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

Immigrant women from low resource countries are a vulnerable group to cervical cancer (CC). They are less likely than native women to participate in CC screening programs, which increases the risk to late diagnosis and treatment and, consequently, lower probability of survival. The reasons that make women participate or not in CC screening are multiple and complex. Individual characteristics, access to health system barriers and the social and cultural context influence CC screening behaviours. A variety of strategies have been used to encourage women to undergo CC screening. However, in many cases, these methods are not culturally sensitive and do not consider the barriers confronted by migrants (e.g. language difficulties). This study will take place in Catalonia, Spain, where the introduction of HPV self-sampling is being piloted among different female groups, including immigrant women, to increase CC screening participation. In this context, the overall aim of my PhD research will be to explore barriers and facilitators to cervical cancer screening and acceptability of HPV self-sampling among Pakistani and Moroccan immigrant women in Catalonia, Spain.
My research has three specific objectives:
1) To explore knowledge, perceptions and beliefs of cervical cancer and understanding attitudes towards cervical cancer screening among Moroccan and Pakistani immigrant women in Catalonia, Spain.
2) To examine the environmental and interpersonal factors that may influence Moroccan and Pakistani immigrant women's participation in cervical cancer screening programs in Catalonia, Spain.
3) To provide recommendations for an HPV self-sampling pilot intervention to increase cervical cancer screening participation among Moroccan and Pakistani immigrants women in Catalonia, Spain.
To achieve the objectives of my study, primary data will be collected through mixed methods. First, key informant interviews with health providers will be conducted, followed by focus group discussions with Moroccan and Pakistani women, to explore knowledge, beliefs and attitudes toward health prevention and CC. Second, a social network analysis will be undertaken, using semi-structured interviews with visual sociograms, to elicit women's personal networks, examine information and social norms transmission, and identify influencing contacts that may facilitate or constrain their participation in CC screening. Finally, a pilot survey will be administered to assess acceptability of HPV self-sampling. Thematic content analysis will be conducted to analyse the qualitative findings, using ATLAS.TI, and descriptive statistics, network graphs and regression statistical analysis will be carried out, using STATA 17 and R.
This formative research will help to inform the adaptation of the above pilot and/or to design a tailored intervention to increase CC screening participation among Moroccan and Pakistani immigrant women in Catalonia, Spain, and beyond.
From an academic perspective, my study will ensure knowledge exchange and collaborative research with other academic institutions and stakeholders outside the UK, and it will provide a better understanding of the linkages between migration, social support networks and health, in particular, participation in prevention programs, such as cervical cancer screening, as well as the need to identify knowledge gaps and understand the beliefs and psychosocial barriers of communities prior to developing innovations for health and social care, which is a key ESRC's goal. On the other hand, the multidisciplinary dimension (social sciences and public health), the proposed research design (mixed methods approach) and the international scope of my study (international migrant women) fit into the ESRC's strategy which seeks to advance knowledge and provide trained social scientists who meet the needs of users and beneficiaries.
Keywords: Cervical cancer screening, HPV self-sampling, migrant health, social network analysis