Immigrant women’s perceptions of cervical cancer prevention strategies in Ontario, Canada: A framework-informed qualitative analysis

Background: In Ontario, it is recommended that people with a cervix who are sexually active and over the age of 21 have a Papanicolaou (Pap) test every three years and that students in grade seven receive the human papillomavirus (HPV) vaccine. The extent to which eligible Canadians engage in regular Pap smear examinations and obtain the HPV vaccination are significant public health issues. Importantly, immigration status is largely associated with being underscreened for cervical cancer (Bacal et al., 2019; Datta et al., 2018). Canadian immigrants are less likely to be screened for cervical cancer and have higher rates of HPV infection compared to non-immigrants (Datta et al., 2018; Lofters et al., 2007; Wilson et al., 2021). To develop targeted public health interventions that encourage screening and vaccination among eligible immigrants in Canada, public health practitioners must explore the behavioural influences that produce screening inequities between immigrants and non-immigrants. Methods: Using a semi-structured theoretically-informed qualitative interview study, this thesis examined two major questions: (1) “What are the experiences and perceptions of cervical cancer prevention strategies among immigrant women in Ontario?” and (2) “How might targeted public health programs improve Pap test adherence and HPV vaccination among immigrant women and their children in Ontario?”. The interview guide was based on Version 1 of the Theoretical Domains Framework (TDF). Interviews were coded inductively to explore barriers and enablers to cervical cancer prevention programs. Using previously published criteria, the behavioural influences identified in the inductive stage were then allocated to relevant TDF domains. Results: The behavioural influences identified in this study were allocated to nine of the 12 TDF domains, including Knowledge, Skills, Beliefs about capabilities, Beliefs about consequences, Motivation and goals, Environmental context and resources, Social influences, Emotion, and Behavioural regulation. Conclusion: The findings from this study informed five recommendations for targeted public health programs aiming to increase screening adherence and vaccination rates within immigrant communities. The recommendations are to (1) improve access to multilingual health resources, (2) disseminate health information to immigrant communities through effective media, (3) provide physicians with educational resources to improve the cultural sensitivity and safety of their approaches to care delivery, (4) increase access to low-barrier healthcare and (5) incorporate self-administered tests into provincial screening programs