Background: Cervical cancer is the second most common cancer among women worldwide and its incidence is higher for certain ethnic groups in Canada, compared to White Canadians. As more women immigrate to Canada, the potential for prevention increases. Failure to prevent cervical cancer is partly due to non-participation in regular screening. The objectives of the research were to (1) explore whether there are cervical cancer screening differences between non-immigrant and immigrant women; (2) explore cervical cancer screening decision-making among immigrant women; and (3) explore the influence of acculturation on cervical cancer screening. Methods: This research consisted of two studies. The first study consisted of quantitative analysis of the 2007-2008 Canadian Community Health Survey (CCHS). Univariate analyses, cross-tabulations, and logistic regression modeling were conducted. Analyses were restricted to women aged 18-69 years old living in Ontario with no history of hysterectomy. Sample weights were applied and bootstrapping was performed. Analyses were conducted on the full Ontario sample (unweighted n=13,549) and the immigrant sample (unweighted n=2,904), the latter of which was stratified into two groups based on self-reported cultural/racial background: immigrant women more likely to report a time-appropriate Pap test (low risk) and those less likely to report a time-appropriate Pap test (high risk). The second study consisted of interviews conducted with 22 older (aged 50-69 years) South Asian immigrant women from Waterloo and Toronto, Ontario. The descriptive qualitative study was informed by grounded theory methodology. Interviews were audio-recorded and transcribed. Results: The first study identified that almost 17% of women reported not having a time-appropriate Pap test. Immigrant women were more likely to report not having a time-appropriate Pap test (21.73%) compared to non-immigrants (14.22%). Among immigrant women, almost 17% of White, Black, and other women (low-risk group) did not report a recent Pap test, compared to 28.67% of Chinese, South Asian, and other Asian women (high-risk group). Among the full Ontario sample, not having a time-appropriate Pap test was associated with being 50-69 years old, single, having low education and income, not having a regular doctor, being of Asian (Chinese, South Asian, other Asian) cultural/racial background, perceiving having less than excellent health, and being a recent immigrant. Among women in the low-risk group, not having a recent Pap test was associated with older age, lower household income, not having a regular doctor, and a lower proportion of life spent in Canada. Among women in the high-risk group, not having a time-appropriate Pap test was associated with lower education and not having a regular doctor. Within the second study, various themes emerged exploring cervical cancer screening decision-making among the sample. Six major categories emerged: (1) the influence of others, (2) health beliefs and knowledge, (3) responsibility over health, (4) experiences in healthcare, (5) components of culture, and (6) the process of acculturation. The influence of doctors on cervical cancer screening decision-making emerged as a strong theme within interviews. Conclusion: Results provide insight into the inequities that still exist in terms of who is participating in cervical cancer screening, as well as the factors involved in screening decision-making and the relationships between them. This research provides an updated overview of Pap test participation in Ontario, as well as advancing our understanding of the influence of factors on screening decision-making among immigrant women. Through this research, it becomes clear that targeted efforts must be directed towards those less likely to get a Pap test.

Cartas al Editor

The development of cervical cancer depends on high-risk human papillomavirus (HR-HPV) persistent infection in the cervix. The transformation process leading to invasive cancer can take many years even decades and provides ample opportunity to detect, prevent and cure true precursor lesions. Although cervical cancer is widely preventable, it is the fourth most common cancer among women throughout the world, being a real public health issue, especially in developing countries, as 85 % of deaths occur in low and middle-income countries. The situation in Bolivia is particularly alarming, as the cervical cancer incidence is around 38.5 per 100,000 women, which is estimated to be the highest incidence in Latin America. Prevention of cervical cancer in Bolivia is mainly based on the cytological examination of a Papanicolaou smear (Pap) and more recently on visual inspection after application of acetic acid (VIA). However, many economic, sociocultural, and geographic barriers impair this prevention program being successful, as reflected by the low coverage obtained with these screening tests.In order to reduce the cervical cancer incidence and mortality in the department of Cochabamba in Bolivia, we aimed to assess a low-cost HPV test applicable on self-samples. We believe that this strategy could improve the poor screening programs developed in our country. An evaluation was first made to knowledge of Bolivian women about human papillomavirus (HPV) and cervical cancer. As expected, Bolivian women, from rural, peri-urban and urban areas, knew little or nothing about those. Secondly, their degree of acceptability and confidence towards HPV self-sampling was assessed. Most of the women found self-sampling easier to perform (86.9 % to 93.2 %) and more comfortable (79.4 % to 83.3 %) compared to physician sampling. However, accuracy to detect cervical pre-cancer was higher in their point of view when it was performed on specimens taken by a physician (35.1% to 63.5%). Accordingly, the campaign of vaginal HPV self-sampling in a peri-urban area increased screening coverage, reaching in three months the annual rate average. Finally, the determination of accuracy to detect preneoplastic lesions was assessed for three screening methods, in 469 women, divided in two groups. The first group included 362 women that underwent three consecutively primary screening tests: self-collected sampling for HR-HPV detection, conventional cervical cytology and visual inspection under acetic acid (VIA). The second group included 107 women referred with a positive HR-HPV test that underwent were triage by conventional cervical cytology and VIA. The presence of high-grade intraepithelial neoplasia or invasive cancer (CIN 2+) was verified by colposcopy and biopsy.Among primary screening tests, the sensitivity of the HR-HPV test to detect CIN 2+ lesions was the highest (76 %). In HR-HPV positive women, the sensitivity of the VIA and cytology to detect CIN 2+ lesions were 100% and 81%, respectively.In conclusion, the knowledge about cervical cancer and HPV infection is poor in Bolivia. Despite greater acceptance of the vaginal self-sampling in all areas, women kept greater confidence in the screening performed by the gynecologist, although HPV self-sampling improved coverage rate. Finally, HPV testing on self- samples was the most sensitive screening test and VIA was the most sensitive method for the triage. / Doctorat en Sciences biomédicales et pharmaceutiques (Pharmacie) / info:eu-repo/semantics/nonPublished

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / To systematically review all studies examining HPV vaccination acceptability among immigrant and ethnic minority parents and eligible individuals for cervical cancer prevention in the Unites states. MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Cochrane database searches were conducted searching for English language, US‐based studies to examine immigrant and ethnic minority population’s acceptability of HPV vaccination. Thirteen of more than 3,098 potentially relevant articles were included in the final analysis. Results. Latinos were statistically more likely to accept vaccination for both their daughters and sons. Foreign‐born adult Latinas were more accepting of the vaccine than U.S.‐born Latinas after controlling for other variables. Overall African American and Asian American parents were less likely to accept HPV vaccination for their daughters than Hispanic and White parents. Of the African American parents who intended to vaccinate their children the majority were significantly non‐Baptist and had higher levels of education. The majority of Haitian immigrants intended to vaccinate daughters and the rest agreed that they would most likely have their daughters vaccinated if their daughters’ physicians recommended it. More research is needed, particularly in the context of health care provider HPV vaccination recommendation to immigrant and ethnic‐minority populations. Acceptance figures so far suggest that the vaccine is generally well received among Hispanic/Latin and Haitian immigrants, but details of ethnic variations among these groups and a qualitative understanding of lower rates of acceptability among African American and Asian American communities are still being awaited. Despite advances in cervical cancer screening rates in the US, cervical cancer remains disproportionately high among low‐income immigrant and minority women, making this subgroup particularly vulnerable to disparities in screening and its detection. The purpose of this study is to examine the qualitative aspects of institutional and community level interventions of Cervical Intraepithelial Neoplasia (CIN) within the immigrant and refugee populations and the use of HPV vaccination as a prevention method. Combinations of the following keywords/phrases will be used: CIN‐ Cervical Intraepithelial Neoplasia, Cervical diseases, Cervical dysplasia, Refugees, Pap smear, Cervical Cancer Screening, HPV‐ Human Papillomavirus, HPV vaccination, Ethnic minorities, Immigrants. Independent reviews of each article will be conducted to assess the study quality and confirm the accuracy, completeness, and consistency of the abstracted data.

Thesis (MPA.) -- University of Limpopo, 2018 / Background: Cancer of the cervix is the fourth most common cancer affecting women worldwide and is currently considered as a sexually transmitted cancer. This type of cancer is caused in most cases by a viral infection, Human Papilloma Virus (HPV) strains 16 and 18. Cervical screening aims to prevent invasive cervical carcinoma by detection and treatment of its precursors cervical intraepithelial neoplasia grade 2 (CIN2) and, particularly, grade 3 (CIN3). The current study aimed at determining the distribution of cervical cancer and the association of cervical cancer with HIV infection in Limpopo Province. Methods: The current study used quantitative retrospective method to systematically review the available data on Papanicolaou (Pap) smears from National Health Laboratory Services at Polokwane hospital from the year 2013 to 2015. The data was kept anonymously by not using the names of the patients and ethical clearance was received from the Turfloop Research Committee of University of Limpopo in consideration of section 14, 15, 16, and 17 of National Health Act 61 of 2004. The data was exported to excel spreadsheet and cleaned before exported into SPSS 23.0 software which was used for data analysis. Results: The findings from the current study show a decline of 33% in the number of Pap smears that were submitted for cytology between 2013 (82 041) and 2015 (23 527) in Limpopo province. However, the study revealed that there is an increase in prevalence of cervical cancer from 16.7% in 2013 to 19.2% in 2015 in Limpopo Province. In the same period this rural province already demonstrates a high burden of cervical cancer among the middle aged women. The positive cervical smears were classified as cervical intraepithelial neoplasia (CIN) I, II, or III and therefore, 78.5% were CIN I, 21% CIN II and 0,5% CIN III. HIV infections have been found to be associated with cervical cancer as the prevalence of cervical cancer among HIV positive women was found to be 25% and most of the affected women are the middle aged group. vi Conclusion: The screening coverage for cervical cancer has decreased in Limpopo Province but the prevalence of cervical cancer has increased by 2.5% therefore, this translates to the need for community awareness about prevention of cervical cancer. Majority of the cases were classified as CIN 1 at 78.5% which can be cured if treatment started early. The Limpopo Province should therefore strengthen strategies to integrate HIV and cervical cancer services as it was found that there is a strong association between the HIV and cervical cancer.

Cervical cancer is the fifth most common cancer in United States with more than 12,000 women diagnosed each year and more than 4,000 preventable deaths with minorities disproportionally represented. Cervical cancer prevention strategies rarely focus on the management of abnormal screening results. The purpose of this quality improvement project was to standardize the management program for abnormal cervical cancer screening results within an integrated health delivery system serving a large minority community. The Plan-Do-Study-Act model guided a comprehensive program evaluation with process improvement, including the creation of an electronic quality data reporting tool to formalize the work process and a quality control and assurance program with exception reports. The evaluation was completed with data to measure the timeliness of abnormal results outreach and continued clinical management. The data were evaluated over time with run charts. Also, an analysis of the data was done through pre- and post-test comparisons with 2-sample t tests to evaluate abnormal cervical cancer screening management before and after the revisions. Although the project did not show a statistically significant difference in the timeliness of outreach and follow-up of abnormal cervical cancer screening results due to the limited data set, the run charts trended positively for timeliness and consistent data reporting with no missed screening reports. Effective cervical cancer screening includes the accurate and timely management of abnormal results to reduce disparities in cervical cancer deaths. This project contributes to positive social change by responding to the Healthy People 2020 goal to reduce the incidence of cervical cancer deaths through a formal process to insure timely intervention for abnormal results in a largely minority community.

In 2015, there were 257,524 women with cervical cancer (CC) in the United States (U.S.). CC is preventable; screening detects early-stage cancer when treatment is most successful. This study aimed to identify predictors for CC screening adherence among U.S. women, describe predictors for screening adherence by marital status, and examine physician recommendation for CC screening and adherence to those recommendations. Predictors were grouped as demographic, acculturation, access to care, chronic conditions, and health behaviors. Descriptive analyses were performed on a sample of 10,667 women from the 2015 National Health Interview Survey, and multiple logistic regression models determined predictors of CC screening adherence, physician recommendations, and adherence to physician recommendations. Overall, 81.7% (95%CI=80.7-82.7%) of U.S. women adhered to CC screening guidelines. Adherence declined with increasing age after 39 years old. Never married women (adjusted odds ratio[aOR]=0.67, CI=0.56-0.79) or current smokers (aOR=0.70, CI=0.59-0.84) had lower odds, while college-educated women had greater odds (aOR=1.38, CI=1.14-1.67) of CC screening adherence. Among unmarried women, 78.6% adhered to CC screening. Unmarried women who were unemployed (aOR=0.48, CI=0.38-0.62), had no physician visits (aOR=0.58, CI=0.40-0.85), no usual source of care (aOR=0.67, CI=0.50-0.89), never heard of HPV (aOR=0.59, CI=0.46-0.76), never received HPV vaccine (aOR=0.50, CI=0.34-0.75), no birth control use (aOR=0.33, CI=0.23-0.47), no flu shot (aOR=0.62, CI=0.48-0.80), and perceived low breast cancer risk (aOR=0.66, CI=0.47-0.92) had lower odds of adherence. Among women with a physician, 55.6% received screening recommendations. Race/ethnicity, access to care, HPV knowledge and vaccine receipt, age when first child was born, and flu shot were significant predictors of physician recommendation for CC screening. Significant predictors of adherence to physician recommendation included education, employment, English proficiency, outpatient clinic visits, usual source of care, age when first child was born, birth control, alcohol use, smoking status, flu shot, and health status. Based on our results, two levels of intervention should be explored. First, targeted interventions are needed for women who are unmarried, have low socio-economic status, and limited access to care to reduce cervical cancer risk. Second, interventions for physicians to increase screening recommendations to all eligible women are needed to improve national screening rates.

Background: In Canada, the prevalence of cervical cancer in Aboriginal women continues to increase with a significantly higher mortality rate than women of non-Aboriginal ancestry. Despite that invasive cervical cancer is highly preventable with regular cervical cancer screening, participation in screening remains lower among Aboriginal women. Since limited information exists on the way cervical cancer screening is perceived and experienced, the purpose of this study was to gain an understanding of Saskatchewan Aboriginal womens perceptions related to and experiences with cervical cancer screening.<p> Methodology: This qualitative exploratory study used an interpretive descriptive approach. Perceptions related to and experiences with cervical cancer screening were elicited through individual interviews with eleven Dakota First Nation women. Women were recruited through purposive sampling techniques. Initially direct quotes from individual transcripts were coded, and then organized with other participant quotes that reflected thematic similarities.<p> Findings: Shared insights reflected a main theme that described perceptions of, experiences with, and factors influencing cervical cancer screening participation among Saskatchewan Aboriginal women. This theme, transitioning from experiencing the negatives of cervical cancer screening participation to living healthier, consisted of the womens mind-set (attitudes and cultural beliefs), knowledge, encounters with the health care system, and sharing information across the generations, which included patterns of communication and a community oriented approach.<p> Discussion: Findings of this study suggest that improving knowledge about cervical cancer screening and cervical cancer may increase screening utilization. Emphasis on health promotion and prevention should be considered when designing education programs. Interventions designed to improve screening rates are more effective when community members are involved in each phase, ensuring cultural relevance. Improving knowledge about, experiences with, and stories shared regarding cervical cancer screening among Aboriginal women may increase screening rates.

Background: In Canada, the prevalence of cervical cancer in Aboriginal women continues to increase with a significantly higher mortality rate than women of non-Aboriginal ancestry. Despite that invasive cervical cancer is highly preventable with regular cervical cancer screening, participation in screening remains lower among Aboriginal women. Since limited information exists on the way cervical cancer screening is perceived and experienced, the purpose of this study was to gain an understanding of Saskatchewan Aboriginal womens perceptions related to and experiences with cervical cancer screening.<p> Methodology: This qualitative exploratory study used an interpretive descriptive approach. Perceptions related to and experiences with cervical cancer screening were elicited through individual interviews with eleven Dakota First Nation women. Women were recruited through purposive sampling techniques. Initially direct quotes from individual transcripts were coded, and then organized with other participant quotes that reflected thematic similarities.<p> Findings: Shared insights reflected a main theme that described perceptions of, experiences with, and factors influencing cervical cancer screening participation among Saskatchewan Aboriginal women. This theme, transitioning from experiencing the negatives of cervical cancer screening participation to living healthier, consisted of the womens mind-set (attitudes and cultural beliefs), knowledge, encounters with the health care system, and sharing information across the generations, which included patterns of communication and a community oriented approach.<p> Discussion: Findings of this study suggest that improving knowledge about cervical cancer screening and cervical cancer may increase screening utilization. Emphasis on health promotion and prevention should be considered when designing education programs. Interventions designed to improve screening rates are more effective when community members are involved in each phase, ensuring cultural relevance. Improving knowledge about, experiences with, and stories shared regarding cervical cancer screening among Aboriginal women may increase screening rates.

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