Reasons behind Low Cervical Screening Uptake among South Asian Immigrant Women: A Qualitative Exploration
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design and Context
2.2. Participants and Recruitment
2.3. Data Collection
2.4. Data Analysis
2.5. Ethical Considerations
2.6. Rigor
3. Results
3.1. Participants’ Characteristics
3.2. Themes
- Theme 1:
- Deficits in knowledge of cervical cancer and its prevention
- Patterns of cervical cancer awareness vary:
“I have heard of breast cancer, just the word cancer but have not heard beyond this that what types of cancer are there.I just know that cancer is a disease, it occurs and is not very good. A person can die of it. I don’t know anything else about it.”(Participant 11)
“No, they have not heard of it either, whomever I have talked to, friends or others don’t know, even I have heard of it today for the first time. We hear that someone died of cancer… but especially this cancer cervical, no one knows.”(Participant 7)
“Living in this society here, I have noted, that common women think that it is more of white people thing, women living here get it due to having different sexual partners. And that is why government has a rule that you need to get Pap smear once a year.”(Participant 5)
- 2.
- Understanding of cervical cancer risk factors is lacking or incorrect:
“Women do not have awareness that it can be caused by sexual partners, their general perception is that it is a genetic disease, hereditary, it is a transmitted from mother or father’s side of the family.”(Participant 2)
“You get infected with that virus, eventually it gets built up, and that can slowly, like grow over there, it can get into a tumor and slowly it can turn into cancer over time.”(Participant 17)
“I did not know that cervical cancer can be prevented by vaccination too.”(Participant 15)
- 3.
- Comprehension of the cervical screening test’s true purpose:
“Maybe they would know, just like me, as I know that there is a Pap test, that ladies should get every 5 years and it stops this disease, so they should get it done. I think they would know more of the term Pap smear than cervical cancer.”(Participant 6)
“It’s done inside your vagina, just to see any abnormalities, anything, if you have sort of discomfort and irregular periods, hormonal issues.”(Participant 19)
“I got it done 2 times before, everything was okay, and also had vaccine so it was in my brain that I don’t need it.”(Participant 19)
- Theme 2:
- Barriers influencing cervical screening uptake
- Inbuilt convictions about preventive health:
“I think the common reason is why go for a test when we are doing well. Girls think that there is nothing wrong apparently, they have no issue, so they don’t need it. Like I said that if there is no symptom such as bleeding or pain, we think we are all good.”(Participant 12)
“There is a time for death, and you have to die once whatever the reason is, why be distressed before it. So, it is the mindset not to know anything bad before it happens.”(Participant 10)
“When I was told by the doctor, I was also hesitant how the test will be like, will there be any pain, I had some concerns, So it seems to me that the rest of the women would have the same concerns as mine like if it is painful or not.”(Participant 2)
- 2.
- Role of healthcare providers and the healthcare system:
“When you go to the doctor with a specific problem or disease, they just treat that or tell you about that only, not anything more than that. My personal experience is that my GP just asked if I had had it or not, she did not seem interested, or took any action. did not provide any information, and even when I visit, she doesn’t stress about doing it.”(Participant 9)
“In my country I have noted that women conceive, even they give birth, but doctors do not tell them nor do they have enough information that Pap test is such a test that diagnoses cancer. Only when one who has some kind of problem, like lots of bleeding then the doctor would say to do the test. And when your doctor recommends it, only then you think about and do it.”(Participant 15)
“I don’t know much, I am new from India, have not been to the doctor yet.”(Participant 11)
- 3.
- Practical constraints:
“Even though they understand as they are educated, sometimes there are names of diseases that they won’t even know about. For example, I have studied accounting, I do not understand all medical terms, if I do NAATI [stands for National Accreditation Authority for Translators and Interpreters] course I might come to know but not now. So, if you are educated, uneducated whatever, the language plays a very important role in making people understand in a better way.”(Participant 6)
“I myself do not have any problem of shyness or anything, even got the report written two times, but could not go because of lack of time, something comes in between like about the child. And after that you even forget about it.”(Participant 10)
“Then if they cannot drive, they have to wait for husbands, who are busy in the week, so they wait for the weekends, and then usually doctors are not available on the weekends, these are factors that certainly delay this thing. Then some of the ladies, they are not working they need money, and then they need to depend on the husband for the money.”(Participant 4)
- 4.
- Societal and cultural norms influencing decisions and uptake:
“We discuss such problems only after marriage, such as ladies’ problems, at most we ask our mothers, but they don’t tell in detail that these problems can be there in women.”(Participant 14)
“Certainly, modesty really is a problem, this is the main point to be noticed. The doctor does suggest, but girls maybe because of shyness do not pursue this much. Embarrassment plays a role even more than awareness.”(Participant 1)
“Because in our culture it is thought that if you marry you won’t have any problems, such problems occur when you do things out of marriage. I think that is the reason if they are married, they consider they won’t have this cancer or infections.”(Participant 15)
“There could be some that think that aah I don’t think you need that thing. Are you having any problem, if you are not, why do you bother doing it?”(Participant 17)
“I would give preference to my son, even in sickness, even if I am tired, do that for my son, my husband, my family, you know. But I can see a difference in younger generation, They look after their kids, but they look after themselves too at the same time.”(Participant 5)
- Theme 3:
- Increasing Cervical Screening Participation
- Provision of appropriate information needed:
“Like how this is caused, what happens, what are the signs and how can we stop it. Obviously, most of it has to do with intercourse, sexual activity, but there are other causes too, so we need to inform about that.”(Participant 11)
“Those who understand English, it is okay to relay in English, but majority, say at least half of the women are those who understand better in Urdu, if it is only in English, they won’t be able to understand. It is necessary that the information is in all languages. It is difficult to explain things sometimes, and because most of community used to come through hardworking. These days immigrants are different they can understand but still some come through deport and are refugees they do not have a lot of English background.”(Participant 14)
- 2.
- Proactive health care workers and health system’s change facilitate access:
“Doctors are given quite importance in our community, people follow them, So, if GP tells during the routine check-up about what it is and why the test is done, it will be taken seriously.”(Participant 13)
“Yes positively, because usually the people come to them because the GP can speak the same language, such as Afghanis and many Urdu speaking people, they come solely for this reason that they do not have to face any barrier while speaking their language, and GP can convince them quite effectively too. So, GPs should be asked, that whenever the women, especially those that cannot understand English language, come to them they should talk to them about it. In fact, GPs can be the best source to convince them.”(Participant 2)
“Every couple of months, like every 6 months, when you do a full blood count and your functional tests, if you make it just a standard procedure, that you have to get this test done. And explain to the women that this needs to be done, it is like a standard procedure.”(Participant 20)
- 3.
- Availability of self-sampling—a convenient option:
“This change is very helpful in routine testing; women will do the test more willingly if allowed to do in their comfort instead of getting it done by a GP. It is such good news that they could do it because definitely there is an element of modesty.”(Participant 13)
“But for that there is a need to create awareness as well as directions on how to carry out the test in the right way. For example, like we do our pregnancy test, we know beforehand that two lines will appear. So, it will be good if shown in a better way.”(Participant 12)
“I think I would not be able to take the liquid or whatever is required in the right way. I think the doctor can take it according to the required way.”(Participant 11)
- 4.
- Proper channels could be helpful in dissemination of screening information:
“You know like Queensland government has forced advertisements, they could just create one for spreading the awareness of importance of having Pap test and cervical screening, just as they do for you know smoking, and they declare smoking is injurious for health, just keep women informed about it.”(Participant 16)
“I think that the people who are already aware, and who are getting the test already will get it done if they are reminded about it through the text messages. But the ones that have no awareness of it would not benefit from mobile messages, they will go through them and delete them. By telling them this short sentence: ‘Take the cervical screening test’, will not be effective enough for them. To move such people the best way can be door to door visit, talk with them in their own languages, make them understand and convince them.”(Participant 3)
- 5.
- Addressing behavioural and societal barriers:
“Since there is a real quick impact on our woman that oh, she got it so I should get it too. Not in a bad way but there is something in our culture and society that we tend to keep up with the others, so I think just talking about it when sitting together and socializing, bringing out the topic and saying that it is just like a blood test, nothing bad or thing to look down on.”(Participant 16)
“Awareness should be given to males as well, you know when sometimes husband and wife both go to the GP, bringing it up in front of husband that it’s just a general test.”(Participant 2)
“Especially parents like mothers need to tell their daughter; mothers, sisters and close friends need to inform others. If a mother won’t tell her child about it, why would another person do it.”(Participant 12)
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- World Health Organization Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem. Available online: https://www.who.int/publications/i/item/9789240014107 (accessed on 19 March 2021).
- Arbyn, M.; Weiderpass, E.; Bruni, L.; de Sanjosé, S.; Saraiya, M.; Ferlay, J.; Bray, F. Estimates of incidence and mortality of cervical cancer in 2018: A worldwide analysis. Lancet Glob. Health 2020, 8, e191–e203. [Google Scholar] [CrossRef] [Green Version]
- Davies-Oliveira, J.; Smith, M.; Grover, S.; Canfell, K.; Crosbie, E. Eliminating cervical cancer: Progress and challenges for high-income countries. Clin. Oncol. 2021, 33, 550–559. [Google Scholar] [CrossRef] [PubMed]
- Whop, L.J.; Cunningham, J.; Garvey, G.; Condon, J.R. Towards global elimination of cervical cancer in all groups of women. Lancet Oncol. 2019, 20, e238. [Google Scholar] [CrossRef] [Green Version]
- Whop, L.J.; Garvey, G.; Baade, P.; Cunningham, J.; Lokuge, K.; Brotherton, J.M.L.; Valery, P.C.; O’ Connell, D.L.; Canfell, K.; Diaz, A.; et al. The first comprehensive report on Indigenous Australian women’s inequalities in cervical screening: A retrospective registry cohort study in Queensland, Australia (2000–2011). Cancer 2016, 122, 1560–1569. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Alam, Z.; Shafiee Hanjani, L.; Dean, J.; Janda, M. Cervical Cancer Screening Among Immigrant Women Residing in Australia: A Systematic Review. Asia Pac. J. Public Health 2021, 33, 816–827. [Google Scholar] [CrossRef] [PubMed]
- Australian Government Department of Home Affairs, 2018–2019 Migration Program Report. 2019. Available online: https://www.homeaffairs.gov.au/research-and-stats/files/report-migration-program-2018-19.pdf (accessed on 15 September 2019).
- Aminisani, N.; Armstrong, B.K.; Canfell, K. Participation in recommended cervical screening by Asian and middle eastern migrants in Australia: A record linkage study. Asia Pac. J. Clin. Oncol. 2011, 7, 111–112. [Google Scholar]
- Taylor, R.J.; Mamoon, H.A.; Morrell, S.L.; Wain, G.V. Cervical screening in migrants to Australia. Aust. N. Z. J. Public Health 2001, 25, 55–61. [Google Scholar] [CrossRef]
- Bronfenbrenner, U. Ecological models of human development. Read. Dev. Child. 1994, 2, 37–43. [Google Scholar]
- Alarcão, V.; Stefanovska-Petkovska, M.; Virgolino, A.; Santos, O.; Costa, A. Intersections of immigration and sexual/reproductive health: An umbrella literature review with a focus on health equity. Soc. Sci. 2021, 10, 63. [Google Scholar] [CrossRef]
- Ussher, J.M.; Rhyder-Obid, M.; Perz, J.; Rae, M.; Wong, T.W.; Newman, P. Purity, privacy and procreation: Constructions and experiences of sexual and reproductive health in Assyrian and Karen women living in Australia. Sex. Cult. 2012, 16, 467–485. [Google Scholar] [CrossRef]
- Jackowska, M.; Von Wagner, C.; Wardle, J.; Juszczyk, D.; Luszczynska, A.; Waller, J. Cervical screening among migrant women: A qualitative study of Polish, Slovak and Romanian women in London, UK. J. Fam. Plan. Reprod. Health Care 2012, 38, 229–238. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Azerkan, F.; Widmark, C.; Sparén, P.; Weiderpass, E.; Tillgren, P.; Faxelid, E. When life got in the way: How Danish and Norwegian immigrant women in Sweden reason about cervical screening and why they postpone attendance. PLoS ONE 2015, 10, e0107624. [Google Scholar] [CrossRef] [Green Version]
- Marlow, L.A.; Waller, J.; Wardle, J. Barriers to cervical cancer screening among ethnic minority women: A qualitative study. J. Fam. Plan. Reprod. Health Care 2015, 41, 248–254. [Google Scholar] [CrossRef] [Green Version]
- Kwok, C.; White, K.; Roydhouse, J.K. Chinese-Australian women’s knowledge, facilitators and barriers related to cervical cancer screening: A qualitative study. J. Immigr. Minor. Health 2011, 13, 1076–1083. [Google Scholar] [CrossRef]
- Jirojwong, S.; Manderson, L. Beliefs and behaviors about Pap and breast self-examination among Thai immigrant women in Brisbane, Australia. Women Health 2001, 33, 47–66. [Google Scholar] [CrossRef] [PubMed]
- Metusela, C.; Ussher, J.; Perz, J.; Hawkey, A.; Morrow, M.; Narchal, R.; Estoesta, J.; Monteiro, M. In My Culture, We Don’t Know Anything About That: Sexual and Reproductive Health of Migrant and Refugee Women. Int. J. Behav. Med. 2017, 24, 836–845. [Google Scholar] [CrossRef]
- Anaman, J.A. Barriers to and Facilitators of Cervical Screening Practice among African Immigrant Women from Refugee and Non-Refugee Backgrounds Living in Brisbane. Ph.D. Thesis, Queensland University of Technology, Brisbane, Australia, 2016. [Google Scholar]
- Anaman, J.A.; Correa-Velez, I.; King, J. A survey of cervical screening among refugee and non-refugee African immigrant women in Brisbane, Australia. Health Promot. J. Aust. 2017, 28, 217–224. [Google Scholar] [CrossRef] [PubMed]
- Wain, G.; Morrell, S.; Taylor, R.; Mamoon, H.; Bodkin, N. Variation in cervical cancer screening by region, socio-economic, migrant and Indigenous status in women in New South Wales. Aust. N. Z. J. Obstet. Gynaecol. 2001, 41, 320–325. [Google Scholar] [CrossRef]
- Australian Government National Cancer Screening Register. Available online: https://www.ncsr.gov.au/ (accessed on 10 September 2020).
- Australian Government Department of Health National Cervical Screening Program. Available online: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-screening-1 (accessed on 15 March 2019).
- Alam, Z.; Dean, J.; Janda, M. What do South Asian immigrant women know about HPV, cervical cancer and its early detection: A cross-sectional Australian study. J. Migr. Health, 2021; accepted. [Google Scholar]
- Marshall, M.N. Sampling for qualitative research. Fam. Pract. 1996, 13, 522–526. [Google Scholar] [CrossRef]
- Karwalajtys, T.L.; Redwood-Campbell, L.J.; Fowler, N.C.; Lohfeld, L.H.; Howard, M.; Kaczorowski, J.A.; Lytwyn, A. Conducting qualitative research on cervical cancer screening among diverse groups of immigrant women: Research reflections: Challenges and solutions. Can. Fam. Physician 2010, 56, e130–e135. [Google Scholar]
- Australian Bureau of Statistics. Australian Standard Classification of Cultural and Ethnic Groups (ASCCEG), 2019; Australian Bureau of Statistics Canberra: Belconnen, Australia, 2019.
- Guest, G.; Bunce, A.; Johnson, L. How many interviews are enough? An experiment with data saturation and variability. Field Methods 2006, 18, 59–82. [Google Scholar] [CrossRef]
- Clarke, V.; Braun, V. Thematic analysis. In Encyclopedia of Critical Psychology; Springer: Berlin/Heidelberg, Germany, 2014; pp. 1947–1952. [Google Scholar]
- QSR International Pty Ltd. NVivo Qualitative Data Analysis Software (released in March 2020). Available online: https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home (accessed on 19 March 2021).
- Jirojwong, S.; Maclennan, R.; Manderson, L. Health beliefs and Pap smears among Thai women in Brisbane, Australia. Asia Pac. J. Public Health 2001, 13, 20–23. [Google Scholar] [CrossRef]
- Anaman-Torgbor, J.A.; King, J.; Correa-Velez, I. Barriers and facilitators of cervical cancer screening practices among African immigrant women living in Brisbane, Australia. Eur. J. Oncol. Nurs. 2017, 31, 22–29. [Google Scholar] [CrossRef] [PubMed]
- Grandahl, M.; Tydén, T.; Gottvall, M.; Westerling, R.; Oscarsson, M. Immigrant women’s experiences and views on the prevention of cervical cancer: A qualitative study. Health Expect. 2015, 18, 344–354. [Google Scholar] [CrossRef] [PubMed]
- Dodd, R.H.; Obermair, H.M.; McCaffery, K.J. A Thematic Analysis of Attitudes Toward Changes to Cervical Screening in Australia. JMIR Cancer 2019, 5, e12307. [Google Scholar] [CrossRef] [Green Version]
- Møen, K.A.; Kumar, B.; Igland, J.; Diaz, E. Effect of an Intervention in General Practice to Increase the Participation of Im-migrants in Cervical Cancer Screening: A Cluster Randomized Clinical Trial. JAMA Netw. Open 2020, 3, e201903. [Google Scholar] [CrossRef]
- De Cuevas, R.M.A.; Saini, P.; Roberts, D.; Beaver, K.; Chandrashekar, M.; Jain, A.; Kotas, E.; Tahir, N.; Ahmed, S.; Brown, S.L. A systematic review of barriers and enablers to South Asian women’s attendance for asymptomatic screening of breast and cervical cancers in emigrant countries. BMJ Open 2018, 8, e020892. [Google Scholar]
- Hulme, J.; Moravac, C.; Ahmad, F.; Cleverly, S.; Lofters, A.; Ginsburg, O.; Dunn, S. I want to save my life: Conceptions of cervical and breast cancer screening among urban immigrant women of South Asian and Chinese origin. BMC Public Health 2016, 16, 1077. [Google Scholar] [CrossRef] [Green Version]
- Crawford, J.; Ahmad, F.; Beaton, D.; Bierman, A.S. Cancer screening behaviours among South Asian immigrants in the UK, US and Canada: A scoping study. Health Soc. Care Community 2016, 24, 123–153. [Google Scholar] [CrossRef] [PubMed]
- Syed, I.U.; Ahmad, F. A scoping literature review of work-related musculoskeletal disorders among South Asian immigrant women in Canada. Columbia Univ. J. Glob. Health 2016, 6, 28–34. [Google Scholar]
- Senarath, U.; Gunawardena, N.S. Women’s autonomy in decision making for health care in South Asia. Asia Pac. J. Public Health 2009, 21, 137–143. [Google Scholar] [CrossRef] [PubMed]
- Chaudhuri, S.; Morash, M.; Yingling, J. Marriage migration, patriarchal bargains, and wife abuse: A study of South Asian women. Violence Against Women 2014, 20, 141–161. [Google Scholar] [CrossRef] [PubMed]
Characteristic | Number of Participants (n) |
---|---|
Age | |
20–30 years | 8 |
31–40 years | 6 |
41–60 years | 6 |
Language | |
English | 5 |
Other (Urdu, Hindi, Punjabi, Fijian Indian) | 15 |
No. of children | |
None | 2 |
Two or less | 9 |
Three or more | 9 |
Ethnicity | |
Indian | 9 |
Pakistani | 6 |
Other (Bangladeshi, Nepalese, Sri Lankan, Indian Fijian) | 5 |
Education completed | |
School (Secondary) | 15 |
University (Undergraduate) | 5 |
Duration of stay in Australia | |
Less than 5 years | 3 |
5–10 years | 14 |
More than 10 years | 3 |
Cervical screening participation | |
Yes—Up to date | 8 |
Yes—Not up to date | 6 |
No | 6 |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Alam, Z.; Deol, H.; Dean, J.A.; Janda, M. Reasons behind Low Cervical Screening Uptake among South Asian Immigrant Women: A Qualitative Exploration. Int. J. Environ. Res. Public Health 2022, 19, 1527. https://doi.org/10.3390/ijerph19031527
Alam Z, Deol H, Dean JA, Janda M. Reasons behind Low Cervical Screening Uptake among South Asian Immigrant Women: A Qualitative Exploration. International Journal of Environmental Research and Public Health. 2022; 19(3):1527. https://doi.org/10.3390/ijerph19031527
Chicago/Turabian StyleAlam, Zufishan, Hanoor Deol, Judith Ann Dean, and Monika Janda. 2022. "Reasons behind Low Cervical Screening Uptake among South Asian Immigrant Women: A Qualitative Exploration" International Journal of Environmental Research and Public Health 19, no. 3: 1527. https://doi.org/10.3390/ijerph19031527