with no identified studies focusing on specific subgroups of underserved women. Generally, self-HPV testing and reminder interventions were shown to be cost-effective to increase the uptake rates. There was also research showing that addressing access issues and adopting different screening modalities could be economically attractive in some settings, but the current evidence is insufficient due to the limited number of studies.

CONCLUSION

This systematic review has revealed a gap in the literature on the cost-effectiveness of interventions to improve uptake rates of cervical cancer screening through tailored provision for specific groups of underserved women.

Socioeconomic differences in use of antiseizure medication in pregnancies with maternal epilepsy: A population-based study from Nordic universal health care systems

OBJECTIVE

Research points to disparities in disease burden and access to medical care in epilepsy. We studied the association between socioeconomic status (SES) and antiseizure medication (ASM) use in pregnancies with maternal epilepsy.

METHODS

We conducted a cross-sectional study consisting of 21 130 pregnancies with maternal epilepsy identified from Nordic registers during 2006-2017. SES indicators included cohabitation status, migrant background, educational attainment, and household income. Main outcomes were the proportion and patterns of ASM use from 90 days before pregnancy to birth. We applied multiple imputation to handle SES variables with 2%-4% missingness. We estimated adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) using modified Poisson regression with the highest SES category as reference.

RESULTS

Mothers with the highest education and the highest income quintile used ASMs least frequently (56% and 53%, respectively). We observed increased risks of ASM discontinuation prior to or during the first trimester for low SES. The risk estimates varied depending on the SES indicator from aRR = 1.27 for low income (95% CI: 1.03-1.57) to aRR = 1.66 for low education (95% CI: 1.30-2.13). Migrant background was associated with ASM initiation after the first trimester (aRR 2.17; 95% CI 1.88-2.52). Low education was associated with the use of valproate during pregnancy in monotherapy (aRR 1.70; 95% CI 1.29-2.24) and in polytherapy (aRR 2.65; 95% CI 1.66-4.21). Low education was also associated with a 37% to 39% increased risk of switching from one ASM to another depending on the ASM used. For the other SES indicators, aRRs of switching varied from 1.16 (foreign origin; 95% CI 1.08-1.26) to 1.26 (not married or cohabiting; 95% CI 1.17-1.36).

SIGNIFICANCE

Low SES was associated with riskier patterns of ASM use: discontinuation, late initiation, and switching during pregnancy. These findings may reflect unplanned pregnancies, disparities in access to preconception counseling, and suboptimal care.

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.

Language and Cultural Barriers and Facilitators of Sexual and Reproductive Health Care for Migrant Women in High-Income European Countries: An Integrative Review

INTRODUCTION

Dealing with intercultural communicative barriers in European countries' national health services is an increasing and necessary challenge to guarantee migrant women's right to health care. This integrative review describes the communication barriers and facilitators that migrant women encounter to access and use sexual and reproductive health (SRH) services in Europe.

METHODS

A literature search was performed to identify original studies in PubMed, CINAHL, PsycINFO, Web of Science, and Scopus, using keywords associated with migrant women and SRH services. This was supplemented by scanning the reference lists from relevant studies and similar reviews. Studies exploring the perspective of migrant women about communication barriers and facilitators to the access and use of SRH services were included, whereas those that solely explored health professional's experiences were excluded. Findings were organized into 4 themes: (1) verbal-linguistic barriers, (2) nonverbal language barriers, (3) cultural barriers, and (4) communication facilitators.

RESULTS

Nineteen studies met the inclusion criteria. Results showed that when women had problems understanding or being understood by health professionals, they experienced feelings of anxiety, fear, insecurity, and discrimination that discouraged them from using SRH services. The most requested facilitators by women were health education, access to professional interpreters and translation of written information, and increasing the practitioners' cultural competence.

DISCUSSION

Communication barriers undermine migrant women's right to benefit from preventive SRH programs and to make informed decisions concerning their health. It is necessary to establish tailored plans in each health care center to improve intercultural communication that integrate facilitators proposed by women. Future research should provide solid evidence on the effectiveness of each facilitator implemented.

Factors affecting cervical cancer screening among Yemeni immigrant women in Klang Valley, Malaysia: A cross sectional study

INTRODUCTION

Cervical cancer is a significant public health problem for women worldwide. It is the fourth most frequent cancer in women globally. While early detection of cancerous lesions through screening tests leads to a better prognosis and a better chance of being cured, the number of people who go for screening is still low, especially for groups that are marginalized, like immigrant women.

OBJECTIVE

The purpose of this study was to identify cervical cancer screening practices and factors influencing screening status among Yemeni immigrant women living in the Klang Valley, Malaysia.

METHOD

A cross-sectional study among 355 randomly selected respondents between the ages of 20 and 65 was conducted through an online survey. A questionnaire was sent directly to the participants via WhatsApp. The analysis was conducted using SPSS 25 with a significance level of 0.05. It included descriptive analysis, chi-square and multiple logistic regression.

RESULTS

The response rate was 59%, with the majority of the respondents being married and between the ages of 35 and 49. Screening was reported at 23.1% in the previous three years. The final model revealed that age group 50-65 years (AOR = 5.39, 95% CI: 1.53-18.93), insurance status (AOR 2.22, 95% CI = 1.15-4.3), knowledge (AOR = 6.67, 95% CI = 3.45-12.9), access to health care facilities (AOR = 4.64, 95% CI = 1.29-16.65), and perceived barriers (AOR = 2.5, 95% CI = 1.3-4.83) were significant predictors of cervical screening uptake among Yemeni immigrant women in Malaysia (p<0.05).

CONCLUSION

According to the results, cervical cancer screening was found to be low among Yemeni immigrant women. The predictors were age group 50-65 years, insurance status, knowledge, access to health care facilities and perceived barriers. Efforts to enhance immigrant women's participation in cervical cancer screening must tackle barriers to access to healthcare services as well as expand cervical cancer screening education programs.

Lower participation among immigrants in colorectal cancer screening in Norway

Introduction

Organized cancer screening programs should be equally accessible for all groups in society. We assessed differences in participation in colorectal cancer (CRC) screening among different immigrant groups.

Methods

Between 2012 and 2019, 140,000 individuals aged 50 to 74 years were randomly invited to sigmoidoscopy or repeated faecal immunochemical test (FIT) in a CRC screening trial. In this study, we included 46,919 individuals invited to sigmoidoscopy and 70,018 invited to the first round of FIT between 2012 and 2017. We examined difference in participation between non-immigrants and immigrants, and within different immigrant groups by geographic area of origin, using logistic regression models, adjusted for several sociodemographic factors and health factors.

Results

In total, we included 106,695 non-immigrants and 10,242 immigrants. The participation rate for FIT was 60% among non-immigrants, 58% among immigrants from Western countries and 37% among immigrants from non-Western countries. The participation rate for sigmoidoscopy was 53% among non-immigrants, 48% among immigrants from Western countries and 23% among immigrants from non-Western countries. Compared to non-immigrants, multivariate adjusted odds ratio for non-participation in FIT screening was 1.13 (95% confidence interval 1.04-1.23) and 1.82 (1.69-1.96) for immigrants from Western and non-Western countries. The corresponding numbers in sigmoidoscopy screening were 1.34 (1.21-1.48) and 2.83 (2.55-3.14). The lowest participation was observed in immigrants from Eastern Europe, Northern Africa and Western Asia, and South-Central Asia.

Conclusion

Participation in CRC screening in Norway was particularly low among non-Western immigrants, which could put them at increased risk for late stage diagnosis of CRC. Participation was lower in sigmoidoscopy screening than in FIT screening, especially among immigrants from non-Western countries.

Unpacking the Lay Epidemiology of Cervical Cancer: A Focus Group Study on the Perceptions of Cervical Cancer and Its Prevention among Women Late for Screening in Norway

Nonattendance for cervical cancer screening is often understood in terms of a lack of 'appropriate' or 'correct' knowledge about the risks and prevention of the disease. Few studies have explored how lay persons-the users themselves-interpret and contextualise scientific knowledge about cervical cancer. In this study, we address the following research question: How is the epidemiology of cervical cancer and its prevention discussed among women who are late for cervical cancer screening in Norway? We completed nine focus group interviews (FGIs) with 41 women who had postponed cervical screening. The analyses were both inductive and explorative, aiming to unpack the complexity of lay understandings of cervical cancer. Interactive associations expressed in the FGIs reflected multiple understandings of aetiology and risk factors, screening, and interpretations of responsibility for acquiring cervical cancer. The term 'candidacy' was employed to provide an enhanced understanding of lay reasoning about the explanations and predictions of cervical cancer, as reflected in the FGIs. Both interpretations of biomedical concepts and cultural values were used to negotiate acceptable and nuanced interpretations of candidacy for cervical cancer. Uncertainties about risk factors for acquiring cervical cancer was an important aspect of such negotiations. The study's findings provide an in-depth understanding of the contexts in which screening may be rendered less relevant or significant for maintaining health. Lay epidemiology should not be considered inappropriate knowledge but rather as a productive component when understanding health behaviours, such as screening attendance.

What is the role of attitudinal barriers on cervical cancer screening non-attendance? Findings from a cross-sectional study with migrant women in Portugal

BACKGROUND

Cervical cancer is a common disease which can be effectively and timely detected by cervical cancer screening. However, access to cervical cancer screening is unequal, and it is known that migrant women have a lower attendance to cervical cancer screening. These inequalities are associated with several factors, including attitudes and beliefs of the women regarding screening practices, which prevents them from participating. This study aims to explore the attitudinal barriers to cervical cancer screening among migrant women in Portugal.

METHODS

A web-based cross-sectional survey was conducted with 1100 migrant women residing in Portugal. Women were recruited through social media platforms. The survey included items on socioeconomic characteristics, cervical cancer screening history and an 11-item attitudinal questionnaire to assess attitudinal barriers. Logistic regression models were used for statistical analysis.

RESULTS

The attitudinal barriers to CCS most often reported by participants were fear of the test result (25.3%), worry about seeing a male health professional (23.8%), perceiving the test as painful (23.1%), embarrassment (18.5%), difficulties scheduling the test (14.3%), and having a negative experience in screening (12.4%). Low perceived need in absence of symptoms and lack of motivation to be screened were reported by less than 5% of the women. However, the results suggest that most of the attitudinal barriers with higher agreement percentage have no association with cervical cancer screening attendance. Among all the attitudinal barriers, low perceived need of screening and lack of motivation were associated with CCS non-attendance.

CONCLUSIONS

Based on the findings, out of all the factors analyzed, low perceived need of screening and lack of motivation are the most relevant factors associated with non-attendance among migrants in Portugal. Promoting health literacy and empowering women with knowledge about benefits of screening may help overcoming these barriers. Therefore, this study provides a foundation for stakeholders on which areas should be prioritized when developing strategies aiming to reduced cervical cancer screening non-attendance among migrant women.

Adherence to Cervical Cancer Screening Programs in Migrant Populations: A Systematic Review and Meta-Analysis

Organized cervical cancer screening programs to promote the early identification of precancerous lesions have proven to be effective in decreasing the burden associated with cervical cancer, but knowledge regarding screening adherence among migrant women compared to that of native women has not been summarized. A systematic search of the literature on PubMed, Scopus and Embase led to the identification of 772 papers that were published up to July 2022 and reported population-based data regarding adherence to cervical screening. The screening participation rates among migrant women, compared to native women, were pooled using a random-effects meta-analysis. A total of 18 papers were included in the review, with most of them being conducted in Europe (83.3%). Overall, migrants showed a significantly lower participation rate compared to native women (OR for screening adherence: 0.54, 95% CI = 0.42-0.70). This discrepancy was especially evident for migrant women from North Africa and Sub-Saharan Africa (OR = 0.47, 95% CI = 0.35-0.63, and OR = 0.35, 95% CI = 0.24-0.49, respectively). The results of this systematic review emphasize the importance of increasing cervical cancer screening adherence among migrant women. A significant heterogeneity in screening adherence was observed based on the country of origin. Interventions aimed at reducing the disparities in screening participation should specifically consider how to improve the recruitment of migrant women.

The Future of Cervical Cancer Prevention: From "One-Size-Fits-All" to Personalized Screening

Cervical cancer screening represents an excellent model system for the development of personalized cancer-prevention strategies [...].

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.

Barriers and facilitators to cervical cancer screening for women from culturally and linguistically diverse backgrounds; a qualitative study of GPs

OBJECTIVE

To explore general practitioners' (GPs) perspectives on the barriers and facilitators to cervical cancer screening (CCS) for women from culturally and linguistically diverse (CALD) backgrounds.

DESIGN

Qualitative descriptive study involving semi-structured interviews, with interview guide informed by the Theoretical Domains Framework.

SETTING

Adelaide, South Australia.

PARTICIPANTS

Twelve GPs with experience in providing CCS to women from CALD backgrounds participated.

RESULTS

Four main themes emerged: 'importance of clinician-patient relationship', 'patients' cultural understanding regarding health care and CCS', 'communication and language' and 'health system related'. Each theme had several subthemes. GPs' professional relationship with their patients and repeated advice from other clinicians, together with the provision of opportunistic CCS, were described as facilitators, and encompassed the theme of 'importance of clinician-patient relationship'. This theme also raised the possibility of self-collection human papilloma virus tests. Lack of awareness and knowledge, lower priority for cancer screening and patients' individual circumstances contributed to the theme of 'patients' cultural understanding regarding health care and CCS', and often acted as barriers to CCS. 'Communication and language' consisted of language difficulties, interpreter use and use of appropriate resources. Language difficulties were a barrier to the provision of CCS, and GPs used interpreters and written handouts to help overcome this. The theme of 'health system related' involved the increased time needed for CCS consults for CALD women, access to appointments, funding, health promotion and effective use of practice management software.

CONCLUSIONS

This study highlights that multiple, inter-related barriers and facilitators influence CALD women's engagement with CCS, and that GPs needed to manage all of these factors in order to encourage CCS participation. More efforts are needed to address the barriers to ensure that GPs have access to appropriate resources, and CALD patients have access to GPs they trust.

Polish immigrants’ access to colorectal cancer screening in Norway – a qualitative study

Background

The Norwegian colorectal cancer (CRC) screening programme started in May 2022. Inequities in uptake of CRC screening is a concern, and we expect that immigrants are at risk of non-uptake. Immigrants from Poland are the most populous immigrant group in Norway. The purpose of this study was to identify and explore factors that may facilitate Polish immigrants’ access to the Norwegian CRC screening programme.

Material and methods

This study was based on qualitative interviews with ten Polish immigrants in Norway. The participants represented a convenience sample that varied in terms of gender, education, employment, time in Norway, place of residence, Norwegian language skills and ties to the Norwegian-Polish community. We performed thematic content analysis to understand CRC screening from the perspective of Polish immigrants, using transnationalism and Levesque’s conceptualization of accessibility as theoretical frameworks.

Results

We grouped our findings into three themes; “understanding of CRC development and the need to access health care”, “binationalism” and “improving accessibility through information”. Within these themes, various factors influenced the participants’ accessibility to CRC screening, namely knowledge about the screening and about causes, development and prevention of the disease, language, choice of screening country, trust in health personnel’s competence, information needs, methods and sources, as well as participants’ perception of the faecal immunochemical test screening user manual. These factors were further influenced by communication between the Polish community in Norway and Poland, as well as travel between the countries.

Conclusion

We identified several factors that can be targeted with an aim to increase Polish immigrants’ access to the Norwegian CRC screening programme. Effective measures could include increasing cultural competence among health care providers and providing information in Polish through Polish-speaking health care professionals, general practitioners and internet portals used by the Polish-speaking community. Focusing on accessibility in a transnational setting, our findings may be of interest for policy makers and service providers planning preventive health measures for immigrants.

HPV self-sampling among long-term non-attenders to cervical cancer screening in Norway: a pragmatic randomised controlled trial

BACKGROUND

Cervical cancer screening participation is suboptimal in most settings. We assessed whether human papillomavirus (HPV) self-sampling may increase screening participation among long-term non-attenders in Norway.

METHODS

A pragmatic randomised controlled trial with participation as the primary outcome was initiated in the national cervical screening programme in March 2019. A random sample of 6000 women aged 35-69 years who had not attended screening for at least 10 years were randomised 1:1:1 to receive either (i) a reminder to attend regular screening (control), (ii) an offer to order a self-sampling kit (opt-in) for HPV testing or (iii) a self-sampling kit unsolicited (send-to-all) for HPV testing.

RESULTS

Total participation was 4.8%, 17.0% and 27.7% among control, opt-in and send-to-all (P < 0.0001; participation difference (%) send-to-all vs. control: 22.9 (95%CI: 20.7, 25.2); opt-in vs. control: 12.3 (95%CI: 10.3, 14.2); send-to-all vs. opt-in: 10.7 (95% CI: 8.0, 13.3)). High-risk HPV was detected in 11.5% of self-samples and 9.2% of clinician-collected samples (P = 0.40). Most women (92.5%) who returned a positive self-sample attended the clinic for triage testing. Of the 933 women screened, 33 (3.5%) had CIN2 + (1.1%, 3.7%, 3.8% among control, opt-in, and send-to-all, respectively), and 11 (1.2%) had cervical cancer (0%, 1.2%, 1.3% among control, opt-in, send-to-all, respectively).

CONCLUSION

Opt-in and send-to-all self-sampling increased screening participation among long-term, higher-risk non-attenders.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT03873376.

Factors Promoting Breast, Cervical and Colorectal Cancer Screenings participation: A Systematic Review

Objective

The present study aims at systematically reviewing research conducted on factors promoting breast, cervical and colorectal cancer screenings participation.

Methods

A literature search in MEDLINE/PubMed and PsycInfo from January 2017 to October 2021 was performed. Data extraction, researchers' full agreement and the inclusion criteria produced 102 eligible studies. Data were narratively synthesized and critically interpreted.

Results

Multiple factors favoring or hindering breast, cervical and colorectal cancer screenings were identified and summarized as factors operating at the individual level (background information, individual characteristics, emotions related to screening procedure and to cancer, knowledge and awareness), at the relational level (relationships with healthcare staff, significant others, community members), and at the healthcare system level (systems barriers/policy, lack of staff). A critical appraisal of studies revealed a fragmentation in the literature, with a compartmentalization of studies by type of cancer screening, country and specific populations of destination.

Conclusions

Overall findings indicated that greater integration of research results obtained independently for each cancer diagnosis and within the different countries/populations could foster a more comprehensive understanding of factors potentially enhancing the participation in breast, cervical and colorectal cancer screenings worldwide. This review, which is grounded in the current context of globalization and superdiversification in population, can help to enhance a better integration between research and practices, by supporting the development of more effective and inclusive evidence‐based interventions and health‐promotion campaigns worldwide. Research and practical implications are highlighted and discussed.

Cancer Incidence in Migrants in Australia: Patterns of Three Infection-Related Cancers

BACKGROUND

Australia provides an ideal population-base for cancer migration studies because of its multicultural society and high-quality cancer registrations. Among migrant groups there is considerable variability in the incidence of infection-related cancers; thus, the patterns of three such cancers were examined among migrant groups relative to Australian-born residents.

METHODS

Using national incidence data for cancers of the stomach, liver, and cervix diagnosed during 2005 to 2014, incidence rates were compared for selected migrant groups with the Australian-born population using incidence rate ratios (IRR), from a negative binomial regression model.

RESULTS

Wide variations in incidence between countries/regions of birth were observed for all three cancers (P < 0.0001). The patterns were similar for cancers of the stomach and liver, in that migrants from countries/regions with higher incidence rates maintained an increased risk in Australia, with the highest being among South American migrants (IRR = 2.35) for stomach cancer and among Vietnamese migrants (5.44) for liver cancer. In contrast, incidence rates of cervical cancer were lower for many migrant groups, with women from Southern Asia (0.39) and North Africa (0.42) having the lowest rates. The rate of cervical cancer was higher in migrants from New Zealand, Philippines, and Polynesia.

CONCLUSIONS

Several Australian migrant groups were found to experience a disproportionate burden of infection-related cancers; further studies of associated risk factors may inform the design of effective interventions to mediate these disparities.

IMPACT

By identifying these migrant groups, it is hoped that these results will motivate and inform prevention or early detection activities for these migrant groups. See related commentary Dee and Gomez, p. 1251.

Cervical Cancer Screening by Refugee Category in a Refugee Health Primary Care Clinic in Calgary, Canada, 2011-2016

Newly arrived refugees and refugee claimants experience low cervical cancer screening (CCS) rates in Canada. We investigated CCS at a dedicated refugee clinic. We completed a retrospective cohort study among patients at the Mosaic Refugee Health Clinic in Calgary, Canada, between 2011 and 2016. We investigated CCS offers and completion by refugee category. We then used multivariable logistic regression to estimate the association of CCS screening and refugee category, accounting for sociodemographic and clinical factors. We included 812 refugees. Most were married (71%) and had limited English proficiency (57%). Overall, 88% and 77% of patients were offered and completed screening, respectively. Compared to government assisted refugees, privately sponsored refugees completed CCS more often (OR 1.60, 95% CI [1.02-2.49]). A dedicated refugee clinic may provide effective CCS to newly arrived refugees irrespective of refugee category, insurance status or other barriers.

Explaining Correlates of Cervical Cancer Screening among Minority Women in the United States

Globally, cervical cancer is the fourth leading cause of death among women. While overall cervical cancer rates have decreased over the last few decades, minority women continue to be disproportionately affected compared to White women. Given the paucity of theory-based interventions to promote Pap smear tests among minority women, this cross-sectional study attempts to examine the correlates of cervical cancer screening by Pap test using the Multi-theory Model (MTM) as a theoretical paradigm among minority women in the United States (U.S.). Structural Equation Modelling (SEM) was done for testing the construct validity of the survey instrument. Data were analyzed through bivariate and multivariate tests. In a sample of 364 minority women, nearly 31% (n = 112) of women reported not having received a Pap test within the past three years compared to the national rate (20.8%) for all women. The MTM constructs of participatory dialogue, behavioral confidence, and changes in the physical environment explained a substantial proportion of variance (49.5%) in starting the behavior of getting Pap tests, while the constructs of emotional transformation, practice for change, and changes in the social environment, along with lack of health insurance and annual household income of less than $25,000, significantly explained the variance (73.6%) of the likelihood to sustain the Pap test behavior of getting it every three years. Among those who have had a Pap smear (n = 252), healthcare insurance, emotional transformation, practice for change, and changes in the social environment predicted nearly 83.3% of the variance in sustaining Pap smear test uptake behavior (adjusted R² = 0.833, F = 45.254, p < 0.001). This study validates the need for health promotion interventions based on MTM to be implemented to address the disparities of lower cervical cancer screenings among minority women.

Incidence of breast cancer subtypes in immigrant and non-immigrant women in Norway

BACKGROUND

Breast cancer incidence differs between non-immigrants and immigrants from low- and middle-income countries. This study investigates whether immigrants also have different subtype-specific incidences.

METHODS

We used national health registries in Norway and calculated subtype-specific incidence rate ratios (IRRs) for invasive breast cancer among women aged 20-75 and 20-49 years between 2005 and 2015. Immigrant groups were classified by country of birth broadly defined based on WHO regional groupings. Subtype was defined using estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor 2 (HER2) status as luminal A-like (ER+ PR+ HER2-), luminal B-like/HER2- (ER+ PR- HER2-), luminal B-like/HER2+ (ER+ PR any HER2+), HER2+ (ER-PR-HER2+) and triple-negative breast cancer (TNBC) (ER-PR-HER2-).

RESULTS

Compared to non-immigrants, incidence of the luminal A-like subtype was lower in immigrants from Sub-Saharan Africa (IRR 0.43 95% CI 0.28-0.66), South East Asia (IRR 0.63 95% CI 0.51-0.79), South Asia (IRR 0.67 95% CI 0.52-0.86) and Eastern Europe (IRR 0.86 95% CI 0.76-0.99). Immigrants from South Asia had higher rates of HER2 + tumors (IRR 2.02 95% CI 1.26-3.23). The rates of TNBC tended to be similar regardless of region of birth, except that women from South East Asia had an IRR of 0.54 (95% CI 0.32-0.91).

CONCLUSIONS

Women from Eastern Europe, Sub-Saharan Africa and Asia had different subtype-specific incidences compared to women from high-income countries (including non-immigrants). These differences in tumor characteristics between immigrant groups should be taken into consideration when planning preventive or screening strategies.

Cervical dysplasia among migrant women with female genital mutilation/cutting type III: A cross-sectional study

Objective

To assess the rate of cervical dysplasia in a population of migrant women with female genital mutilation/cutting (FGM/C) type III who attended a specialized clinic for FGM/C.

Methods

Descriptive retrospective cross‐sectional study reviewing electronic medical records of all infibulated women who attended a specialized clinic for women and girls with FGM/C at Geneva University Hospitals (2010–2016). We examined sociodemographic characteristics, parity, FGM/C subtypes, presence/grade of cervical dysplasia, colposcopy follow up/treatment, infections, and history of sexual violence.

Results

Out of 360 women reviewed, 188 women with FGM/C type III were included. Mean age of the women was 37.7 (±5.14) years. They were mostly from East Africa (n = 116, 61.7%). A total of 113 (60%) had undergone defibulation, the majority (105; 92.9%) without undergoing re‐infibulation. Cervical dysplasia was found in 20 (10.6%): 16 (8.5%) had a low‐grade grade squamous intraepithelial lesion or HPV‐positive atypical squamous cells of undetermined significance, Four (2.1%) had a high‐grade squamous intraepithelial lesions, of which one was a carcinoma in situ. Seven (35%) of the women with dysplasia underwent colposcopies regularly, five (25%) irregularly, and eight (40%) dropped out of colposcopy follow up.

Conclusion

Cervical dysplasia is frequent among women with FGM/C type III and efforts should be made to guarantee follow up for migrant women.

Migrant women with female genital mutilation/cutting type III have a high prevalence of cervical dysplasia.

Effect of a community-based intervention to increase participation in cervical cancer screening among Pakistani and Somali women in Norway

BACKGROUND

Norway implemented a regular cervical cancer screening program based on triennial screening in 1995, recommending participation of all women between 25 and 69 years of age. Somali and Pakistani women have the lowest participation in cervical cancer screening in Norway. This study evaluates the effect of a community-based intervention aimed at increasing participation in the screening program among women from these two groups.

METHODS

The intervention consisted of an oral 20-25 min presentation in Urdu and Somali on cervical cancer and screening and practical information on how to make an appointment and payment for the test. The participants were invited to pose questions related to the topic after the presentation. This study was carried out in four geographical areas surrounding the capital Oslo between February and October 2017, among women aged 25-69 years from Pakistan and Somalia. We recruited women in the intervention group directly from different community institutions, households, and religious sites. Women from Pakistan and Somalia residing in Oslo were the controls. The absolute intervention effect was measured as difference in absolute proportion of women screened and estimated as the interaction between time and group allocation in a generalized estimation equation model with binomial distribution and identity link function.

RESULTS

The percentage of women screened in the intervention group increased, from 46 to 51%. The corresponding increase in proportion in the control group was from 44 to 45.5%. After adjustment for potential confounders the intervention group showed a significant larger increase in participation in the screening program as compared to the control group with an absolute difference in change in proportion screened of 0.03 (95% CI; 0.02- 0.06).

CONCLUSIONS

Our findings suggest that theory-based, culturally and linguistically sensitive educational interventions can raise awareness and motivate immigrant women to participate in cervical cancer screening program. In addition, approaching health professionals as well as immigrant women, might improve participation even more.

TRIAL REGISTRATION

NCT03155581 . Retrospectively registered, on 16 May 2017.

Prevalence of positive screening test results and agreement between cytology and human papillomavirus testing in primary cervical cancer screening in North-Western Romania

Using data from a pilot study conducted in North-Western Romania, we aimed to estimate the prevalence of abnormal cytology and positive high-risk human papillomavirus (hr-HPV) test results in an ethnically diverse screening population and to assess the agreement between cytology and hr-HPV testing to evaluate the feasibility of integrating the latter as a primary test in the national cervical cancer screening program. The cross-sectional pilot study included Roma women, other ethnic minorities, and women in rural remote areas. Samples were taken for liquid-based cytology and hr-HPV testing (Hybrid Capture 2 DNA test) by a mobile health unit. The prevalence of positive screening results and the agreement between cytology and hr-HPV testing were estimated by κ coefficient. A total of 1019 women were included in the study. The population prevalence of positive screening results was similar for both tests (12%). The prevalence of abnormal cytology increased with increasing age, whereas the prevalence of positive hr-HPV test showed a bimodal age pattern. Substantial differences in the prevalence of abnormal cytology were found by ethnicity, with highest prevalence in Romanian women (14%), followed by Roma women (6%) and women of other ethnicities (5%) (P = 0.002). Similar ethnic differences in the prevalence of positive hr-HPV test were not observed. The overall agreement of positive screening results between the two methods was fair (κ = 0.25; 95% confidence interval = 0.18-0.30, P < 0.001) and ranged from poor to substantial depending on the age group. The prevalence of abnormal cytology result was high and similar to the prevalence of positive hr-HPV test result, which could allow for the implementation of hr-HPV testing as a primary test in the cervical cancer screening program in Romania.

Human papillomavirus vaccination in immigrants and descendants of immigrants in Denmark

OBJECTIVE

In Denmark, human papillomavirus (HPV) vaccination has been offered at age of 12 to girls born in 1996 and later. In this cohort study, we examined routine HPV vaccination uptake in immigrants and descendants from different countries and regions compared with native Danes, including the influence of socioeconomic characteristics and potential changes in uptake by birth cohort.

METHODS

In nationwide registers, we identified all girls born in 1996-2003 (n = 260 251) and obtained information on country of origin, HPV vaccinations and parents' income and employment. Vaccination was defined as receiving ≥1 dose within 2 years after eligibility for routine vaccination. Odds ratios (ORs) were estimated by logistic regression separately for birth cohorts 1996-2000 and 2001-2003.

RESULTS

Uptake in immigrants and descendants varied by country and region of origin. Overall, immigrants had lower uptake than native Danes, in birth cohorts 1996-2000 [79% vs. 93%, OR = 0.31; 95% confidence interval (CI), 0.29-0.34] and 2001-2003 (63% vs. 73%, OR = 0.60; 95% CI, 0.54-0.66). Descendants had lower uptake than native Danes in cohorts 1996-2000 (89% vs. 93%, OR = 0.65; 95% CI, 0.60-0.68), but higher uptake in cohorts 2001-2003 (76% vs. 73%, OR = 1.15; 95% CI, 1.08-1.21). Most associations were attenuated, but not entirely explained, when adjusting for socioeconomic characteristics.

CONCLUSION

HPV vaccination uptake varied by country and region. Most immigrants had lower uptake than native Danes, and in most groups, this was not fully explained by socioeconomic differences. Patterns in descendants were mixed. Interventions to increase uptake should be tailored to specific groups of immigrants/descendants.

Exploring Participation and Interaction in a Bottom-Up Health Promotion Program for Migrant Women in Norway

In this article, we examine the participation and interactions of migrant women and experts who attended health parties. Based on data from participation observations and semi-structured interviews from participants of health parties, we examine how health parties may be considered an innovative bottom-up community program that could influence how migrant women focus, learn, and discuss health issues as well as interact with health care. Through a qualitative analysis, the article demonstrates two ways of organizing health parties and different approaches to the health expert role, and how this impacts the social setting and interactions of a health party. In the Norwegian setting, migrant women are considered by health authorities to be the most difficult group to reach due to cultural and language barriers. Health parties may represent an alternative for bridging these barriers and may create a useful context for active participation and learning about health for migrant women.

Investigating the decrease in participation in the Dutch cervical cancer screening programme: The role of personal and organisational characteristics

Declining attendance in the Dutch cervical cancer screening programme was recently observed, coinciding with preparations for implementing primary hrHPV-based screening, which was implemented in January 2017. We aimed to investigate which factors were related to decreased attendance. We conducted a population-based cohort study including all women aged 30 to 60 years who were eligible for screening between 2014 and 2018. Attendance was defined as participation in the screening programme within 15 months of the start of the invitation-eligible year. We used data from the Dutch pathology archive (PALGA) linked with data from Statistics Netherlands to investigate population characteristics (position in the household, household income, socio-economic status, number of people in the household, migration background, age) and data from the five Dutch screening organisations (SO) to investigate the effect of cessing self-inviting GP's ('inviting organisation'). SO's were termed SO 1 to 5. Higher attendance rates were observed in women who were employed (60.8%), married (62.9%), Dutch (61.2%), in the highest income bracket (63.4%), living in households with four persons (65.3%) and women who were invited by their GP (69.8%). Differences in personal characteristics did not explain the decline in attendance rates. By adjusting for whether the GP or the SO sent the invitation, the differences in attendance rates between 2014 and 2015 and 2016 and between 2014 and 2015 and 2017-2018 were explained in some screening organisations. Removing the possibility for GPs to send invitations explains some of the decline in participation, although this did not account for the total change in attendance.

Barriers and facilitators to cervical screening for Filipino women – a narrative literature review

Purpose

Mortality rates of cervical cancer are high amongst Filipino women; however, uptake of cervical screening is low. The purpose of this paper is to identify known barriers and facilitators to cervical screening for Filipino migrant women.

Design/methodology/approach

A systematic approach was adopted for the search, data extraction, critical appraisal and synthesis processes of this review. Eight electronic databases were searched. Studies published in peer review journals in English between 1995 and 2019 were reviewed.

Findings

In total, 20 relevant studies were identified. Studies were heterogeneous in design and focus and mostly conducted in the USA. A complex multifactorial picture of barriers to cervical screening was identified, which included: demographic, cognitive, access, health-care provider and cultural factors. None of the studies incorporated all factors.

Practical implications

This review demonstrates the complexity and multifactorial characteristic of cervical screening for Filipino migrant women. To increase uptake of screening, barriers to cervical screening for Filipino migrant women need to be fully understood. Future research should be conducted in different locations, focussing on multiple factors.

Originality/value

Aggregation of barriers and facilitators for Asian women combined tends to ignore cultural differences between groups. This review synthesises the existing but scarce literature to identify known barriers and facilitators to cervical screening for this specific population of Filipino migrant women.

Antidepressant adherence and its predictors in immigrants with depression: A population-based study

Immigrants in Korea are relatively vulnerable in terms of medication self-management and have low levels of medication adherence. We aimed to evaluate antidepressant adherence and its patterns in immigrants and to identify predictors of nonadherence.In this matched cohort study using the National Health Insurance claims database, immigrants who were newly prescribed antidepressants were identified (n = 2,398). The immigrants were matched with native-born Koreans in a 1:1 ratio. Antidepressant adherence was measured by the medication possession ratio at monthly intervals. Logistic regression was performed to compare antidepressant nonadherence between immigrants and native-born Koreans, and to identify factors affecting immigrants' nonadherence.The average medication possession ratio of immigrants was 27.1%, which was lower than that of native-born Koreans (30.9%) (P = .038). Immigrants had a lower likelihood of adherence than native-born Koreans (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.3-0.92). Older age, visiting a psychiatrist for the first diagnosis of depression (OR 2.24, 95% CI 1.60-3.13), achieving appropriateness of care (OR 3.54, 95% CI 2.51-4.98), and having a usual source of care (OR 1.69, 95% CI 1.25-2.27) were associated with a higher likelihood of adherence in immigrants.This study showed that antidepressant adherence of immigrants was lower than that of native-born Koreans. However, it appears that visiting a psychiatrist, achieving appropriateness of care, and having a usual source of care might increase antidepressant adherence among immigrants. Further research that focuses on cultural and/or linguistic factors affecting immigrants' adherence and healthcare utilization is suggested as a way to increase adherence.

Cancer incidence in non-immigrants and immigrants in Norway

BACKGROUND

Major cancers are associated with lifestyle, and previous studies have found that the non-immigrant populations in the Nordic countries have higher incidence rates of most cancers than the immigrant populations. However, rates are changing worldwide - so these differences may disappear with time. Here we present recent cancer incidence rates among immigrant and non-immigrant men and women in Norway and investigate whether previous differences still exist.

MATERIAL AND METHODS

We took advantage of a recent change in the Norwegian Cancer Registry regulations that allow for the registry to have information on country of birth. The number of person years for 2014-2018 was aggregated for every combination of sex, five-year age-group and country of birth, by summing up each year's population in these groups. The number of cancer cases was then counted for the same groups, and age-standardised incidence rates calculated by weighing the age-specific incidence rates by the Nordic and World standard populations. Further, we calculated incidence rate ratios using the non-immigrant population as a reference.

RESULTS

Immigrants from Eastern Europe, the Middle East, Africa and Asia had lower incidence of total cancer compared to the non-immigrant population in Norway and immigrants born in the other Nordic or high-income countries. However, some cancers were more common in certain immigrant groups. Asian men and women had threefold the incidence of liver cancer than non-immigrant men and women. Men from the other Nordic countries and from Eastern Europe had higher lung cancer rates than non-immigrant men.

CONCLUSION

National registries should continuously monitor and present cancer incidence stratified on important population subgroups such as country of birth. This can help assess population subgroup specific needs for cancer prevention and treatment, and could eventually help reduce the morbidity and mortality of cancer.

Cervical Cancer Screening Participation among Women of Russian, Somali, and Kurdish Origin Compared with the General Finnish Population: A Register-Based Study

Migrant-origin women are less prone to cervical screening uptake compared with host populations. This study examined cervical cancer screening participation and factors associated with it in the Finnish mass screening program during 2008–2012 in women of Russian, Somali and Kurdish origin compared with the general Finnish population (Finns) in Finland. The study population consists of samples from the Finnish Migrant Health and Well-being Study 2010–2012 and Health 2011 Survey; aged 30–64 (n = 2579). Data from the Finnish screening register linked with other population-based registry data were utilized. For statistical analysis we employed logistic regression. Age-adjusted screening participation rates were Russians 63% (95% CI: 59.9–66.6), Somalis 19% (16.4–21.6), Kurds 69% (66.6–71.1), and Finns 67% (63.3–69.8). In the multiple-adjusted model with Finns as the reference; odds ratios for screening were among Russians 0.92 (0.74–1.16), Somalis 0.16 (0.11–0.22), and Kurds 1.37 (1.02–1.83). Among all women, the substantial factor for increased screening likelihood was hospital care related to pregnancy/birth 1.73 (1.27–2.35), gynecological 2.47 (1.65–3.68), or other reasons 1.53 (1.12–2.08). Screening participation was lower among students and retirees. In conclusion, screening among the migrant-origin women varies, being significantly lowest among Somalis compared with Finns. Efforts using culturally tailored/population-specific approaches may be beneficial in increasing screening participation among women of migrant-origin.

Barriers and Facilitators to Cervical Screening among Migrant Women of African Origin: A Qualitative Study in Finland

Globally, cervical cancer constitutes a substantial public health concern. Evidence recommends regular cervical cancer screening (CCS) for early detection of "precancerous lesions."Understanding the factors influencing screening participation among various groups is imperative for improving screening protocols and coverage. This study aimed to explore barriers and facilitators to CCS participation in women of Nigerian, Ghanaian, Cameroonian, and Kenyan origin in Finland. We utilized a qualitative design and conducted eight focus group discussions (FGDs) in English, with women aged 27-45 years (n = 30). The FGDs were tape-recorded, transcribed verbatim, and analyzed utilizing the inductive content analysis approach. The main barriers to CCS participation included limited language proficiency, lack of screening awareness, misunderstanding of screening's purpose, and miscomprehension of the CCS results. Facilitators were free-of-charge screening, reproductive health services utilization, and women's understanding of CCS's importance for early detection of cervical cancer. In conclusion, among women, the main barriers to CCS participation were language difficulties and lack of screening information. Enhancing screening participation amongst these migrant populations would benefit from appropriate information about the CCS. Those women with limited language skills and not utilizing reproductive health services need more attention from healthcare authorities about screening importance. Culturally tailored screening intervention programs might also be helpful.

Differences in cervical test coverage by age, socioeconomic status, ethnic origin and municipality type - A nationwide register-based study

An invitational organized cervical cancer screening together with widely spread opportunistic testing has coexisted for decades in Finland. The aim of this study was to examine the coverage of cervical tests by age, socioeconomic status, ethnicity and municipality type within and outside the organized screening program. We had a cohort of women of whom 1,2 million were in the target age range of screening and residing in Finland in 2010-2014. Data on Pap and/or HPV -tests within and outside the screening program were collected from the Mass Screening Registry, the pathology laboratories and the health insurance reimbursement registry and five-year population coverages of tests were reported. The total test coverage was 86.0%; 95% CI, (85.8-86.1), and was notably lower for those with an unknown socioeconomic status and pensioners (68.8%; 95% CI, (67.9-69.6) and 77.1%; 95% CI, (76.5-77.6), respectively) compared to upper-level employers (89.8%; 95% CI, (89.5-90.2)). Coverage was also lower for non-native speaking women (72.4%; 95% CI, (71.8-73.0)) compared to native speakers (86.9%; 95% CI, (86.7-87.0)) and for women living in urban municipalities (85.5%; 95% CI, (85.3-85.7)) compared to semi-urban (87.4%; 95% CI, (87.0-87.8)). Although overall coverage was high, tests within and outside the program seemed to concentrate on women with presumably good access to health services. Tests outside the program were especially common among young women who are at a low risk of invasive cervical cancer. Efforts should be made to reduce excessive opportunistic testing and to increase attendance at the program among hard-to-reach populations.

Perceptions about cancer and barriers towards cancer screening among ethnic minority women in a deprived area in Denmark - a qualitative study

BACKGROUND

Screening programmes for cervical cancer, breast cancer and colorectal cancer have been implemented in many Western countries to reduce cancer incidence and mortality. Ethnic minority women are less likely to participate in cancer screening than the majority population. In worst case this can result in higher incidence rates, later diagnosis and treatment and ultimately inferior survival. In this paper we explored the perceptions about cancer and perceived barriers towards cancer screening participation among ethnic minority women in a deprived area in Denmark.

METHODS

Interview study with ethnic minority women in a deprived area in Denmark. The interviews were transcribed verbatim followed by an inductive content analysis.

RESULTS

Cancer was perceived as a deadly disease that could not be treated. Cancer screening was perceived as only relevant if the women had symptoms. Knowledge about cancer screening was fragmented, often due to inadequate Danish language skills and there was a general mistrust in the Danish healthcare system due to perceived low medical competences in Danish doctors. There was, however, a very positive and curious attitude regarding information about the Danish cancer screening programmes and a want for more information.

CONCLUSION

Ethnic minority women did not have sufficient knowledge about cancer and the purpose of cancer screening. Perceptions about cancer screening were characterised by openness and the study showed positive and curious attitudes towards screening participation. The findings emphasise the importance of culturally adapted interventions for ethnic minority women in attempts to reduce inequality in screening participation.

Risks and perception of non-communicable diseases and health promotion behavior of middle-aged female immigrants in Japan: a qualitative exploratory study

BACKGROUND

Ensuring good health of immigrants is a serious issue across countries, including Japan. This study focused on the health of middle-aged female immigrants in Japan who experienced changes to their health as well as an increased risk of non-communicable diseases. Specifically, the study aimed to clarify the risks and perceptions of non-communicable diseases and health promotion behavior of middle-aged female immigrants in Japan.

METHODS

This investigation used an exploratory design. The participants were a purposive sample of 35 middle-aged female immigrants (age ≥ 40 years) living in urban and rural areas of Japan. Data were generated using mixed methods. A quantitative approach provided data of their risks of non-communicable diseases. Focus group discussions provided insights to identify their health promotion perceptions.

RESULTS

Blood pressure measurement revealed that 29% of the immigrants had hypertension, 29% had a body mass index of > 30, and 71% had an abdominal girth of > 80 cm. About 31% had a history of chronic disease and 34% had regular medication. There were 80% who received regular health check-up, 49% who received breast cancer screening, and 34% who received cervical cancer screening. The focus group discussions indicated that the middle-aged female immigrants recognized the threat of non-communicable diseases. However, they lacked knowledge about the prevention of non-communicable diseases, and they felt that non-communicable diseases were unavoidable. They also failed to understand the benefits of health promotion behavior. The study revealed that the monolingual Japanese health service prevented immigrant women from understanding their health check-up and cancer screening results, and how to utilize the health service system.

CONCLUSIONS

Middle-aged female immigrants in Japan had potential risks of non-communicable diseases, and recognized their threat. These settled immigrant women received health check-ups and cancer screenings with the support of their family, and consequently attained the same level of adherence as that of Japanese women. However, lack of knowledge about health promotion and its benefits and the absence of a culturally sensitive health service system for immigrants in Japan constrained their health-promotion behavior. Sociocultural multilingual-tailored interventions including interpretation services by care providers with cultural sensitivities must be developed.

Effect of an Intervention in General Practice to Increase the Participation of Immigrants in Cervical Cancer Screening: A Cluster Randomized Clinical Trial

IMPORTANCE

Immigrant women have lower participation in cervical cancer screening (CCS) programs. At the same time, some groups of immigrants have higher prevalence of cervical cancer. Targeted interventions are therefore necessary.

OBJECTIVE

To determine whether an intervention among general practitioners (GPs) could influence immigrant women's participation in the Norwegian CCS program.

DESIGN, SETTING, AND PARTICIPANTS

Cluster-randomized clinical trial using the 20 subdistricts of the Bergen, Norway, municipality as clusters. The clusters were matched in 10 pairs according to the number of immigrant women living in them and randomized thereafter. The intervention was implemented between January and June 2017 among urban, primary care, general practices in Bergen. Follow-up ended in January 2018. General practices belonging to the control areas continued treatment as usual. A total of 10 360 women who attended 73 general practices in the 20 subdistricts were included as participants.

INTERVENTION

The intervention consisted of 3 elements: an educational session for GPs at lunch describing the importance of CCS among immigrants and giving advice about how to invite them to participate, a mouse pad as a reminder, and a poster placed in waiting rooms. In the educational session, we elaborated the need for GPs to ask every immigrant woman about CCS, regardless of their reason for contacting their GP.

MAIN OUTCOMES AND MEASURES

The main outcome, screening status of immigrant women by January 1, 2018, was obtained from the Norwegian Cancer Registry. The effect of the intervention was measured as odds ratio (OR) for CCS status as of January 1, 2018, for the intervention group vs the control group, with 3 levels of adjustments: baseline CCS status at January 1, 2017 (model 1), additional adjustment for women's age, marital status, income level, and region of origin (model 2), and further adjustment for the GP's sex, age, and region of origin (model 3). Two subgroup analyses, screening status at baseline and women's country of origin, were conducted to assess whether these factors had any influence on the effect of the intervention. Data were analyzed as intention to treat.

RESULTS

A total of 10 360 immigrant women, 5227 (50.4%; mean [SD] age, 44.0 [12.0] years) in the intervention group and 5133 (49.6%; mean [SD] age, 44.5 [11.6] years) in the control group, belonging to 39 general practices in the intervention area and 34 in the control area, were included in the study. The proportion of immigrant women screened increased by 2.6% in the intervention group and 0.6% in the control group. After adjustment for screening status at baseline, women in the intervention group were more likely to have participated in CCS (OR, 1.24 [95% CI, 1.11-1.38]). This statistically significant effect remained unchanged after adjustment for women's characteristics (OR, 1.24 [95% CI, 1.11-1.38]) and was reduced, but still significant, after further adjustment for GP characteristics (OR, 1.19 [95% CI, 1.06-1.34]). In subgroup analyses, the intervention particularly increased participation among women who were not previously screened at baseline (OR, 1.35 [95% CI, 1.16-1.56]), and those from Poland, Pakistan, and Somalia (OR, 1.74 [95% CI, 1.17-2.61]) when adjusting for baseline screening status.

CONCLUSIONS AND RELEVANCE

Our intervention targeting general practices significantly increased CCS participation among immigrants, although the absolute effect size of 2% in the fully adjusted model was small. Engaging other primary health professionals such as midwives to perform CCS could further contribute to increasing participation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03155581.

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.

Uptake of Gynecological Cancer Screening and Performance of Breast Self-Examination Among 50-Year-Old Migrant and Non-migrant Women in Germany: Results of a Cross-Sectional Study (InEMa)

Our aim was to provide data regarding uptake of gynecological early detection measures and performance of breast self-examinations among migrant women in Germany. Cross-sectional self-reported data were collected using paper-and-pencil questionnaires. Descriptive analyses, Chi square-tests, and logistic regression were applied. Results were adjusted for educational level. Of 5387 women, 89.9% were autochthonous, 4.1% German resettlers, 2.8% Turkish, 3.1% other migrants. Participation rates regarding cancer screening differed significantly, with the lowest proportion in Turkish migrants (65.0%), resettlers (67.8%), other migrants (68.2%) and autochthonous population (78.2%). No differences in performance of breast self-examinations were detected. When adjusted for education, results indicated only slight changes in the odds to participate in screening irregularly or not at all. Results support existing evidence by showing lower participation rates in cancer screening among migrant women, but there were no differences regarding breast self-examinations. Migrant women form a potential high-risk group for late-stage diagnosis of cervical or breast cancer.

Does migrant background predict to what extent colorectal cancer patients want to be informed about their life expectancy? - a cross-sectional analysis

BACKGROUND

Although migrant health is a topic of interest across Europe and although health care services in Germany consider migrant health issues, people with a migrant background often experience difficulties regarding health care provision. The prevalence of various cancers among migrants is lower relative to non-migrants although this equalizes with increasing duration of residence. There are documented differences in health behavior and disease-coping strategies between migrants and non-migrants, but data are scarce on this subject. This analysis investigates the extent of information migrant and non-migrant colorectal cancer (CRC) patients in Germany want about their life expectancy and the level of trust they have in their treating physician.

METHOD

Data from 522 CRC patients were collected through a self-reported questionnaire. Migrant background was determined by the patients' and/or their parents' birthplace. Bivariate analyses were applied to determine the differences between migrants and non-migrants. A multivariate analysis was used to measure the effect of migration background, demographics, and cancer stage and treatment on the preferred extent of information about life expectancy and trust in their treating physician.

RESULTS

There were no significant differences regarding demographics or cancer stage and treatment between migrant and non-migrant CRC patients. Having a migrant background had no influence on the level of trust in the treating physician, but migrants preferred to be less informed about their life expectancy than non-migrants (21.4% vs. 13.4%, p = 0.04). The multivariate analysis showed that men (aOR = 2.102, CI: 1.123-3.932) and patients with a non-migrant background (aOR = 5.03, CI: 1.02-24.73) preferred receiving information about the approximate value of their life expectancy, rather than receiving no information.

CONCLUSION

The study found more similarities than discrepancies between migrant and non-migrant CRC patients regarding demographic factors and stage of disease and treatment, which may be a consequence of an increasingly homogeneous cross-cultural society. However, cultural differences between the minority and host population remain and should always be taken into account in daily clinical practice and in the communication skills training of health care professionals. The study also indicates that recording migration background into health registers would facilitate migrant-sensitive research.

Non-Adherence To Childhood HPV Vaccination Is Associated With Non-Participation In Cervical Cancer Screening - A Nationwide Danish Register-Based Cohort Study

Background

The combination of organized cervical cancer screening and childhood HPV vaccination programs has the potential to eliminate cervical cancer in the future. However, only women participating in both programs gain the full protection, and combined non-attenders remain at high risk of developing cervical cancer. Our aim was to analyze the association between non-adherence to HPV vaccination and non-participation in cervical cancer screening for the total population and stratified by native background and parental education.

Participants

Women born in 1993 eligible for both childhood HPV vaccination and first cervical cancer screening.

Analysis

Logistic regression models were used to estimate the odds ratio (OR) of non-participation in cervical cancer screening with 95% confidence intervals (CI). Stratified and adjusted logistic regression models were used along with the Wald test in order to test for interaction.

Results

24,828 women were included in the study. Among vaccinated women, 61.4% participated in cervical cancer screening; only 39.0% of unvaccinated women participated in cervical cancer screening. Unvaccinated and unscreened women were often non-native and had the lowest socio-economic status, whereas vaccinated and screened women were often native and had the highest socio-economic status. The adjusted OR for non-participation in cervical cancer screening was 2.07 [95% CI: 1.88–2.28] for unvaccinated compared to vaccinated women. After stratifying by country of origin, unvaccinated natives had the highest adjusted OR of not participating in cervical cancer screening compared to non-native women from both western and non-western countries (adjusted ORs of 2.2 [95% CI: 2.0–2.4], 1.3 [95% CI: 0.6–2.8], and 1.5 [95% CI: 1.1–2.0], respectively) (Wald test p=0.019).

Conclusion

Among natives, non-adherence to HPV vaccination and non-participation in screening seem to be signs of generally poor health-preventive behavior, whereas among non-natives from non-western countries, non-attendance in HPV vaccination and cervical cancer screening seem to be influenced by unrelated factors. Therefore, a differentiated and culturally sensitive approach is needed to enhance overall cervical cancer preventive behavior across different nativities.

Sources of Support and Information During Disease: An Exploratory Study, Comparing Migrant and Nonmigrant Colorectal Cancer Patients in Germany

Introduction: The prevalence of cancer diseases among migrants is lower relative to nonmigrants, although this equalizes with increasing duration of residence. There are differences in the health behaviors and disease coping strategies between these two groups. The aim of this analysis is to compare migrant and nonmigrant colorectal cancer (CRC) patients in Germany regarding their sources of support and information during disease. Method: Data from 522 CRC patients, collected through a survey about satisfaction with care, were analyzed by descriptive and multivariate statistics. Results: Migrants and nonmigrants differed in two aspects: Migrants reported to receive the most relevant support during disease more often by nonmedical people, compared with nonmigrants, and they favored videos explaining the therapeutic steps of CRC more than nonmigrants. Discussion: Anticipating which types of support and information sources patients will access during their disease may help guide future diversity management across the field of cancer care.

Awareness of and attitudes towards cervical cancer prevention among migrant Eastern European women in England

Objectives

It has been hypothesized that, in England, the rise in incidence of cervical cancer and the fall in screening coverage might be attributable in part to the effect of migration of Eastern European born women. We explored the attitudes and behaviours of these women towards cervical cancer prevention strategies.

Methods

A mixed methods study using quantitative surveys and in-depth semi-structured qualitative interviews was conducted between April 2015 and December 2016.

Results

In total, 331 surveys and 46 interviews were completed. Native English women had greater knowledge that a smear test is a screening test for pre-cancerous cervical cells (90% vs. 71% p≤0.01), whereas migrant Eastern European women believed that it was conducted as part of a full gynaecological examination (46% vs. 21% p≤0.01) and that the screen interval was annual (18% vs. 4% p≤0.01). Distrust of the English healthcare system resulted in some Eastern European women returning to their country of birth for screening. Poor awareness of cervical cancer prior to migration and lack of information at registration with a general practitioner in England were associated with failure to participate in screening.

Conclusions

The views and attitudes expressed by the migrant Eastern European women in this study suggest that they are not fully participating in cervical screening in England. Targeted education at the point of contact with healthcare services in England is needed to increase cervical screening participation among these women.

Perspectives of non-attenders for cervical cancer screening in Norway: a qualitative focus group study

OBJECTIVE

The attendance rate for cervical cancer screening in Norway is currently suboptimal at 69%, and an in-depth understanding of postponement of cervical cancer screening from the perspective of non-attenders is lacking. This study aims to generate knowledge about how non-attenders for cervical cancer screening reflect on booking a screening appointment.

METHODS

Using the Norwegian cervical cancer screening registry, we identified and recruited women who were non-attenders to screening. Nine focus group interviews were carried out, with 41 women participating in the interviews.

RESULTS

Four main themes were generated, which provide a comprehensive understanding of how women who are overdue for screening reflect on their hesitancy to book a screening appointment: 'It's easy to forget about it', 'Women have to arrange their own appointment', 'It has to be a 'must'' and 'It's a humiliating situation'.

CONCLUSION

The degree to which women regard screening as important is affected by the nudging strategies employed in the screening programme and the facilitation of attendance provided by healthcare services. Dependence on one's personal initiative to schedule a screening appointment and perception of a lack of responsibility on the part of healthcare services to attend screening may undermine informed and shared decision-making about screening attendance.

A community-based intervention to increase participation in cervical cancer screening among immigrants in Norway

BACKGROUND

The attendance to cervical cancer screening is low among immigrants in many high-income countries. Although several interventions have been experimentally tested,implementation remains a challenge. Several factors are an impediment, including the lack of methodological descriptions of the development and implementation of such interventions. In this paper,we present in detail the development, methodological challenges and practical implementation of a community based intervention aimed to increase the participation of immigrant women in cervical cancer screening in Norway.

METHODS

This study was initially designed as a cluster randomized trial to be carried out in four geographical areas near Oslo between Feb-October 2017. Participants were immigrant women aged 25-69 years from Pakistan and Somalia. This paper describes the theoretical background for the development of the intervention,followed by challenges,the changes in the original design and solutions adopted related to the study design,recruitment and implementation of the intervention. The intervention was developed based on two theoretical frameworks, the Ecological and the Heron's six categories intervention framework. An oral 20-25 min presentation in the language of participants encompassing topics of cervical cancer and screening was given according to the needs detected in focus groups conducted at the beginning of the study,followed by an opportunity to raise questions and answering a short questionnaire.

RESULTS

Contrary to the initial study design, this had to be converted into a non-randomised trial due to the difficulties associated with randomization of immigrant families who are finely scattered in heavily populated towns and a high risk of contamination. We therefore adopted a pragmatic approach and recruited women in the intervention areas through a variety of channels and institutions. Neighboring areas were considered to be non-randomised controls. Female researchers with Pakistani and Somali background invited as many women as possible in the intervention areas. Among the women who were invited to participate,42% of the Pakistani and 78% of Somali attended the meetings.

CONCLUSION

Despite the careful development of a culturally adapted health intervention in collaboration with the community; randomization and recruitment of immigrants for community trials remains challenging. Nevertheless, sharing strategies to overcome specific challenges related to promoting health interventions for immigrants, can be of potential help to scale-up interventions and for building new research projects.

TRIAL REGISTRATION

NCT03155581 . Retrospectively registered, on 16 May 2017.

Participation in cervical cancer screening among immigrants and Danish-born women in Denmark

In this nationwide register-based cohort study, we examined cervical cancer screening participation among immigrants in Denmark by country and region of origin. Furthermore, we assessed whether differences in screening participation between immigrants and Danish-born women were explained by sociodemographic or health-related characteristics, and examined predictors of participation among immigrants. Using high-quality registries, we identified women invited for cervical cancer screening during 2008-2009 and retrieved individual-level data on sociodemographic-, health- and immigration-related characteristics. A total of 610,907 women were followed for up to 2.9 years after screening invitation. We estimated the probability of participation using the Aalen-Johansen estimator and the hazard ratios (HRs) of participation using Cox regression. The probability of participation within follow-up was 74.5% (95% CI, 74.4%-74.6%) in Danish-born women; 61.2% (95% CI, 60.4%-62.1%) in Western immigrants; and 61.3% (95% CI, 60.9%-61.8%) in non-Western immigrants. Participation in immigrants varied by region of origin from 44.3% (95% CI, 41.4%-47.4%) in immigrants from North America, New Zealand and Australia to 67.8% (95% CI, 65.4%-70.3%) in immigrants from South- and Central America. Substantial variation was seen between specific countries of origin. Differences in participation between immigrants and Danish-born women were not explained by sociodemographic or health-related characteristics. Predictors of low participation in immigrants included lower income, unemployment, being unmarried, having a history of schizophrenia or other psychoses, and ≤5 years' stay in Denmark. In conclusion, cervical cancer screening participation in immigrants varied by region and country of origin, but all immigrant groups had lower participation than Danish-born women.

A missed opportunity? Lack of knowledge about sexual and reproductive health services among immigrant women in Sweden

OBJECTIVE

Poor sexual and reproductive health (SRH) among immigrant women is often related to limited access, or suboptimal use of healthcare services. This study investigates the knowledge about and use of sexual and reproductive healthcare services among immigrant women in Sweden.

METHOD

A cross-sectional study of 288 immigrant women. A structured questionnaire was distributed among immigrants speaking Arabic, Dari, Somali or English registered at Swedish language schools for immigrants. Data collection took place in 19 strategically selected schools in Sweden. Descriptive statistics, chi-square tests, and logistic regressions were used for the analysis.

RESULTS

About one-third of the immigrant women reported lack of knowledge of where to go for contraceptive counselling. Experiencing lack of emotional social support and not having had children was associated with this lack of knowledge. An even higher proportion (56%) lacked knowledge of where to go to be HIV tested, and this was associated with not having participated in a health examination. Almost 25% stated that their culture kept them back from using contraception.

CONCLUSION

Lack of knowledge of where to turn for contraceptive counselling and HIV testing among immigrant women participating in Swedish language schools for immigrants could be considered as a missed opportunity, as all citizens in Sweden have free access to these services. New health policies and strategies should aim to increase knowledge of SRH services among immigrants. Swedish language schools could play an important role in increasing knowledge of SRH-related information as many new immigrants become students during their first years in Sweden.

Cervical Cancer Screening Programs in Europe: The Transition Towards HPV Vaccination and Population-Based HPV Testing

Cervical cancer is the fourth most frequently occurring cancer in women around the world and can affect them during their reproductive years. Since the development of the Papanicolaou (Pap) test, screening has been essential in identifying cervical cancer at a treatable stage. With the identification of the human papillomavirus (HPV) as the causative agent of essentially all cervical cancer cases, HPV molecular screening tests and HPV vaccines for primary prevention against the virus have been developed. Accordingly, comparative studies were designed to assess the performance of cervical cancer screening methods in order to devise the best screening strategy possible. This review critically assesses the current cervical cancer screening methods as well as the implementation of HPV vaccination in Europe. The most recent European Guidelines and recommendations for organized population-based programs with HPV testing as the primary screening method are also presented. Lastly, the current landscape of cervical cancer screening programs is assessed for both European Union member states and some associated countries, in regard to the transition towards population-based screening programs with primary HPV testing.

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.

Is Immigrant Status Associated With Cervical Cancer Screening Among Women in Canada? Results From a Cross-Sectional Study

OBJECTIVE

Cervical cancer accounts for the highest mortality rate from cancer in women worldwide. Despite widespread availability of cervical cancer screening programs in Canada, immigrant women are largely underscreened. The most recently published Canadian-wide study evaluated screening uptake from 2001 to 2002. The objectives included identifying the prevalence of underscreened women in Canada, determining the risk of underscreening for cervical cancer among immigrant women, and providing an update on Canadian screening practices.

METHODS

This study included women aged 20 to 69 who completed the Canadian Community Health Survey 2012. The prevalence of underscreening among Canadian-born and immigrant women was estimated. A log-binomial model was fit to estimate the relative risk (RR) of underscreening for immigrant women while controlling for age, income level, visible minority status, smoking status, and access to a regular physician. A secondary analysis compared immigrants residing in Canada for greater or less than 10 years to Canadian-born women.

RESULTS

Of the 17 854 women eligible for this study, 18.6% of Canadian-born women and 28.9% of immigrant women were underscreened (P < 0.05). Immigrant women were at significantly higher risk of being underscreened compared with Canadian-born women (RR 1.32; 95% CI 1.20-1.45). The relative risk did not change when stratifying by length of time since immigration (RR_{recent immigrant} 1.32; 95% CI 1.16-1.50; and RR_{long-term immigrant} 1.32; 95% CI 1.19-1.47).

CONCLUSION

Immigrant status continues to be associated with a significantly higher risk of underscreening, irrespective of time in Canada. Social and educational programs targeted towards immigrants are needed to mitigate the disparity in cervical cancer screening.