Volume 11 Issue 1
a peer reviewed article
AIM: This literature review presents factors that have led to decreased cervical cancer screening rates in Australian migrant women. It also evaluates past interventions that have been implemented to solve this issue in screening.
METHODS: A wide range of peer reviewed articles from databases such as CINAHL and SCOPUS were analysed to determine factors that have led to migrant women having a lower cervical cancer screening rate in comparison to the general Australian population. This review also analysed the reference lists from these articles.
RESULTS: The factors that have led to this reduction in screening rates include cultural differences, limited acculturation, modesty, and logistical issues. Specific cultural issues such as female genital mutilation and the use of Ayurvedic medicine in certain ethnic groups may also contribute. There have been interventions aimed at increasing screening rates, including ethnic media campaigns and education of health professionals, such as doctors and nurses who work in these communities. However, their effectiveness is uncertain due to a lack of evaluation after implementation.
CONCLUSION: Whilst research has provided a basic understanding of the reasons that have contributed to the difference in screening between these two populations, there have been insufficient strategies applied to remedy it. Moreover, there has been inadequate appraisal of current interventions and discussion of the cultural appropriateness of current programs.
This year, the Australian government has renewed the National Cervical Cancer Screening Program (NCSP) to incorporate updated screening protocols in accordance to new research. Hence, it is important to assess the value of the previous screening protocols in underscreened populations such as Australia’s migrant women. From 2012-2013, 58.2% of the target population partook in the NCSP and since the introduction of organised cervical cancer screening in Australia, cervical cancer mortality has fallen by 44% (95% CI 0.51-0.62).[1,2,3] Whilst migrant women have benefited from screening, the results have not been as favourable in comparison to the general population. The incidence of cervical cancer is higher in migrant women from countries with higher incidence of cervical cancer, including Sub-Saharan Africa, Central America, South East Asia and Melanesia.
Consequently, this paper will examine relevant literature since the current NCSP’s introduction in 1991. It will analyse the factors that have caused lower screening rates in migrants, at the level of both the individual and the health system. It will also analyse past and future interventions that may reduce these disparities evident in the rates of cervical cancer screening in Australian migrant women.
This literature review used various online databases to source information. It concentrated on articles that surveyed Australian migrant women, however some larger international studies were also used to provide global context. CINAHL was searched with keywords “cervical cancer AND migrant women”, and SCOPUS was searched with the key words “cervical cancer AND migrant AND Australia”. Only peer reviewed journal articles were used, and opinion papers were excluded in the search. Relevant articles since 1991 were analysed, from the implementation of the NCSP in Australia. Additionally, reference lists of relevant articles were examined using similar inclusion criteria.
What is a pap smear?
Pap smears are the recommended primary screening tool for cervical cancer by the NCSP. During the procedure, the doctor collects a cytological sample from the ectocervical and endocervical canal of the uterus, which is then analysed to see if any pre-cancerous or cancerous changes are present. If a cytological abnormality is identified, the patient will then be referred for colposcopy. Pap smears are routinely used in general practice and account for approximately 1.7 of 100 consultations. Disease incidence and burden is reduced in Australia through organised screening for cervical cancer. A key strategy lies in general practitioners instigating accessible screening, recall systems and opportunistic screening in their practice.
Factors that prevent regular screening
Lack of Knowledge
Prior to living in Australia, many migrant women from developing countries had never heard of cervical cancer screening or understood the risk factors associated with the disease. This is the result of a lack of organised screening programs in countries such as Ghana and Vietnam, as their health systems lack the appropriate human resources and infrastructure to support such programs.[8,9,10] Hence, Australian general practitioners are key in providing health education to new migrant women about the NCSP. A qualitative study of 21 West African women in Australia showed that they became informed about pap smears via public health campaigns and from antenatal care during pregnancy in Australia. After this initial point of contact, they had their first pap smear after their pregnancy and then received reminders every two years. Although migrant women of reproductive age were educated through these campaigns, post-menopausal women who have a greater risk of cancer with age were neglected.
Even with health education on cervical cancer, it appears that migrant women still have a misconstrued understanding about the NCSP or why they require a pap smear.[8,12] The surveyed West African migrant women believed that they did not require a pap smear without a family history of cervical cancer. Thai and Chinese migrant women also had misconceptions about the risk factors of cervical cancer which included promiscuous behaviour, karma or having a sexual partner who had unhygienic genitalia.[7,13] Some Chinese migrant women did not understand the role of pap smears as a screening tool and none of the surveyed women were aware of the role of Human Papillomavirus (HPV) in cervical cancer. Furthermore, these migrant women believed they did not require a pap smear as they were asymptomatic, had no family history and only had one sexual partner.[7,8]
Language is a common barrier for women from non-English speaking backgrounds (NESB). Migrant women have a strong preference to see a doctor who speaks their native language, regardless of their English proficiency, as it allows for clearer articulation of their concerns, particularly regarding intimate procedures. However, a study of migrant women from NESB portrayed that 75.1% of the surveyed women would prefer female health providers to male practitioners to conduct their pap smear, and only 36.4% would travel a large distance to see a doctor who spoke their own language. Another study of Thai immigrant women analysed that 61% would prefer a female general practitioner to perform the pap smear due to embarrassment. This implied that modesty was important to migrant women from a NESB, especially as the newer migrant population often were from very conservative cultures in the discussion of sexual and reproductive health is surrounded by stigma. Additionally, cultural beliefs about maintaining purity may also affect cervical cancer screening, with Assyrian migrants believing that unmarried women should not have pap smears as premarital sex is prohibited. Throughout the literature, it appears that migrant women feel vulnerable and embarrassed during their pap smears and would ideally prefer a female doctor who spoke their language to assist them.[7,8,12]
Moreover, there are factors that are culturally specific, such as female genital mutilation (FGM) and the use of Ayurvedic medicine. Approximately 130 million females worldwide have experienced FGM, mainly in Asia, the Middle East and Africa. Migrant women with FGM may not wish to undergo pap smears due to pain, both physical and psychological, and the reminder of the initial traumatic experience. Ayurvedic medicine is practised throughout Asia. A study of Thai women in Brisbane showed these women saw a variety of alternative medical practitioners; including naturopaths, chiropractors, herbalists and traditional Chinese healers; both in Australia and Thailand. As these women would often rely on these traditional methods for medical care, they were less likely to present to their general practitioner for ailments and thus have a reduced chance of undertaking opportunistic cervical cancer screening.
Finally, the time since migration to Australia is directly proportional to a woman’s probability of having regular pap smears. As acculturation occurs, the individuals becomes more integrated into the Australian community and start to adopt health preventative behaviours. Single migrants or those who are married to other migrants took the longest time to adjust to the health system. On the other hand, migrants who married an Australian or had a catalytic health event, such as the birth of a child, had a faster trajectory to health acculturation.
Various factors further contribute to the lower participation of migrant women in cervical cancer screening. Several migrant women from Asia and the Middle East hold a fatalistic view of health and believe that screening is superfluous, as they have no control over their destiny. Migrant women from Yugoslavian and West African communities describe their fear of their results and do not wish to start looking for problems that did not exist.[8,20] Similar to women in the general population, Chinese Australian women describe how previous negative experiences have deterred them from having regular pap smears. Additionally, they may simply forget or have logistical barriers that prevent regular pap smears, such as lack of transportation or childcare.[7,20]
From 2002 to 2011, the Australian Research Council (ARC) spent 7.8% of their funding for people-related research on the migrant population; insufficient considering migrants comprise over a quarter of the Australian population.[21,22] Moreover, the lack of funding for migrant research does not allow for the provision of strongly evidence-based interventions into migrant health, especially as data is not available as to the amount of ARC funding allocated specifically to cervical cancer screening. Nonetheless, using available Australian data supplemented with some international publications, the following conclusions can be drawn about the effectiveness of past interventions and discussion of what is required for future success.
Migrant women state that they largely receive information about cervical cancer from health professionals and public media campaigns. Therefore, the lack of awareness about pap smears must be targeted in both health and community settings; through general practice, migrant resource centres and community centres. General practitioners play a key role in advocating for cervical cancer screening in consultations and through reminder letters, as migrant women who have never had a pap smear may not be comfortable asking for the test.[7,8,23] Similarly, the use of nurses in community, refugees health, women’s health, and child and family health is key in facilitating discussions regarding cancer screening amongst the migrant population.
The Ethnic Communities Council of Queensland (ECCG) created the Pilot Cancer Screening Education Program (PCSEP) which identified cervical cancer screening levels in various migrant populations before and after their program. In this program, 76% of participants participated in cervical cancer screening and this increased to 91% after the PCSEP. Yet as this result was not statistically significant, we cannot confirm that this target program would be successful in increasing cervical cancer screening rates in migrant populations.
As cultural factors play a key role in the decreased screening rate amongst migrant women, it is essential for Australian doctors to undertake cultural sensitivity training. This may improve understanding of factors affecting women from certain cultures such as modesty and fatalistic views of health. This will allow health practitioners to appropriately tailor their consultations and the way that they promote cervical cancer screening with their migrant patients.
There may also be reduced rates of cancer screening referrals from migrant doctors to patients of their own nationality. A study of Korean American doctors showed that there were reduced referral rates of colorectal cancer screening for their Korean patients. This was because they understood the cultural sensitivities surrounding cancer screening and perceived that compliance would be lower amongst their Korean patients. It is key for doctors providing carer to patients of the same nationality to undergo training in cancer screening. The significance of bilingual health practitioners cannot be underestimated, as migrants prefer to see practitioners of the same nationality.[7,23] In the Vietnamese community, information sessions for bilingual practitioners about cervical cancer has been documented, but the effectiveness of this intervention has not been assessed.
Use of ethnic media
Previous interventions have used ethnic media as a health promotion strategy to increase cervical cancer screening in various migrant populations.[23,26] Between 1991 and 1994, Pap Test Victoria conducted three sets of interventions in ethnic media outlets for over 12 migrant groups including Vietnamese, Chinese, Arabic and Turkish populations. During these interventions, the respective ethnic media outlets conducted live interviews, paid announcements and competitions with prizes. These three interventions led to an increase in screening compliance by 6.7% (95% CI 4.4-9.2). As ethnic media can be utilised for health promotion and appears to be an effective method of increasing screening uptake, funding should be allocated for a nationwide ethnic media campaign on cervical screening.
Lower rates of cervical cancer screening in migrant women is a multifaceted issue. Factors contributing to these lower rates include lack of knowledge, cultural differences, limited acculturation and logistical issues. While research has been undertaken to understand the cause of the decreased participation of migrant women in regular pap smears, there have not been sufficient evidence-based interventions to address the issue. Although the government has redesigned the NCSP to reflect current medical research, there has been little evaluation of the cultural appropriateness of the current NCSP and the effectiveness of previous interventions to increase participation amongst the migrant population. The renewal of the NCSP should parallel the increased number of research projects that occurred during its initial implementation, as this is necessary to provide updated information on cervical cancer screening to migrant women. This will then allow for the application of evidence-based interventions to increase pap smear rates in this underscreened population.
Archana is a fourth year medical student from James Cook University with interests in global health and women’s health.
Conflict of Interest
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