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

来自资源匮乏国家的移民妇女是宫颈癌的易感人群。他们比当地妇女更不可能参加CC筛查计划，这增加了晚期诊断和治疗的风险，因此，生存的可能性更低。女性参与或不参与CC筛查的原因是多方面的、复杂的。个体特征、获得卫生系统的障碍以及社会和文化背景影响CC筛查行为。人们采用了多种策略来鼓励女性接受CC筛查。然而，在许多情况下，这些方法对文化不敏感，也没有考虑到移徙者面临的障碍（例如语言困难）。这项研究将在西班牙加泰罗尼亚进行，在那里，HPV自我抽样的引入正在不同的女性群体中进行试点，包括移民妇女，以增加CC筛查的参与。在这种背景下，我博士研究的总体目标将是探索西班牙加泰罗尼亚巴基斯坦和摩洛哥移民妇女宫颈癌筛查和接受HPV自采样的障碍和促进因素。我的研究有三个具体目标：1)探讨西班牙加泰罗尼亚地区摩洛哥和巴基斯坦移民妇女对宫颈癌的知识、认知和信念，以及对宫颈癌筛查的理解态度。2)研究可能影响摩洛哥和巴基斯坦移民妇女参与加泰罗尼亚地区宫颈癌筛查项目的环境和人际因素。3)为提高西班牙加泰罗尼亚地区摩洛哥和巴基斯坦移民妇女宫颈癌筛查参与率提供HPV自采样试点干预建议。为了实现我的研究目标，将通过混合方法收集原始数据。首先，将与卫生服务提供者进行关键信息提供者访谈，然后与摩洛哥和巴基斯坦妇女进行焦点小组讨论，以探索对健康预防和CC的知识、信念和态度。其次，将进行社会网络分析，使用带有视觉社会图的半结构化访谈，以了解妇女的个人网络，检查信息和社会规范的传播。并确定可能促进或限制其参与CC筛查的影响接触者。最后，将进行一项试点调查，以评估HPV自我抽样的可接受性。专题内容分析将进行分析定性结果，使用ATLAS。将使用STATA 17和r进行TI、描述性统计、网络图和回归统计分析。这种形成性研究将有助于为上述试点的适应提供信息和/或设计量身定制的干预措施，以增加加泰罗尼亚、西班牙和其他地区摩洛哥和巴基斯坦移民妇女的CC筛查参与。从学术角度来看，我的研究将确保与英国以外的其他学术机构和利益相关者进行知识交流和合作研究，并将更好地了解移民，社会支持网络和健康之间的联系，特别是参与预防计划，如宫颈癌筛查。以及在发展保健和社会保健方面的创新之前，有必要查明知识差距，了解社区的信仰和心理障碍，这是经济和社会研究中心的一个关键目标。另一方面，多学科方面（社会科学和公共卫生）、拟议的研究设计（混合方法方法）和我的研究的国际范围（国际移徙妇女）符合ESRC的战略，该战略旨在促进知识和提供训练有素的社会科学家，以满足用户和受益者的需求。关键词：宫颈癌筛查，HPV自采样，流动人口健康，社会网络分析

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