Participation in cancer screening among female migrants and non-migrants in Germany: A cross-sectional study on the role of demographic and socioeconomic factors

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.

Investigating associated factors of primary and specialist health care utilization among people with selected nationalities: results of a multilingual survey in two German federal states

BACKGROUND

Approximately every fourth person in Germany has a migration background. Health research on the use of primary and specialist health care in this group is still scarce. Few studies have suggested a difference in the use of primary and specialist health care among people with a migration background. Potential resources and barriers to health care access should be investigated as they are critical to health equity. This study investigates associated sociodemographic, migration-sensitive, and health-related factors of primary and specialist health care utilization among people with a migration background as defined by nationality.

METHODS

Analyses are based on data from a feasibility study of the project "Improving Health Monitoring in Migrant Populations" (IMIRA), conducted by the Robert Koch Institute. The sample (n = 1055) included persons with Croatian, Polish, Romanian, Syrian, and Turkish nationalities living in the federal states of Berlin and Brandenburg, Germany. Descriptive and bivariate analyses as well as multiple binary logistic regression analyses were carried out to assess sociodemographic (sex, age, socioeconomic position), health-related (self-rated health), and migration-sensitive factors (duration of residence in Germany, residence status, German language proficiency) associated with the use of primary and specialist health care services in the past 12 months.

RESULTS

Of the total study population, 79.62% visited a general practitioner and 59.53% a specialized physician in the past 12 months. Participants who were female sex, aged 65 and older, and with moderate/poor/very poor self-rated health had higher odds of visiting a general practitioner and a specialized physician, with the strongest impact from self-rated health. After controlling for sociodemographic and health-related factors, duration of residence in Germany and residence status were associated with primary but not with specialist health care utilization.

CONCLUSIONS

Our results suggest that migration-sensitive characteristics, such as duration of residence, should be considered in a differentiated manner in health services research to gain detailed insights into health care utilization and its potential barriers among the heterogenous group of people with a migration background. Further research needs to be done to evaluate how to get people into contact with a general practitioner.

Does Women's Screening History Have Any Impact on Mammography Screening Attendance After Tailored Education?: A Systematic Review and Meta-analysis

BACKGROUND

Many ethnic minority women have low attendance at breast cancer screening.

OBJECTIVES

This brief report explores whether women's screening histories impact mammography screening attendance after tailored education.

RESEARCH DESIGN

Systematic searches were conducted in 5 databases. Randomized controlled trials of educational interventions tailored to ethnic minority women that measured attendance at mammography screening were eligible for inclusion. Data extraction and risk of bias assessment were performed independently. Data were combined in a meta-analysis by using random effects models. Heterogeneity was estimated by using I2 statistics.

RESULTS

Six studies with 3521 women were eligible for inclusion. The D+L pooled risk ratio (RR) for mammography attendance for never screened participants was 1.54 (95% confidence interval, 1.24-1.91; P<0.001), with low heterogeneity (I2=27.1%, P=0.231). The D+L pooled risk ratio for attendance for ever screened participants was 1.26 (95% confidence interval, 1.11-1.43; P<0.001), with low heterogeneity (I2=35.5%, P=0.213).

CONCLUSIONS

Tailored education increased attendance at mammography by 54% among never screened women and 26% among ever screened women. Although these findings must be interpreted with caution, the findings suggest that women's screening history is an important and ignored variable that affects how effective tailored education is on mammography screening attendance.

Socioeconomic deprivation and cancer survival in a metropolitan area: An analysis of cancer registry data from Hamburg, Germany

Background

Few studies have investigated socioeconomic inequalities within cities. Yet, such analyses are particularly important given the increasing international trend to urbanization. Here we investigated area-based socioeconomic inequalities in cancer survival in Hamburg, a port city in the North of Germany (population: 1.84 million people).

Methods

Patients with a diagnosis of colorectal, lung, female breast, and prostate cancer in 2004–2018 (follow-up until 31.12.2018) and registered in the Hamburg cancer registry were included. Area-based socioeconomic deprivation on urban district level was assigned to the patients and grouped in five quintiles. Relative survival in 2014–2018 was calculated using the period approach. Trend analyses between 2004 and 2018 were conducted. Relative excess risks adjusted for age and stage were computed with model-based period analyses.

Findings

For the 73,106 included patients, age-standardized 5-year relative survival in 2014–2018 decreased with increasing deprivation with significant differences between the most and least deprived group of 14·7 (prostate), 10·8 (colorectal), 8·0 (breast), and 2·5 (lung) percent units. Standardization by cancer stage decreased the difference for prostate cancer to 8·5 percent units and for breast cancer to 3·6 percent units but had only a minor effect for colorectal and lung cancer. Similar socioeconomic inequalities were already present in 2004–08.

Interpretation

Strong socioeconomic inequalities in cancer survival were observed in Hamburg, which could be partly explained by differences in the stage distribution. Further research including information on screening participation as well as information on cancer care are important to further understand and finally overcome these inequalities.

Funding

10.13039/501100005972German Cancer Aid.

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.

Utilization of preventive care among migrants and non-migrants in Germany: results from the representative cross-sectional study 'German health interview and examination survey for adults (DEGS1)'

BACKGROUND

In Germany, different health checks for adults are offered for primary and secondary prevention. Previous findings indicate that preventive care utilization varies according to social determinants, especially migration background. This study examined the extent to which migration background is associated with preventive care utilization, independent of factors like age and socioeconomic status and whether length of stay in Germany has a positive effect on the use of preventive care.

METHODS

The first wave of the 'German Health Interview and Examination Survey for Adults' (DEGS1) is a comprehensive data collection facilitating the description of the utilization of general health checks, dental check-ups, skin cancer screening, and cervical cancer screening among people aged 18-79 years with and without migration background. Migration background was differentiated in first-generation migrants having immigrated to Germany themselves or second-generation migrants born in Germany. First-generation migrants were further differentiated by length of stay in Germany, and second-generation migrants as having one or two parents who were born abroad. Multivariate binary logistic regression models with average marginal effects were calculated to analyse the associations between preventive care utilization and migration background.

RESULTS

The sample comprised 7987 participants, 1091 of whom had a migration background. Compared with non-migrants, women and men with migration background- particularly first-generation migrants with length of stay <=20 years in Germany - make less use of preventive care. This association was observed statistically independent from sociodemographic factors. For dental check-ups a significantly lower use was also found for first-generation migrants who have lived in Germany for more than 20 years and second-generation of migrants with two parents born abroad. Post-model predictions showed that the utilization rates of first-generation migrants are gradually converging to the average values for non-migrants.

CONCLUSIONS

Our findings suggest inequalities in realized access to preventive care for first-generation migrants particularly for those who have lived in Germany for 20 years or less. Barriers to the utilization of preventive care may be addressed by informing migrant communities about preventive health care services at an early stage after immigration using migrant-sensitive information strategies.

Inequalities in Cervical Cancer Screening Uptake Between Chinese Migrant Women and Local Women: A Cross-Sectional Study

INTRODUCTION

Uptake of cervical cancer screening services in Chinese migrant workers is unknown and may be lower than non-migrant workers in China.

METHODS

We conducted a cross-sectional study among migrant and non-migrant women aged 21-65 at 7 provinces across China and administered a questionnaire investigating knowledge and attitudes regarding cervical cancer, human papillomavirus (HPV), and HPV vaccine. We used multivariable logistic regression to evaluate odds of previous cervical cancer screening in migrant workers.

RESULTS

737 women participated in the study. Mean age was 41.9 ± 7.2 years. 50.2% of the participants were migrant workers. 27.6% of the migrant workers reported previous cervical cancer screening compared to 33.2% of local participants. 36.6% migrant workers reported awareness of HPV compared to 40.2% of local participants. In adjusted analysis migrant status was not associated with increased odds of previous cervical cancer screening (aOR = 1.11 95%CI: 0.76-1.60). High school or higher education compared to less than high school education and employer-sponsored insurance compared to uninsured were associated with increased odds of previous cervical cancer screening (aOR = 2.15 95%CI: 1.41-3.27 and aOR = 1.67 95% CI: 1.14-2.45, respectively). Having heard of HPV compared to no awareness of HPV was associated with increased odds of cervical cancer screening (aOR = 2.02 95%CI: 1.41-2.91). Awareness of HPV among migrant workers was associated with increased odds of cervical cancer screening compared to migrant and local participants without awareness (aOR = 2.82 95% CI: 1.70-4.69 and 2.97 95%CI: 1.51-5.83, respectively).

CONCLUSIONS

Efforts to increase education opportunities, provide insurance, and promote HPV awareness could increase cervical cancer screening uptake in migrant women in China.

Cancer information seeking and scanning behavior among Nepalese migrants in Japan and its association with preventive behavior

Background

Increasing attention is being paid to cancer information seeking (CISE) (active searching for cancer-related health information) and information scanning (CISC) (passive collection of cancer-related health information) among migrants. However, information is lacking with respect to the extent and distribution of CISE and CISC among migrants, particularly in Japan. This study aimed to evaluate the prevalence of both CISE and CISC, to clarify factors associated with CISE and CISC, and to elucidate the association of CISE and CISC with basic cancer knowledge and preventive behavior among Nepalese migrants living in Tokyo, Japan.

Methods

Nepalese migrants living in Tokyo were recruited from March to August 2019, with snowball sampling. We collected data on CISE, CISC, sociodemographic components, health-related factors, knowledge about risk factors for cancer, and cancer-prevention behavior using a structured questionnaire. We employed several regression approaches to fulfill our study objectives.

Results

Out of the total 200 participants, 53 (27%) were actively involved in CISE and 176 (88%) in CISC. Internet was the most common information source. High education level and Japanese language skills were positively associated with both CISE and CISC. Migrants with low perceived health status were more likely to perform CISC, while those who had been ill last year and who perceived proper access to doctors were more likely to undertake CISE. Migrants with high CISE (B = 0.10, 95% CI: 0.01, 0.19) and high CISC (B = 0.16, 95% CI: 0.08, 0.23) were more likely to have better knowledge on risk factors of cancer. Furthermore, migrants with high CISE were more likely to eat fruits (B = 0.17, 95%CI: 0.01, 0.32), undergo pap smear test (OR = 1.72, 95%CI: 1.12, 2.65), and colonoscopy (OR = 6.02, 95%CI: 1.63, 22.13).

Conclusion

In this study, the proportion of Nepalese migrants who deliberately undertook CISE was low, while the practice of CISC was relatively common. Given that the CISE was associated with cancer-prevention behavior, proper strategies should be implemented to alleviate barriers for CISE and improve its impact on providing reliable evidence about cancer to migrants in Japan.

Utilization of cervical cancer screening among migrants and non-migrants in Germany: results from a large-scale population survey

BACKGROUND

Studies from European and non-European countries have shown that migrants utilize cervical cancer screening less often than non-migrants. Findings from Germany are inconsistent. This can be explained by several limitations of existing investigations, comprising residual confounding and data which is restricted to only some regions of the country. Using data from a large-scale and nationwide population survey and applying the Andersen Model of Health Services Use as the theoretical framework, the aim of the present study was to examine the role that different predisposing, enabling and need factors have for the participation of migrant and non-migrant women in cervical cancer screening in Germany.

METHODS

We used data from the 'German Health Update 2014/2015' survey on n = 12,064 women ≥20 years of age. The outcome of interest was the participation in cancer screening (at least once in lifetime vs. no participation). The outcome was compared between the three population groups of non-migrants, migrants from EU countries and migrants from non-EU countries. We employed multivariable logistic regression to examine the role of predisposing, enabling and need factors.

RESULTS

Non-EU and EU migrant women reported a lower utilization of cervical cancer screening (50.1 and 52.7%, respectively) than non-migrant women (57.2%). The differences also remained evident after adjustment for predisposing, enabling and need factors. The respective adjusted odds ratios (OR) for non-EU and EU migrants were OR = 0.67 (95%-CI = 0.55-0.81) and OR = 0.80 (95%-CI = 0.66-0.97), respectively. Differences between migrants and non-migrants were particularly pronounced for younger age groups. Self-rated health was associated with participation in screening only in non-migrants, with a poorer health being indicative of a low participation in cancer screening.

CONCLUSIONS

The disparities identified are in line with findings from studies conducted in other countries and are indicative of different obstacles this population group encounters in the health system. Implementing patient-oriented health care through diversity-sensitive health services is necessary to support informed decision-making.

Are there disparities in different domains of physical activity between school-aged migrant and non-migrant children and adolescents? Insights from Germany

Background

Large proportions of the populations in many European countries, including Germany, are migrants. Migrant children and adolescents tend to be less physically active than their non-migrant peers. However, current research is limited as it does not sufficiently consider different domains of physical activity. Using a representative dataset, the present study examines the patterns of sports participation and other domains of physical activity among migrant and non-migrant children and adolescents residing in Germany.

Methods

Nationwide data from the Motorik-Modul (MoMo) Study is used. Five different domains of physical activity participation (sports clubs, outside of sports clubs, extra-curricular physical activity, physical activity, outdoor play and active commuting to school) were compared between children and adolescents with no, one-sided and two-sided migration background using logistic regression adjusted for demographic factors. Interaction terms were included in order to examine whether difference between the three groups differ by age and gender.

Results

Information on n = 3,323 children and adolescents was available. As compared to non-migrants, children and adolescents with a two-sided migration background had a 40% (adjusted odds ratio [aOR] = 0.60, 95%-CI: 0.44–0.81), those with a one-sided migration background a 26% (aOR = 0.74, 95%-CI: 0.55-<1.00) lower chance of participating in sport club activities. In contrast, children and adolescents with a two-sided migration background were at 65% higher chance of participating in extra-curricular physical activity than non-migrants (OR = 1.65, 95%-CI: 1.15–2.36).

Conclusion

The study shows that differences in levels of physical activity between migrant and non-migrant children and adolescents are less pronounced than previous research has suggested. In particular, it reveals that migrants are only disadvantaged regarding participation in sports clubs whereas they fare better with respect to extra-curricular physical activity. Interventions should therefore address barriers migrant children and adolescents encounter in the access to sport clubs while maintaining their high level of extra-curricular physical activity.

Inequalities in health care utilization among migrants and non-migrants in Germany: a systematic review

BACKGROUND

Despite the growing number of people with migrant background in Germany, a systematic review about their utilization of health care and differences to the non-migrant population is lacking. By covering various sectors of health care and migrant populations, the review aimed at giving a general overview and identifying special areas of potential intervention.

METHODS

A systematic review was conducted in PubMed database including records that were published until 1st of June 2017. Further criteria for eligibility were a publication in a peer-reviewed journal written in English or German language. The studies have to report quantitative and original data of a population residing in Germany. The appropriateness of the studies was judged by both authors. Studies were excluded if native controls were not originated from the same sample. Moreover, indicators of health care utilization have to assess individual behaviour like consultation or participation rates. 63 studies met the inclusion criteria for a qualitative synthesis of the findings.

RESULTS

The overall findings indicate a lower utilization among migrants, although the results vary in terms of health care sector, indicator of health care utilization and migrant population. For specialist care, medication use, therapist consultations and counselling, rehabilitation as well as disease prevention (early cancer detection, prevention programs for children and oral health check-ups) a lower utilization among people with migrant background was found. The lower usage was particularly shown for migrants of the 1st generation, people with two-sided migrant background, children/adolescents and women. Due to the methodological heterogeneity a meta-analysis was not feasible. As most of the studies were cross-sectional, no causal interpretations could be drawn.

CONCLUSIONS

The inequalities in utilization could not substantially be explained by differences in the socioeconomic status. Other reasons of lower utilization could be due to differences in need, preferences, information, language and formal access barriers (e.g. charges, waiting times, travel distances or lost wages). Different migrant-specific and migrant-sensitive strategies are relevant to address the problem for certain health care sectors and migrant populations.

TRIAL REGISTRATION

The review protocol was registered on PROSPERO ( CRD42014015162 ).

[Participation of the immigrant population in breast cancer screening in Tarragona, Spain]

OBJECTIVE

To evaluate the differences between autochthonous and allochthonous women's participation in a breast cancer screening programme.

METHOD

Retrospective study based on data from the Breast Cancer Screening Programme of the province of Tarragona (2008-2015). The sample is the target population of the programme with known country of origin.

RESULTS

Cohort of 40,824 women. Allochthonous women participate less than autochthonous women (41.8% vs. 72.3%) although they have a similar global detection rate to the latter but with differences according to the human development index of their country of origin. Both groups present similar tumour stages on detection (p=.59).

CONCLUSIONS

Strategies specifically aimed at the immigrant population are required to improve their participation in breast cancer screening.

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

Background

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

Methods

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

Results

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

Conclusions

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

Oral health behaviour in migrant and non-migrant adults in Germany: the utilization of regular dental check-ups

Background

Migrants in many European countries including Germany tend to utilize preventive measures less frequently than the majority population. Little is known about the dental health of migrants as well as about their oral health behaviour, particularly in the adult population. The aim of this study was to examine differences in the uptake of annual dental check-ups in adult migrants and non-migrants in Germany.

Methods

We used data from the cross-sectional survey ‘German Health Update 2010’ conducted by the Robert Koch Institute (n = 22,050). Data from 21,741 German-speaking respondents with information on the use of dental check-ups was available, of which 3404 (15.7%) were migrants. Multiple logistic regression models were applied to adjust for demographic and socioeconomic confounders, including the place of residence as well as type of health insurance.

Results

Migrants were generally younger, had a lower socioeconomic status and showed a lower utilization of dental check-ups. The unadjusted odds ratio (OR) for utilization was 0.67 (95%-CI = 0.61–0.73). After adjusting for demographic and socioeconomic confounders the chance only increased slightly (adjusted OR = 0.71; 95%-CI = 0.65–0.77).

Conclusions

The analysis shows that migration status is associated with a reduced chance of attending dental check-ups, independently of demographic and socioeconomic factors. The influence of other factors, such as type of health insurance and place of residence had also no influence on the association. Migrants are exposed to different barriers in the health care system, comprising the patient, provider and system level. Further studies need to examine the relevant barriers for the uptake of preventive dental services in order to devise appropriate migrant- sensitive measures of dental prevention.