Interventions Increase Breast Cancer Screening for Newcomers and Marginalized Women
A multifaceted intervention providing education and support for pap and mammography screening is a sound strategy to increase screening among under-screened newcomers and marginalized women according to a recent study led by University of Toronto Department of Family and Community Medicine’s (DFCM) researcher Dr. Sheila Dunn.
Dr. Dunn and other researchers including DFCM’s Dr. Aisha Lofters reached out to a diverse group of newcomers and other marginalized women in Toronto—groups who are known to have lower rates of screening. Women were invited to take part in an education program named Cancer Awareness: Ready for Education and Screening (CARES). Its intent was to enhance their knowledge about breast and cervical cancer screening and support them to be screened, with the hope of sustaining engagement in regular screening after the study. Women who participated in CARES were matched with a control sample who were the same age and had the same screening status, and lived in a similar geographical area. Researchers observed that those who received the CARES intervention were more likely to be tested than those who did not.
“We used a multifaceted approach with this intervention which has been shown to be successful in promoting screening among marginalized groups,” says Dr. Dunn. “In these types of studies, it’s hard to know if one component is more meaningful or might have more impact than another. Some women were very uncomfortable travelling outside their own neighbourhood and this navigation and accompaniment was vital. We saw some great results.”
First, researchers developed outreach activities to target groups through a network of community agencies and peer leaders. Educational sessions were promoted with the use of flyers, personal invitation from peer leaders and, at times, word of mouth. Researchers developed educational programming in 20 languages that were delivered by peer leaders from the same community to engage, increase knowledge and support cancer screening for these women. Access to screening was supported through transportation and accompaniment for group screening visits. One session stood out more than others.
“Past evidence for the value of group educational sessions is somewhat conflicting but we did notice that group sessions were much appreciated among our participants. We observed the importance of the mutual support that arose in the group environment. Group discussion offered an opportunity to normalize behaviours, fears, and questions and solidify the information learned during the educational sessions. The group allowed the women to become stronger. It became a safe space where women would be comfortable talking about these issues in their language.”
Research has shown that screening rates are lower in newcomer women especially those of older women of South Asian origin. Reasons for low screening include lack of knowledge of the health practice, limited language-specific resources and the difficulty of navigating the often complicated Canadian healthcare system. Ontario cancer screening guidelines recommend cervical screening every three years for women between the ages of 21-69 years and mammography every two years for women between the ages of 50-74 years.
“A total of 1,993 women attended 145 sessions provided in 20 languages. Participants who were underscreened were about 3 1/2 times more likely to go on to screening after the intervention than those in the control group. The peer leaders were great in breaking down the barriers that prevent this population from seeking care as they knew their cultural affinities. The concept of screening and prevention is challenging to get across to anyone, and it is notably harder where there is a language barrier, and the understanding of health is not the same.”
The study’s strength is that the intervention was delivered to women in diverse ethnocultural groups, unlike many previous studies which have targeted one community. Also, administrative data rather than self-reporting was used to measure screening. Dr. Dunn says that many other studies have relied on self-reports of screening, or more proximal measures of their impact such as knowledge or motivation to be screened. This study specifically measured each participant's screening activity following the intervention. Dr. Dunn is hopeful that women who participated in CARES continue to have regular screening again despite cultural and linguistic barriers.
“My hope is that all women who participated are informed and familiar with screening and the process to be screened in the mainstream health system. In other words, once they are engaged in the screening process through this type of supportive intervention, the next time they will access screening through the regular channel of their family doctor.”