Relative risk of cervical cancer in indigenous women in Australia, Canada, New Zealand, and the United States: A systematic review and meta-analysis

Addressing the burden of cervical cancer for Indigenous women in Latin America and the Caribbean: a call for action

Cervical cancer, primarily caused by human papillomavirus (HPV) infection, poses a significant global health challenge. Due to higher levels of poverty and health inequities, Indigenous women worldwide are more vulnerable to cervical cancer than their non-Indigenous counterparts. However, despite constituting nearly 10% of the population in Latin America and the Caribbean (LAC), the true extent of the burden of cervical cancer among Indigenous people in this region remains largely unknown. This article reviews the available information on cervical cancer incidence and mortality, as well as HPV infection prevalence, among Indigenous women in LAC. The limited existing data suggest that Indigenous women in this region face a heightened risk of cervical cancer incidence and mortality compared to non-Indigenous women. Nevertheless, a substantial knowledge gap persists that must be addressed to comprehensively assess the burden of cervical cancer among Indigenous populations, especially through enhancing cancer surveillance across LAC countries. Numerous structural, social and cultural barriers hindering Indigenous women's access to HPV vaccination and cervical cancer screening worldwide have been identified and are reviewed in this article. The discussion highlights the critical role of culturally sensitive education, community engagement, and empowerment strategies in overcoming those barriers. Drawing insights from the success of targeted strategies in certain high-income countries, the present article advocates for research, policies and healthcare interventions tailored to the unique context of LAC countries.

Population-Based Trends in Cervical Cancer Incidence and Mortality in Brazil: Focusing on Black and Indigenous Population Disparities

OBJECTIVE

This study aimed to explore trends in cervical cancer (CC) incidence and mortality rates according to race/skin color in Brazil focusing on the seriousness of the racial disparity.

METHODS

Data from Brazilian Population-Based Cancer Registries (PBCRs) were analyzed for trends in incidence between 2010 and 2015. For mortality, data from the National Mortality Information System were retrieved between 2000 and 2020. A self-declaration on race/skin color was collected following the classification proposed by the Brazilian Institute of Geography and Statistics - white, black, brown/mixed race, yellow, or indigenous. For the analysis, black and brown/mixed race were grouped as black.

RESULTS

Between 2010 and 2015, 10,844 new cases of CC were registered in the participating PBCRs, distributed among white women (49.6%), black (48.0%), and other race/skin color (2.3%). Compared with white counterparts, black women had a 44% higher risk of incident CC. As for mortality, between 2000 and 2020, 108,590 deaths from CC occurred nationwide. The mean age-adjusted mortality rates according to race/skin color were 3.7/100,000 for white, 4.2/100,000 for black, 2.8 for yellow, and 6.7 for indigenous women. Taking the mortality rates in white women as a reference, there was a 27% increase in death risk in black women (RR = 1.27) and 82% in indigenous women (RR = 1.82).

CONCLUSION

These findings suggest that the higher rates of incidence and mortality from CC in vulnerable populations of black and more impactfully indigenous women in Brazil remain alarming. More efficient HPV vaccination strategies synchronized with well-conducted Pap smear-based screening should be prioritized in these more vulnerable populations.

Indigenous women's experiences of cervical cancer screening: Incorporating Indigenous ways of knowing into a systematic review and meta-synthesis of qualitative research

Due to historical and contextual factors, cervical cancer is typically detected at a later stage in Indigenous women, and so has higher morbidity and mortality. Increasing participation in cervical cancer screening (CCS) could ameliorate this health inequity by detecting cancer when it is more easily treatable. To understand the perspectives, preferences, and experiences of Indigenous women related to participation in CCS, we conducted a systematic review and meta-synthesis of nine qualitative research studies. To advance decolonised qualitative evidence synthesis approaches, we use a modified version of the Two Row Wampum-Covenant Chain Tradition, a Haudenosaunee two-eyed seeing analytic approach that integrates Western approaches with Indigenous worldviews. Using the metaphor of a network of forest plants, we illustrate the systemic and topical barriers and facilitators to CCS, as reported by Indigenous women. We use this metaphor to reiterate the importance of all levels of change to improve CCS experiences for Indigenous women.

HPV molecular detection from urine versus cervical samples: an alternative for HPV screening in indigenous populations

Background

Cervical cancer (CC) is the fourth leading cause of death from neoplasms in women and is caused by the human papilloma virus (HPV). Several methods have been developed for the screening of cervical lesions and HPV; however, some socio-cultural factors prevent women from undergoing gynecological inspection, which results in a higher risk of mortality from cervical cancer in certain population groups as indigenous communities. This study aimed to compare the concordance in HPV detection from urine and cervical samples, to propose an alternative to cervical scraping, which is commonly used in the cervical cancer screening.

Methodology

The DNA from cervical scrapings and urine samples was extracted using the proteinase K method followed by precipitation with alcohol, phenol andchloroform; a modification of the proteinase K method was developed in the management of urine sediment. Viral genotyping was performed using INNOLipa.

Results

The study population consisted of 108 patients from an indigenous population at southern Mexico, 32 without squamous intraepithelial lesions (NSIL) and 76 with low squamous intraepithelial lesions (LSIL). The majority of NSIL cervical scrapes were negative for HPV (90.63%), whereas more than half of LSIL cases were high-risk HPV positive (51.32%), followed by multiple infection by HR-HPV (17.11%), and multiple infection by LR- and HR-HPV (9.21%). No statistically significant relationship between the cytological diagnosis and the HPV genotypes detected in the urine samples was observed. A concordance of 68.27% for HPV positivity from urine and cervical samples was observed. Similarly, a concordance of 64.52% was observed in the grouping of HPVs by oncogenic risk. HR-HPV was detected in 71% of the urine samples from women with LSIL diagnosis, which suggests that HR-HPV detected in a urine sample could indicate the presence or risk of developing SIL.

Conclusion

HR-HPV detection in urine samples could be an initial approach for women at risk of developing LSIL and who, for cultural reasons, refuse to undergo a gynecological inspection.

A systematic review and meta-analysis of the prevalence of human papillomavirus infection in Indigenous populations - A Global Picture

BACKGROUND AND AIM

Recent trends have shown a decline in the rates of human papillomavirus (HPV)-associated cervical cancer in the vaccinated population but there has been a spike in the HPV-associated oropharyngeal, anal and penile cancers in the majority of the unvaccinated population which are young and middle-aged males. Indigenous populations at an international level carry a disproportionate burden of most diseases. The aim of this meta-analysis was to ascertain the worldwide prevalence of HPV infection in Indigenous populations stratified by sex and site and to document the most commonly reported HPV types.

METHODS

Published articles on HPV infection in Indigenous populations from PubMed, Scopus, EMBASE and Web of Science were systematically searched from inception until 23 December 2019.

RESULTS

A total of 41 studies were included in the final analysis. The pooled worldwide prevalence of HPV infection (for both oral and genital sites, both males and females) in Indigenous populations was 34.2% (95% CI: 28.9%-39.8%). Subgroup analysis (geographical) showed that the pooled prevalence for African Indigenous, American Indigenous and Asian-Oceanic Indigenous populations were 33.0% (95% CI: 12.8%-57.1%), 33.0% (95% CI: 27.4%-38.9%) and 33.3% (95% CI: 0.17.5%-51.3%), respectively.

CONCLUSION

There are not enough data on the burden of the infection carried by males especially with respect to highly suspicious sites like oropharynx. Also, we conclude an overall high prevalence of HPV infection in the Indigenous populations and increasing their susceptibility to benign and malignant manifestations of HPV.

A rapid review of Indigenous boys' and men's sexual health in Canada

Indigenous boys and men in Canada face adverse social and structural circumstances that affect their ability to achieve and maintain sexual health. Research about Indigenous sexual health, however, is largely limited to matters relating to women and statistics on sexually transmitted infections. A rapid review of research was conducted to determine what is currently known about Indigenous boys' and men's sexual health in Canada. Given the prevalence of research documenting quantitative disparities, the current review included qualitative research only. Thirteen included studies explored a wide range of topics relating to sexual health and an overarching intersection between social conditions and individual health outcomes was observed. The results of this review reveal significant gaps in the literature relating to the holistic sexual health of Indigenous boys and men and highlight important domains of sexual health to consider in future research. Findings suggest that sexual health programmes that promote traditional Indigenous knowledge and intergenerational relationships may be effective for promoting sexual health among Indigenous boys and men.

Achieving cervical cancer elimination among Indigenous women

Achieving the World Health Organisation (WHO) cervical cancer elimination target of fewer than four new cases per 100,000 woman-years requires scaling up HPV vaccination of girls, cervical screening, and pre-cancer and cancer treatment. We reviewed data from four high-income colonised countries (Australia, Canada, Aotearoa New Zealand (NZ), and the United States (US)) to identify how each is currently performing compared to the cervical cancer incidence elimination and triple-intervention targets, nationally and in Indigenous women. We also summarise barriers and enablers to meeting targets for Indigenous women. To achieve elimination, cervical cancer incidence must be reduced by 74% in Indigenous women in Australia, and 63% in Maori women in NZ; data were not published in sufficient detail to compare incidence in Indigenous women in Canada or the US to the WHO target. Only Australia meets the vaccination coverage target, but uptake appears comparatively equitable within Australia, NZ and the US, whereas there appears to be a substantial gap in Canada. Screening coverage is lower for Indigenous women in all four countries though the differential varies by country. Currently, only Australia universally offers HPV-based screening. Data on pre-cancer and cancer treatment were limited in all countries. Large inequities in cervical cancer currently exist for Indigenous peoples in Australia, Canada, New Zealand and the US, and elimination is not on track for all women in these countries. Current data gaps hinder improvements. These countries must urgently address their systemic failure to care and provide health care for Indigenous women.

Tangled pasts, healthier futures: Nursing strategies to improve American Indian/Alaska Native health equity

American Indian/Alaska Native (AI/AN) populations in the United States continue to experience overall health inequity, despite significant improvement in health status for nearly all other racial-ethnic groups over the past 30 years. Nurses comprise the bulk of healthcare providers in the U.S. and are in an optimal position to improve AI/AN health by transforming both nursing education and practice. This potential is dependent, however, on nurses' ability to recognize the distinct historical and political conditions through which AI/AN health inequities have been produced and sustained. Nurse providers, educators, and leaders must in turn recognize how the sustained conditions of marginalization and expropriation that underpin current AI/AN health inequities continue to shape contemporary AI/AN health outcomes. This manuscript builds upon the extant literature of AI/AN historical health policy and utilizes decolonial theorizations of nursing and a cultural safety framework to propose a series of immediately actionable steps for nursing intervention into AI/AN health inequity. Ultimately, we suggest that it is crucial for nurses to collaborate with AI/AN individuals and communities across educational and clinical settings to further refine these approaches in alignment with the disciplinary obligation of promoting social justice within healthcare.

Comparing cancer incidence, stage at diagnosis and outcomes of First Nations and all other Manitobans: a retrospective analysis

Background

Globally, epidemiological evidence suggests cancer incidence and outcomes among Indigenous peoples are a growing concern. Although historically cancer among First Nations (FN) peoples in Canada was relatively unknown, recent epidemiological evidence reveals a widening of cancer related disparities. However evidence at the population level is limited. The aim of this study was to explore cancer incidence, stage at diagnosis, and outcomes among status FN peoples in comparison with all other Manitobans (AOM).

Methods

All cancers diagnosed between April 1, 2004 and March 31, 2011 were linked with the Indian Registry System and five provincial healthcare databases to compare differences in characteristics, cancer incidence, and stage at diagnosis and mortality of the FN and AOM cohorts. Cox proportional hazard regression models were used to examine mortality.

Results

The FN cohort was significantly younger, with higher comorbidities than AOM. A higher proportion of FN people were diagnosed with cancer at stages III (18.7% vs. 15.4%) and IV (22.4% vs. 19.9%). Cancer incidence was significantly lower in the FN cohort, however, there were no significant differences between the two cohorts after adjusting for age, sex, income and area of residence. No significant trends in cancer incidence were identified in either cohort over time. Mortality was generally higher in the FN cohort.

Conclusions

Despite similar cancer incidence, FN peoples in Manitoba experience poorer survival. The underlying causes of these disparities are not yet understood, particularly in relation to the impact of colonization and other determinants of health.

Nurses' Experiences of Establishing Meaningful and Effective Relationships With American Indian Patients in the Cancer Care Setting

Introduction

The establishment of caring relationships with racial and ethnic minority populations is challenging for many cancer care nurses. Nurses serving American Indian (AI) patients frequently encounter population-specific issues, yet their experiences are largely unknown.

Objective

The purpose of this study was to describe the meaning of the AI patient-cancer care nurse relationship from nurses' perspectives. The study included three objectives: (a) to describe the immediate experiences of nurses that have engaged in cancer care relationships with AI patients, (b) to identify the underlying structures of the AI patient-cancer care nurse relationship as described by nurses, and (c) to interpret the meaning of the patient-nurse relationship within the context of AI cancer care experiences.

Methods

This was an interpretive phenomenological study using a hermeneutical process for data collection and analysis of multiple, exploratory interviews. Thematic reduction was completed to explicate the fundamental structures of this particular relationship. Reduction of individually situated themes resulted in seven shared meta-themes including from task to connection; unnerving messaging; we are one; the freedom of unconditional acceptance; attuning and opening; atoning for the past, one moment at a time; and humanizing the inhumane.

Results

Nine cancer care nurses participated. Reconstitution of data and reflective writing suggested that the essential meaning of the AI patient-cancer care nurse relationship was expressed in contradictory yet simultaneous patterns for nurses. Nurses sought synchronicity with their AI patients despite their contextual differences and similarities, yet most lacked adequate cultural safety training. Being in relationship provided nurses great purpose within the universal human context of caring.

Conclusions

Results contribute to the development of interventions designed to improve both the AI cancer care experience and the support and training of nurses. The mutually dependent nature of the patient-nurse relationship implies that strengthening and improving support for one entity may in turn positively impact the other.

Human papillomavirus vaccination and genital warts in young Indigenous Australians: national sentinel surveillance data

OBJECTIVES

To examine the impact of the national human papillomavirus (HPV) vaccination program (available to girls and women [12-26 years] since 2007 and to boys [12-15 years] since 2013) on the number of diagnoses of genital warts in Australian Aboriginal and Torres Strait Islander (Indigenous) people.

DESIGN, SETTING, PARTICIPANTS

Analysis of routinely collected data from patients attending 39 sexual health clinics (SHCs) in the Genital Warts Surveillance Network for the first time.Major outcome: The average annual proportion of Indigenous and non-Indigenous SHC patients diagnosed with genital warts during the pre-vaccination (2004-2007) and vaccination periods (2008-2014), stratified by age group and sex.

RESULTS

7.3% of the 215 599 Australian-born patients with known Indigenous status and seen for the first time at participating SHCs during 2004-2014 were Indigenous Australians. The average proportion of female Indigenous patients diagnosed with warts was lower during the vaccination period than during the pre-vaccination period (in those under 21, summary rate ratio [SRR], 0.12; 95% CI, 0.07-0.21; P < 0.001); in 21-30-year olds: SRR, 0.41; 95% CI, 0.27-0.61; P < 0.001); there was no significant difference for women over 30 (SRR, 0.84; 95% CI, 0.51-1.36; P = 0.47). The proportion of male Indigenous heterosexual SHC patients under 21 diagnosed with warts was also lower during the vaccination period (SRR, 0.25; 95% CI, 0.12-0.49; P < 0.001), with no significant changes among older Indigenous men over 30.

CONCLUSIONS

There were marked declines in the proportions of diagnoses of genital warts in young Indigenous women and men attending SHCs after the introduction of the HPV vaccination program. If high levels of HPV vaccine coverage are sustained, HPV-related cancer rates should also decline.

The global burden of women's cancers: a grand challenge in global health

Every year, more than 2 million women worldwide are diagnosed with breast or cervical cancer, yet where a woman lives, her socioeconomic status, and agency largely determines whether she will develop one of these cancers and will ultimately survive. In regions with scarce resources, fragile or fragmented health systems, cancer contributes to the cycle of poverty. Proven and cost-effective interventions are available for both these common cancers, yet for so many women access to these is beyond reach. These inequities highlight the urgent need in low-income and middle-income countries for sustainable investments in the entire continuum of cancer control, from prevention to palliative care, and in the development of high-quality population-based cancer registries. In this first paper of the Series on health, equity, and women's cancers, we describe the burden of breast and cervical cancer, with an emphasis on global and regional trends in incidence, mortality, and survival, and the consequences, especially in socioeconomically disadvantaged women in different settings.

Community-randomised controlled trial embedded in the Anishinaabek Cervical Cancer Screening Study: human papillomavirus self-sampling versus Papanicolaou cytology

OBJECTIVES

The incidence of cervical cancer is up to 20-fold higher among First Nations women in Canada than the general population, probably due to lower participation in screening. Offering human papillomavirus (HPV) self-sampling in place of Papanicolaou (Pap) testing may eventually increase screening participation and reduce cervical cancer rates in this population.

DESIGN

A community-randomised controlled screening trial.

SETTING

First Nations communities in Northwest Ontario, Canada.

PARTICIPANTS

Women aged between 25 and 69, living in Robinson Superior Treaty First Nations. The community was the unit of randomisation.

INTERVENTIONS

Women were asked to complete a questionnaire and have screening by HPV self-sampling (arm A) or Pap testing (arm B).

PRIMARY OUTCOME MEASURES

The number of women who participated in cervical screening.

RANDOMISATION

Community clusters were randomised to include approximately equivalent numbers of women in each arm.

RESULTS

6 communities were randomised to arm A and 5 to arm B. One community withdrew, leaving 5 communities in each group (834 eligible women). Participation was <25%. Using clustered intention-to-treat (ITT) analysis, initial and cumulative averaged uptakes in arm A were 1.4-fold (20% vs 14.3%, p=0.628) and 1.3-fold (20.6% vs 16%, p=0.694) higher compared to arm B, respectively. Corresponding per protocol (PP) analysis indicates 2.2-fold (22.9% vs 10.6%, p=0.305) and 1.6-fold (22.9% vs 14.1%, p=0.448) higher uptakes in arm A compared to arm B. Screening uptake varied between communities (range 0-62.1%). Among women who completed a questionnaire (18.3% in arm A, 21.7% in arm B), the screening uptake was 1.8-fold (ITT; p=0.1132) or 3-fold (PP; p<0.01) higher in arm A versus arm B.

CONCLUSIONS

Pap and HPV self-sampling were compared in a marginalised, Canadian population. Results indicated a preference for self-sampling. More research on how to reach underscreened Indigenous women is necessary.

TRIAL REGISTRATION NUMBER

ISRCTN84617261.

Engaging Canadian First Nations Women in Cervical Screening through Education

Recognition of the need to decrease cervical cancer rates in Indigenous populations has been ongoing-yet few successful interventions have been reported. In addition, literature addressing the challenges and barriers associated with designing screening programs aimed to specifically reach Indigenous women is limited. Here, we report findings from a mixed methods cervical cancer research project conducted in partnership with 10 First Nations communities in northwest Ontario, Canada. Individual interviews with community health professionals (the majority of whom identified as First Nations) stressed that awareness of cervical screening benefits is lacking. In contrast, focus group participants (women with no formal health education) emphasized the desire to learn more about the science of human papillomavirus (HPV), and that a positive HPV or abnormal Papanicolaou test need not mean a woman will undoubtedly develop cervical cancer. Both the health professionals and the focus group participants highlighted that sexual health education must start early, in schools, preferably before girls are sexually active and that it has to continue throughout life to create a screening culture with a focus on women's wellbeing. Both interview and focus group participants highlighted that sexual health education must start early, in schools, preferably before girls are sexually active and that it has to continue throughout life to create a screening culture with a focus on women's wellbeing. Health professionals elaborated mainly on special events for community women whereas focus group participants also recognized the need to include community men in health education particularly for de-stigmatizing the sexually-transmitted HPV infection.

Teaching tools to engage Anishinaabek First Nations women in cervical cancer screening: Report of an educational workshop

OBJECTIVE

To explore educational strategies for engaging First Nations women in Canada to attend cervical cancer screening.

DESIGN

Within a participatory action research framework, semi-structured interviews with health-care providers in First Nations communities revealed that education about the value of screening is perceived as being a key factor to promote cervical cancer screening.

SETTING

To obtain feedback from workshop informants, a 1-day educational workshop was held to identify appropriate educational intervention strategies, which would be applied in a forthcoming randomised controlled cervical screening trial.

METHODS

Common discussion and discussion groups, which were facilitated by a First Nations workshop moderator and a note taker.

RESULTS

This workshop helped to strengthen the ethical space dialogue with the First Nations communities with whom the study team had established research partnerships. The workshop atmosphere was relaxed and the invited informants decided that an educational health promotion event for community women needed to be held prior to inviting them to the cervical screening trial. Such an event would provide an opportunity to communicate the importance of attending regular cervical screening allowing women to make informed decisions about screening participation. Complementary promotional items, including an eye-catching pamphlet and storytelling, were also suggested.

CONCLUSION

The key messages from the events and promotional items can help to destigmatise women who develop a type of cancer that is caused by a sexually transmitted virus that affects both men and women. Developing and implementing positive health education that respectfully depicts female bodies, sexuality and health behaviours through a First Nations lens is strongly warranted.

Human papillomavirus variants among Inuit women in northern Quebec, Canada

Background

Inuit communities in northern Quebec have high rates of human papillomavirus (HPV) infection, cervical cancer and cervical cancer–related mortality as compared to the Canadian population. HPV types can be further classified as intratypic variants based on the extent of homology in their nucleotide sequences. There is limited information on the distribution of intratypic variants in circumpolar areas.

Objective

Our goal was to describe the HPV intratypic variants and associated baseline characteristics.

Design

We collected cervical cell samples in 2002–2006 from 676 Inuit women between the ages of 15 and 69 years in Nunavik. DNA isolates from high-risk HPVs were sequenced to determine the intratypic variant.

Results

There were 149 women that were positive for HPVs 16, 18, 31, 33, 35, 45, 52, 56 or 58 during follow-up. There were 5 different HPV16 variants, all of European lineage, among the 57 women positive for this type. There were 8 different variants of HPV18 present and all were of European lineage (n=21). The majority of samples of HPV31 (n=52) were of lineage B. The number of isolates and diversity of the other HPV types was low. Age was the only covariate associated with HPV16 variant category.

Conclusions

These frequencies are similar to what was seen in another circumpolar region of Canada, although there appears to be less diversity as only European variants were detected. This study shows that most variants were clustered in one lineage for each HPV type.

Tumor-induced VEGF-C overexpression in retroperitoneal lymph nodes in VX2 carcinoma-bearing rabbits

Objective

To establish the retroperitoneal lymph node (RLN) metastasis model of cervical carcinoma in rabbits and evaluate the relationship of vascular endothelial growth factor-C (VEGF-C) expression and the lymph node status.

Methods

Forty-eight rabbits were injected with VX2 cells or RPMI solution at muscular mucosae of the myometrium 0.5 cm away from the cervix. Animals were treated with or without cis-diamminedichloroplatinum(II) (cisplatin: DDP) and sacrificed on days 15, 21, and 27 post-VX2 or RPMI injections. Tumor mass and RLNs were examined histopathologically. Quantitative real-time PCR was used to examine the changes in VEGF-C mRNA expression. Levels of VEGF-C protein expression in tissues were determined using immunohistochemistry staining.

Results

Development of VX2 cervical carcinoma and the RLNs metastasis was confirmed with pathological examination. Significantly increased tumor volume was observed on days 15, 21, and 27 postinjection (P<0.05). The enlargement of RLNs was found on day 21. Expression of VEGF-C was significantly upregulated in peripheral white blood cells, tumor mass, and RLNs in an association with cancer progression. DDP resulted in a suppression of VEGF-C expression, whereas the influences on tumor mass and lymphatic metastasis were insignificant.

Conclusion

Elevated VEGF-C expressions in peripheral white blood cells and RLNs are associated with tumor progression and lymphatic metastasis. DDP treatment inhibits VEGF-C expression and fails to protect against metastatic cervical cancer.

Health of Indigenous Peoples

Indigenous populations worldwide are experiencing social, cultural, demographic, nutritional, and psychoemotional changes that have a profound impact on health. Regardless of their geographical location or sociopolitical situation, health indicators are always poorer for indigenous populations than for nonindigenous ones. The determinants of this gap are multiple and interactive, and their analysis requires a biocultural framework. Indigenous populations suffer from lower life expectancy, high infant and child mortality, high maternal morbidity and mortality, heavy infectious disease loads, malnutrition, stunted growth, increasing levels of cardiovascular and other chronic diseases, substance abuse, and depression. The devastating effects of colonization, the loss of ancestral land, and language and cultural barriers for access to health care are among the most salient themes characterizing the poor health situation of indigenous people. Anthropology is extremely well suited to address the interplay among social, economic, and political forces that shape the local experiences of illness.

Atrial fibrillation in the Indigenous populations of Australia, Canada, New Zealand, and the United States: a systematic scoping review

Background

The epidemiology of atrial fibrillation (AF) among Indigenous minorities in affluent countries is poorly delineated, despite the high cardiovascular disease burden in these populations. We undertook a systematic scoping review examining the epidemiology of AF in the Indigenous populations of Australia, Canada, New Zealand (NZ) and the United States (US).

Methods

PubMed, Scopus, EMBASE and CINAHL-Plus databases were systematically searched in May 2014. Supplementary full-text searches of Google Scholar and government website searches were also undertaken.

Results

Key findings from 27 publications with diverse aims and methods were included. Small studies from Canada and NZ suggest higher AF prevalence in Indigenous than other populations. However, this was not reflected in a large sample of US male military veterans. No data were identified on community-based incidence rates of AF in Indigenous populations. Australian and Canadian studies indicate higher first-ever and overall AF hospitalisation rates among Indigenous than other populations, at younger ages and with more comorbidity. Studies in stroke, heart failure and other clinical groups demonstrate AF as a common comorbidity, with AF possibly more prevalent at younger ages in Indigenous people. Indigenous patients have similar early post-hospitalisation adjusted mortality but higher 1-year risk-adjusted mortality than non-Indigenous patients.

Conclusions

No clear epidemiological pattern of AF frequency across the considered Indigenous populations emerges from the limited available evidence. AF should be included in key conditions reported in national surveillance reports, although Indigenous identifiers are required in administrative data from Canada and the US. Sufficiently powered, community-based studies of AF epidemiology in diverse Indigenous populations are needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-015-0081-6) contains supplementary material, which is available to authorized users.

Prevalência de atipias citológicas e infecção pelo papilomavírus humano de alto risco em mulheres indígenas Panará, povo indígena do Brasil Central

O objetivo do estudo foi analisar a prevalência das atipias citológicas e infecção pelo papilomavírus humano em mulheres indígenas Panará no período de 2006 a 2007. Trata-se de estudo observacional transversal, com dados obtidos por coleta de amostras cérvico-vaginais para colpocitologia oncótica e captura híbrida, exame de colposcopia e biópsia. O trabalho incluiu 86 mulheres com idades de 12 anos ou mais, com história de vida sexual ativa ou pregressa. Os resultados mostraram que 10,7% das mulheres tinham atipias citológicas e que 28,6% estavam infectadas pelo HPV de alto risco oncogênico, principalmente entre as mais jovens (média = 25,6 anos). Dessas, 41,7% foram positivas para um ou mais dos tipos de HPV de alto risco dos genótipos 16, 18 ou 45, e a maioria, 58,3%, para outros tipos de HPV de alto risco. Conclui-se que é uma população especial, susceptível ao desenvolvimento das lesões precursoras do câncer do colo do útero e vulnerável às DST. Medidas preventivas como o rastreamento populacional sistemático para o câncer cervical e imunização contra o HPV são necessárias.

Strategies for Increasing Cervical Cancer Screening Amongst First Nations Communities in Northwest Ontario, Canada

The high burden of cervical cancer in Indigenous populations worldwide is due to underscreening and inadequate follow-up. Using qualitative, participatory action research, we interviewed health care staff to identify ways to increase screening recruitment in First Nations communities in Northwest Ontario, Canada. Our findings suggest the value of a multilevel social-ecological model to promote behavioral changes at the community, health care service and stakeholder, and decision-maker level. Participants emphasized the central role of First Nations women as nurturers of life and for the well-being of their family members. They stressed the importance of building awareness and motivation for cervical cancer screening through various activities including continuous education, hosting screening events specifically for women, improving the attitude and service of health care providers, and promoting screening tools and policies that complement and are respectful of First Nations women.

Ethics and Community Involvement in Syntheses Concerning American Indian, Alaska Native, or Native Hawaiian Health: A Systematic Review

BACKGROUND

The objective of the research was to review reporting of ethical concerns and community involvement in peer-reviewed systematic reviews or meta-analyses concerning American Indian, Alaska Native, or Native Hawaiian (AI/AN/NH) health.

METHODS

Text words and indexed vocabulary terms were used to query PubMed, Embase, Cochrane Library, and the Native Health Database for systematic reviews or meta-analyses concerning AI/AN/NH health published in peer-reviewed journals, followed by a search through reference lists. Each article was abstracted by two independent reviewers; results were discussed until consensus was reached.

RESULTS

We identified 107 papers published from 1986-2012 that were primarily about AI/AN/NH health or presented findings separately for AI/AN/NH communities. Two reported seeking indigenous reviewer feedback; none reported seeking input from tribes and communities. Approximately 7% reported on institutional review board (IRB) approval of included studies, 5% reported on tribal approval, and 4% referenced the sovereignty of AI/AN tribes. Approximately 63% used evidence from more than one AI/AN/NH population study, and 28% discussed potential benefits to communities from the synthesis research.

CONCLUSIONS

Reporting of ethics and community involvement are not prominent. Systematic reviews and meta-analyses making community-level inferences may pose risks to communities. Future systematic reviews and meta-analyses should consider ethical and participatory dimensions of research.

Using community engagement to inform and implement a community-randomized controlled trial in the anishinaabek cervical cancer screening study

Social, political, and economic factors are directly and indirectly associated with the quality and distribution of health resources across Canada. First Nations (FN) women in particular, endure a disproportionate burden of ill health in contrast to the mainstream population. The complex relationship of health, social, and historical determinants are inherent to increased cervical cancer in FN women. This can be traced back to the colonial oppression suffered by Canadian FN and the social inequalities they have since faced. Screening - the Papinacolaou (Pap) test - and early immunization have rendered cervical cancer almost entirely preventable but despite these options, FN women endure notably higher rates of diagnosis and mortality due to cervical cancer. The Anishinaabek Cervical Cancer Screening Study (ACCSS) is a participatory action research project investigating the factors underlying the cervical cancer burden in FN women. ACCSS is a collaboration with 11 FN communities in Northwest Ontario, Canada, and a multidisciplinary research team from across Canada with expertise in cancer biology, epidemiology, medical anthropology, public health, virology, women's health, and pathology. Interviews with healthcare providers and community members revealed that prior to any formal data collection education must be offered. Consequently, an educational component was integrated into the existing quantitative design of the study: a two-armed, community-randomized trial that compares the uptake of two different cervical screening modalities. In ACCSS, the Research Team integrates community engagement and the flexible nature of participatory research with the scientific rigor of a randomized controlled trial. ACCSS findings will inform culturally appropriate screening strategies, aiming to reduce the disproportionate burden of cervical disease in concert with priorities of the partner FN communities.

Evolution of cervical cancer screening and prevention in United States and Canada: implications for public health practitioners and clinicians

OBJECTIVE

Declines in cervical cancer incidence and mortality in Canada and in the United States have been widely attributed to the introduction of the Papanicolaou (Pap) test. This article reviews changes in screening and introduction of HPV vaccination.

METHOD

Sentinel events in cervical cancer screening and primary prevention through HPV vaccination in the US and Canada are described.

RESULTS

Despite commonalities, cervical cancer screening and prevention differ between the two countries. Canada has a combination of opportunistic and organized programs at the provincial and territorial level, while the US has opportunistic screening and vaccination systems. In the US, the HPV test along with the Pap test (co-testing) is part of national recommendations for routine cervical cancer screening for women age 30 and older. Co-testing is not being considered anywhere in Canada, but primary HPV testing is currently recommended (but not implemented) in one province in Canada.

CONCLUSION

Many prevention strategies are available for cervical cancer. Continued public health efforts should focus on increasing vaccine coverage in the target age groups and cervical cancer screening for women at appropriate intervals. Ongoing evaluation will be needed to ensure appropriate use of health resources, as vaccinated women become eligible for screening.

Quantitative assessment of the relationship between p21 Ser31Arg polymorphism and cervical cancer

Though many studies were published to assess the relationship between p21 Ser31Arg polymorphism and cervical cancer, there was no definite conclusion on this association. To provide a quantitative assessment of the relationship between p21 Ser31Arg polymorphism and cervical cancer, we performed a meta-analysis of 10 eligible studies (1,539 cases and 2,161 controls). All those 10 studies were from Asians. The odds ratios (OR) with 95% confidence intervals (95%CIs) were used to assess the strength of the association, and the pooled ORs were calculated for the codominant model (ArgArg vs. SerSer), the dominant model (ArgArg/SerArg vs. SerSer), and the recessive model (ArgArg vs. SerSer/SerArg). Meta-analysis of those 10 studies showed that there was no association between p21 Ser31Arg polymorphism and cervical cancer risk in Asians under all three models (ArgArg vs. SerSer: OR = 1.04, 95%CI 0.66-1.65, P = 0.86, I(2) = 78%; ArgArg/SerArg vs. SerSer: OR = 0.93, 95%CI 0.66-1.30, P = 0.66, I(2) = 81%; ArgArg vs. SerSer/SerArg: OR = 1.20, 95%CI 0.84-1.73, P = 0.32, I(2) = 72%). Sensitivity analysis performed by omitting each study in turn showed that the pooled results were stable. In summary, there is no association between p21 Ser31Arg polymorphism and cervical cancer risk in Asians. Further studies are needed to assess the possible association between p21 Ser31Arg polymorphism and cervical cancer risk in Caucasians.

Planning cancer control in Latin America and the Caribbean

Non-communicable diseases, including cancer, are overtaking infectious disease as the leading health-care threat in middle-income and low-income countries. Latin American and Caribbean countries are struggling to respond to increasing morbidity and death from advanced disease. Health ministries and health-care systems in these countries face many challenges caring for patients with advanced cancer: inadequate funding; inequitable distribution of resources and services; inadequate numbers, training, and distribution of health-care personnel and equipment; lack of adequate care for many populations based on socioeconomic, geographic, ethnic, and other factors; and current systems geared toward the needs of wealthy, urban minorities at a cost to the entire population. This burgeoning cancer problem threatens to cause widespread suffering and economic peril to the countries of Latin America. Prompt and deliberate actions must be taken to avoid this scenario. Increasing efforts towards prevention of cancer and avoidance of advanced, stage IV disease will reduce suffering and mortality and will make overall cancer care more affordable. We hope the findings of our Commission and our recommendations will inspire Latin American stakeholders to redouble their efforts to address this increasing cancer burden and to prevent it from worsening and threatening their societies.

Factors associated with cervical cancer screening uptake among Inuit women in Nunavik, Quebec, Canada

BACKGROUND

The Canadian circumpolar Inuit population has a higher incidence rate of cervical cancer than the general population and the majority of cases occur among underscreened women. The objectives of this study were to determine Pap smear utilization rates and to determine factors associated with time-inappropriate use of cervical cancer screening among a cohort of Inuit women from Nunavik, Quebec, Canada.

METHODS

This study utilizes baseline information collected from a cohort formed between January 2002 and December 2007 to study the natural history of HPV among Inuit women aged 21-69 years in Nunavik, Quebec. Cervical cancer screening history and other variables were obtained from a baseline questionnaire and medical chart review. Unconditional logistic regression was used to estimate the odds ratios and 95% confidence intervals for potential predictors of not having a Pap smear within the previous 3 years prior to cohort entry.

RESULTS

A total of 403 Inuit women who had a baseline questionnaire and chart review were included. The mean age of the study population was 34.2 years. In the three years prior to study entry, 25% of women did not have a Pap smear. Older age and never giving birth were significant predictors of time-inappropriate Pap smear use.

CONCLUSIONS

Our results suggest that older women and women who are not accessing reproductive care have a lower compliance with time-appropriate cervical cancer screening and future research should address potential strategies to increase screening coverage among this group.

Barreras percibidas por el personal de salud para la toma de la citología cervical en mujeres zapotecas de Juchitán, Oaxaca

Antecedentes: El cáncer cervicouterino (CaCU) representa un problema de salud pública en México. Las mujeres indígenas presentan mayor riesgo de morir por esta enfermedad. El estudio sobre las barreras que afronta la población indígena mexicana para la toma de la citología cervical es escaso. Propósitos: Objetivo: Identificar las barreras estructurales, psicosociales y culturales percibidas por el personal de salud para la toma de la citología cervical en mujeres juchitecas. Método: Tipo de estudio: exploratorio-descriptivo de corte cualitativo. Se aplicaron entrevistas semiestructuradas a personal sanitario de centros de salud públicos y privados de Juchitán. Muestreo intencional por cuotas, 9 participantes, 7 clínicas elegidas al azar. Se realizó análisis de contenido. Resultados: Se identificaron barreras estructurales, psicosociales y culturales. Las principales: tardanza en entrega de resultados, falta de material, espacios para la toma y recursos humanos, alto nivel de desinformación sobre la prueba y la enfermedad, miedo a tener algo “malo” y al dolor, el tabú de la sexualidad, la actitud de la pareja hacia la prueba, prejuicios y falta de traductores que apoyen en la comunicación entre las mujeres y el personal del sistema de salud. Conclusiones: Existe desinformación sobre el CaCu y su detección oportuna en esta población; hay múltiples barreras de tipo estructural, prejuicios y mitos rodean la enfermedad. Se detectó desinterés por parte del sistema de salud en la promoción de programas preventivos del CaCu. Informar a la población en su lengua, cuidar y ser empáticos ante la exposición del cuerpo y diseñar políticas de salud incluyentes, son aspectos fundamentales a considerar y desarrollar en programas locales.