Cervical screening uptake: A cross-sectional study of self-reported screening attitudes, behaviours and barriers to participation among South Asian immigrant women living in Australia

Introduction:

Cervical cancer remains a major cause of morbidity and mortality among women from low and lower middle-income countries, as well as underserved population subgroups in high-income countries. Migration from South Asia to Australia has increased over the last decade, and immigrant women from this region have been reported as a subgroup, with less than optimal cervical screening participation in Australia. This study examined cervical screening uptake and associated behavioural attitudes among South Asian immigrant women living in Queensland Australia.

Methods:

A cross-sectional, Internet-based survey was used to collect data from a convenience sample of 148 South Asian women living in Queensland. The main outcome measure was receipt of cervical screening test ever (yes/no) and its recency (within 2 years/more than 2 years). The survey also examined participants’ views on barriers towards screening and ways to enhance it.

Results:

Of 148 women who completed the survey, 55.4% (n = 82) reported ever having a cervical screening test before and 43.9% (n = 65) reported having it in previous two years. Not having a previous cervical screening test was significantly associated with duration of stay in Australia for less than five years, not having access to a regular general practitioner (GP), not being employed, having low cervical cancer knowledge level and not knowing if cervical screening test is painful or not. Most commonly reported barriers to screening uptake included considering oneself not at risk, lack of time and lack of information. The most favoured strategy among participants was encouragement by GP and awareness through social media advertisements.

Conclusion:

This study provided insights into factors that need consideration when developing future targeted interventions.

Understanding the Acceptability and Uptake of HPV Self-Sampling Amongst Women Under- or Never-Screened for Cervical Cancer in Toronto (Ontario, Canada): An Intervention Study Protocol

Cervical cancer remains a global public health concern, even though scientific advancements have made the disease almost entirely preventable. With the link between human papillomavirus (HPV) and cervical cancer, and the subsequent improvement in screening technology, there is potential to improve access and coverage of cervical screening with the introduction of HPV self-sampling. In Ontario, Canada, a province with a cytology-based screening program (i.e., Pap test), women who identify as South Asian, West Asian, Middle Eastern and North African have some of the lowest rates of screening, and research suggests they have a higher burden of cervical cancer. In this study, we will use both quantitative and qualitative methods to understand the acceptability and uptake of a take-home HPV self-sampling kit. Working with community champions—people with pre-existing connections with local groups—we will recruit women from these groups who are under- or never-screened for cervical cancer. Women will self-select whether they are in the group that tries HPV self-sampling or in the group that does not. We will aim for 100 women in each group. All participants will provide feedback on the feasibility, acceptability and preferences for cervical screening through a survey and phone follow-up. Women who self-select the HPV self-sampling group, will be followed up to find out if they followed through with self-sampling and to understand their experience using the device. Women who do not want to try self-sampling will be followed up to see if they went on to get a Pap test. The qualitative phase of this study consists of five focus groups with participants and semi-structured interviews with key informants in the community.

A critical exploration of nurses' perceptions of access to oncology care among Indigenous peoples: Results of a national survey

Inequities in access to oncology care among Indigenous peoples in Canada are well documented. Access to oncology care is mediated by a range of factors; however, emerging evidence suggests that healthcare providers, including nurses, play a significant role in shaping healthcare access. The purpose of this study was to critically examine access to oncology care among Indigenous peoples in Canada from the perspective of oncology nurses. Guided by postcolonial theoretical perspectives, interpretive descriptive and critical discourse analysis methodologies informed study design and data analysis. Oncology nurses were recruited from across Canada to complete an online survey (n = 78). Nurses identified a range of barriers experienced by Indigenous peoples when accessing oncology care, yet located these barriers primarily at the individual and systems levels. Nurses perceived themselves as mediators of access to oncology care; however, their efforts to facilitate access to care were constrained by the dominance of biomedicine within healthcare. Nurses' constructions of access to oncology care highlight the embedded narrative of individualism within nursing practice and the relative invisibility of racism as a determinant of equitable access to care among Indigenous peoples. This suggests a need for oncology nurses to better understand and incorporate structural determinants of health perspectives.

Engagement barriers and service inequities in the NHS Breast Screening Programme: Views from British-Pakistani women

Objectives

Previous research has largely attempted to explore breast screening experiences of South Asian women by combining opinions from Pakistani, Bangladeshi, and Indian women. This research often fails to reach the most underserved sub-groups of this population, with socioeconomic status not routinely reported, and English fluency being a participation requirement. With uptake low amongst British-Pakistani women, this study explores the experiences these women encounter when accessing the NHS Breast Screening Programme.

Methods

19 one-to-one semi-structured interviews were carried out with British-Pakistani women from East Lancashire, UK. 14 interviews were conducted via an interpreter.

Results

Data were analysed using thematic analysis. Three themes were identified: ‘Absence of autonomy in screening and healthcare access’ describes how currently the screening service does not facilitate confidentiality or independence. Access requires third-party intervention, with language barriers preventing self-expression. ‘Appraisal of information sources’ makes distinctions between community and NHS communication. Whereas community communication was invaluable, NHS materials were deemed inaccessible due to translation incongruences and incomprehensible terminology. ‘Personal suppositions of breast screening’ explores the subjective issues associated with disengagement, including, the cultural misalignment of the service, and perceiving screening as a symptomatic service.

Conclusions

British-Pakistani women face some unique challenges when accessing breast screening. To promote uptake, the service needs to address the translation of screening materials and optimize upon community networks to disseminate knowledge, including knowledge of the screening environment within the context of culture to promote informed choice about attendance.

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.

Barriers to cervical cancer screening faced by immigrant women in Canada: a systematic scoping review

Background

The objective of this scoping study is to review the published literature and summarize findings related to barriers experienced by immigrant women in Canada while accessing cervical cancer screening.

Methods

Electronic databases of peer-reviewed articles and grey literature were searched using comprehensive sets of keywords, without restricting the time period or language. Articles were selected based on the following criteria: (a) the study population consisted of Canadian immigrant women and healthcare providers and other stakeholders serving immigrant women, (b) the research focused on the barriers to accessing cervical cancer screening, and (c) the study was conducted in Canada.

Results

Extracted data were grouped and analyzed, resulting in barriers comprised of six themes: economic barriers, cultural barriers, language barriers, healthcare system-related barriers, knowledge-related barriers, and individual-level barriers. Lack of education, low income, preference for a female physician, lack of knowledge, lack of effective communication, and embarrassment were some of the most common barriers mentioned.

Conclusions

Immigrant access to health services, including cervical cancer screening, is a complex issue concerning a wide range of barriers. Our findings offer insights into barriers to cervical cancer screening in immigrant communities in Canada that can be used to assist policymakers, healthcare providers, and researchers enhance the health and well-being of these populations by mitigating barriers and improving screening.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0654-5) contains supplementary material, which is available to authorized users.

A systematic review of barriers and enablers to South Asian women's attendance for asymptomatic screening of breast and cervical cancers in emigrant countries

OBJECTIVES

The aim of this review was to identify the cultural, social, structural and behavioural factors that influence asymptomatic breast and cervical cancer screening attendance in South Asian populations, in order to improve uptake and propose priorities for further research.

DESIGN

A systematic review of the literature for inductive, comparative, prospective and intervention studies. We searched the following databases: MEDLINE/In-Process, Web of Science, EMBASE, SCOPUS, CENTRAL, CDSR, CINAHL, PsycINFO and PsycARTICLES from database inception to 23 January 2018. The review included studies on the cultural, social, structural and behavioural factors that influence asymptomatic breast and cervical cancer screening attendance and cervical smear testing (Papanicolaou test) in South Asian populations and those published in the English language. The framework analysis method was used and themes were drawn out following the thematic analysis method.

SETTINGS

Asymptomatic breast or cervical screening.

PARTICIPANTS

South Asian women, including Bangladeshi, Indian, Pakistani, Sri Lankan, Bhutanese, Maldivian and Nepali populations.

RESULTS

51 included studies were published between 1991 and 2018. Sample sizes ranged from 25 to 38 733 and participants had a mean age of 18 to 83 years. Our review showed that South Asian women generally had lower screening rates than host country women. South Asian women had poorer knowledge of cancer and cancer prevention and experienced more barriers to screening. Cultural practices and assumptions influenced understandings of cancer and prevention, emphasising the importance of host country cultures and healthcare systems.

CONCLUSIONS

High-quality research on screening attendance is required using prospective designs, where objectively validated attendance is predicted from cultural understandings, beliefs, norms and practices, thus informing policy on targeting relevant public health messages to the South Asian communities about screening for cancer.

PROSPERO REGISTRATION NUMBER

CSD 42015025284.

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.

Interventions to improve cervical cancer screening uptake amongst young women: a systematic review

OBJECTIVES

In view of declining screening uptake in young women, this review aims to summarise the available evidence relating to interventions designed to increase cervical screening uptake amongst women aged ≤ 35 years.

METHODS

Electronic databases were searched and further articles located by manual searches. Study designs employing a valid comparison group and including women aged ≤ 35 years published through 2012 were considered. Data was extracted on the uptake from either screening programme statistics or as reported by the study subjects. A narrative synthesis was undertaken for each category of interventions identified.

RESULTS

Ninety-two records were screened with 36 articles retrieved for further assessment. Four studies met the inclusion criteria, two of which evaluated more than one intervention. One of the studies evaluated the use of a modified invitation letter and reported no significant increase in uptake compared to a standard invitation. Three studies investigated the use of a reminder letter, with two reporting a positive effect on screening uptake in women aged 24-34. Three studies were included which supported the use of physician and telephone reminders. One study on HPV self-sampling reported a positive effect when compared with a reminder letter.

CONCLUSIONS

There is a lack of randomised controlled trials designed to specifically address falling cervical screening uptake in amongst young women. Cervical screening programmes need to look beyond the use of invitation/reminders letters in this group of women to develop interventions which attempt to overcome as many barriers to uptake as possible.

Development of culturally tailored educational brochures on HPV and pap tests for American Indian women

PURPOSE

Participatory formative research guided the creation of a culturally tailored educational brochure about human papillomavirus (HPV) at an American Indian women's clinic.

METHOD

A review of existing educational materials and in-depth interviews were conducted. Nine steps for creating health communications messages that were patterned after National Cancer Institute guidelines guided the brochure development process.

RESULTS

Of 95 women tested for HPV, 41% were positive, 32 (34%) agreed to the in-depth interview, and 9 agreed to the pretesting interview. Mean age was 41 years. Interviews revealed key themes concerning emotional reactions to abnormal Pap test results and HPV; need for basic information about HPV, Pap tests, and results; concerns about HPV stigma, sexual transmission, and communication with sexual partner; and the preferred source and format for HPV educational materials. A literature review revealed 12 areas of basic HPV content.

CONCLUSIONS

A participatory process successfully engaged nursing staff and patients in creating culturally appropriate brochures for clinic use.

IMPLICATIONS

This article provides specific steps for creating culturally tailored patient education materials.

Exploring ways to overcome barriers to mammography uptake and retention among South Asian immigrant women

South Asians comprise one of the fastest growing immigrant groups in North America. Evidence indicates that South Asian (SA) immigrant women are vulnerable to low rates of breast cancer screening. Yet, there is a dearth of knowledge pertaining to socioculturally tailored strategies to guide the uptake of screening mammography in the SA community. In 2010, the authors conducted semi-structured focus groups (FG) to elicit perspectives of health and social service professionals on possible solutions to barriers identified by SA immigrant women in a recent study conducted in the Greater Toronto Area. Thirty-five health and social services staff members participated in five FG. The discussions were audio taped and detailed field notes were taken. All collected data were transcribed verbatim and thematic analysis was conducted using techniques of constant comparison within and across the group discussions. Three dominant themes were identified: (i) 'Target and Tailor' focused on awareness raising through multiple direct and indirect modes or approaches with underlying shared processes of involving men and the whole family, use of first language and learning from peers; (ii) 'Enhancing Access to Services' included a focus on 'adding ancillary services' and 'reinforcement of existing services' including expansion to a one-stop model; and (iii) 'Meta-Characteristics' centred on providing 'multi-pronged' approaches to reach the community, and 'sustainability' of initiatives by addressing structural barriers of adequate funding, healthcare provider mix, inter-sectoral collaboration and community voice. The findings simultaneously shed light on the grassroot practical strategies and the system level changes to develop efficient programmes for the uptake of mammography among SA immigrant women. The parallel focus on the 'Target and Tailor' and 'Enhancing Access to Services' calls for co-ordination at the policy level so that multiple sectors work jointly to streamline resources, or meta-characteristics.

Testing an optimized community-based human immunodeficiency virus (HIV) risk reduction and antiretroviral adherence intervention for HIV-infected injection drug users

The authors conducted a preliminary study of the 4-session Holistic Health for HIV (3H+), which was adapted from a 12-session evidence-based risk reduction and antiretroviral adherence intervention. Improvements were found in the behavioral skills required to properly adhere to HIV medication regimens. Enhancements were found in all measured aspects of sex-risk reduction outcomes, including HIV knowledge, motivation to reduce sex-risk behavior, behavioral skills related to engaging in reduced sexual risk, and reduced risk behavior. Improvements in drug use outcomes included enhancements in risk reduction skills as well as reduced heroin and cocaine use. Intervention effects also showed durability from post-intervention to the follow-up assessment point. Females responded particularly well in terms of improvements in risk reduction skills and risk behavior. This study suggests that an evidence-based behavioral intervention may be successfully adapted for use in community-based clinical settings where HIV-infected drug users can be more efficiently reached.

Health Care Communications with Diverse Ethnic Groups

The concept of respect is rooted in the core value of human relations, and interpersonal relationships with others. The notion of respect in these relationships is entrenched in the broader context of the processes of relationships between professionals and clients in general, along with the philosophical and ethical foundations of respect. Although nursing principles and values, such as autonomy and dignity have built their foundation of care on the concept of respect, these concepts (ie. autonomy and dignity) are still different from respect. Respect within health professional-client relationships, indicates that respect is a fundamental concept within nursing, permeating a number of other concepts that provide purposeful nursing care within the process of nurse-client relationships and respect has been discussed as an ethical and moral concept of care that addresses the values of human dignity in the nursing discipline, however research examining the client's perspectives of respect as an ethical principle of care, especially within Canada's diverse population is non-existent. There is limited research from the client's perspective addressing challenges communicating the concept of respect in relationships between health professionals and clients, specifically research directed at immigrant or the vulnerable population.

A comparison of health care in Canada and the United States: the case of Pap smears

RATIONALE

Compliance with preventive care recommendations differs between countries. Directly comparable data are often not available. The recent release of the Joint Canada/United States Survey of Health makes available data for both Canadians and Americans.

OBJECTIVES

The health care systems in the United States and Canada differ quite dramatically. Canadians are covered by a universal health care system while residents of the United States, if they are insured, obtain their insurance from various private or public sources. This paper examines how the use of the Papanicolaou test (Pap smear) by women differs in the United States and Canada.

METHODOLOGY

American women are more likely than Canadians to receive a pap smear. A Blinder/Oaxaca type decomposition is used to determine influence of observed population characteristics and unobserved differences between the 2 countries on this gap.

RESULTS

The decomposition shows that the gap in Pap smears between Canada and the United States is not influenced by observed demographic differences. Most of the difference is attributable to unobserved heterogeneity or how women are treated in the 2 systems.

CONCLUSIONS

Although Canada has universal health coverage, the use of Pap smears is lower than that of all US women and equal to that of uninsured US women. Most of the differences in use of Pap smears is the result of differences in unobserved heterogeneity or the way that the systems treat women which may be a function of differences between the 2 health care systems in marketing, delivering, and reimbursing care.

Providing family planning and reproductive healthcare to Canadian immigrants: perceptions of healthcare providers

Cultural impacts on health experiences and behaviours are profound in the area of reproductive health and family planning. Explored through interviews with family planning healthcare professionals, this paper evaluates their experiences in providing family planning and reproductive healthcare to immigrants in the Greater Toronto and Hamilton area of Ontario, Canada. Results reveal the complexity of delivering care to members of this group, particularly when dealing with language barriers, situations when professional and non-professional interpreters are used, and instances where healthcare professionals realize that they themselves have misconceptions and misunderstandings about other cultures. The paper concludes by discussing future research options and implications for the delivery of reproductive health family planning services to this population.

Cancer screening practices of Asian American physicians in New York City

Cancer screening rates are lower among Asian Americans than the general USA population. While prior studies examined characteristics of Asian American patients as predictors of cancer screening, few investigated their health care providers. Asian American primary care physicians practicing in New York City were surveyed by questionnaire regarding their demographics, practice characteristics, and cancer screening of their Asian American patients. Of the 117 eligible respondents, 96% recommended mammograms to their Asian patients 50+ years of age and 70% to patients 40-49-year-old. Only 30% of respondents use both age and onset of sexual activity to determine when to recommend Pap smears. For colorectal cancer screening, the rates of performing fecal occult blood testing or recommending colonoscopy or sigmoidoscopy were 77% and 74%. About 70% recommend screening for hepatitis B. Gender and ethnicity of the physician were found to be significant predictors for cancer screening practice.

Punjabi women's stories of breast cancer symptoms: Gulti (lumps), bumps, and Darad (pain)

The purpose of this study was to examine experiences related to self-discovered breast cancer symptoms from the perspective of Punjabi immigrant women residing in Canada. Interviews were conducted with 25 women, 19 of whom had received a diagnosis of breast cancer. Using narrative analysis, 4 types of stories were identified. In the stories that were based on constructions of breast symptoms as "nothing serious," women emphasized that they had not even considered the possibility of breast cancer and were encouraged to dismiss concerns about their health. Stories focusing on suspicions about the presence of a health problem included descriptions of mounting concern and tension as the women began to realize that the breast symptoms they experienced might not be of the regular or normal variety. In stories dominated by worry, vivid descriptions of fears of breast cancer were juxtaposed with explanations about how women protected family members by downplaying their symptoms. Finally, in stories that focused on gaining strength in readiness to deal with whatever may lie ahead, women drew on the support of their extended families, their religious beliefs, and their need to care for their families. These findings provide a basis for guiding the development of culturally appropriate health education for Punjabi women.

Predictors of Papanicolaou Testing in Working Women in Bangkok, Thailand

Cervical cancer is the leading cause of death among women in Thailand. A significant number of Thai women have never received cervical cancer screening. This study examined the perceived susceptibility, benefits, and barriers that influence Papanicolaou testing and examined the relationships between socioeconomic factors and obtaining a Papanicolaou test among women working in 1 government agency and 3 private sector companies in Bangkok, Thailand. The Health Belief Model was used to guide the cross-sectional design of the study. The Susceptibility, Benefits, and Barriers Scale was mailed to 300 working women. The response rate to the survey was 63% (N = 189). Logistic regression analysis showed that perceived barriers were significant predictors of Papanicolaou testing (beta = -.13, P < .001). Women who reported barriers were significantly less likely to obtain a Papanicolaou test (odds ratio, 0.88; P < .001). The specific barriers to engaging in Papanicolaou testing were embarrassment, fear, time constraints, knowledge deficits, and cost. Marital status, age, education, and family income were other factors related to Papanicolaou testing. Findings suggest that screening rates may be improved by addressing a combination of research, health policy, and cultural factors in these women through a nationwide campaign.

"It's much easier than going to the dentist": high levels of satisfaction in a mammography screening program

OBJECTIVES

To develop a suitable instrument for measuring client satisfaction in the BreastScreen New South Wales (NSW) program and to use the instrument to measure client satisfaction.

METHOD

The survey was designed and administered to 2,091 women who attended mammography screening in the BreastScreen NSW program during 2001 (85% response rate). The survey evaluated experiences of making appointments, the screening environment, the screening procedure, and the receipt of results. Socio-demographic differentials in client satisfaction were examined using logistic regression models.

RESULTS

The majority of women were highly satisfied with their experience, with transport/parking, breast discomfort and time to results causing the most dissatisfaction (8-9%). The main source of dissatisfaction was during the appointment and related to discomfort during the mammogram (9%) and breast problems following the mammogram (9%). Predictors of dissatisfaction with screening (p<0.05) included high education level (OR=1.4), non-Australian born (OR=1.4), and aged 40-49 years (OR=1.6).

CONCLUSIONS

Although overall satisfaction was high, the survey indicated service functions where improvements could be made.

IMPLICATIONS

This research has developed an appropriate tool for assessing and monitoring client satisfaction with breast screening services.

Inadequacy of cervical cancer screening among urban recent immigrants: a population-based study of physician and laboratory claims in Toronto, Canada

OBJECTIVE

In Canada, Pap smears are recommended from 18 to 69. Self-reported socioeconomic gradients in screening have been documented in North America but there have been few direct measures of Pap smear use among immigrants or socially disadvantaged groups. Our purpose was to investigate whether socioedemographic factors are related to cervical cancer screening in Toronto, Canada.

METHOD

Pap smears were identified using fee and laboratory codes in Ontario physician service claims for 3 years (2000-2002 inclusive) for women aged 18-66. Area-level socioeconomic factors were derived from the 2001 census. At the individual level, recent registrants for health coverage, over 80% of whom are expected to be recent immigrants, were identified as women first registering after January 1, 1993.

RESULTS

Among 724,584 women, 55.4% had Pap smears within 3 years. Recent immigration, visible minority, foreign language, low income and low education were all associated with significantly lower area rates. Recent registrants had much lower rates than non-recent registrants (36.9% versus 60.9%).

CONCLUSION

Pap smear rates in Toronto fall below those dictated by evidence-based practice. Recent registrants, a largely immigrant group, have particularly low rates. Efforts to improve coverage need to emphasize women who recently immigrated and those with socioeconomic disadvantage.

Family support of immigrant Punjabi women with breast cancer

Women with breast cancer have been found to rely heavily on family members for providing support during their illness experiences. There has been limited research on ethnocultural families' experiences of illness and how these families respond to a diagnosis of breast cancer. This study examined the experiences and responses of family members of immigrant Punjabi women diagnosed with breast cancer. Through interviews with 19 Punjabi women diagnosed with breast cancer and 18 family members, key practical and emotional support strategies were described. Recommendations for culturally appropriate, family-centered models of care are provided that acknowledge breast cancer as a family event.

Reflections on cancer in the context of women's health: focus group discussions with Iranian immigrant women in Sweden

In cancer prevention, culture and ethnicity have often been considered in negative terms as a variable to explain "misconceptions" and "knowledge deficits." This study, based on data from nine focus groups with Iranian immigrant women of various ages residing in Sweden, was instead conducted to explore reasoning on cancer prevention and screening within a framework of beliefs on health, illness and sickness for women in general. Complex relationships and reasoning about health maintenance and disease prevention were found to be related to perceptions of body and self, and to the continual construction of social roles throughout the life span. Spontaneous discussion of relationships between stress, maintaining health and developing disease arose in all groups. Negative outcomes associated with stress have consequences for information provision, as focusing on the negative is viewed as leading to negative outcomes. "Cultural" differences appear to be as related to social roles and phases in the life cycle, as to ethnicity.

A Pap Test Screening Clinic in a South Asian Community of Vancouver, British Columbia: Challenges to Maintaining Utilization

The purpose of this article is to describe experiences and challenges in establishing a South Asian Pap Test Clinic. The specialized Pap test clinic for immigrant South Asian women was a community-initiated response to high rates of cervical cancer within this population. Efforts were made to ensure that the clinic provided health services in a sensitive and culturally appropriate manner. Although women were generally positive about their experiences at the South Asian Pap Test Clinic and often encouraged other women to attend the clinic for Pap testing, attendance patterns have not been maintained. The three most significant challenges to the clinic's ongoing success were: (1) maintaining the continued involvement of stakeholders in developing long-term strategies to enhance community awareness about cervical cancer; (2) creating mechanisms to strengthen support from physicians in the community; and (3) meeting the needs of the underserved within a specialized health service for South Asian immigrant women. These challenges provide important lessons for others to increase the participation of immigrant women in screening practices. Nurses can play a key role in mobilizing and maintaining collaborations that are essential to the continuing success of community-based programs.

Immigrant women implementing participatory research in health promotion

Few studies on women's health include immigrant women as participants, and fewer are conducted by immigrant women themselves. In this article, the authors present a model that allowed their full participation as researchers and authors. They describe their experiences using participatory research methods with Hispanic women in multiple ways to reach out to isolated women, collect data about community needs, and provide health education. They explore the advantages and challenges of being trained for both researcher and health educator roles, describe opportunities to use this approach to assess service needs, and discuss the potential for personal empowerment. They also report on the time commitment that such a bilingual project requires. In the process of interviewing marginalized women, they realized how much health promotion and participatory research complement each other. The authors conclude that combining participatory research with health promotion activities has promise to contribute toward increased empowerment of immigrant communities.