- Email: [email protected]
The impact of community-based multimedia intervention on the new and repeated cervical cancer screening participation among South Asian women
p u b l i c h e a l t h 1 7 8 ( 2 0 2 0 ) 1 e4
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
The impact of community-based multimedia intervention on the new and repeated cervical cancer screening participation among South Asian women D.N.S. Chan*, W.K.W. So The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong SAR, China
article info
abstract
Article history:
Objectives: The objectives of this study were to reveal the screening uptake of South Asian
Received 18 May 2019
women who had participated in the community-based multimedia intervention and to
Received in revised form
identify the reasons among those women who remained unscreened after receiving the
15 August 2019
intervention.
Accepted 25 August 2019
Study design: This was a cross-sectional study. Methods: South Asian women (Indian, Pakistani and Nepalese) who had attended a community-based multimedia intervention and who agreed to participate in a follow-up
Keywords:
telephone survey were contacted. A structured telephone survey was conducted to
Multimedia intervention
collect data on their screening uptake status.
Cervical cancer
Results: There were altogether 371 women who completed the survey. Before attending the
Screening uptake
intervention, 220 of them had never had a Pap test. After the intervention, 75 of those 220
South Asian women
women (34.1%) decided to attend screening, of which 43 underwent their first Pap test, while 32 made their first Pap test appointment. Among those 151 women who previously underwent screening, 76 of them completed the screening or had scheduled a repeated test. Perceived barriers to screening such as lack of time, language barriers and perception that it was unnecessary to attend screening remained the major reasons for women who were not screened. Conclusion: Some South Asian women started to have their first Pap test, while some continued to attend screening after the intervention. As barriers that affect women's screening participation still exist, continuous and sustainable efforts should be made to improve the overall screening uptake. © 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Rm 812, 8/F, Esther Lee Building, The Chinese University of Hong Kong, Shatin, China. Tel.: þ852 39438165; fax: þ852 26035269. E-mail address: [email protected] (D.N.S. Chan). https://doi.org/10.1016/j.puhe.2019.08.015 0033-3506/© 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
2
p u b l i c h e a l t h 1 7 8 ( 2 0 2 0 ) 1 e4
Cervical cancer is a serious health condition affecting women of different ages worldwide. It is the fourth most common cancer and one of the leading causes of cancer-related death among women. The incidence and mortality rates of cervical cancer were 25.0 and 11.0 per 100,000 individuals among women aged 25 years or older, respectively.1 Despite the high prevalence of cervical cancer among women worldwide, it is preventable through the regular utilisation of cancer screening (Pap test).1 A previous study revealed that women who had their cancer detected through screening had longer 5-year relative survival rate than those who did not attend screening.2 In view of the effectiveness of the Pap test, public health policies had been developed based on cervical cancer screening guidelines, and they are implemented in different countries, providing recommendations on who should attend screening, as well as when and how this should be done.3,4 Despite the existence of such guidelines, disparity in Pap test utilisation was observed across different ethnic groups. According to the Centre for Disease Control and Prevention, the percentage of white women who had a Pap test within the past three years was 73.9%, while Asians (67%) and American Indians or Alaska Natives (65.5%) living in the United States exhibited a lower screening uptake.5 In Hong Kong, previous local studies found that only 36.9% of the South Asian women (one of the largest local ethnic minority groups) had ever had a Pap test, while 59% among the general population had ever had a Pap test.6e8 In general, factors such as lack of knowledge on cancer and cancer screening, personal health beliefs and language barriers could directly influence their screening uptake.9 Besides, South Asian culture dictates that women should observe the importance of fulfiling their family duties, with taking care of the children and family being their top priority and taking care of their own health considered to be of low priority. Moreover, the maintenance of modesty, by not exposing their private body parts to people other than their husbands, was required among South Asian women. They may therefore feel embarrassed for the need to expose their body parts during cancer screening, and this is considered a major barrier to cancer screening utilisation among South Asian women.9,10 To address these barriers and to enhance their screening uptake, a culturally relevant multimedia intervention, comprising an interactive health talk, presentation of linguistically appropriate videos and distribution of information booklets, was implemented within the community between the late 2016 and 2017 to enhance their knowledge on cervical cancer and cervical cancer screening and how cancer screening services and interpretation services can be accessed.10 We did receive positive feedback from the participants on the multimedia intervention. Community centres and ethnic minority associations which partnered with us for intervention implementation also continued to provide support in distributing booklets and sharing the educational videos presented during the intervention to South Asian members at their centres/associations and in their newsletters and social media platforms.10 In this report, we present the results of a one-year followup survey that revealed the screening uptake of the South Asian women who had participated in the community-based multimedia intervention.10 It also aimed at identifying the
reasons among those women who remained unscreened even after they have received the intervention. This cross-sectional study, conducted from April to November 2018 in Hong Kong, explored the participation of South Asian women in cervical cancer screening one year after receiving the community-based multimedia intervention. South Asian women originated from India, Pakistan or Nepal who were aged 21 years or older and without a history of cervical cancer were invited to participate in the study. A total of 371 women received the multimedia intervention and the intervention materials from community centres/ethnic minority associations. They all agreed to provide us with their phone numbers for a follow-up survey. All of them were contacted for this survey. The study, approved by the ethics committee of the study institution, involved a structured telephone survey for data collection. It was conducted by trained telephone interviewers who were of the same ethnic background as the target participants. These interviewers were trained for the enhancement of their health-related knowledge and had considerable previous experience in conducting telephone surveys in several projects involving ethnic minorities as participants. Participants were briefed on the purpose of the study and data collection procedures. Informed verbal consent was obtained before the commencement of the survey. Apart from focussing on sociodemographic data, the survey also included three questions for the determination of the uptake rate of Pap test. In particular, participants were asked if they had undergone a Pap test in the past year after the intervention.10 Those women who did not have a Pap test in the past year were asked if they had scheduled a Pap test appointment. Those who had neither undertaken nor scheduled a Pap test were asked to provide reasons for not doing so. The IBM Statistical Package for Social Sciences, version 25.0, was used for statistical analysis. Descriptive statistics such as frequencies and percentages were used to present the sociodemographic characteristics of participants and patterns of Pap test uptake. Furthermore, reasons for not undertaking a Pap test were also presented. The 371 interviewed South Asian women included 137 Indians, 128 Pakistanis and 106 Nepalese. The mean age of the participants was 37.82 years. Most of them were married and had given birth to at least one child. Only 9.7% of the participants had a family history of cervical cancer. Around 38% of them used both English and their native language for communication in daily life, and around 57% of them had lived in Hong Kong for more than ten years. Most of the participants (83%) did not have health insurance. Before receiving the intervention, 151 of the study participants (40.7%) reported to have received a Pap test within the past five years, while the remaining 220 women had not previously received one. In this survey, 43 of these 220 women without a history of Pap test utilisation (19.5%) underwent their first Pap test. Among the remaining 177 women, 32 reported that they had scheduled an appointment for cancer screening and were pending to receive it. Therefore, among these 220 women who had not received the Pap test previously, 75 (34.1%) had decided to undertake the Pap test after having received the intervention. Among the 151 women who had a Pap test
p u b l i c h e a l t h 1 7 8 ( 2 0 2 0 ) 1 e4
previously, 50 had received a repeat Pap test in the past year and 26 had scheduled a Pap test according to physicians’ recommendation and were pending to receive it. In other words, 76 of 151 women (50.3%) decided to continue attending cervical cancer screening after having received the intervention. Regarding the overall screening uptake in our sample, which included 151 women who reported to have undergone a Pap test previously and 43 women who completed their first Pap test in the present survey, 194 (52.3%) of 371 women had undertaken at least one Pap test in their lifetime. In the current survey, 220 women reported that they had not received a Pap test or had not scheduled any Pap test appointments even after receiving the intervention. Perceived barriers to screening remained the major reasons for women who decided not to attend screening. Nearly 30% of the South Asian women stated that they were busy owing to the need to do household chores, deliver childcare and work and therefore did not have time to attend screening. The other barrier commonly cited is language barrier. They expressed that they had difficulties to communicate with the healthcare providers about their concerns. Some of them reported that they could not make cancer screening appointments because they could not communicate in English. Moreover, some women expressed that they did not know where cervical cancer screening services are available. They did not have the information on the addresses of the clinics where the Pap test is provided. Apart from the perceived barriers, South Asian women's knowledge on the perceived risks to the disease also served as a major reason for not utilising the Pap test. Some
Table 1 e Reasons for not undergoing a Pap test or not scheduling a Pap test appointment (N ¼ 220). Reasons 1. Perceived barriers to screening I am busy (housework, childcare, job) and have no time for Pap test. I have a language problem. I do not know where to have the test. I do not think about the test. I am scared of the test. I am shy to attend the test or do not want others to touch me I am too lazy to make an appointment 2. No reason. 3. I have no intention to have a test. 4. My doctor suggested me to have the test once every 3 years 5. I have missed and forgotten to arrange the appointment. 6. Knowledge about personal risk I am not sexually active. I am too old for the test. I do not have menses anymore. The test is not necessary for me, as my health has been fine. 7. Other reasons, e.g., out of town, pregnancy, cervix removed, other existing medical problems
Number of South Asian women [n (%)] 65 (29.6%) 21 (9.6%) 8 (3.6%) 6 (2.7%) 2 (0.9%) 2 (0.9%) 6 (2.7%) 25 (11.3%) 15 (6.8%) 7 (3.2%) 5 (2.3%)
5 2 2 40
(2.3%) (0.9%) (0.9%) (18.2%)
9 (4.1%)
3
participants stated that the test was unnecessary because their health status was fine and they did not experience any discomfort (Table 1). This is the first follow-up survey on South Asian women's participation in cervical cancer screening. The findings revealed a continual increase in the number of South Asian women who have attended a Pap test (52.3%), compared with the figure of the reported Pap test uptake in a previous survey (36.9%). Among the 220 participants who did not have a Pap test previously, 43 women (19.5%) had their first Pap test completed and 32 women (14.5%) had scheduled an appointment after attending the multimedia intervention. The health information received by these participants through their participation in the intervention may have increased their knowledge on cancer and cancer screening.10 Besides, 76 women (50.3%) who attended screening previously had scheduled and repeated the Pap testing. The intervention delivered reminded them on the importance of regular screening utilisation in maintaining health and thus exerted certain influence on those women's cancer screening behaviours.10 Some women reported that they did not have or had not scheduled any Pap test. Apart from being too busy with family duties and work, they claimed that the language barrier was an obstacle to screening utilisation. Although information on the available interpretation services was delivered to the participants, it appears that they still found it difficult to access the service. In Hong Kong, interpretation service is offered by social enterprises and non-government organisations. Those women who wish to use the service must either make a booking through the clinic staff or arrange and pay for the services by themselves. To enhance their screening participation, the utilisation of community health workers who are of the same ethnicity and speak the same language as these women could be useful as they can help overcoming language barriers, delivering health education, providing assistance in scheduling appointments and accompanying them to attend screening tests.10 Meanwhile, there are limitations of the study that need to be addressed. First, because the survey participants were recruited via convenience sampling and information was obtained cross-sectionally, the sole effect of the intervention on screening uptake could not be determined. Hence, the conduction of further randomised controlled trials is warranted to examine the intervention effect on women's screening behaviour. Second, because those South Asian women who had attended the community-based multimedia intervention were the only ones who had taken the survey, the screening status of those who did not attend the intervention could not be determined and compared. Future study should therefore explore the screening status in South Asian women who did not receive the intervention. In sum, while the overall screening uptake has increased with some South Asian women having attended their first test and some continued to be screened, barriers that hamper them from taking part in cancer screening still exist. Continuous and sustainable efforts should be made to help overcome the barriers, such as the utilisation of community health workers in helping these women by providing interpretation services and arrangement of Pap test appointments.
4
p u b l i c h e a l t h 1 7 8 ( 2 0 2 0 ) 1 e4
Author statements Acknowledgement The authors would like to thank the South Asian women who participated in this study.
Ethical approval The ethics committee of the study institution approved the study.
Funding This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Competing interests All authors declare they have no conflict of interest.
references
1. International Agency for Research on Cancer. Estimated number of new cases in 2018, worldwide, females, ages 25þ. 2018. Available from: http://gco.iarc.fr/today/online-analysis-table? v¼2018&mode¼cancer&mode_population¼continents& population¼900&populations¼900&key¼asr&sex¼2& cancer¼39&type¼0&statistic¼5&prevalence¼0&population_ group¼0&ages_group%5B%5D¼5&ages_group%5B% 5D¼17&nb_items¼5&group_cancer¼1&include_ nmsc¼1&include_nmsc_other¼1. [Accessed 10 May 2019]. 2. Andrae B, Andersson TML, Lambert PC, Kemetli L, Silfverdal L, Strander B, et al. Screening and cervical cancer cure: population based cohort study. BMJ 2012;344:e900. https://doi. org/10.1136/bmj.e900.
3. Canadian Task Force of Preventive Health Care. Cervical cancer (2013). 2019. Available from: https://canadiantaskforce.ca/ guidelines/published-guidelines/cervical-cancer/. [Accessed 10 May 2019]. 4. United States Department of Health and Human Services. Agency for healthcare research and quality. Women: stay healthy at any age, 2014 update. 2014. Available from: https://archive. ahrq.gov/patients-consumers/prevention/lifestyle/healthywomen.html. [Accessed 10 May 2019]. 5. Centre for Disease Control and Prevention. Use of Pap smears among women aged 18 and over, by selected characteristics: United States, selected years 1987e2015. 2017. Available from: https:// www.cdc.gov/nchs/hus/contents2017.htm#071. [Accessed 10 May 2019]. 6. Census and Statistics Department. Population By-census. Thematic report: ethnic minorities. 2017. 2016. Available from: https://www.statistics.gov.hk/pub/B11201002016XXXXB0100. pdf. [Accessed 10 May 2019]. 7. So WKW, Wong CL, Chow KM, Chen JMT, Lam WWT, Chan CWH, et al. The uptake of cervical cancer screening among South Asians and the general population in Hong Kong: a comparative study. Journal of Cancer Policy 2017;12:90e6. http://www.sciencedirect.com/science/article/ pii/S2213538317300206. 8. Surveillance and Epidemiology Branch Centre for Health Protection Department of Health. Cervical screening programme annual statistics report 2017. 2018. Available from: https:// www.cervicalscreening.gov.hk/english/sr/files/sr_statistics_ stat.pdf. [Accessed 10 May 2019]. 9. So WKW, Chan DNS, Rana T, Law BMH, Leung DYP, Chan HYL, et al. Development and evaluation of multimedia interventions to promote breast and cervical health among South Asian women in Hong Kong: a project protocol. Asia Pac J Oncol Nurs 2017;4:361e5. https://doi.org/10.4103/apjon. apjon_37_17. 10. So WKW, Kwong ANL, Chen JMT, Chan JCY, Law BMH, Sit JWH, et al. A theory-based and culturally aligned training program on breast and cervical cancer prevention for South Asian community health workers: a feasibility study. Cancer Nurs 2019;42:E20e30. https://doi.org/10.1097/NCC. 0000000000000543.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
The impact of community-based multimedia intervention on the new and repeated cervical cancer screening participation among South Asian women D.N.S. Chan*, W.K.W. So The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong SAR, China
article info
abstract
Article history:
Objectives: The objectives of this study were to reveal the screening uptake of South Asian
Received 18 May 2019
women who had participated in the community-based multimedia intervention and to
Received in revised form
identify the reasons among those women who remained unscreened after receiving the
15 August 2019
intervention.
Accepted 25 August 2019
Study design: This was a cross-sectional study. Methods: South Asian women (Indian, Pakistani and Nepalese) who had attended a community-based multimedia intervention and who agreed to participate in a follow-up
Keywords:
telephone survey were contacted. A structured telephone survey was conducted to
Multimedia intervention
collect data on their screening uptake status.
Cervical cancer
Results: There were altogether 371 women who completed the survey. Before attending the
Screening uptake
intervention, 220 of them had never had a Pap test. After the intervention, 75 of those 220
South Asian women
women (34.1%) decided to attend screening, of which 43 underwent their first Pap test, while 32 made their first Pap test appointment. Among those 151 women who previously underwent screening, 76 of them completed the screening or had scheduled a repeated test. Perceived barriers to screening such as lack of time, language barriers and perception that it was unnecessary to attend screening remained the major reasons for women who were not screened. Conclusion: Some South Asian women started to have their first Pap test, while some continued to attend screening after the intervention. As barriers that affect women's screening participation still exist, continuous and sustainable efforts should be made to improve the overall screening uptake. © 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Address: Rm 812, 8/F, Esther Lee Building, The Chinese University of Hong Kong, Shatin, China. Tel.: þ852 39438165; fax: þ852 26035269. E-mail address: [email protected] (D.N.S. Chan). https://doi.org/10.1016/j.puhe.2019.08.015 0033-3506/© 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
2
p u b l i c h e a l t h 1 7 8 ( 2 0 2 0 ) 1 e4
Cervical cancer is a serious health condition affecting women of different ages worldwide. It is the fourth most common cancer and one of the leading causes of cancer-related death among women. The incidence and mortality rates of cervical cancer were 25.0 and 11.0 per 100,000 individuals among women aged 25 years or older, respectively.1 Despite the high prevalence of cervical cancer among women worldwide, it is preventable through the regular utilisation of cancer screening (Pap test).1 A previous study revealed that women who had their cancer detected through screening had longer 5-year relative survival rate than those who did not attend screening.2 In view of the effectiveness of the Pap test, public health policies had been developed based on cervical cancer screening guidelines, and they are implemented in different countries, providing recommendations on who should attend screening, as well as when and how this should be done.3,4 Despite the existence of such guidelines, disparity in Pap test utilisation was observed across different ethnic groups. According to the Centre for Disease Control and Prevention, the percentage of white women who had a Pap test within the past three years was 73.9%, while Asians (67%) and American Indians or Alaska Natives (65.5%) living in the United States exhibited a lower screening uptake.5 In Hong Kong, previous local studies found that only 36.9% of the South Asian women (one of the largest local ethnic minority groups) had ever had a Pap test, while 59% among the general population had ever had a Pap test.6e8 In general, factors such as lack of knowledge on cancer and cancer screening, personal health beliefs and language barriers could directly influence their screening uptake.9 Besides, South Asian culture dictates that women should observe the importance of fulfiling their family duties, with taking care of the children and family being their top priority and taking care of their own health considered to be of low priority. Moreover, the maintenance of modesty, by not exposing their private body parts to people other than their husbands, was required among South Asian women. They may therefore feel embarrassed for the need to expose their body parts during cancer screening, and this is considered a major barrier to cancer screening utilisation among South Asian women.9,10 To address these barriers and to enhance their screening uptake, a culturally relevant multimedia intervention, comprising an interactive health talk, presentation of linguistically appropriate videos and distribution of information booklets, was implemented within the community between the late 2016 and 2017 to enhance their knowledge on cervical cancer and cervical cancer screening and how cancer screening services and interpretation services can be accessed.10 We did receive positive feedback from the participants on the multimedia intervention. Community centres and ethnic minority associations which partnered with us for intervention implementation also continued to provide support in distributing booklets and sharing the educational videos presented during the intervention to South Asian members at their centres/associations and in their newsletters and social media platforms.10 In this report, we present the results of a one-year followup survey that revealed the screening uptake of the South Asian women who had participated in the community-based multimedia intervention.10 It also aimed at identifying the
reasons among those women who remained unscreened even after they have received the intervention. This cross-sectional study, conducted from April to November 2018 in Hong Kong, explored the participation of South Asian women in cervical cancer screening one year after receiving the community-based multimedia intervention. South Asian women originated from India, Pakistan or Nepal who were aged 21 years or older and without a history of cervical cancer were invited to participate in the study. A total of 371 women received the multimedia intervention and the intervention materials from community centres/ethnic minority associations. They all agreed to provide us with their phone numbers for a follow-up survey. All of them were contacted for this survey. The study, approved by the ethics committee of the study institution, involved a structured telephone survey for data collection. It was conducted by trained telephone interviewers who were of the same ethnic background as the target participants. These interviewers were trained for the enhancement of their health-related knowledge and had considerable previous experience in conducting telephone surveys in several projects involving ethnic minorities as participants. Participants were briefed on the purpose of the study and data collection procedures. Informed verbal consent was obtained before the commencement of the survey. Apart from focussing on sociodemographic data, the survey also included three questions for the determination of the uptake rate of Pap test. In particular, participants were asked if they had undergone a Pap test in the past year after the intervention.10 Those women who did not have a Pap test in the past year were asked if they had scheduled a Pap test appointment. Those who had neither undertaken nor scheduled a Pap test were asked to provide reasons for not doing so. The IBM Statistical Package for Social Sciences, version 25.0, was used for statistical analysis. Descriptive statistics such as frequencies and percentages were used to present the sociodemographic characteristics of participants and patterns of Pap test uptake. Furthermore, reasons for not undertaking a Pap test were also presented. The 371 interviewed South Asian women included 137 Indians, 128 Pakistanis and 106 Nepalese. The mean age of the participants was 37.82 years. Most of them were married and had given birth to at least one child. Only 9.7% of the participants had a family history of cervical cancer. Around 38% of them used both English and their native language for communication in daily life, and around 57% of them had lived in Hong Kong for more than ten years. Most of the participants (83%) did not have health insurance. Before receiving the intervention, 151 of the study participants (40.7%) reported to have received a Pap test within the past five years, while the remaining 220 women had not previously received one. In this survey, 43 of these 220 women without a history of Pap test utilisation (19.5%) underwent their first Pap test. Among the remaining 177 women, 32 reported that they had scheduled an appointment for cancer screening and were pending to receive it. Therefore, among these 220 women who had not received the Pap test previously, 75 (34.1%) had decided to undertake the Pap test after having received the intervention. Among the 151 women who had a Pap test
p u b l i c h e a l t h 1 7 8 ( 2 0 2 0 ) 1 e4
previously, 50 had received a repeat Pap test in the past year and 26 had scheduled a Pap test according to physicians’ recommendation and were pending to receive it. In other words, 76 of 151 women (50.3%) decided to continue attending cervical cancer screening after having received the intervention. Regarding the overall screening uptake in our sample, which included 151 women who reported to have undergone a Pap test previously and 43 women who completed their first Pap test in the present survey, 194 (52.3%) of 371 women had undertaken at least one Pap test in their lifetime. In the current survey, 220 women reported that they had not received a Pap test or had not scheduled any Pap test appointments even after receiving the intervention. Perceived barriers to screening remained the major reasons for women who decided not to attend screening. Nearly 30% of the South Asian women stated that they were busy owing to the need to do household chores, deliver childcare and work and therefore did not have time to attend screening. The other barrier commonly cited is language barrier. They expressed that they had difficulties to communicate with the healthcare providers about their concerns. Some of them reported that they could not make cancer screening appointments because they could not communicate in English. Moreover, some women expressed that they did not know where cervical cancer screening services are available. They did not have the information on the addresses of the clinics where the Pap test is provided. Apart from the perceived barriers, South Asian women's knowledge on the perceived risks to the disease also served as a major reason for not utilising the Pap test. Some
Table 1 e Reasons for not undergoing a Pap test or not scheduling a Pap test appointment (N ¼ 220). Reasons 1. Perceived barriers to screening I am busy (housework, childcare, job) and have no time for Pap test. I have a language problem. I do not know where to have the test. I do not think about the test. I am scared of the test. I am shy to attend the test or do not want others to touch me I am too lazy to make an appointment 2. No reason. 3. I have no intention to have a test. 4. My doctor suggested me to have the test once every 3 years 5. I have missed and forgotten to arrange the appointment. 6. Knowledge about personal risk I am not sexually active. I am too old for the test. I do not have menses anymore. The test is not necessary for me, as my health has been fine. 7. Other reasons, e.g., out of town, pregnancy, cervix removed, other existing medical problems
Number of South Asian women [n (%)] 65 (29.6%) 21 (9.6%) 8 (3.6%) 6 (2.7%) 2 (0.9%) 2 (0.9%) 6 (2.7%) 25 (11.3%) 15 (6.8%) 7 (3.2%) 5 (2.3%)
5 2 2 40
(2.3%) (0.9%) (0.9%) (18.2%)
9 (4.1%)
3
participants stated that the test was unnecessary because their health status was fine and they did not experience any discomfort (Table 1). This is the first follow-up survey on South Asian women's participation in cervical cancer screening. The findings revealed a continual increase in the number of South Asian women who have attended a Pap test (52.3%), compared with the figure of the reported Pap test uptake in a previous survey (36.9%). Among the 220 participants who did not have a Pap test previously, 43 women (19.5%) had their first Pap test completed and 32 women (14.5%) had scheduled an appointment after attending the multimedia intervention. The health information received by these participants through their participation in the intervention may have increased their knowledge on cancer and cancer screening.10 Besides, 76 women (50.3%) who attended screening previously had scheduled and repeated the Pap testing. The intervention delivered reminded them on the importance of regular screening utilisation in maintaining health and thus exerted certain influence on those women's cancer screening behaviours.10 Some women reported that they did not have or had not scheduled any Pap test. Apart from being too busy with family duties and work, they claimed that the language barrier was an obstacle to screening utilisation. Although information on the available interpretation services was delivered to the participants, it appears that they still found it difficult to access the service. In Hong Kong, interpretation service is offered by social enterprises and non-government organisations. Those women who wish to use the service must either make a booking through the clinic staff or arrange and pay for the services by themselves. To enhance their screening participation, the utilisation of community health workers who are of the same ethnicity and speak the same language as these women could be useful as they can help overcoming language barriers, delivering health education, providing assistance in scheduling appointments and accompanying them to attend screening tests.10 Meanwhile, there are limitations of the study that need to be addressed. First, because the survey participants were recruited via convenience sampling and information was obtained cross-sectionally, the sole effect of the intervention on screening uptake could not be determined. Hence, the conduction of further randomised controlled trials is warranted to examine the intervention effect on women's screening behaviour. Second, because those South Asian women who had attended the community-based multimedia intervention were the only ones who had taken the survey, the screening status of those who did not attend the intervention could not be determined and compared. Future study should therefore explore the screening status in South Asian women who did not receive the intervention. In sum, while the overall screening uptake has increased with some South Asian women having attended their first test and some continued to be screened, barriers that hamper them from taking part in cancer screening still exist. Continuous and sustainable efforts should be made to help overcome the barriers, such as the utilisation of community health workers in helping these women by providing interpretation services and arrangement of Pap test appointments.
4
p u b l i c h e a l t h 1 7 8 ( 2 0 2 0 ) 1 e4
Author statements Acknowledgement The authors would like to thank the South Asian women who participated in this study.
Ethical approval The ethics committee of the study institution approved the study.
Funding This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Competing interests All authors declare they have no conflict of interest.
references
1. International Agency for Research on Cancer. Estimated number of new cases in 2018, worldwide, females, ages 25þ. 2018. Available from: http://gco.iarc.fr/today/online-analysis-table? v¼2018&mode¼cancer&mode_population¼continents& population¼900&populations¼900&key¼asr&sex¼2& cancer¼39&type¼0&statistic¼5&prevalence¼0&population_ group¼0&ages_group%5B%5D¼5&ages_group%5B% 5D¼17&nb_items¼5&group_cancer¼1&include_ nmsc¼1&include_nmsc_other¼1. [Accessed 10 May 2019]. 2. Andrae B, Andersson TML, Lambert PC, Kemetli L, Silfverdal L, Strander B, et al. Screening and cervical cancer cure: population based cohort study. BMJ 2012;344:e900. https://doi. org/10.1136/bmj.e900.
3. Canadian Task Force of Preventive Health Care. Cervical cancer (2013). 2019. Available from: https://canadiantaskforce.ca/ guidelines/published-guidelines/cervical-cancer/. [Accessed 10 May 2019]. 4. United States Department of Health and Human Services. Agency for healthcare research and quality. Women: stay healthy at any age, 2014 update. 2014. Available from: https://archive. ahrq.gov/patients-consumers/prevention/lifestyle/healthywomen.html. [Accessed 10 May 2019]. 5. Centre for Disease Control and Prevention. Use of Pap smears among women aged 18 and over, by selected characteristics: United States, selected years 1987e2015. 2017. Available from: https:// www.cdc.gov/nchs/hus/contents2017.htm#071. [Accessed 10 May 2019]. 6. Census and Statistics Department. Population By-census. Thematic report: ethnic minorities. 2017. 2016. Available from: https://www.statistics.gov.hk/pub/B11201002016XXXXB0100. pdf. [Accessed 10 May 2019]. 7. So WKW, Wong CL, Chow KM, Chen JMT, Lam WWT, Chan CWH, et al. The uptake of cervical cancer screening among South Asians and the general population in Hong Kong: a comparative study. Journal of Cancer Policy 2017;12:90e6. http://www.sciencedirect.com/science/article/ pii/S2213538317300206. 8. Surveillance and Epidemiology Branch Centre for Health Protection Department of Health. Cervical screening programme annual statistics report 2017. 2018. Available from: https:// www.cervicalscreening.gov.hk/english/sr/files/sr_statistics_ stat.pdf. [Accessed 10 May 2019]. 9. So WKW, Chan DNS, Rana T, Law BMH, Leung DYP, Chan HYL, et al. Development and evaluation of multimedia interventions to promote breast and cervical health among South Asian women in Hong Kong: a project protocol. Asia Pac J Oncol Nurs 2017;4:361e5. https://doi.org/10.4103/apjon. apjon_37_17. 10. So WKW, Kwong ANL, Chen JMT, Chan JCY, Law BMH, Sit JWH, et al. A theory-based and culturally aligned training program on breast and cervical cancer prevention for South Asian community health workers: a feasibility study. Cancer Nurs 2019;42:E20e30. https://doi.org/10.1097/NCC. 0000000000000543.