Breast and Colorectal Cancer Screening Barriers Among Immigrants and Refugees: A Mixed-Methods Study at Three Community Health Centres in Toronto, Canada (2018) 

What is this research about? 

Ontario has strong screening programs for breast and colorectal cancer, offering universal screening tools like mammography and fecal occult blood testing (FOBT). When cancer is found late, patients often face much harder treatment and worse outcomes. Recent immigrants and refugees have lower screening rates. This 2018 research was designed to understand why gaps exist in screening among immigrants and refugees.  

The study sought to answer two questions:  

• What specific hurdles prevent recent immigrants and refugees from getting screened? 
• What practical steps can healthcare providers take to fix these problems? 

Looking closely at the experiences of newcomers, this study provides a clear path for building a healthcare system that works for everyone. 

What do you need to know? 

Research shows that immigrants who arrived after 1985 have much lower screening rates than those born in Canada or those who have lived here for many decades.  Breast cancer (BCa) and colorectal cancer (CRC) cause a massive amount of illness in Canada. Tests like mammography and FOBT are proven to catch cancer early and reduce deaths.  

Most studies look at the general population. Unlike many provincial reports, this study included refugee claimants and people without health insurance. These groups are often invisible in medical data. By including them, the study gives us a deeper understanding of how the first few years in Canada affect health. These insights allow us to move from just identifying a problem to finding the specific evidence needed for a roadmap to change.  

What did the researchers find? 

The data shows that a patient’s history and the time they have spent in the country directly impact their chance of getting screened.  

Mammography and fecal occult blood testing (FOBT) improve the detection and management of breast and colorectal cancer. However, these tests are not used enough by recent immigrant and refugee populations.  

Mammography completion was associated with how long a person had lived in Canada and with where they came from. FOBT completion was linked to the patient’s region of origin. Key barriers included a lack of time, language and cultural differences, and poor communication between staff. Potential solutions include matching cultural peer workers, screening workshops, and visual aids. 

Interviews with healthcare providers identified five main themes that stop patients from getting screened. Researchers provided suggested solutions for each theme: 

Practical: Time is the biggest obstacle. Staff often have only 30 minutes to manage several urgent health issues, leaving no time for screening talks. “When they’re dealing with seven other issues… you don’t necessarily have that much time to explain.” Researchers suggest incentivizing screening for staff, including automated reminders in client charts and other approaches to prevent overdue screening. A previously successful initiative was hiring a nurse practitioner to perform roster audits and contact clients overdue for screening. 

Conceptual: Many clients follow a “feel well, am well” way of thinking. They may not see the point of a test if they are without symptoms. One provider noted: “If they’re asymptomatic… ‘my GI system is working fine,’ why do I need another test?” Researchers suggest creating educational pamphlets for clients to take home, raise awareness 

Language: Forms and test kits are usually only in English or French, which is intimidating for many. Staff noted it is: “Difficult to perform education around screening through an interpreter.” Researchers suggested increasing staff and organization cultural competency, including involving peer workers in discussions and education. 

Cultural: Modesty and gender are very important. Some women feel uncomfortable with male technicians. Also, discussing stool for an FOBT is often seen as “gross” or “distasteful.” Researchers suggest working with existing programs to develop screening workshops, which are in group format, language- or culture-specific; as well as creating educational materials in different languages. They also suggested increasing involvement of peer worker staff, recruited from or belonging to the same cultural and/or ethnic group responsible for client outreach, health education and health promotion work. 

Administrative: Newcomers move often, making it hard to send reminders. Clinics also have tools they aren’t using. One staff member said, “We have a TV in the waiting room, but it’s never on.” Researchers suggest using multi-media, multilingual approaches such as posters, TV announcements, and information. 

How can you use this research? 

For Practitioners and Primary Care Providers: 

• Hire Peer Workers: Use staff who share the same culture and language as your patients. They can explain how-to steps for screening tests in a way that builds trust. 
• Train Community Champions: Find and train leaders within newcomer communities to talk about screening and make it a normal part of health conversations. 
• Use Visual Tools: Use simple pictures and pamphlets in different languages to help teach patients about screening during short appointments. 
• Update Waiting Room Media: Turn on the clinic TVs and show health messages in the main languages spoken by the local community. 
• Prioritize Comfort: Ask patients if they prefer a specific gender for their medical technicians to help reduce anxiety and fear. 

For Policy Makers and Health Administrators: 

• Fund Community Workshops: Support large-group screening sessions taught in a patient’s primary language. Group learning has been very successful for other health topics. 
• Automate Clinic Reminders: Set up electronic medical record (EMR) triggers that alert the whole care team when a patient is overdue for a test. 
• Translate All Forms: Work with provincial agencies to make sure screening instructions and consent forms are available in many languages, not just English and French. 

What did the researchers do? 

This study used a mixed-methods approach. To identify barriers to screening and find potential solutions, researchers used two methods: a review of patient charts and focus group interviews with staff. 

Chart Review: Researchers started by looking at 2,420 registered patients who had at least one clinic encounter between November 1, 2012, and October 31, 2015, at three Access Alliance sites. Inclusion criteria:  

• For breast cancer, the exclusion criteria were clients who were male, previously or currently diagnosed with breast cancer, had a lesion of concern identified on a previous mammogram, had a genetic or family history that placed them at increased risk for breast cancer, or were symptomatic. 
• For colorectal cancer, the exclusion criteria were clients who had a previous or current diagnosis of colorectal cancer, had a previous lesion of concern, had a genetic or family history that predisposed them to an increased risk of colorectal cancer, or were symptomatic. 

Client demographics included a median of 7-8.5 years in Canada, 75% who did not speak English as their first language, predominantly from Asia, Latin America & Caribbean, Southeastern Europe, and 30–33% were Refugee Claimants. 

Focus Groups: Two meetings were held with 13 healthcare professionals. This included doctors, registered nurses, nurse practitioners, social workers, settlement workers, and peer workers who shared their on-the-ground experiences. 

Study authors  

Alamgir, A.K.M., Lofters, A.K., Nitti, N., Shakya, Y.B., Wang, A.M.Q., Yung, E.M. 

Journal: Journal of Immigrant and Minority Health (2019) 21:473–482. https://doi.org/10.1007/s10903-018-0779-5  

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