Interventions on Cervical Cancer Screening Increase Participation in Immigrant Women

A study published in JAMA Network Open, found that raising the awareness of general practitioners (GPs) and drawing attention to the importance of encouraging immigrant women to participate in cervical cancer screening (CCS) is a feasible and effective strategy to increase participation in the program. 

In order to achieve even greater participation, the researchers also suggested studying the effect of regular reminders which specifically target immigrants in general practice and evaluating the feasibility and effectiveness of including CCS as a task assigned to midwives as an additional option to screening done by GPs. 

“Previous studies suggest that economic restraints of immigrant women and GPs’ time constraints are important barriers to screening, and our intervention did not change any of these factors,” the authors wrote. “Therefore, in addition to encouraging GPs through targeted interventions such as ours, the inclusion of other HCPs such as midwives in CCS routines could contribute toward even higher participation in the CCS program among immigrants.”

In this cluster-randomized clinical trial which used 20 subdistricts of the Bergen, Norway, municipality as clusters, the researchers matched the clusters to 10 pairs according to the number of immigrant women living in them and randomized thereafter. The intervention was then implemented between January and June 2017 among urban, primary care, general practices in Bergen, and follow-up ended in January 2018. 

The intervention was comprised of 3 elements: an educational session for GPs at lunch describing the importance of CCS among immigrants and giving advice about how to invite them to participate, a mouse pad as a reminder, and a poster placed in waiting rooms. In the educational session, the need for GPs to ask every immigrant woman about CCS was stressed, regardless of their reason for contacting their GP.

A total of 10,360 women, 5,227 in the intervention group and 5,133 in the control group, who attended 39 general practices in the intervention area and 34 in the control area across the 20 subdistricts were included in the study. Overall, the proportion of immigrant women screened was found to have increased by 2.6% in the intervention group and 0.6% in the control group. 

After adjusting for screening status at baseline, women in the intervention group were more likely to have participated in CCS (OR, 1.24; 95% CI, 1.11-1.38). Moreover, this statistically significant effect persisted, unchanged after adjustment for women’s characteristics (OR, 1.24; 95% CI, 1.11-1.38), and was reduced, but still significant, after further adjustment for GP characteristics (OR, 1.19; 95% CI, 1.06-1.34). In subgroup analyses, the intervention particularly increased participation among women who were not previously screened at baseline (OR, 1.35; 95% CI, 1.16-1.56), and those from Poland, Pakistan, and Somalia (OR, 1.74; 95% CI, 1.17-2.61) when adjusting for baseline screening status.

“Despite this group’s obvious heterogeneity, we chose to group them together because the languages used by these women were used on the poster,” the authors wrote. “The stronger effect related to women from Poland, Somalia, and Pakistan might have resulted not only from women reading the poster, but also because their GPs recommended the CCS test to them more often than to other immigrant groups.”

Additional analyses of 69,269 nonimmigrant women living in the same subdistricts of Bergen during the same time period did not demonstrate any impact on the intervention among them. Therefore, the researchers assumed that the effects observed among the immigrants was caused by the interventions among GPs that specifically targeted immigrant women. 

“A future study to measure the effect of this intervention after some years of reminders would be appropriate as the next step in this project. Cost-effectiveness analyses would also be useful but were beyond the scope of the present study,” the authors wrote. “Furthermore, our intervention among GPs might also be relevant for other providers in primary care in urban settings of high-income countries with lower participation of immigrants in CCS and eventually for other preventive interventions.”

Reference:

Møen KA, Kumar B, Igland J, Diaz E. Effect of an Intervention in General Practice to Increase the Participation of Immigrants in Cervical Cancer Screening. JAMA Network Open. doi:10.1001/jamanetworkopen.2020.1903.