Understanding barriers to cervical cancer screening and acceptability of HPV self-sampling among immigrant women in Spain: a mixed-methods study

Cervical cancer (CC) is the fourth most common cancer among women worldwide. The highest incidence is found in low and middle income countries (LMIC) (GLOBOCAN 2020). Although it is a preventable disease, cervical cancer remains an important global public health problem (WHO 2020). It is a disease which reflects inequities among different populations depending on the availability of a national vaccination program and population-based CC screening (Ginsburgh et al., 2017). In high income countries (HIC) where primary (vaccination) and secondary (screening) prevention measures are extensively implemented, these global health disparities are still reflected among migrant and ethnic minority groups. A great number of studies conducted mainly in HIC suggest higher incidence rates of cervical cancer among migrant women (Arnold et al., 2010; Azerkan et al., 2012; Rodriguez-Sales 2013) and lower screening participation compared to nationals (Tatari et al., 2021; Marques et al., 2020; Barrera-Castillo et al., 2020; Marshall et al., 2019; Morgan et al., 2018; Vosters et al, 2017; Leinonen et al. 2017). The reasons that make women participate or not in CC screening programs are related to individual characteristics, health system barriers, but also to the social and cultural context (Moudatsou et al. 2014). Studies have identified a range of individual and health system barriers to participate in CC screening programs among migrant and ethnic minority groups, such as low health literacy, language difficulties, not being registered in the country's healthcare system, lack of knowledge about cancer and screening offers, lack of free time, family obligations, sexual morality, embarrassment and stigma (Marques et al., 2020; Tatari et al., 2020; Idehen et al., 2017). Additionally, social influences from family members and other close ties have been proved to be another determinant on cancer screening participation (Soskolne et. al, 2006; Griva et al., 2009, Pasick et al., 2009).
Over the last decades, diverse methods have been used to encourage women to undergo cervical screening, including invitations, reminders, education programs, message framing, counselling, risk factor assessment, economic interventions (Everett et al. 2014). However, in many cases these interventions are not culturally sensitive and do not take into account migrants' specific barriers, excluding them from CC screening programs. In recent years, increasing efforts have been made in tailoring interventions to increase migrants and ethnic minority groups' participation in CC screening through HPV self-sampling in some HIC, such as Denmark, Norway, Sweden, USA, Canada and Australia. Most of these interventions were community-based and used faith-based clinical outreach, community 'champions', 'lay health workers' and 'peers' (Tatari et al 2021; Lofters et al., 2021 ; Quresh et al. 2019; Olsson et al 2014; Pratt et al. 2020; Luque et al. 2017; Dunn et al., 2017; Luque et al., 2011 ; Manderson 2006). Although some of these community-based approaches have been proved successful, the evidence is still limited. On the other hand, tailored interventions to increase CC screening among migrant populations must be context-specific in terms of screening policies in the host country and population characteristics (e.g. age, country of origin, religion).The proposed study will focus on Spain, where CC screening programs are currently experiencing the transition from cytology (Pap test) based to HPV test based and from opportunistic to population-based approaches (BOE 2019). These preventive programs were disrupted due to the COVID-19 pandemic, causing severe delays in screening and early detection of CC. This situation has accelerated the introduction of HPV self-sampling test in some Spanish regions, such as Catalonia, as a strategy to mitigate the effects of the pandemic, but more importantly to increase screening participation, especially among vulnerable populations, such as....