Colonial legacy and the experience of First Nations women in cervical cancer screening: a Canadian multi-community study

Regular Papanicolaou (Pap) screening has dramatically reduced cervical cancer incidence in Canada since the 1950s. However, Indigenous women’s rates of cervical cancer remain disproportionately high, a factor which is not acknowledged in national media or in educational materials reporting Canada’s new cervical cancer screening guidelines. Here, we present findings from a cervical cancer screening initiative in Northwestern Ontario. Based on participatory action research, we worked with 10 First Nations communities in the Robinson Superior Treaty area to increase awareness of cervical cancer risk, develop culturally sensitive tools for screening and education and test the efficacy of human papillomavirus (HPV) self-sampling as an alternative to Pap cytology. We conducted 16 interviews with health care professionals and 9 focus groups with 69 women from the communities. A central theme for both health care providers (HCPs) and community members was the colonial legacy and its influence on women’s experiences of cervical cancer screening. This was evidenced by a strong sense of body shyness, including shame related to sexuality and sexually transmitted infections, concerns about confidentiality in clinical encounters and distrust or caution around HCPs. Reaffirming women’s traditional caregiving and educational roles, enhancing mother and daughter communication, improving cultural sensitivity in health care and education and adoption of HPV self-sampling to increase women’s privacy and control of the cervical cancer screening experience were endorsed. We argue that education and screening initiatives must reflect the cultural preferences of Indigenous women, empowering them to take control of their experiences of health and body in cervical cancer screening.     

Pap smear receipt among Vietnamese immigrants: the importance of health care factors

Objective. Recent US data indicate that women of Vietnamese descent have higher cervical cancer incidence rates than women of any other race/ethnicity, and lower levels of Pap testing than white, black, and Latina women. Our objective was to provide information about Pap testing barriers and facilitators that could be used to develop cervical cancer control intervention programs for Vietnamese American women.

Design. We conducted a cross-sectional, community-based survey of Vietnamese immigrants. Our study was conducted in metropolitan Seattle, Washington, DC. A total of 1532 Vietnamese American women participated in the study. Demographic, health care, and knowledge/belief items associated with previous cervical cancer screening participation (ever screened and screened according to interval screening guidelines) were examined.

Results. Eighty-one percentage of the respondents had been screened for cervical cancer in the previous three years. Recent Pap testing was strongly associated (p<0.001) with having a regular doctor, having a physical in the last year, previous physician recommendation for testing, and having asked a physician for testing. Women whose regular doctor was a Vietnamese man were no more likely to have received a recent Pap smear than those with no regular doctor.

Conclusion. Our findings indicate that cervical cancer screening disparities between Vietnamese and other racial/ethnic groups are decreasing. Efforts to further increase Pap smear receipt in Vietnamese American communities should enable women without a source of health care to find a regular provider. Additionally, intervention programs should improve patient–provider communication by encouraging health care providers (especially male Vietnamese physicians serving women living in ethnic enclaves) to recommend Pap testing, as well as by empowering Vietnamese women to specifically ask their physicians for Pap testing.     

Beliefs and behaviors about Pap and breast self-examination among Thai immigrant women in Brisbane, Australia.

Regular screening is an important preventive method in reducing morbidity and mortality from cervical and breast cancer. In 1998, a cross-sectional study was conducted in Brisbane, Australia, among 145 Thai immigrant women, to explore cultural and social factors related to their use of Pap smear tests and breast self-examination (BSE). The study aimed at describing women's beliefs and perceptions about the body, breast and cervical cancer, and their perceptions of the causes of the diseases. It explored the women's perception of the severity and the effects of both cancers on aspects of patients' lives, and their chance of developing both cancers. The Thai immigrant women explained the causes of breast and cervical cancer using both traditional beliefs and medical knowledge. They perceived that both cancers affect a patient's health and her daily activities. Some women believed that they would develop cervical cancer if their perineum or vulva was "dirty." Some believed that they would have breast cancer because they had a history of benign tumor or cyst of a breast. Forty-four percent of the women had biennial Pap smears in the past five years and only 25% conducted BSE monthly in the past two years. Information relating to perceived barriers to undertake regular cervical cancer and breast cancer screenings and other health beliefs can be applied by health care personnel to increase Thai immigrant women's preventive health behaviors.     

Cervical cancer screening among South Asian women in Canada: the role of education and acculturation

Cervical cancer screening by Papanicolaou (Pap) smear lowers the incidence and provides early detection of cervical cancer and is a preventative health care measure that should be available on a regular basis to all women at risk. As the population of ethnic women increases, it is important to assess whether these women are aware of and are utilizing this health service. A self-administered questionnaire was completed by 124 South Asian women, aged 18 to 60 years. Sixty-two South Asian students were selected from a university setting and 62 Tamil women were selected from a community center for South Asian women. This study examined the knowledge and use of Pap smears in South Asian women in Canada, and whether their level of acculturation or formal education influenced whether they know about and receive Pap smears. Low level of knowledge about the Pap test and a low prevalence of Pap testing behaviour was significantly correlated (p < 0.001) with a low level of formal education, education taking place outside of Canada, and a low index of acculturation. South Asian students were significantly more acculturated than Tamil women (p < 0.001). In conclusion, there was a low level of knowledge and prevalence of cervical cancer screening among South Asian women. This study highlights the need for educational interventions in Canada directed to ethnic women especially from South Asia.     

Cultural Views,English Proficiency and Regular Cervical Cancer Screening Among Older Chinese American Women

ObjectiveThe purpose of this study was to investigate the association between cultural views, English proficiency, and regular cervical cancer screening among older Chinese women.MethodsThe study sample consisted of 473 asymptomatic Chinese participants aged 50 and older recruited from community organizations. The study outcome was regular receipt of Pap tests, defined as having a recent test in the past 3 years and another within 3 years before the present test. Eastern cultural views were measured by a 30-item scale that assessed beliefs about illness and cancer. Sociodemographics, cancer worry, physician recommendation, health insurance, and access barriers were included as covariates in multiple logistic regression models.ResultsA total of 239 (50.5 %) Chinese American women had regular Pap tests. Findings indicate that 1) women who held more traditional Chinese cultural views were less likely to be a regular screener (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.94–0.99); 2) women with higher English proficiency were 1.39 times more likely to have received regular Pap tests than women with lower proficiency (OR, 1.39; 95% CI, 1.13–1.72).ConclusionCultural views and English proficiency were significant predictors of older Chinese American women regular receipt of Pap tests. Future research is needed to identify and design culturally and linguistically competent programs to promote cervical cancer screening.     

Cervical cancer screening beliefs among young Hispanic women

OBJECTIVES: This study examined beliefs, attitudes, and personal characteristics that correlated with self-reported cervical cancer screening history among Hispanic women aged 18 to 25 years old in El Paso, TX, a large metropolitan area on the U.S.-Mexico border. METHODS: Data were collected through a cross-sectional, face-to-face survey. The study questionnaire was based primarily on the Health Belief Model, and included scales that measured perceived susceptibility and seriousness of cervical cancer, and perceived benefits and barriers to Pap test screening. The study questionnaire also included measures of acculturation, Pap test history, pregnancy and sexual history, use of birth control, type of medical insurance, and educational attainment. RESULTS: Sixty-nine percent reported ever having had a Pap test and 56% reported having had a test in the past year. Eighty percent reported that they were sexually active, and of these, 63% reported using birth control. Respondents understood the seriousness of cervical cancer, their susceptibility to cervical cancer, and the benefits of Pap testing; however, only 61% agreed that most young women whom they know have Pap tests. Greater acculturation and the belief that most young unmarried women have Pap tests were positively associated with ever having screening. The perception that the test would be painful and not knowing where to go for the test were negatively associated with ever having a Pap test. CONCLUSIONS: This study found suboptimal rates of screening for cervical cancer in a sample of young Hispanic women residing along the U.S.-Mexico border. Although women may understand the seriousness of cervical cancer and the benefits of screening, perceptions about Pap tests may pose barriers to undergoing screening. Efforts to increase screening also may need to focus specifically on women who are least acculturated, as they also were least likely to have had prior Pap tests.     

CERVICAL CANCER SCREENING AMONG SOUTH ASIAN WOMEN IN CANADA: THE ROLE OF EDUCATION AND ACCULTURATION

Cervical cancer screening by Papanicolaou (Pap) smear lowers the incidence and provides early detection of cervical cancer and is a preventative health care measure that should be available on a regular basis to all women at risk. As the population of ethnic women increases, it is important to assess whether these women are aware of and are utilizing this health service. A self-administered questionnaire was completed by 124 South Asian women, aged 18 to 60 years. Sixty-two South Asian students were selected from a university setting and 62 Tamil women were selected from a community center for South Asian women. This study examined the knowledge and use of Pap smears in South Asian women in Canada, and whether their level of acculturation or formal education influenced whether they know about and receive Pap smears. Low level of knowledge about the Pap test and a low prevalence of Pap testing behaviour was significantly correlated ( p < 0.001) with a low level of formal education, education taking place outside of Canada, and a low index of acculturation. South Asian students were significantly more acculturated than Tamil women ( p < 0.001). In conclusion, there was a low level of knowledge and prevalence of cervical cancer screening among South Asian women. This study highlights the need for educational interventions in Canada directed to ethnic women especially from South Asia.     

Low knowledge of cervical cancer and cervical pap smears among women in Peru, and their ideas of how this could be improved

Estimates of the percentage of women who have had Pap smears in Peru vary between 7% and 43%. This study explores what women know about cervical cancer and Pap smears, as well as their barriers to obtaining Pap smears. Focus group discussions (FGD) were conducted with a total of 177 women in four Peruvian cities. Discussions reveal that most women did not know what causes cervical cancer. Most women did not know the purpose of Pap smears, although knowledge about Pap smears was higher than knowledge about cervical cancer. Fear, embarrassment, and lack of knowledge were the main barriers identified for not getting Pap smears. Programs and policies aiming to increase Pap smear coverage must start by educating women on cervical cancer and its prevention in order to improve women's perceptions about the screening test and increase Pap smear seeking behaviors in the long term.     

Understanding the Role of Violence in Incarcerated Women's Cervical Cancer Screening and History

In this exploratory study the authors investigated characteristics, including reported experiences of violence, related to incarcerated women's self-report of cervical cancer screening and cancer history and treatment. During a four month period in 2010, 204 women in Kansas City jails were surveyed. Multiple logistic regression models were used to examine the relations of socio-demographic and community characteristics and history of violence among the women to their cervical cancer screening, diagnosis, and treatment histories. Forty percent of the women in the current sample reported abnormal Pap histories, though only 6% of all Pap smears done in the U.S. are abnormal. Women who reported abuse histories in this study were found to be more likely to report having ever had an abnormal Pap smear (for physical abuse Odds Ratio [OR] = 6.05; CI 2.36, 15.54 and for past year intimate partner violence OR = 2.41; CI 1.09, 5.31). Participants who did not fear neighborhood violence were less likely to report an abnormal Pap history (OR = 0.57; CI 0.34, 0.96) and more likely to visit a family doctor for their Pap screenings (OR = 1.91; CI 1.01, 3.60). Women who perceived greater neighborhood violence had increased odds of reporting that they received Pap screenings in a hospital setting (OR = 1.47; CI 1.08, 2.00). Frequency of Pap screening did not differ in women who did and did not have fear of neighborhood violence. This study highlights the heightened cervical cancer risk experienced by women with criminal justice histories and suggests that violence at several levels has implications for cervical cancer prevention for these women.     

Perceived Experiences of Discrimination in Health Care: A Barrier for Cancer Screening Among American Indian Women with Type 2 Diabetes

PurposeBreast and cervical cancer-mortality disparities are prominent among American Indian women. These disparities, in part, may result from patients perceived experiences of discrimination in health care. This report evaluates the impact of perceived discrimination on screening for breast and cervical cancer in a sample of 200 American Indian women with type 2 diabetes.MethodsData were collected from patient report and medical records. Prevalence of breast and cervical cancer screening were assessed. Unadjusted and adjusted logistic regression analyses were used to assess associations between perceived discrimination, cancer screening status, and patients' health care-seeking behaviors.FindingsSubstantial proportions of AI women in our sample were behind the recommended schedules of screening for breast and cervical cancer. Adjusted estimates revealed that perceived discrimination was significantly associated with not being current for clinical breast examination and Pap test, and was close to statistical significance with not being current for mammography. The number of suboptimal health care-seeking behaviors increased with higher mean levels of perceived discrimination.ConclusionsAmong AI women, perceived discrimination in health care may negatively influence use of breast and cancer screening services, and health care-seeking behaviors. More research is needed among AIs to examine features of health care systems related to the phenomenon patients perceived experience of discrimination.     

Why many visible minority women in Canada do not participate in cervical cancer screening

Objective. To determine a high-risk group of visible minority women in Canada who do not participate in cervical cancer screening and the reasons why they do not participate.

Design. We combined two cycles of a large Canadian health survey, Canadian Community Health Survey (CCHS), to obtain a large sample size of visible minority women. Proportions of ‘never having a Papanicalaou (Pap) test’ and ‘not having a Pap test within the last three years’ were then calculated for different ethnic groups using sampling weights advised by Statistics Canada to account for the complex sampling procedure used in CCHS. A logistic regression model was developed to test the association between demographic and health-related variables and not having a Pap test. To identify visible minority women who were at a high risk of not having a Pap test, we stratified these women simultaneously on three variables that were significant in the logistic regression model.

Results. Visible minority women were more than twice as likely never to have had a Pap test. Among visible minority women, those who recently immigrated to Canada and did not have a regular physician had the highest risk for not having a Pap test. Common reasons reported for not having a Pap test included believing it was not necessary and simply not getting around to it.

Conclusion. Visible minority women in Canada may not be participating in regular Pap testing because of cultural beliefs and a lack of an understanding of the importance of Pap testing. A culturally appropriate cervical cancer screening intervention program that involves members of visible minority communities may increase participation of this subgroup of Canadian women. This study provides preliminary information on why visible minority women in Canada do not participate in cervical cancer screening. However, the lumping together of all visible minority may obscure differences between different ethnic groups. Therefore, further research on each ethnic group is required to develop tailored culturally appropriate intervention.     

Understanding the role of violence in incarcerated women's cervical cancer screening and history

In this exploratory study the authors investigated characteristics, including reported experiences of violence, related to incarcerated women's self-report of cervical cancer screening and cancer history and treatment. During a four month period in 2010, 204 women in Kansas City jails were surveyed. Multiple logistic regression models were used to examine the relations of socio-demographic and community characteristics and history of violence among the women to their cervical cancer screening, diagnosis, and treatment histories. Forty percent of the women in the current sample reported abnormal Pap histories, though only 6% of all Pap smears done in the U.S. are abnormal. Women who reported abuse histories in this study were found to be more likely to report having ever had an abnormal Pap smear (for physical abuse Odds Ratio [OR] = 6.05; CI 2.36, 15.54 and for past year intimate partner violence OR = 2.41; CI 1.09, 5.31). Participants who did not fear neighborhood violence were less likely to report an abnormal Pap history (OR = 0.57; CI 0.34, 0.96) and more likely to visit a family doctor for their Pap screenings (OR = 1.91; CI 1.01, 3.60). Women who perceived greater neighborhood violence had increased odds of reporting that they received Pap screenings in a hospital setting (OR = 1.47; CI 1.08, 2.00). Frequency of Pap screening did not differ in women who did and did not have fear of neighborhood violence. This study highlights the heightened cervical cancer risk experienced by women with criminal justice histories and suggests that violence at several levels has implications for cervical cancer prevention for these women.     

Perceptions of cervical cancer risk and screening among transmasculine individuals: patient and provider perspectives

Transmasculine people (individuals assigned a female sex at birth who identify as male or masculine) are at risk of cervical cancer. Despite low rates of Pap test use in this population, research examining the determinants of cervical cancer screening among transmasculine individuals is scarce. We conducted in-depth interviews and focus groups with 49 participants (32 transmasculine patients and 17 healthcare providers) in order to examine transmasculine individuals’ and healthcare providers’ perceptions of cervical cancer risk and screening among individuals on the transmasculine continuum. Overall, patients believed that transmasculine individuals should receive regular Pap tests, especially in the event of gynaecological concerns. While healthcare providers’ views varied, many perceived transmasculine individuals to be at low risk of cervical cancer. Contrary to existing screening guidelines, several providers believed that transmasculine individuals who did not engage in penile-vaginal intercourse with cisgender men, expressed discomfort about Pap testing or intended to obtain a hysterectomy might not need to be screened regularly or at all. Our findings underscore the importance of educating patients and providers about cervical cancer risk among transmasculine individuals and establishing evidence-based guidelines for cervical cancer screening in this underserved population.     

Rural physicians' perspectives on cervical and breast cancer screening: a gender-based analysis

Several studies highlight the role of physicians in determining cervical and breast cancer screening rates, and some urban studies report higher screening rates by female physicians. Rural women in North America remain underscreened for breast and cervical cancers. This survey was conducted to determine if there were significant gender differences in practices and perceptions of barriers to breast and cervical cancer screening among rural family physicians in Ontario, Canada. One hundred ninety-one family physicians (response rate 53.1%) who practiced in rural areas, small towns, or small cities completed a mail questionnaire. The physicians' mean age was 44.4 years (SD 9.9), and mean number of years in practice was 16.6 years (SD 10.3). Over 90% of physicians reported that they were very likely to conduct a Pap test and clinical breast examination (CBE) during a periodic health examination, and they had high levels of confidence and comfort in performing these procedures. Male (68%) and female (32%) physicians were similar in their likelihood to conduct screening, levels of confidence and comfort, and knowledge of breast and cervical cancer screening guidelines. However, the self-reported screening rates for Pap tests and CBE performed during last year were higher for female than male physicians (p < 0.01). Male physicians reported they were asked more frequently by patients for a referral to another physician to perform Pap tests and CBE (p < 0.001). Also, male physicians perceived patients' embarrassment as a stronger barrier to performing Pap tests (p < 0.05) and CBE (p < 0.01) than female physicians. No gender differences were observed in screening rates or related barriers to mammography referrals. These findings suggest that physicians' gender plays a role in sex-sensitive examination, such as Pap tests and CBE. There is a need to facilitate physician-patient interactions for sex-sensitive cancer screening examinations by health education initiatives targeting male physicians and women themselves. The feasibility of providing sex-sensitive cancer screening examinations by a same-sex health provider should also be explored.     

Knowledge and Attitudes of Cervical Cancer Screening Among Caribbean Women: A Qualitative Interview Study From Barbados

The purpose of this study was to explore Barbadian women’s attitudes toward and knowledge of routine cervical cancer screening (Pap tests). We conducted semi-structured individual interviews with fourteen female patients between the ages of 20 and 60 years who attended a selected public clinic in Barbados in May and June 2013. Interviews were audio-recorded with participants’ consent. The interviews were then transcribed verbatim and, using thematic content analysis, indexed and coded inductively for emerging similar themes. We identified four themes: (1) women had poor knowledge of the purpose of Pap tests. The most frequently occurring misconception was that the test was for the detection of sexually transmitted infections. (2) The women displayed limited cervical cancer awareness. (3) Health professionals were identified by the women as the main driving force behind women taking up screening. (4) The screening procedure was perceived as painful, but women’s overriding attitude was that screening was necessary. These findings suggest that Barbadian women would benefit from focused health education efforts surrounding cervical cancer screening to eradicate the misconception that the purpose of the Pap test is the detection of sexually transmitted diseases.     

UK national Lesbians and Health Care Survey

Lesbians are less prevention oriented in their health care behavior than heterosexual women and avoid routine screening tests such as Pap smears and mammograms. The reasons for these differences have been partly attributed to beliefs about risk, (for example, lesbians are said to be at lower risk of cervical cancer) and partly attributed to lesbians' poor experiences of health care because of heterosexism. The Lesbians and Health Care Survey was conducted during the 12 month period of 1997-8. The sample consisted of 1066 lesbians living throughout the UK. The study examined whether risk perceptions, experiences of health care and health-seeking behavior were correlated. Data were analyzed using SPSS to determine which variables were associated with participation in screening. While lesbians were less likely than lesbians in a similar US study to report that their risk of cervical cancer was the same as that of heterosexual women, perceptions of risk were not correlated with participation in screening. We assumed that bad experiences of screening would act as a barrier to attendance; instead, good experiences were associated with the increased likelihood of attendance. These findings under-score the need for a pro-active agenda for lesbian health which addresses the need for culturally competent health care, the sharing of best practice amongst health care providers and the creation of systemic institutional change to improve the care lesbians receive.     

Communicating Cervical Cancer Screening Results in Light of New Guidelines: Clinical Practices at Federally Qualified Health Centers

ABSTRACT

New guidelines for cervical cancer screening (CCS) incorporate both HPV and Pap tests, and there is a need to understand communication of these cotesting results to patients, especially in at-risk populations disproportionally affected by cervical cancer. This study used computer-assisted telephone interviews in 2017 at 51 federally qualified health centers (FQHCs) in Indiana to evaluate the characteristics of clinical communication CCS results to women. Results revealed that clinical communication practices varied on channel, timing, and content. Almost half of the clinics (n = 23, 45%) communicate results to patients by phone. Most clinics (n = 47, 92%) notify patients of results in two weeks or less. For cotesting, 70% (n = 36) always communicate Pap/HPV results at the same time. The majority of clinics (n = 42, 82%) explain the type of abnormal Pap test, while only 43% (n = 22) discuss the cervical cancer risk as indicated by the HPV test result. Even though 98% (n = 48) of participants rated their communication strategy as effective, qualitatively participants acknowledged difficulties in communicating cotesting results with their often transient and low health literate patients populations. These results indicate considerable variation and potential deficits in clinical communication of cotesting results in FQHCs, but several promising communication strategies were identified that may inform improved screening communication for other clinics.     

Maternal Factors and Sexual Orientation-Related Disparities in Cervical Cancer Prevention

ObjectivesOur objective was to explore how mothers’ attitudes and relationships with their daughters may impact the cervical cancer prevention behaviors of daughters with diverse sexual orientations.MethodsWe examined 8,143 mother–daughter dyads from the Nurses' Health Study 2 and Growing Up Today Study. During the daughter's adolescence, each mother reported her beliefs about the importance of regular Pap testing for her daughter, the frequency of communication with her daughter about Pap testing, her beliefs about Pap testing and human papillomavirus (HPV) vaccines, and her acceptance of sexual minorities (e.g., bisexuals, lesbians). Mothers and daughters separately reported relationship satisfaction. Log-binomial models were used to examine the longitudinal association between maternal factors and daughter's receipt of a Pap test and HPV vaccination.ResultsNearly all maternal factors predicted the daughter's likelihood to have a Pap test and HPV vaccination. Higher levels of acceptance for sexual minorities and better relationship quality were also positively associated with these cervical cancer prevention behaviors. Yet, after adjusting for the maternal factors, there was little attenuation of the existing sexual orientation-related disparities in Pap tests or HPV vaccination.ConclusionsMothers can play an important role in their daughters' cervical cancer prevention behaviors through novel processes like being more accepting of sexual minorities and having a good relationship quality. However, in this study, maternal factors did not explain much of the sexual orientation-related disparities in cervical cancer prevention. Efforts to ensure a mother is accepting of sexual minorities and has a good relationship quality with her daughter may improve that daughter's reproductive health.     

The Impact of Near‐Universal Insurance Coverage on Breast and Cervical Cancer Screening: Evidence from Massachusetts

This paper investigates the effect of expansion to near‐universal health insurance coverage in Massachusetts on breast and cervical cancer screening. We use data from 2002 to 2010 to compare changes in receipt of mammograms and Pap tests in Massachusetts relative to other New England states. We also consider the effect specifically among low‐income women. We find positive effects of Massachusetts health reform on cancer screening, suggesting a 4 to 5% increase in mammograms and 6 to 7% increase in Pap tests annually. Increases in both breast and cervical cancer screening are larger 3 years after the implementation of reform than in the year immediately following, suggesting that there may be an adjustment or learning period. Low‐income women experience greater increases in breast and cervical cancer screening than the overall population; among women with household income less than 250% of the federal poverty level, mammograms increase by approximately 8% and Pap tests by 9%. Overall, Massachusetts health reform appears to have increased breast and cervical cancer screening, particularly among low‐income women. Our results suggest that reform was successful in promoting preventive care among targeted populations. Copyright © 2015 John Wiley & Sons, Ltd.