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

来自低资源国家的移民妇女是宫颈癌(CC)的弱势群体。她们比本地妇女更不可能参加CC筛查计划，这增加了延迟诊断和治疗的风险，从而降低了生存概率。女性是否参与CC筛查的原因是多方面的，也是复杂的。个人特征、获得卫生系统障碍以及社会和文化背景影响CC筛查行为。已使用各种策略来鼓励妇女接受CC筛查。然而，在许多情况下，这些方法在文化上不敏感，没有考虑移民面临的障碍(例如语言障碍)。这项研究将在西班牙加泰罗尼亚进行，那里正在包括移民妇女在内的不同女性群体中试行HPV自我采样，以增加CC筛查的参与率。在此背景下，我博士研究的总体目标将是探索在西班牙加泰罗尼亚的巴基斯坦和摩洛哥移民妇女中宫颈癌筛查的障碍和促进者以及HPV自我采样的可接受性。我的研究有三个具体目标：1)探索在西班牙加泰罗尼亚的摩洛哥和巴基斯坦移民妇女中关于宫颈癌的知识、看法和信念，以及了解对宫颈癌筛查的态度。2)检查可能影响摩洛哥和巴基斯坦移民妇女参与西班牙加泰罗尼亚宫颈癌筛查项目的环境和人际因素。3)为HPV自我抽样试点干预提供建议，以提高西班牙加泰罗尼亚摩洛哥和巴基斯坦移民妇女的宫颈癌筛查参与率。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，将对卫生保健提供者进行关键信息提供人的访谈，然后与摩洛哥和巴基斯坦妇女进行焦点小组讨论，以探讨卫生预防和CC的知识、信念和态度。第二，将进行社会网络分析，使用视觉社会图的半结构化访谈，以引出妇女的个人网络，检查信息和社会规范的传播，并确定可能促进或限制她们参与CC筛查的有影响力的联系人。最后，将进行一项试点调查，以评估HPV自我采样的可接受性。将使用ATLAS.TI进行专题内容分析以分析定性结果，并将使用STATA 17和R进行描述性统计、网络图和回归统计分析。这项形成性研究将有助于为上述试点的适应提供信息和/或设计有针对性的干预措施，以增加加泰罗尼亚、西班牙和其他地区的摩洛哥和巴基斯坦移民妇女参与CC筛查。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，特别是参与预防项目，如宫颈癌筛查，以及在开发医疗和社会护理创新之前识别知识差距和了解社区的信仰和心理社会障碍的必要性，这是ESRC的一个关键目标。另一方面，多学科维度(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(国际移民妇女)符合ESRC的战略，该战略旨在促进知识并提供受过培训的社会科学家，满足用户和受益者的需求。关键词：宫颈癌筛查，HPV自我采样，移民健康，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