The borders that remain: prevention of cervical cancer in refugee and immigrant women in Canada

Abstract

Objectives: Cancer of the uterine cervix is primarily caused by infection of human papillomavirus (HPV), and annually results in the deaths of 266,000 women worldwide. Screening for cervical cancer, predominantly via Papanicolau (Pap) tests, has tremendously reduced cervical cancer morbidity and mortality in many developed countries, Canada included. Vaccination against HPV also shows great potential as a preventative measure. Unfortunately, refugee and recently immigrated women are among the least likely to par­ticipate in screening or vaccination at rates recommended by national and provincial guidelines. To gain insight into the barriers faced by refugee women in their access to preventative measures against cervical cancer, it is imperative that we understand the current state of screening and vaccination in this population, and the cultural and systemic barriers by which they are affected.Methods: To gather information on prevention of cervical cancer in refugee women in Canada, three databases were searched: PubMed, CINAHL, and Web of Science. A total of thirteen studies were analyzed, as well as eight other supplemental resources.Results: Rates of cervical cancer screening among refugee and immigrant women were consistently lower than those recommended by provincial guidelines. However, little research dedicated to analyzing HPV vaccination rates of refugees exists. Predictors of low screening and vaccination rates included low socioeconomic factors, recent entry into Canada, and lack of proficiency in English, whereas indicators of screening participation include longer duration spent in Canada, proficiency in English, and access to female physicians and physicians of a similar ethnic background. Screening rates were notably high in an Ontario facility that offers multidisci­plinary support to refugees. Furthermore, a study in the Netherlands has drawn attention to the cultural differences that can act as a barrier to HPV vaccination for immigrants and refugees in Western countries.Conclusions: Preventative health care initiatives should consider the barriers specific to the population at which they are aimed, and work in close collaboration with multidisciplinary settlement services. Further research regarding HPV vaccination rates among refugees in Canada is also required. In light of the current global refugee crisis, applying the insight gained from this research to the incoming Syrian refugee population will be of vital importance. RÉSUMÉObjectifs: Le cancer du col de l’utérus est causé principalement par le virus du papillome humain (VPH), et est responsable du décès de 266 000 femmes annuellement à l’échelle mondiale. Le dépistage du cancer du col de l’utérus, notamment avec le frottis de Pa­panicolaou (test Pap), a vastement réduit la morbidité et la mortalité dues au cancer du col utérin dans plusieurs pays développés, incluant le Canada. La vaccination contre le VPH démontre aussi un grand potentiel en tant que mesure préventive. Malheureusement, les femmes réfugiées et les femmes ayant récemment immigré sont parmi les moins susceptibles de participer au dépistage et à la vaccination aux taux recommandés par les lignes directrices nationales et provinciales. Pour mieux comprendre les obstacles auxquels font face les femmes réfugiées en ce qui a trait à l’accès aux mesures préventives contre le cancer du col utérin, il est impératif de com­prendre l’état actuel du dépistage et de la vaccination de cette population, et les obstacles culturels et systémiques qui les affectent.Méthodes: Pour rassembler de l’information sur la prévention du cancer du col de l’utérus chez les femmes réfugiées au Canada, trois bases de données ont été examinées : PubMed, CINAHL et Web of Science. Un total de treize études ont été analysées, ainsi que huit autres ressources supplémentaires.Résultats: Les taux de dépistage du cancer du col de l’utérus parmi les femmes réfugiées et immigrantes étaient invariablement plus bas que ceux recommandés par les lignes directrices provinciales. Toutefois, il existe peu de recherche dévouée à l’analyse des taux de vaccination contre le VPH chez les réfugiés. Les facteurs prédictifs de faibles taux de dépistage et de vaccination incluent les facteurs socio-économiques faibles, l’arrivée récente au Canada et le manque de compétence en anglais, tandis que les indicateurs prédictifs de participation au dépistage incluent un plus long séjour au Canada, la maîtrise de l’anglais, et l’accès à des femmes médecins et des médecins d’origine ethnique similaire. Les taux de dépistage étaient particulièrement élevés dans un établissement ontarien offrant du soutien multidisciplinaire aux réfugiés. En outre, une étude aux Pays-Bas a attiré l’attention sur les différences culturelles pouvant agir comme obstacle à la vaccination contre le VPH pour les immigrants et réfugiés dans les pays occidentaux.Conclusions: Les initiatives de soins de santé préventifs devraient considérer les obstacles précis auxquels fait face la population ciblée, et devraient travailler en étroite collaboration avec les services multidisciplinaires d’établissement. Plus de recherche sur les taux de vaccination contre le VPH parmi les réfugiés au Canada est également nécessaire. À la lumière de l’actuelle crise mondiale de réfugiés, l’application des connaissances acquises par l’entremise de cette recherche à la population de nouveaux réfugiés syriens sera d’importance vitale.

Cervical Cancer Screening by Refugee Category in a Refugee Health Primary Care Clinic in Calgary, Canada, 2011–2016

“…We used multivariable logistic regression models to estimate the association between refugee category (our primary exposure of interest), and the two outcomes of interest: CCS test completion (primary outcome) and CCS test offered (secondary outcome), while accounting for important sociodemographic and clinical factors which were included in the models as covariates [ 26 , 27 ]. We calculated odds ratios for the outcomes of interest using GARs as the reference group, as they were the largest group (Table 1 ).…”

“…As multidisciplinary clinics, they aim to reduce barriers, provide free or low-cost and comprehensive care with cultural humility, despite clinical complexity. However, while some studies recommend these dedicated clinics, limited evidence exists to show if these clinics do improve preventative care such as CCS for this vulnerable population, especially amidst major health policy changes such as the IFHP cuts [ 16 , 26 , 27 ].…”

Women, Migrations and Health

“…Refugees and immigrants are often of low education and income. Language and cultural barriers can result in lack of knowledge and understanding of preventative procedures, and, especially when coinciding with past trauma, can result in fear authoritative physician with whom they would likely struggle to communicate (Beckett, 2016). Important factors are also older ages and recent entry into host county.…”

“…Meta-analysis assessing the burden of cervical HPV infection among more than one million women without cervical disease showed that 11.7 of the women worldwide are positive for HPV DNA (Bruni et al, 2010). The prevalence of high risk HPV ranges from 11 in healthy women in Belgium, 20 in female university students in the USA to 46 in Spanish women in prisons (Beckett, 2016). Study from 2010 shows that 59.2 of Slovenian women in life have been infected (they have genotypically specific antibodies in the blood) with at least one of the 12 high-risk HPV genotypes and that at the time of the study, in 12.2  of women HPV genotype was proven in a cervical smear (Komloš et al, 2011).…”

Immigrant women cancer survivors’ perceptions of healthcare services in Canada: A phenomenological study

“…Access to health services is one of the significant challenges that many immigrant women face in Canada during their cancer care. [2][3][4] Low socioeconomic status, low levels of education, and language are the main reasons that complicate immigrant women's ability to access health services. [5] The availability of interpreters is also considered a barrier to access to health services.…”