Variation in cervical cancer screening by region, socio-economic, migrant and indigenous status in women in New South Wales

What do South Asian immigrant women know about HPV, cervical cancer and its early detection: A cross-sectional Australian study

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Low HPV and cervical cancer knowledge levels among South Asian immigrant women.

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One third participants aware of the renewed cervical screening program changes.

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Screening uptake significantly associated with HPV and cervical cancer awareness.

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GP discussion on the topic found to have important role in increasing knowledge.

Cervical cancer commonly caused by Human Papillomavirus (HPV) imposes a significant burden in Asia. This study examined the awareness and knowledge of HPV, cervical cancer, and its early detection methods among South Asian immigrant women in Australia to determine factors associated with knowledge deficits. A cross-sectional internet-based survey was completed by a convenience sample of women (n=148), with South-Asian background, residing in Queensland during May-October 2019. Main outcome variables were awareness of HPV, cervical cancer, cervical screening test (Pap test and HPV test) and HPV test self-sampling availability (Yes/No). HPV and cervical cancer knowledge were assessed via 16-item and 20 item aggregated scales respectively, (higher scores indicating better knowledge). Five individual items queried knowledge of the Pap and HPV test, and one item actual cervical screening uptake. One-way ANOVA was used to study differences in HPV and cervical cancer knowledge among sociodemographic groups. Of 148 participating women, 55% (n=86) had heard of HPV, 77% (n=114) of cervical cancer and 81.8% (n=121) of Pap tests. Only one third of participants (n=49) were aware that now an HPV test is used for cervical screening and 10% (n=15) of its self-sampling availability, whereas 55.4% (n=82) reported participation in screening previously. The mean HPV knowledge score was 5.3 (S.D: 5.7) and mean cervical cancer knowledge score 9.8 (S.D: 6.5) with zero being the most common score on both scales. Higher knowledge scores were significantly associated with higher educational level, English language proficiency, discussion with a GP on the topic and previous participation in screening. The majority of participants lacked detailed knowledge about the available screening tests. This study identified key target groups for future interventions.

Reasons behind Low Cervical Screening Uptake among South Asian Immigrant Women: A Qualitative Exploration

Despite advancements in prevention strategies, cervical cancer remains a leading cause of death among underprivileged women. Although Australia has low age-standardized cervical cancer incidence rates compared with other countries, disparities exist in cervical screening uptake among certain population subgroups, especially those from culturally and linguistically diverse (CALD) backgrounds. South Asian immigrant women have been reported to have lower cervical screening uptake than Australian-born women and those from other immigrant backgrounds. The objective of this study was to gain insight into the reasons and barriers for low cervical screening participation among South Asian immigrant women, through qualitative exploration. Semi-structured, in-depth interviews were conducted with 20 women, aged 26-50 years, living in Queensland, Australia, who were recruited via purposive sampling. After translation and transcription of recorded interviews, data was analysed via inductive thematic approach. Resulting themes, illustrating barriers towards screening, included: lack of cervical cancer and screening knowledge, especially of the changes in the revised screening program; effect of preventive, health-seeking behaviours; health care system factors; role of practical constraints and influence of sociocultural beliefs. Results suggest that culturally informed interventions, that involve relevant information provision and behavioural change strategies, to clarify women's misconceptions, are required.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exploring the influence of rural residence on uptake of organized cancer screening - A systematic review of international literature

Lower screening uptake could impact cancer survival in rural areas. This systematic review sought studies comparing rural/urban uptake of colorectal, cervical and breast cancer screening in high income countries. Relevant studies (n = 50) were identified systematically by searching Medline, EMBASE and CINAHL. Narrative synthesis found that screening uptake for all three cancers was generally lower in rural areas. In meta-analysis, colorectal cancer screening uptake (OR 0.66, 95 % CI = 0.50-0.87, I² = 85 %) was significantly lower for rural dwellers than their urban counterparts. The meta-analysis found no relationship between uptake of breast cancer screening and rural versus urban residency (OR 0.93, 95 % CI = 0.80-1.09, I² = 86 %). However, it is important to note the limitation of the significant statistical heterogeneity found which demonstrates the lack of consistency between the few studies eligible for inclusion in the meta-analyses. Cancer screening uptake is apparently lower for rural dwellers which may contribute to poorer survival. National screening programmes should consider geography in planning.

Cervical Cancer Screening Among Immigrant Women Residing in Australia: A Systematic Review

Since the introduction of systematic population-based cervical cancer screening in Australia in 1991, age-standardized incidence of cervical cancer has halved. Given recent advances in human papillomavirus (HPV) vaccination and screening, cervical cancer may be eliminated nationally within 20 years. However, immigrant women are not equitably reached by screening efforts. This study systematically reviewed evidence on cervical cancer screening practices among immigrant women in Australia. A systematic search of MEDLINE, Embase, PubMed, CINAHL, and PsycINFO and gray literature for English language studies published till March 1, 2019, was conducted. Observational and qualitative studies evaluating cervical cancer screening awareness and participation of immigrant women were screened. Of 125 potentially relevant studies, 25 were eligible: 16 quantitative (4 cohort, 12 cross-sectional), 6 qualitative, and 3 mixed-methods studies. Quantitative studies indicated 1% to 16% lower screening rates among migrant women compared with Australian-born women, with participation of South Asian women being significantly lower (odds ratio = 0.54, 95% confidence interval = 0.48-0.61). Qualitative studies illustrated factors affecting women's willingness to participate in screening, including insufficient knowledge, low-risk perception, and unavailability of a female health professionals being key barriers. Future studies should focus on South Asian women, due to recent increase in their immigration.

Association between sexual behavior and cervical cancer screening

BACKGROUND

Not much is known about whether women who follow Pap testing recommendations report the same pattern of sexual behavior as women who do not.

METHODS

Data come from part of a larger population-based computer-assisted telephone survey of 8656 Australians aged 16-64 years resident in Australian households with a fixed telephone line (Australian Longitudinal Study of Health and Relationships [ALSHR]). The main outcome measure in the current study was having had a Pap test in the past 2 years.

RESULTS

Data on a weighted sample of 4052 women who reported sexual experience (ever had vaginal intercourse) were analyzed. Overall, 73% of women in the sample reported having a Pap test in the past 2 years. Variables individually associated with Pap testing behavior included age, education, occupation, cohabitation status, residential location, tobacco and alcohol use, body mass index (BMI), lifetime and recent number of opposite sex partners, sexually transmitted infection (STI) history, and condom reliance for contraception. In adjusted analyses, women in their 30s, those who lived with their partner, and nonsmokers were more likely to have had a recent Pap test. Those who drank alcohol at least weekly were more likely to have had a recent test than irregular drinkers or nondrinkers. Women with no sexual partners in the last year were less likely to have had a Pap test, and women who reported a previous STI diagnosis were more likely to have had a Pap test in the past 2 years.

CONCLUSIONS

There are differences in Pap testing behavior among Australian women related to factors that may affect their risk of developing cervical abnormalities. Younger women and regular smokers were less likely to report a recent test. Screening programs should consider the need to focus recruitment strategies for these women.

Disparities in cancer care in australia and the pacific

Disparities in cancer care across populations become apparent only when there is a cancer registry to record the cancer incidence and mortality statistics and data capture is comprehensive. In Australia, one of the obvious disparities is geography, with mortality in some cancers being worse with increasing remoteness. The reasons are not just poorer access to screening and treatment but lifestyle and occupational factors which encompass increased cancer risk factors compared with urban counterparts. There are also higher proportions of lower socioeconomic groups and Aboriginal and Torres Strait Islanders, both of which in addition to remoteness have poorer cancer outcomes. Indigenous Australians have a higher exposure to risk factors of smoking and obesity, live remotely, and have lower participation rates in screening and treatment than non-Indigenous Australians. Immigrants to Australia from diverse backgrounds have a lower incidence of the common cancers and a lower overall mortality. They have a different spectrum of cancers such as more liver cancer because of their exposure to hepatitis B. The Māori in New Zealand are well studied and display disparities in cancer outcomes similar to Indigenous Australians. There is less known of the Pacific Islanders, but they often have worse outcomes than Europeans living in the same environment, a greater exposure to risk factors, and the added problem of often needing to travel from the Pacific Islands to New Zealand for treatment. Poorer socioeconomic status is the other major factor associated with poorer outcomes in cancer treatment. Often, low socioeconomic status groups have lifestyles with higher levels of smoking and obesity, do not participate in screening as readily, and may not be able to afford unsubsidized treatments such as high-cost drugs.

Can mobile units improve the strategies for cervical cancer prevention?

Cervical cancer is a serious public health problem in women in developing countries because of absence or ineffectiveness of screening programs. Several biases to access medical care and inequity of public health system in a continental country like Brazil limit the implementation of adequate programs to appropriately prevent the cervical cancer. Therefore, the aim of this study was to evaluate the results of applying the mobile unit (MU) for cervical cancer screening. From May 2003 to May 2004, a cervical cancer screening was offered to women aged 20-69 years, residing in 19 municipal districts of the Barretos county region, in São Paulo. Out of the 9,560 examination available, 2,964 (31%) women underwent screening. The medium distance traveled by the MU was 45 km. The medium time spent by women in the MU for completion of the questionnaire and doing the exam was 20 minutes. It was observed that 17.0% of women screened had never had the test or had not had it repeated within the last 3 years. The negative response was more common among women aged 20 to 29 years and 60 to 69 years and among women with less schooling and lower socio-economic income (P < 0.05). MU can significantly overcome the chronic deficiency of public health system accessibility offering opportunity to these women to participate in screening programs.

Innovation in cervical cancer prevention and control in Mexico

Disparities related to cervical cancer continue to exist in Mexico, including insufficient screening coverage, problems with quality control and a resulting greater risk of mortality among women from marginalized areas. A lack of opportunities and requirements for continuing education and accreditation of healthcare personnel involved in the screening program is also an issue. HPV DNA testing and HPV vaccines are recent technological innovations that offer a potential solution to the continued negative impact of cervical cancer among Mexican women. This essay attempts to answer questions such as: Why should HPV testing be integrated into the early detection program in Mexico? How can HPV testing best be integrated into the program in Mexico? How-from a public health perspective that seeks to reduce disparities-can HPV vaccination best be implemented in Mexico? HPV testing allows increased positive predictive value while also reducing costly and unnecessary overtreatment of low-grade abnormalities, and HPV vaccines offer the possibility of primary prevention of cervical cancer. The strategy proposed for Mexico includes primary prevention with HPV vaccination for girls aged between 12 and 16 years (before sexual initiation), Pap testing with excellent quality control for women 24-34 years of age and high-risk HPV DNA testing for women 35 years and older. HPV samples would be either clinically collected or self-collected and women with positive HPV test results would receive follow-up high-quality Pap testing. This approach is creative and focuses on reducing disparities and providing high-quality care that is also cost effective.

Mass media campaign improves cervical screening across all socio-economic groups

Low socio-economic status (SES) has been associated with lower cervical screening rates. Mass media is one known strategy that can increase cervical screening participation. This study sought to determine whether a mass media campaign conducted in Victoria, Australia, in 2005 was effective in encouraging women across all SES groups to screen. Data were obtained from the Victorian Cervical Cytology Registry for each Pap test registered during 2005 and categorized into SES quintiles using the Index of Socio-Economic Advantage/Disadvantage. Negative binomial regression was used to determine the impact of the campaign on the weekly number of Pap tests and whether the media campaign had a differential effect by SES, after adjusting for the number of workdays per week, age group and time since previous test. Cervical screening increased 27% during the campaign period and was equally effective in encouraging screening across all SES groups, including low-SES women. Mass media campaigns can prompt increased rates of cervical screening among all women, not just those from more advantaged areas. Combining media with additional strategies targeted at low-SES women may help lessen the underlying differences in screening rates across SES.

Participation in cervical screening by Indigenous women in the Northern Territory: a longitudinal study

OBJECTIVE

To investigate the effectiveness of the Northern Territory Women's Cancer Prevention Program in improving cervical screening participation for Indigenous women.

DESIGN

Descriptive longitudinal period prevalence study.

PARTICIPANTS

All NT resident women aged 20-69 years who had at least one Pap smear recorded on the NT Pap Smear Register between 1997 and 2004.

MAIN OUTCOME MEASURES

Indirectly estimated percentage of NT Indigenous women in rural and remote areas with a predominantly Indigenous population (accounting for 55% of the NT Indigenous population) who participated in screening, in biennial periods between 1997 and 2004. Participation by all eligible NT women (both Indigenous and non-Indigenous) is also reported by region for the same period.

RESULTS

In 1997-1998, estimated participation for Indigenous women was about half the national rate (33.9% [95% CI, 32.6%-35.2%] v 63.9% [95% CI, 63.8%-63.9%]). Participation increased to 44.0% (95% CI, 42.7%-45.4%) in 1999-2000, and changed little thereafter; participation was higher in the Top End compared with Central Australia, and varied from 16.6% to 75.0% between remote areas. Participation rates for all women living in rural/remote regions were lower than those in urban regions.

CONCLUSIONS

Recruitment of Indigenous women for cervical screening has improved since 1999. This may have partly contributed to the fall in their cervical cancer incidence and mortality in recent years. Although in most areas Indigenous participation is lower than national levels, in one area it was considerably higher. Improvements can be achieved by learning from these communities, to further close the gap in morbidity and mortality between Indigenous and non-Indigenous women.

Screening for cervical carcinoma

BACKGROUND

Differences exist between defined groups of women in their attendance to screening programs for cervical carcinoma. Data from the screening organization in the southwest Netherlands were used to evaluate differences between subpopulations to get information to improve the screening procedure.

METHODS

Between 1998 and 2001, a total of 251,446 women had been invited to participate in the screening program. The ethnic background of all invited women was documented. Both the results of Papanicolaou tests and the reason women did not participate were stored in a data base that was matched with the invitation data base. The resulting data set was analyzed with regard to participation rates and results of screening in relation to age, ethnic background, and socioeconomic status.

RESULTS

Overall participation was 55.7%. Women who were born in The Netherlands participated at a rate of 56.8%, whereas women who were born in other Western countries participated at a rate of 45.3%. The participation rate for women who had a Moroccan background was as low as 35.9%. The prevalence of high-grade squamous intraepithelial lesion was 6.2 times higher among women in the younger age groups compared with women in the oldest age group. Women with low socioeconomic status were 1.5 times more likely to have high-grade squamous intraepithelial lesions. Women from The Netherlands Antilles had greater percentages of both low-grade and high-grade squamous intraepithelial lesions (1.6 and 3.0 times more frequent, respectively) compared with women who were born in The Netherlands.

CONCLUSIONS

Although cervical screening is free of charge in The Netherlands, participation rates differed greatly between ethnic groups and between women from different socioeconomic strata. Abnormalities were found more often in women who were not born in The Netherlands and in women with lower socioeconomic status. In these groups, attendance at the screening program was lower compared with the attendance of women who were born in The Netherlands.

How much does a reminder letter increase cervical screening among under-screened women in NSW?

OBJECTIVE

To evaluate a direct mail-out campaign to increase Pap screening rates in women who have not had a test in 48 months.

METHODS

Ninety thousand under-screened women were randomised to be mailed a 48-month reminder letter to have a Pap test (n=60,000), or not to be mailed a letter (n=30,000). Differences in Pap test rates were assessed by Kaplan-Meier survival analysis, by chi2 tests of significance between Pap test rates in letter versus no-letter groups, and by proportional hazards regression modelling of predictors of a Pap test with letter versus no-letter as the main study variable. T-tests were conducted on mean time to Pap test to assess whether time to Pap test was significantly different between the intervention and control groups.

RESULTS

After 90 days following each mail-out, Pap test rates in the letter group were significantly higher than in the non-letter group, by approximately two percentage points. After controlling for potential confounders, the hazard ratio of a Pap test within 90 days of a mail-out in the letter group was 1.5 compared with 1.0 in the no-letter group. Hazard ratios of having a Pap test within 90 days decreased significantly with time since last Pap test (p<0.0001); were significantly higher than 1.0 for most non-metropolitan areas of NSW compared with metropolitan areas; and increased significantly with age (p<0.0001). Pap test hazard ratios were not associated with socio-economic status of area of residence, but the hazard ratio was significantly higher than 1.0 if the reminder letter was sent after the Christmas/New Year break. No significant differences in mean time to Pap test were found between the letter and no-letter groups.

CONCLUSIONS AND IMPLICATIONS

Being sent a reminder letter is associated with higher Pap testing rates in under-screened women.

A perspective from countries using organized screening programs

Cancer screening may be offered to a population opportunistically, as part of an organized program, or as some combination of the preceding two options. Organized screening is distinguished from opportunistic screening primarily on the basis of how invitations to screening are extended. In organized screening, invitations are issued from centralized population registers. In opportunistic screening, however, due to the lack of central registers, invitations to screening depend on the individual's decision or on encounters with health care providers. The current article outlines key differences between organized and opportunistic screening. In the current study, literature searches were performed using PubMed and MEDLINE. Additional data were assembled from interviews with health officials in the five countries investigated and from the authors' personal files. Opportunistic screening was found to be distinguishable from organized screening on the basis of whether screening invitations were issued from centralized population registers. Organized screening programs also assumed centralized responsibility for other key elements of screening, such as eligibility requirements, quality assurance, follow-up, and evaluation. Organized programs focused on reducing mortality and morbidity at the level of the population rather than at the level of the individual. Thus, programs did not necessarily offer the most sensitive screening test for a particular cancer, and tests sometimes were offered at suboptimal intervals with respect to individual-level protection. Nonetheless, organized systems paid greater attention to the quality of screening, as measured by factors such as cancer detection rates, tumor characteristics, and false-positive biopsy rates. As a result, participants in organized screening programs received greater protection from the harmful effects associated with screening. In addition, organized programs worked more systematically toward providing value for money in an inevitably resource-limited environment. Although organized and opportunistic models of screening can yield similar uptake rates, organized programs exhibited greater potential ability to reduce cancer incidence and mortality, because of the higher levels of population coverage and centralized commitment to quality and monitoring; were more likely to be cost-effective; and offered greater protection against the harmful effects associated with poor quality or overly frequent screening.

Human papillomavirus and cervical cancer: issues for biobehavioral and psychosocial research

There is now overwhelming evidence that high-risk, sexually transmitted types of human papillomavirus (HPV) are the main causal agent in cervical cancer. Biobehavioral and psychosocial research is uniquely capable of addressing many of the issues raised by HPV and its link with cervical cancer. In this article we review current findings in this area and identify issues for future research. The first of the three sections explores issues associated with the introduction of HPV testing for the detection and management of cervical abnormalities and the impact of growing public awareness of the sexually transmitted nature of cervical cancer. The implications for public understanding of cervical cancer, psychosocial issues associated with screening, and the potential impact on screening uptake are discussed. The second section addresses the role of biobehavioral factors in the persistence and progression of HPV infection as well as possible interventions to minimize the risk of persistence. Finally, primary prevention of HPV is discussed.

Sociodemographic predictors of pap test receipt, currency and knowledge among Australian women

BACKGROUND

Knowledge of sociodemographic variations in cervical cancer screening can help identify population groups at risk of underutilization of cervical cancer procedures and practices. The aim of this research was to examine sociodemographic predictors of receipt, currency (being up-to-date for), and knowledge of Pap test.

METHODS

We used data from the 1995 National Health Survey. A subsample of women was given self-administered questionnaires that included questions about the Pap test. The sample size was 7,572. Using multiple logistic regression, we examined the association of age, marital status, region of residence, country of birth, Index of Relative Socioeconomic Disadvantage (IRSD), and education with Pap test receipt, currency, and knowledge.

RESULTS

Women under 30 and over 49 years of age, those not presently married, those with lower levels of education, and those born in the Middle East or Asia (compared with the Australian/New Zealand-born women) were at a greater risk of not receiving and having no knowledge of Pap test.

CONCLUSIONS

The results of this study suggest that, as part of a comprehensive cancer screening strategy, women who are unlikely to obtain a Pap smear might benefit from targeted interventions to improve adherence to cervical cancer screening programs.