Understanding Barriers To Cervical Cancer Screening And HPV Vaccination Among Refugee - PowerPoint Presentation

1. Understanding Barriers To Cervical Cancer Screening And HPV Vaccination Among Refugee Women Living In San DiegoSelemawit Ghebrendrias1, Sarah Pfeil1, Sheila K. Mody1, Bonnie Crouthamel1, Morgen Chalmiers1, Gennifer Kully11. Division Of Family Planning, Department Of Obstetrics, Gynecology, And Reproductive Sciences, University Of California, San DiegoPoster Presenter: Selemawit GhebrendriasResident Physician, UCSD OBGYN

2. Background and ObjectiveCervical cancer remains one of the leading causes of cancer-related deaths in low-resource countriesMany of the women migrating from these countries to the US did not previously have access to routine pap screening or HPV vaccination. On arrival to the US, African immigrants in particular underutilize screening and have significantly lower rates than the national goal (from the Healthy People 2020 initiative) of 93% of women aged 21 to 65 screened annually. Rates of screening are even lower than traditionally underserved communities, including Black American women who have three times rate of cervical cancer screening While we know the lack of access to routine gynecologic care is due to a range of obstacles from socioeconomic limitations to cultural and linguistic barriers there are few studies assessing the depth of the disparity for refugee women. The ways in which refugees navigate the healthcare system are more complex then those of immigrants who have not had the defining experience of life in a war-torn community or refugee camp where gynecologic care may have been provided under coercion. Thousands of these refugee women are living in San Diego, as the county has one of the highest resettlement rates in the nation. Because of this there is an increasing need to understand the status of screening and assess what can be done to improve it. Study objective: To assess the cervical cancer screening and prevention practices of refugee women in San Diego, California and to identify desired components of a cervical cancer screening toolkit.

3. Methods Study DesignThis qualitative study utilized semi-structured focus groups with translators present to discuss cervical cancer screening, HPV vaccination and barriers to care. Participants were reproductive age between 20-50 years old, refugee women who recently resettled in the US within the last 17 years from countries in sub-Saharan Africa and the Middle East.A total of 6 focus groups were conducted between  February 2019-March 2020. Staff associated with the United Women of East Africa Support Team(UWEAST) facilitated the outreach .Each session was between 60-120 minutes. Participants were unique to each group and were reimbursed with $50 dollar gift cards. Data AnalysisFocus groups were recorded and transcribed.Two coders generated a mutually agreed upon set of themes from which a framework was then developed to facilitate coding using Dedoose software.

4. Results The analysis of the focus group transcripts revealed multiple areas of potential intervention to improve participation in cervical cancer screening and prevention.  Influential factors included a lack of knowledge surrounding the purpose of pap smears, the screening schedule and interpretation of results. There was significant fear of pelvic exams, from the pain associated with speculums to the concern for modesty. Many women described an unfamiliarity with routine health screening and only saw the value in gynecologic care when they were feeling unwell or were pregnant. This point of view was shaped by experiences living in countries and refugee camps where resources for preventative health measures were not available. The vast majority of women had never heard of the HPV vaccination and denied having had their children vaccinated. There was also confusion regarding the recommendation to vaccinate male children as well. Linguistic barriers were also an important factor as many of these women require translation services when receiving care and have limited literacy in both English and their native language. This was likely one of the leading reasons participants requested visual aids when discussing ideal methods of providing health education. FGM was not highlighted as a barrier to receiving gynecologic care, though there were important insights discussed regarding the intention behind the practice and the general impacts it has on a woman’s life.

5. Looking Forward…This study builds a framework from which providers throughout San Diego can begin to grasp the extent of the problem and can potentially increase rates of cervical cancer screening by empowering women in a way and language they can understand. The current plan is for a follow up study that will incorporate the development of a cervical cancer screening toolkit. In light of the eagerness of women to increase their own participation in routine pap tests and HPV vaccination after having had received adequate health information during these focus groups, we suspect that the development of an educational toolkit would stimulate actionable change. Follow up focus groups with women from these communities will be conducted with structured surveys to investigate the response to the educational materials created. By assuming cultural knowledge is shared, a cultural consensus analysis will be utilized to systematically asses the practicality of the toolkit in clinical practice. Life in America provides refugees with enormous opportunity, but that opportunity has no value when it is not accessed. They deserve, as do all Americans, the ability to prevent cervical cancer through HPV vaccination and routine pap smears.

6. AcknowledgementsThe United Women of East Africa Support Team (UWEST) The Howell Foundation and Academy of Clinical Scholars The University of California, San Diego