We observed fair rates of breast and cervical cancer screening, and low screening rates for CRC among immigrant women. Cambodian women were more likely to be screened for each malignancy than Vietnamese women, who, in turn, were more likely to be screened than the Somalis. Longer duration of time in the US was related to improved screening rates. In our population, most Cambodians have resided in the US for an average of 15 years, while the Vietnamese and Somalis have been residing in the country for an average of 9 and 6 years, respectively.
Our rates for the Asian immigrants are similar to West Coast studies on Vietnamese and Cambodian immigrants [8
] and to those reported among Hispanics in the US and Puerto Rico [9
]. Prior research on cancer screening among immigrants suggests that language barriers, low educational attainment, and poverty lead to decreased access to preventive care [10
]. In our studied population, increased discomfort of immigrant women with male providers was a reported barrier, however, this barrier was ascertained by our pilot questionnaire (with limited possible responses) rather than an empiric qualitative method such as focus groups, where patients may have offered other barriers to screening. Similar observations of non-English speaking immigrant women declining examination by male physicians, and other cultural factors acting as barriers, may contribute to low screening rates [12
We found that among the screening tests studied, colonoscopies/sigmoidoscopies were the least performed examination for immigrant women, similar to findings in other studies [3
]. In our review of charts, we observed health care providers were often unable to discuss screening due to other dominating issues. This problem of "tyranny of the urgent" has been described in well known work attempting to improve the consistency of preventive care and care of chronic illnesses [14
]. The process for requesting an endoscopy procedure is also more complex than that for a Pap test or a CBE, which can be done by the patient's own provider. Additional appointments must be set up with translators to explain the endoscopy preparatory procedures, which, in turn, must be done correctly in order to obtain valid results. If the patient misses these appointments or the actual procedure itself, the probability of completing the screening test decreases. Moreover, the concept of disease states (e.g
. cancer) and of preventative care, in general, may be difficult for immigrants, and cultural health beliefs may influence choices even with health care education. These observations highlight the importance of enhanced systems of care for immigrant populations. Improvement of patient health care via increased physician-patient communication, professional interpreters, cultural understanding, counseling about gender bias, and awareness of patient health beliefs are needed for high quality preventive health care.
This study was limited by its small sample size. Our data suggested trends that could be confirmed only with a larger sample, and ideally at more than one center. Local factors may also have influenced our findings. For example, a recent educational project in the Vietnamese community in the Portland area may have raised breast cancer screening rates in that population locally. We did not assess the role of insurance status, as the vast majority of this population was covered by Medicaid. An additional limitation is that we did not explore problems with access to health care such as rides, work, or childcare constraints. Patient surveys were also conducted with mostly Cambodian and Vietnamese women. For unclear reasons (perhaps chance), there were few Somali women having clinic visits during enrollment. Of those that were seen in the Internal Medicine Clinic, many did not meet entry requirements, while others declined participation; as a result, only two Somali women were interviewed. Additionally, many respondents had difficulty choosing a single response to the questions. Future work might include focus groups or other methodology rather than questionnaires to gather information on themes related to understanding of cancer and cancer screening. This would also avoid bias that may have been introduced by the questionnaire responses (such as that having a male provider was a problem).
We report inadequate cancer screening rates among women immigrants, specifically Somalis, receiving care at our medical center. Screening rates were highest among Cambodian women, who had been in the US the longest. If duration of residence in the US is a proxy for acculturation, this is likely to explain our findings. Most of the (albeit small) sample of immigrant women we spoke to were genuinely interested in learning about cancer screening with written information and videos in their own languages (low levels of education among these women may decrease use of written information). Additional detailed assessment of immigrant understanding of cancer screening may be better approached using a qualitative method such as focus groups. Examination of the various belief systems by cultural group in this setting would allow for exploration of a wider variety of potential beliefs, understanding levels, and barriers to full participation in medical care in the US. Additional studies could assess the value of "screening days" (which appeared to have been successful in the case of Vietnamese women and mammography screening in our community) which could be held for specific groups of immigrants with involvement of community leaders and in-person professional interpreters. These would provide women with access to female health care providers, cultural liaisons, and interpreters in a setting that promotes cultural awareness. In the case of Somali immigrants, additional work is needed to understand health beliefs and to engage the population in cancer screening. The first steps again may need to be focus groups or in-depth interviews. Working with religious leaders or community leaders around educational interventions for the community may also be helpful. Additional research into provider bias or perceptions of cancer risk and screening adherence and ability in immigrants would also extend this field of inquiry. To improve colon cancer screening among immigrant populations, more intensive educational efforts may be necessary, regardless of ethnicity. In conclusion, we suggest several areas for study and community work that may help improve cancer screening rates among immigrants.