A Pap Test Screening Clinic in a South Asian Community of Vancouver, British Columbia: Challenges to Maintaining Utilization

Interventions to increase cervical screening uptake among immigrant women: A systematic review and meta-analysis

Numerous intervention studies have attempted to increase cervical screening uptake among immigrant women, nonetheless their screening participation remains low. This systematic review and meta-analysis aimed to summarise the evidence on interventions to improve cervical screening among immigrant women globally and identify their effectiveness. Databases PubMed, EMBASE, Scopus, PsycINFO, ERIC, CINAHL and CENTRAL were systematically searched from inception to October 12, 2021, for intervention studies, including randomised and clinical controlled trials (RCT, CCT) and one and two group pre-post studies. Peer-reviewed studies involving immigrant and refugee women, in community and clinical settings, were eligible. Comparator interventions were usual or minimal care or attention control. Data extraction, quality appraisal and risk of bias were assessed by two authors independently using COVIDENCE software. Narrative synthesis of findings was carried out, with the main outcome measure defined as the cervical screening uptake rate difference pre- and post-intervention followed by random effects meta-analysis of trials and two group pre-post studies, using Comprehensive Meta-Analysis software, to calculate pooled rate ratios and adjustment for publication bias, where found. The protocol followed PRISMA guidelines and was registered prospectively with PROSPERO (CRD42020192341). 1,900 studies were identified, of which 42 (21 RCTS, 4 CCTs, and 16 pre-post studies) with 44,224 participants, were included in the systematic review, and 28 with 35,495 participants in the meta-analysis. Overall, the uptake difference rate for interventions ranged from -6.7 to 96%. Meta-analysis demonstrated a pooled rate ratio of 1.15 (95% CI 1.03-1.29), with high heterogeneity. Culturally sensitive, multicomponent interventions, using different modes of information delivery and self-sampling modality were most promising. Interventions led to at least 15% increase in cervical screening participation among immigrant women. Interventions designed to overcome logistical barriers and use multiple channels to communicate culturally appropriate health promotion messages are most effective at achieving cervical screening uptake among immigrant women.

Understanding the Acceptability and Uptake of HPV Self-Sampling Amongst Women Under- or Never-Screened for Cervical Cancer in Toronto (Ontario, Canada): An Intervention Study Protocol

Cervical cancer remains a global public health concern, even though scientific advancements have made the disease almost entirely preventable. With the link between human papillomavirus (HPV) and cervical cancer, and the subsequent improvement in screening technology, there is potential to improve access and coverage of cervical screening with the introduction of HPV self-sampling. In Ontario, Canada, a province with a cytology-based screening program (i.e., Pap test), women who identify as South Asian, West Asian, Middle Eastern and North African have some of the lowest rates of screening, and research suggests they have a higher burden of cervical cancer. In this study, we will use both quantitative and qualitative methods to understand the acceptability and uptake of a take-home HPV self-sampling kit. Working with community champions—people with pre-existing connections with local groups—we will recruit women from these groups who are under- or never-screened for cervical cancer. Women will self-select whether they are in the group that tries HPV self-sampling or in the group that does not. We will aim for 100 women in each group. All participants will provide feedback on the feasibility, acceptability and preferences for cervical screening through a survey and phone follow-up. Women who self-select the HPV self-sampling group, will be followed up to find out if they followed through with self-sampling and to understand their experience using the device. Women who do not want to try self-sampling will be followed up to see if they went on to get a Pap test. The qualitative phase of this study consists of five focus groups with participants and semi-structured interviews with key informants in the community.

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

OBJECTIVES

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

DESIGN

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

SETTINGS

Asymptomatic breast or cervical screening.

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

PROSPERO REGISTRATION NUMBER

CSD 42015025284.

Lay health educators within primary care practices to improve cancer screening uptake for South Asian patients: challenges in quality improvement

BACKGROUND

Cancer screening uptake is known to be low among South Asian residents of Ontario. The objective of this pilot study was to determine if lay health educators embedded within the practices of primary care providers could improve willingness to screen and cancer screening uptake for South Asian patients taking a quality improvement approach.

MATERIALS AND METHODS

Participating physicians selected quality improvement initiatives to use within their offices that they felt could increase willingness to screen and cancer screening uptake. They implemented initiatives, adapting as necessary, for six months.

RESULTS

Four primary care physicians participated in the study. All approximated that at least 60% of their patients were of South Asian ethnicity. All physicians chose to work with a preexisting lay health educator program geared toward South Asians. Health ambassadors spoke to patients in the office and telephoned patients. For all physicians, ~60% of South Asian patients who were overdue for cancer screening and who spoke directly to health ambassadors stated they were willing to be screened. One physician was able to track actual screening among contacted patients and found that screening uptake was relatively high: from 29.2% (colorectal cancer) to 44.6% (breast cancer) of patients came in for screening within six months of the first phone calls. Although physicians viewed the health ambassadors positively, they found the study to be time intensive and resource intensive, especially as this work was additional to usual clinical duties.

DISCUSSION

Using South Asian lay health educators embedded within primary care practices to telephone patients in their own languages showed promise in this study to increase awareness about willingness to screen and cancer screening uptake, but it was also time intensive and resource intensive with numerous challenges. Future quality improvement efforts should further develop the phone call invitation process, as well as explore how to provide infrastructure for lay health educator training and time.

Facilitators of and barriers to accessing clinical prevention services for the South Asian population in Surrey, British Columbia: a qualitative study

BACKGROUND

British Columbia falls short in uptake of recommended clinical prevention services, with even lower rates among immigrant populations. This study explored facilitators of and barriers to uptake of clinical prevention services among people from South Asia, who represent 31% of the population in Surrey, British Columbia.

METHODS

We used a qualitative descriptive approach and employed vignettes in a focus group setting to elicit perspectives of South Asian people on accessing clinical prevention services. Participants aged 40 years or more were recruited between October 2014 and February 2015 from health care and community settings such as older-adult housing, day programs and health education events. Letters of introduction to the study were provided in English or Punjabi or both to all potential participants. We conducted qualitative content analysis of the results.

RESULTS

Sixty-two South Asian adults (36 women and 26 men) aged 40-87 years participated in 1 of 8 focus groups in health care or community settings. Facilitators of and barriers to accessing clinical prevention services were noted at the patient, primary care provider and health care system levels. Facilitators at the patient level included taking ownership over one's health, health literacy and respecting the provider's advice; barriers included fear of the diagnosis, death and/or procedures, perceived low risk of disease or utility of the intervention, and side effects of procedures. Provider factors centred on a trust-based patient-provider relationship, strong communication and adequate time during visits. Health care system factors included such facilitators as processes to routinely offer prevention services as part of other health care or social services, systems that encourage prevention-oriented family practice and services at low or no cost to the patient.

INTERPRETATION

Our findings validate previously identified facilitators of and barriers to accessing preventive care for immigrant populations. However, the results suggest that system-level factors influencing the duration of primary care visits may have a more salient impact on uptake of clinical prevention services in this population.

Physicians' perceived barriers to management of sexually transmitted infections in Vietnam

Background

Sexually transmitted infections (STIs) are a public health problem in Vietnam with sub-optimal care in medical practice. Identifying practitioners’ perceived barriers to STI care is important to improve care for patients with STIs.

Methods

A cross-sectional survey was conducted among 451 physicians. These physicians were dermatology and venereology (D&V) doctors, obstetrical/gynaecological (Ob/Gyn) doctors, general practitioners, and assistant doctors working in health facilities at provincial, district and communal levels in three provinces in Vietnam.

Results

Almost all (99%) respondents mentioned at least one barrier to STI care. The barriers were “lack of STI training” (57%), “lack of professional resources” (41%), “lack of time” (38%), “lack of reimbursement” (21%), “lack of privacy/confidentiality” (17%), “lack of counselling” (15%), and “not the role of primary care provider” (7%). Multivariable logistic regression analysis showed that “lack of professional resources” was associated with respondents being in medical practice for ten years or under (vs. 11–20 years), and working at district or communal health facilities (vs. provincial facilities); “lack of time” were associated with respondents being female, seeing more than 30 patients a week (vs. <15 patients/week); and “lack of privacy/confidentiality” was associated with physicians’ seeing more than 30 patients a week (vs. <15 patients/week).

Conclusion

The study has identified several barriers to STI care in medical practice in Vietnam. Results of the study can be used to improve areas in STI care including policy and practice implications.

Exploring ways to overcome barriers to mammography uptake and retention among South Asian immigrant women

South Asians comprise one of the fastest growing immigrant groups in North America. Evidence indicates that South Asian (SA) immigrant women are vulnerable to low rates of breast cancer screening. Yet, there is a dearth of knowledge pertaining to socioculturally tailored strategies to guide the uptake of screening mammography in the SA community. In 2010, the authors conducted semi-structured focus groups (FG) to elicit perspectives of health and social service professionals on possible solutions to barriers identified by SA immigrant women in a recent study conducted in the Greater Toronto Area. Thirty-five health and social services staff members participated in five FG. The discussions were audio taped and detailed field notes were taken. All collected data were transcribed verbatim and thematic analysis was conducted using techniques of constant comparison within and across the group discussions. Three dominant themes were identified: (i) 'Target and Tailor' focused on awareness raising through multiple direct and indirect modes or approaches with underlying shared processes of involving men and the whole family, use of first language and learning from peers; (ii) 'Enhancing Access to Services' included a focus on 'adding ancillary services' and 'reinforcement of existing services' including expansion to a one-stop model; and (iii) 'Meta-Characteristics' centred on providing 'multi-pronged' approaches to reach the community, and 'sustainability' of initiatives by addressing structural barriers of adequate funding, healthcare provider mix, inter-sectoral collaboration and community voice. The findings simultaneously shed light on the grassroot practical strategies and the system level changes to develop efficient programmes for the uptake of mammography among SA immigrant women. The parallel focus on the 'Target and Tailor' and 'Enhancing Access to Services' calls for co-ordination at the policy level so that multiple sectors work jointly to streamline resources, or meta-characteristics.

A systematic review of interventions to enhance access to best practice primary health care for chronic disease management, prevention and episodic care

BACKGROUND

Although primary health care (PHC) is a key component of all health care systems, services are not always readily available, accessible or affordable. This systematic review examines effective strategies to enhance access to best practice processes of PHC in three domains: chronic disease management, prevention and episodic care.

METHODS

An extensive search of bibliographic data bases to identify peer and non-peer reviewed literature was undertaken. Identified papers were screened to identify and classify intervention studies that measured the impact of strategies (singly or in combination) on change in use or the reach of services in defined population groups (evaluated interventions).

RESULTS

The search identified 3,148 citations of which 121 were intervention studies and 75 were evaluated interventions. Evaluated interventions were found in all three domains: prevention (n = 45), episodic care (n = 19), and chronic disease management (n = 11). They were undertaken in a number of countries including Australia (n = 25), USA (n = 25), and UK (n = 15). Study quality was ranked as high (31% of studies), medium (61%) and low (8%). The 75 evaluated interventions tested a range of strategies either singly (n = 46 studies) or as a combination of two (n = 20) or more strategies (n = 9). Strategies targeted both health providers and patients and were categorised to five groups: practice re-organisation (n = 43 studies), patient support (n = 29), provision of new services (n = 19), workforce development (n = 11), and financial incentives (n = 9). Strategies varied by domain, reflecting the complexity of care needs and processes. Of the 75 evaluated interventions, 55 reported positive findings with interventions using a combination of strategies more likely to report positive results.

CONCLUSIONS

This review suggests that multiple, linked strategies targeting different levels of the health care system are most likely to improve access to best practice PHC. The proposed changes in the structure of PHC in Australia may provide opportunities to investigate the factors that influence access to best practice PHC and to develop and implement effective, evidence based strategies to address these.

A study of Iranian immigrants' experiences of accessing Canadian health care services: a grounded theory

BACKGROUND

Immigration is not a new phenomenon but, rather, has deep roots in human history. Documents from every era detail individuals who left their homelands and struggled to reestablish their lives in other countries. The aim of this study was to explore and understand the experience of Iranian immigrants who accessed Canadian health care services. Research with immigrants is useful for learning about strategies that newcomers develop to access health care services.

METHODS

The research question guiding this study was, "What are the processes by which Iranian immigrants learn to access health care services in Canada?" To answer the question, a constructivist grounded theory approach was applied. Initially, unstructured interviews were conducted with 17 participants (11 women and six men) who were adults (at least 18 years old) and had immigrated to Canada within the past 15 years. Eight participants took part in a second interview, and four participants took part in a third interview.

RESULTS

Using a constructivist grounded theory approach, "tackling the stumbling blocks of access" emerged as the core category. The basic social process (BSP), becoming self-sufficient, was a transitional process and had five stages: becoming a stranger; feeling helpless; navigating/seeking information; employing strategies; and becoming integrated and self-sufficient. We found that "tackling the stumbling blocks of access" was the main struggle throughout this journey. Some of the immigrants were able to overcome these challenges and became proficient in accessing health care services, but others were unable to make the necessary changes and thus stayed in earlier stages/phases of transition, and sometimes returned to their country of origin.

CONCLUSION

During the course of this journey a substantive grounded theory was developed that revealed the challenges and issues confronted by this particular group of immigrants. This process explains why some Iranian immigrants are able to access Canadian health care effectively while others cannot. Many elements, including language proficiency, cultural differences, education, previous experiences, financial status, age, knowledge of the host country's health care services, and insider and outsider resources work synergistically in helping immigrants to access health care services effectively and appropriately.

Fostering excellence: development of a course to prepare graduate students for research on migration and health

Canada is an immigrant-receiving nation and many graduate students in nursing and other disciplines pursue immigrant health research. As these students often start with inadequate understanding of the policy, theoretical, and research contexts in which their work should be situated, we became concerned that the theses and dissertations were less sophisticated than were both possible and desirable. This led to development of a PhD-level course titled Migration and Health in the Canadian Context. In this study, we provide an analytic overview including course description, objectives, assignments, and specific class topics. Areas of focus include historical and theoretical considerations; determinants of immigrant health; refugee health; cultural competence and cultural safety; research challenges, approaches, and skills; policy-relevant research; and educational imperatives in the health and related disciplines. Salient research is introduced in each of these classes. While Canada is the main focus, comparative data are provided and there is relevance for nurse-researchers in other immigrant-receiving countries.

'Before you teach me, I cannot know': immigrant women's barriers and enablers with regard to cervical cancer screening among different ethnolinguistic groups in Canada

OBJECTIVE

To describe the similarities and differences among multiple groups of immigrant women and Canadian-born women of low socio-economic status regarding barriers and enablers associated with cervical cancer screening, in order to inform core elements of a strategy that would be acceptable across multiple underscreened groups.

METHOD

Within a health behaviour framework, we used a qualitative explanatory multiple-case study approach consisting of focus group interviews (n = 11) in Hamilton, Canada. Participants were newly immigrated (1-5 years) women and a group of Canadian-born women of low socio-economic status; all participants were in the age range 35-69 years and married. Language groups were Arabic, Cantonese, Somali, Dari (Afghanistan) and Spanish (Latin America). Two separate focus groups for each ethnolinguistic group were conducted; one in English and one in the native language. A template approach to analysis was used.

RESULTS

All groups indicated a strong need for information on necessity of screening and on how the procedure is done. Use of a video and a group discussion format were desired strategies. Women had positive feelings about being proactive for their health even if prevention had not been the norm in their home countries. There were differences between groups with respect to preferring a female clinician, which was a higher priority than language congruence with the provider. Only Chinese and Arabic groups discussed embarrassment and modesty as barriers.

CONCLUSION

Addressing key knowledge gaps around cervical cancer screening through personal approaches, educational videos and invitations may be useful core strategies to remove stigma and fear around screening and improve uptake across multiple ethnic groups and in women of lower socioeconomic status.

A comparison of health care in Canada and the United States: the case of Pap smears

RATIONALE

Compliance with preventive care recommendations differs between countries. Directly comparable data are often not available. The recent release of the Joint Canada/United States Survey of Health makes available data for both Canadians and Americans.

OBJECTIVES

The health care systems in the United States and Canada differ quite dramatically. Canadians are covered by a universal health care system while residents of the United States, if they are insured, obtain their insurance from various private or public sources. This paper examines how the use of the Papanicolaou test (Pap smear) by women differs in the United States and Canada.

METHODOLOGY

American women are more likely than Canadians to receive a pap smear. A Blinder/Oaxaca type decomposition is used to determine influence of observed population characteristics and unobserved differences between the 2 countries on this gap.

RESULTS

The decomposition shows that the gap in Pap smears between Canada and the United States is not influenced by observed demographic differences. Most of the difference is attributable to unobserved heterogeneity or how women are treated in the 2 systems.

CONCLUSIONS

Although Canada has universal health coverage, the use of Pap smears is lower than that of all US women and equal to that of uninsured US women. Most of the differences in use of Pap smears is the result of differences in unobserved heterogeneity or the way that the systems treat women which may be a function of differences between the 2 health care systems in marketing, delivering, and reimbursing care.

Documentation of preventive screening interventions by general practitioners: a retrospective chart audit

Background

Screening and early diagnosis has been shown to reduce the morbidity and mortality associated with certain conditions such as cervical cancer. The role of general practitioners in promoting primary prevention of diseases is particularly important given that they have frequent contact with a large proportion of the population. This study assessed the extent to which general practitioners documented recommended preventive screening interventions among eligible patients.

Methods

We used a retrospective chart audit to assess patient visits to primary care clinics in Calgary, Canada from 2002-2004. We included fee for service physicians who practiced ≥ 2 days per week at their current location and excluded those whose primary practice was at walk-in clinics, community health centers, hospitals or emergency rooms. We included charts of patients who during the study period were age 35 years or older and had at least 2 visits to a clinic. We randomly selected and reviewed charts (N = 600) from 12 primary care clinics and abstracted information on 6 conditions recommended for preventive screening. Opportunities for preventive screening were determined based on recommendations of the Canadian Task Force on Preventive Health Care, the American College of Physicians, and the Canadian Cancer Society. Our main outcome measures included cancer screening (mammography and pap smears), immunization (influenza and pneumococcal), and risk factor assessment (cholesterol measurement and smoking cessation consultation).

Results

Patient visits to GP clinics present opportunities for preventive screening. However, we found that documentation of interventions was low, ranging from 40.3% (cholesterol measurement) to 0.9% (pneumococcal vaccination) within 1 year, and from 67.4% to 1.8% within the prior 3 years.

Conclusions

Documentation of preventive screening interventions by general practitioners was relatively low compared to the number of patients eligible for preventive screening. Some physicians opt to screen for PSA and DRE which is not recommended by the Canadian Task Force on Preventive HealthCare.

Punjabi immigrant women's breast cancer stories

The breast cancer experiences of Punjabi immigrant women, who represent the most populace group of South Asians in Canada, need to be understood in order to inform culturally appropriate cancer services. The purpose of this qualitative study was to explore women's stories of breast cancer in order to uncover how they made sense of their experiences. Interviews with twelve Punjabi immigrant women who had breast cancer within the last 8 years were available for this study. The four storylines that emerged from the ethnographic narrative analysis were: getting through a family crisis, dealing with just another health problem, living with never-ending fear and suffering, and learning a "lesson from God." A minor theme, "being part of a close-knit family," highlighted the family context as the most pronounced influence on the women's experiences. These findings provide valuable insights into how women's experiences of breast cancer were shaped by the intersections of culture, family, community, cancer treatments, and interactions with health care professionals.

Inadequacy of cervical cancer screening among urban recent immigrants: a population-based study of physician and laboratory claims in Toronto, Canada

OBJECTIVE

In Canada, Pap smears are recommended from 18 to 69. Self-reported socioeconomic gradients in screening have been documented in North America but there have been few direct measures of Pap smear use among immigrants or socially disadvantaged groups. Our purpose was to investigate whether socioedemographic factors are related to cervical cancer screening in Toronto, Canada.

METHOD

Pap smears were identified using fee and laboratory codes in Ontario physician service claims for 3 years (2000-2002 inclusive) for women aged 18-66. Area-level socioeconomic factors were derived from the 2001 census. At the individual level, recent registrants for health coverage, over 80% of whom are expected to be recent immigrants, were identified as women first registering after January 1, 1993.

RESULTS

Among 724,584 women, 55.4% had Pap smears within 3 years. Recent immigration, visible minority, foreign language, low income and low education were all associated with significantly lower area rates. Recent registrants had much lower rates than non-recent registrants (36.9% versus 60.9%).

CONCLUSION

Pap smear rates in Toronto fall below those dictated by evidence-based practice. Recent registrants, a largely immigrant group, have particularly low rates. Efforts to improve coverage need to emphasize women who recently immigrated and those with socioeconomic disadvantage.