Abstract B65: Barriers to recommended screening among U.S. immigrants: A literature review
Authors: Allen Elizabeth M. , Loftus John O. 
Published: May 2016

Abstract
Purpose/Objectives: Maximizing cancer screening uptake has been a high public health priority in the United States, particularly for three prevalent and high-mortality cancers which benefit from early detection: breast, cervical, and colorectal cancers. However, screening rates for these cancers remain very low for US immigrants. Immigrants face unique barriers in accessing preventative healthcare that may or may not be specific to particular cultural and socioeconomic backgrounds. This review aims to synthesize literature on barriers to cancer screening among US immigrants in order to help design interventions that aim to increase screening in these diverse populations.
Methods: We conducted a comprehensive search in Ovid Medline using Medical Subject Headings to capture articles discussing broadly defined barriers to screening for breast, cervical, or colorectal cancer in any immigrant communities in the United States. An initial 1148 articles was reduced to a final sample of 90 based on the following inclusion criteria: (1) population-based studies that were not evaluating an intervention (2) at least 80% of the study population immigrants or refugees to the United States (3) focus on uptake or receipt of any screening procedure for one or more of the three cancers of interest (4) study population did not include cancer patients or survivors (5) outcomes included factors influencing screening uptake (studies showing a disparity in screening but not seeking to explain it were excluded) and (6) publication year of 2000 or later.
Results: Of the 90 studies included in the analysis, 26 (28.8%) were qualitative in design while the rest were quantitative survey studies. Men and women from most major immigrant groups in the United States were represented. Studies reported a large range but generally reported higher rates of having ever been screened (25-96%), and low rates of regular screening for all cancers (20-60%). Studies identified a wide-range of barriers including structural barriers such as insurance/cost (n=61), not having a regular provider or not receiving screening recommendation (n=47), language barriers (n=40), discrimination (n=18), navigating health systems (n=11) work/family responsibilities (n=9), and transportation (n=7). Fear and stigma of cancer and screening, concerns about pain, modesty, embarrassment, and lack of knowledge about availability or reason for screening were also identified. Some groups expressed fatalistic conceptions of health, or cultural/religious barriers, however many expressed interest in prevention. General themes important for increasing screening among US immigrants emerged: (1) It is important to disaggregate immigrant groups from racial categories and (2) it is equally important to understand communities' unique cultural or religious concerns. (3) The effects of cultural or psychosocial barriers were less inhibitory than structural barriers. (4) Structural and language barriers, socioeconomic status, and time in the US, were most important for predicting screening uptake.
Conclusions: There is no one-size-fits-all solution for increasing cancer screening among all US immigrants. Results suggest the importance of providers taking time to counsel all patients but perhaps especially those who were raised in cultures with differing conceptions of health. Community-based educational and motivational programs in conjunction with programs to increase structural access may help to increase screening uptake. For providers, identifying community members and/or friends and relatives of patients who can be motivators to screening is likely an effective method to improve screening rates. Targeted interventions that address both individual and structural barriers may be most effective in increasing cancer screening in immigrant communities.
Citation Format: Elizabeth M. Allen, John O. Loftus. Barriers to recommended screening among U.S. immigrants: A literature review. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B65.