Breast cancer screening and immigrant women—A scoping review of attendance, knowledge, barriers and facilitators

Abstract

Aim

The aim of this study was to summarize the latest research reports about immigrant women and attendance in breast cancer screening.

Design

Scoping review.

Methods

Literature searches were made in CINAHL, PubMed, Web of Science, Google Scholar, Oatd and Oalster. Twenty-three articles were included in the study. Data were analysed with inductive content analysis.

Results

Out of data four main categories were formed: attendance rates, incidence, barriers and facilitators, and knowledge and perception. The results show that attendance rates, barriers and facilitators for attendance, knowledge and experience of breast cancer and breast cancer screening differ between several factors such as the woman's migrant background, country of origin, religion, length of stay in the new home country and sociodemographic factors.

INTRODUCTION

Breast cancer is the most common form of cancer in women in the world. Over two million women were diagnosed with breast cancer in 2020, and 684,000 women died because of the disease (The Global Cancer Observatory, 2020). The 5-year survival rate in the world varies between 40% and 90% where the higher rate is found in high income countries. According to the WHO, early detection is a key to improve breast cancer outcomes and survival (World Health Organization, 2021). One strategy for early detection is breast cancer screening. A systematic review, containing data about breast cancer screening and mortality from 43 different studies (conducted in Europe, Asia, North America and Oceania) has shown that screening can reduce breast cancer mortality by 20% (Myers et al., 2015). A recent study conducted in Sweden shows a 40% reduction in the mortality rate for women who participate in the screening programme (Duffy et al., 2020).

The participation rate between countries varies between 15% and 85%, and there are differences between countries within geographical areas and socio-economic groups (International Agency for Research on Cancer, 2016). There are several factors that have been associated with non-attendance when it comes to BCS, such as women's previous experiences with BCS (Carney et al., 2002; Norfjord Van Zyl et al., 2018; Tang et al., 2009), perception of risk of developing breast cancer, history of breast cancer in close relationships and perception of the screening programme (Ersin et al., 2015; Waters et al., 2016; Watson-Johnson et al., 2011). Other factors that may affect or be associated with the attendance rate are psychosocial, for example, being socially isolated, or socio-economic factors, for example, being unemployed or having been born in another country (Lagerlund et al., 2014, 2021; Zackrisson et al., 2007). Previous studies have shown that immigrant women are a group associated with higher non-attendance rate than native women in BCS (Andreeva & Pokhrel, 2013; Bhargava et al., 2018). The International Organization of Migration (IOM) states that there are 272 million migrants in the world and 130 million of them are women. Some people migrate voluntarily, but forced migration (due to conflicts, extreme violence, economic and political instability or environmental or climate change) is the cause behind 70 million of the worlds' migrants (International Organization for Migration, 2019). Since 2015, European countries have registered over 10 million female immigrants and over 1.5 million of these females were asylum seekers (Eurostat—Immigration by Age and Sex, 2022). The World Health Organization (2018) reports that due to lack of resources and language or cultural barriers, immigrants can have hard time accessing healthcare in their new country. Previous studies also show that cancers are detected at a more advanced stage in some immigrant groups than in native population. This can lead to a more severe outcomes, such as tumours detected at a more advanced stage and higher mortality rates (Bakkal Temi et al., 2017; Latif et al., 2015; Mousavi et al., 2013). The purpose of this review was to summarize the latest research about immigrant women and BCS in the countries where population-based screening programmes are offered.

The research question for this study is:

• What does the latest research report about immigrant women and their attendance in breast cancer screening?

METHODS

In order to gain a broad perspective of immigrant women and BCS, the methodology used for this review was the scoping review, which allows for an open research question that should provide an overview of the research field (Peters et al., 2021). Scoping reviews are a suitable method for identifying, mapping and describing the scope and results of the current research in a specific field and identifying possible knowledge gaps (Grant & Booth, 2009; Munn et al., 2018). The method allows for research with any kind of methodology, non-research materials and grey literature to be included (Grant & Booth, 2009; Munn et al., 2018). The review was carried out using the framework developed by Peters et al. (2020). The framework comprise nine steps. The first one is about formulating the purpose and review questions. In the second step, inclusion criteria are created and in the third step, the review process is planned and described. In the fourth step, the literature searches are carried out and finally in the fifth step, selection process proceeding from title level to abstract level and finally to full text, is performed. In the sixth step, data extraction is performed and then analysed (step seven). Finally, in the eighth and ninth step, data are reported, summarized and conclusions drawn from it.

Search strategy

The research question was set according to guidelines for scoping reviews, that is, to design a clear research question; it is recommended to design it in the PCC format, P (population), C (concept), C (context) (Peters et al., 2021). In this case, immigrant women stand for (P), attendance for (Concept), and BCS for (Context). Databases used for the literature search were Pub Med, Web of Science, Cinahl, Google Scholar, Oatd and Oalster. The search terms were as follows: Breast neoplasm, breast cancer, breast tumour, BCS, mammography and emigrants and Immigrants, foreigner and refugee. In order to only include the latest research on the topic, a limitation set for the search was articles that were published no more than 5 years before the initiation of the searches. Inclusion criteria were that the articles were written in English and that they were about participation in population-based BCS programmes. Hand searching and The IARC Handbook of Cancer Prevention (International Agency for Research on Cancer, 2016) was used to identify which countries had population-based screening. Studies where immigrant women were not the main target group of the study were excluded, as well as master and bachelor theses and studies that were conducted in countries where population-based screening does not take place. The choice to exclude articles from countries that do not have population-based (PB) screening was made because it is difficult to draw conclusions about population-based screening from research done on opportunistic screening as the conditions for participation and factors associated with attendance rates differ.

Study selection and critical appraisal

The full selection process is described in the PRISMA flow chart (Page et al., 2021) (Figure 1). The search in the databases generated 248 articles. After duplicates were removed, 143 articles remained. These articles were uploaded into Rayyan (Ouzzani et al., 2016), which is a software tool that can be used in the selection process for review studies. The entire selection process was carried out by two reviewers. In the first selection, conducted in Rayyan, the reviewers read the articles individually at the title and abstract level and marked them as ‘keep’, ‘maybe’ or ‘exclude’, based on the inclusion and exclusion criteria. This process was done with the choice of ‘blindfolds on’, so the reviewers would not influence each other in the process. In the case of articles marked as ‘maybe’, the reviewers discussed the article until a decision to include or exclude was made. In selection 1, the agreement was 100% and 46 items remained in the study and 99 were excluded. Of these articles, 45 were retrieved in full (one article could not be accessed). The 45 articles were read in full to evaluate if they matched the inclusion/exclusion criteria and this was performed individually by the two reviewers. The agreement between the two reviewers was 100% and 22 articles were included and 23 excluded. After this, another search was conducted by going through the citing articles and reference lists of the selected articles to find more studies that could be relevant for this review. In this search, nine articles were identified that matched the inclusion criteria and fulfilled the limitation set for the database searches. Seven of these articles were duplicates, so an additional two articles were added to the selection. The quality of the 24 articles was examined using JBI's quality assessment tools (Moola et al., 2020). To be included in the study, the articles needed to fulfil at least 70% of the criteria in the assessment tool. This selection was also conducted individually by the two reviewers. Agreement was 96% and the reviewers discussed the disagreement and reached consensus. In this selection, one article did not fulfil the criteria set for quality and was therefore excluded, meaning that 23 articles were finally included in the study.

FIGURE 1. PRISMA flow chart showing the selection process for the literature search of immigrant women and breast cancer screening.

Data extraction and analysis

Following the recommendation from JBI on conducting a scoping review, a chart table was developed for data extraction (Peters et al., 2021). Information about the resources and results relevant for the purpose of this study was inserted in the table chart (Table 1). Data were analysed with inductive content analysis, which is a suitable method for both qualitative and quantitative data, and an inductive approach is recommended when knowledge of the research area is deficient or fragmented (Elo & Kyngäs, 2008). The analysis was conducted in three steps; first, the material was read to gain an overall picture. Second, the material was organized by open coding, creating categories and abstraction. Last, the process of the analysis was reported.

TABLE 1 Included studies.

Author	Country	Article	Objective of the study	Result
Tsuruda et al. (2018)	Norway	Lower attendance rates in immigrant versus non-immigrant women in the Norwegian breast cancer programme	Compare attendance rates between immigrants and non-immigrants	Attendance rates at first invitation were 76.1% in non-immigrant women and 53.1% in immigrant women. During the 20-year observation period, non-immigrants has higher attendance rates then immigrant women. Countries with the lowest attendance rates were Somalis, Afghanistan, Iraq and Pakistan. Attendance rates increase with time since immigration
Bhargava, Akslen, et al. (2019)	Norway	Performance measures among non-immigrants and immigrants attending BreastScreen Norway: A population-based screening programme	Describe participation measures and comparing between immigrant and non-immigrants	Attendance rates for immigrants (56%) were lower than for non-immigrants (78%). When divided in to high- and low-incidence countries immigrants still had a lower attendance rate then non-immigrants. Prevalent screens were 24% for non-immigrants and 32% for immigrants. Recall rates was higher for immigrants from both high- and low-incidence countries compared to non-immigrants. Rates of screening detected cancers were the same for both immigrant and non-immigrants (0.55%). Rates for interval breast cancers were highest for immigrants from high-incidence countries (22%) and lower for non-immigrants (0.17%). Lowest rates for interval breast cancers had immigrants from low-incidence countries (0.13%)
Yeasmeen et al. (2020)	Australia	Understanding the participation of breast cancer screening among women born in predominantly Muslim countries living in Victoria, Australia from record-linkage data	Examine differences in participation in breast cancer screening between Muslim born women compared to women born in a non-Muslim country and Australia	The attendance rates were higher in women born in Australia (29.7%) and in a non-Muslim country (26.8%) compared to women born in a Muslim country (24.8%). Somalian women had the lowest attendance rates in the Muslim country born group. Immigrant women between the ages of 60 and 64 women showed a higher participation rate (37% for women form Muslim majority countries, 42% for women from non-Muslim majority countries) than women in other age groups
Woods et al. (2018)	Canada	Breast screening participation and retention among immigrants and non-immigrants in British Colombia: A population-based study	To investigate breast cancer screening participation and retention between immigrants and non-immigrants and identify factors that could influence participation rates	The highest attendance rates for immigrants were from women from United Kingdom (55%) and Iran (54%) which was higher than for native born women with 51%. Lowest rates were shown in women from South Korea (39%) and India (45%). The result showed that participation rate increased with length of stay. Retention rates generally increased with greater physician contact. Screening rates were higher for the refugee immigrants compared to family or economical immigrants for CMHT, India and South Korea but for Former USSR the effect was reverse
Kaucher et al. (2020)	Germany	Breast cancer incidence and mammography screening among resettlers in Germany	Identify differences in participation in breast cancer screening between resettlers from former Soviet union and the general German population	Resettlers had a higher participation rate (84%) than the native participants (73%). Incidence rate between immigrant and native women were similar from 2009 when the screening programme were introduced. Lower and medium educational level had a higher participation rate than women from higher educational levels
Vahabi et al. (2016)	Canada	Breast screening disparities among immigrant women by world region of origin: A population-based study in Ontario, Canada	Describe differences in appropriate breast cancer screening in immigrant women and investigate associations between appropriate breast cancer screening and region of origin and individual and structural factors	South Asian women had the lowest attendance rates (48.5%) together with eastern Europe (52.5%). Women from the Caribbean, Latin America, and western Europe had the highest attendance rates. The attendance rates increased with neighbourhood income and the largest difference between low and high economic class were seen in Sub-Saharan women (19%). Having a contact with a physician were identified as a facilitator. Women from the economical immigrant group had higher attendance than women from the family or refugee immigrant group. Attendance rates increased with length of stay. Male radiographers were identified as barrier
Vahabi et al. (2017)	Canada	Breast cancer screening utilization among women from Muslim majority countries in Ontario, Canada	Examine differences in breast cancer screening uptake between women from Muslim and non-Muslim majority countries	A total of 51% of immigrants were up to date in breast cancer screening. Muslim majority countries in east Asia and the pacific had a lightly higher attendance rate then the non-Muslim majority countries. The other Muslim majority countries had lower attendance rates the non-Muslim majority countries. For the Muslim majority countries—Sub-Saharan and South Asia had the lowest attendance rates (35.35% and 43.1%). Factors that were connected to low attendance such as low income, no primary care physician and a male physician
Kuehnle et al. (2021)	Germany	First prospective cross-sectional study on the impact of immigration background and education in early detection of breast cancer	Analyse immigration background and educational status effect on breast cancer detection.	A total of 73% of the study population participated in screening and highest participation rate was seen in in the group of first-generation immigrants (80.4%). No difference was noted between tumour biology between immigrants and native Germans. Participation rate decreased when the educational level increased
Wang et al. (2019)	Canada	Breast and colorectal cancer screening barriers among immigrants and refugees	Identify barriers to screening and possible solutions	Fifty-nine were up to date with screening. Region of origin and time spent in Canada was factors that was associated with if mammograms were up to date or not. Women with longer time spent in Canada were more likely to be up to date. Barriers were identified as lack of time, lack of understanding, language difficulties, attitudes towards being uncomfortable with males performing screening and loss of follow-up. Migration status was not connected with attendance. Women described mammography as painful and uncomfortable
Le et al. (2019)	Norway	Lower attendance rates in BreastScreeb Norway among immigrants across all levels of sociodemographic factors: A population-based study	Describe relationship between first attendance in immigrant and non-immigrant women and sociodemographic factors	Immigrants had a higher non-attendance rate than non-immigrants in all sociodemographic groups. Recent immigrants had a lower attendance rate than immigrants who had been at least 10 years in Norway. For most regions, immigrants who were not married had a lower attendance rate than the ones who were married. Lower income and lower education were related to lower attendance in all immigrant groups
Lam et al. (2018)	Australia	Prevalence and sociodemographic correlates of routine breast cancer screening practices among migrant Australian women	To investigate participation in breast cancer screening and the relationship between sociodemographic factors and mammography, breast awareness and clinical breast examinations	In the age group 50–69, 421 women (60.6%) had participated in biannual breast cancer screening. Factors that were seen to lead to increased odds for participation in screening were being over 56, had lived in Australia for more than 14 years, were English proficient and had a partner. Education level could not be connected to attendance rates
Kwok et al. (2020)	Australia	Breast cancer perceptions and screening behaviours among Korean women in Australia	Describe perception, knowledge about breast cancer and breast cancer screening and participation and factors that could affect participation in breast cancer screening	A total of 88% of the women had participated at least once in breast cancer screening and 54.5% of the women had participated in in the recommended biannual screening programme. Length of stay was identified as a factor that would have an influence on participation. The longer a women had stayed in Australia, the grater were the odds of having participated in the screening programme. Over 71% of the study participants had heard about mammography
Adu et al. (2017)	Canada	Association between recency of immigration and mammography uptake	To determine if participation in mammography varied according to recency of immigration	Recency of immigration did not affect the odds of having a mammogram or could be associated with recency of uptake. Higher income, higher education and being between 60 and 64 was associated with higher attendance. Respondents who identified as a ‘visual minority’ had significantly lower odds of attending
Ogunsiji et al. (2017)	Australia	Breast cancer screening practices of African migrant women in Australia: A descriptive cross-sectional study	Describe factors that can be associated with breast cancer screening behaviour of African migrant women	A total of 66% had attended mammography biannually. Employment status and age were identified as factors that could influence participation. Younger women were less likely to attend breast screening every second year than older women. Unemployed women and retired women were less likely to attend than employed. Most of the informants were aware of breast awareness and mammography. A total of 85% had heard of mammography
Hulme et al. (2016)	Canada	‘I want to say my life’: Conception of cervical and breast cancer screening among urban immigrant women of South Asian and Chinese origin	To gain knowledge about Chinese and South Asian immigrants perception about breast and cervical cancer screening	Barriers identified were language, cultural, low risk perception and logistical. Gentle operator and clear information about the process were described as a facilitator for reducing anxiety and to have a positive effect on participating in the programme. Women described that if they had no symptom, they did not see the purpose of being screened. A fear of pain and anxiety for mammograms were identified but after first positive experience, the screening was normalized. Fear of possible positive results were also expressed
Hippman et al., 2016	Canada	Breast cancer and mammography screening: Knowledge, Beliefs and Predictors for Asian Immigrant Women Attending a Specialized Clinic in British Columbia, Canada	To study uptake in the screening programme, women's knowledge and beliefs about breast cancer and barrier and facilitators to participation	A total of 87% reported having had a mammogram at least once, 61% said their last mammogram were approximately 1 year ago and 28% stated that the last time they attended screening were between 1 and 2 years. A total of 7% stated two or more years and 5% did not know. Factors that were identified as facilitation to breast cancer screening were as follows: knowing a non-family member who had been diagnosed with breast cancer, age and being recommended to participate by a healthcare professional. The women answered three of nine questions correctly about breast cancer. A total of 55% believed that having breast cancer always meant that one breast had to be removed; less than half of the women knew that having a close relative with breast cancer or not having had children could increase the risk of developing breast cancer. Less than 25% knew that the risk increases with age. A total of 7% stated that it was unlikely they would develop breast cancer in their lifetime
Bhargava, Hofvind, and Moen (2019)	Norway	Gender, letters relatives and God: Mediating actors in mammographic screening among Pakistani women in Norway	Identify and describe actors that effect Pakistani women's attendance in breast cancer screening	Several factors that could have an influence on attendance were identified. Informants had high trust in the government, non-government organizations and their GP's recommendations. Digital tools, information at the mosque and accessibility were identified as possible tools to improve attendance. Actors that could have a negative effect on participation were the cost, the format of the letter which were described as to long and too much information and not being sure if the radiographer would be a women or a man. Fear of participating in mammography was expressed if they would have cancer and they rather died without knowing
March et al. (2018)	Spain	Barriers and discourses about cancer prevention among immigrant women	Identify barriers to and knowledge about breast cancer screening in immigrants from low income countries and native women with low socio-economic status	Lack of time, language barriers, moving around a lot, not being able to take time of work and fear of authorities or the radiation were identified as barriers to screening. Some women preferred to get screened in their native country. A fatalistic view was expressed in some women as a reason to avoid prevention. Some women had a more proactive approach which was related to a more positive view of preventive care. All the women associated cancer with death and many women were reluctant to talk about the topic for various reasons
Suwankhong and Liamputtong (2018)	Australia	Early detection of breast cancer screening and barrier to screening programmes among Thai Migrant women in Australia	Discuss barriers to breast cancer screening attendance in Thai migrant women living in Australia	Barriers to breast cancer screening were identified as inconvenient locations, unfamiliar health service structures and language barriers. Most of the informants did not feel that breast cancer screening was relevant for them and some women did not have the knowledge about the service. Women described that early diagnoses were not as important as eating vegetables, fruits, organic foods and living in a healthy environment to decrease the risk of developing cancer. The women who had attended screening described it as embarrassing and painful
Robinson et al. (2016)	Australia	Breast cancer knowledge and participation in breast screening practices among Southeast Asian women living in Sydney	Explore factors that influence participation in breast cancer screening	For the Filipino, Indonesian and Vietnamese women, a majority stated that they had participated in mammography (73%, 58%, 59%). The lowest participation rates reported from the Thai women were 39% stated that they had participated. The results showed that women with more knowledge about symptoms of breast cancer where more likely to participate in the screening programme. The Vietnamese women in the study had less knowledge of symptoms and treatment options, the other groups of women had average knowledge. More than the majority of the women had heard of mammography. Sources of information was family, friends and physicians
Kwok et al. (2016)	Australia	Psychometric properties of the breast cancer screening beliefs questionnaire among women of Indian ethnicity living in Australia	Report the psychometric performances of ‘The Chinese breast cancer screening beliefs questionnaire’	Positive attitudes towards health check-ups were shown to be connected with attendance in breast cancer screening
Tatari et al. (2020)	Denmark	Perceptions about cancer screening and barriers towards cancer screening among ethnic minority women in deprived area in Denmark—A qualitative study	Describe ethnic minority women's perceptions about cancer and barriers to breast cancer screening participation	Barriers were identified as fear of the possible result of breast cancer, language difficulties and lack of knowledge. Women were aware of risk factors but described the screening as only relevant if they had symptoms and had limited knowledge about the screening programme. Breast cancer was described as uncurable and mortal. Younger women showed a higher knowledge of the benefits of breast cancer screening
Parajuli et al. (2019)	Australia	Access to breast cancer screening—perception, and received barriers among older Bhutanese refugee women resettled in Australia: A qualitative study	To explore perception and barriers of Bhutanese refugee women to the access and use of breast cancer screening	Nine out of 14 women had attended mammography. One of the women had done the biannual check-up. Barriers identified in the study were lack of knowledge and encouragement. Communication difficulties was also identified as a barrier. The women in the study were only motivated to seek help when a problem occurred—not as a preventive measure

RESULTS

In this review, the 23 included articles were from Canada (n = 7), Spain (n = 1), Norway (n = 4), Australia (n = 8), Denmark (n = 1) and Germany (n = 2). Various methodologies were used, qualitative interview studies (n = 7), Cohort studies (n = 7), Cross-sectional (n = 9), and mixed methods, with a cohort/focus group (n = 1). The articles were published in 18 different journals and a total of 94 authors were involved in the different studies. Data from the 23 different studies were analysed and merged into four main categories (Figure 2)—Attendance rates, Incidence, Barriers and facilitators, and Knowledge and perception.

FIGURE. 2. Main and subcategories and number of articles included under each main category.

Attendance rates

Studies that compared attendance rates between immigrant and native women showed contradictory results, as three studies showed lower attendance rates for immigrant women than for native women (Bhargava, Akslen, et al., 2019; Tsuruda et al., 2018; Yeasmeen et al., 2020), but a fourth study showed a higher participation among immigrant women than native women (Woods et al., 2018). Whether immigrant women had higher or lower attendance rate than native women was also shown to depend on their migrant background and country of origin. A German study compared the participation of resettlers (migrants with German ancestors) with the general population (native and ‘other immigrants’) and these results showed a higher attendance rate among resettlers (84.1%) than among the general population (73.6%). When comparing native Germans with ‘other immigrants’, the differences between attendance rates varied depending on country of origin (Kaucher et al., 2020). Some of the included studies compared attendance rates between immigrants by country of origin. The highest attendance rates were seen in immigrants from Europe, Latin America, the Caribbean and the Philippines, and the lowest were seen in women from North and East Africa, South and Central Asia, India and Eastern Europe (Tsuruda et al., 2018; Vahabi et al., 2016; Woods et al., 2018). When investigating the difference in attendance rates between immigrant women from Muslim and non-Muslim majority countries, it was found that, with the exception for East Asia and the pacific, immigrant women from non-Muslim majority countries had a slightly higher attendance rate than immigrant women from Muslim majority countries (Vahabi et al., 2017).

Incidence

Three studies in this review covered the topic of differences in detection, tumour biology and incidence between immigrant women and native women (Kaucher et al., 2020; Kuehnle et al., 2021). In two of these studies, no significant differences in tumour biology or the stage of the tumour were detected when comparing between immigrant and native women (Bhargava, Akslen, et al., 2019; Kaucher et al., 2020; Kuehnle et al., 2021). The third study did not show any significant differences in the proportion of screening detected cancers (SDC) and interval breast cancers (IBC) between immigrant and native women. However, a difference was identified between immigrant women from low and high-incidence countries both in SCD and IBC, where the rate of SDCs was 0.61% for women from high-incidence countries and 0.50% for women from low-incidence countries. Immigrant women from low-incidence countries had the lowest proportion (0.13%) of IBC compared with native women (0.17%) and women from high-incidence countries (0.22%). In SDCs, a lower proportion of cancer cells in the lymph nodes was detected in natives (23%) than in immigrants (26%) and the proportion of tumours larger than 2 cm was higher in immigrants (24%) than in native women (23%). SDC rate with histological grade 3 (fast growing) was higher in immigrants (24%) than in native women (21%), but immigrants from high-incidence countries had only 20% of SDCs with histological grade 3, thus lower than in native women, compared to women from high-incidence countries where it was 28% (Bhargava, Akslen, et al., 2019).

Barriers/facilitators Years since migration/immigration status

Longer stay in the new home country was associated with increased attendance (Kwok et al., 2020; Lam et al., 2018; Le et al., 2019; Tsuruda et al., 2018; Vahabi et al., 2016; Wang et al., 2019). Attendance rates for immigrants with a refugee status were shown both to be lower (Vahabi et al., 2016) or higher (Woods et al., 2018) than for immigrants with other migrant status. Other studies reported no impact on attendance rates due to the number of years since migration and immigration status (Kuehnle et al., 2021; Vahabi et al., 2017; Wang et al., 2019; Woods et al., 2018).

Sociodemographic factors

Income (Adu et al., 2017; Le et al., 2019; Woods et al., 2018), receiving disability benefits (Le et al., 2019) and being employed (Le et al., 2019; Ogunsiji et al., 2017) were positively associated with attendance rates. However, one study showed no significant connection between employment status and attendance (Lam et al., 2018). Age was also associated with participation, however, the results in these studies were contradictory, as older women were described as both being less likely to attend than younger women (Vahabi et al., 2016; Woods et al., 2018) but also more likely to participate in biannual screenings (Lam et al., 2018; Ogunsiji et al., 2017). Studies regarding how educational status influences attendance rates also showed contradictory results. Lower levels of education were linked to lower participation (Lam et al., 2018; Le et al., 2019), but other studies showed a decrease in participation in connection with increased level of education (Kaucher et al., 2020; Kuehnle et al., 2021) or no connection at all (Lam et al., 2018). Other sociodemographic factors that were shown to have a connection to lower attendance rates were being single or separated (Lam et al., 2018; Le et al., 2019), having a foreign citizenship, living in a capital city (Le et al., 2019) or living in a low-income area (Vahabi et al., 2017).

Healthcare contacts

Immigrant women who in different ways were connected with healthcare services had a higher tendency to attend BCS (Vahabi et al., 2016, 2017; Woods et al., 2018). Recommendations to attend BCS by a physician were described as something that would influence biannual attendance (Hulme et al., 2016). If the women's physician was trained domestically in their new homeland instead of internationally was a factor shown to have an effect on attendance, but depending on which country of origin the women came from the effect could be either positive or negative (Vahabi et al., 2016). Knowing someone who experienced breast cancer was identified as a facilitator for attendance in BCS (Hippman et al., 2016). Being examined by a male radiographer was described as uncomfortable and identified as a possible barrier (Bhargava, Hofvind, & Moen, 2019; Wang et al., 2019).

Family and religion

Both Muslim and Catholic women described religion as a facilitator stating that their religion encouraged a healthy lifestyle. Migrant women from Eastern Europe, Sub-Saharan Africa and Maghreb expressed fatalistic views and expressed them as a reason to not use preventive services—‘what will happen is meant to be’ (March et al., 2018). Several women mentioned that their responsibilities with their home and family were more important than going to a mammography and it therefore was not prioritized (Bhargava, Hofvind, & Moen, 2019; March et al., 2018). Contrary to this, some women described it as not only important for themselves but also that it was their duty to attend a mammography and take care of their health because if they got sick, no one would take over their duties at home (Bhargava, Hofvind, & Moen, 2019; Hulme et al., 2016).

Language

Language barriers were identified as being connected to attendance rates in BCS. Immigrant women stated that the language barrier made them feel insecure and sometimes stopped them from seeking help. Using a translator was described by some women as removing confidentiality (March et al., 2018; Suwankhong & Liamputtong, 2018). Immigrant women who did speak the language of the country they migrated to had a higher attendance rate than women who did not (Lam et al., 2018).

Knowledge

The probability of attending BCS has been shown to increase with the level of knowledge (Robinson et al., 2016). A positive attitude towards health check-ups, knowledge about the procedure and benefits of BCS, and a low perception of barriers to participation has also been identified as increasing the attendance rate for immigrant women (Hippman et al., 2016; Kwok et al., 2016, 2020).

Logistics and economy

Logistics were described as a barrier. Screening centres were described as being too far away and difficult to get to if you do not have a car (Hulme et al., 2016; Suwankhong & Liamputtong, 2018). Women stated that having screening centres close would help since they have a tradition of community and group gatherings and then the women can help each other with childcare and the older women can meet and socialize (Hulme et al., 2016). Some women expressed that women from their native countries sometimes are dependent on their husbands to accompany them to the screening centre and it can be difficult for these women to coordinate their screening appointments with their husbands’ schedules (Bhargava, Hofvind, & Moen, 2019). Women expressed prioritizing work, worrying about money and job security and having difficulties taking time off for appointments (March et al., 2018; Suwankhong & Liamputtong, 2018). A fear of discovering that they developed cancer and had to stop working and would not be able to provide for their families was also expressed (March et al., 2018). Some women expressed that mammography is a very expensive procedure in their native country and therefore they never went, other women had their mammograms performed in their native countries when they went back to visit (March et al., 2018).

Perception/knowledge Knowledge and perception about breast cancer

Knowledge of breast cancer and the perception of risk of developing the disease varied. The word cancer created fear in some women, and they did not want to talk about it; it was expressed that ‘talking about it might cause it’. Breast cancer was also described as connected with death, lack of effective treatment and being incurable (March et al., 2018). Factors that could increase the risk of developing breast cancer were described by some women as genes, smoking, no exercise, stress and unhealthy diets (Tatari et al., 2020). Some women were aware that early detection with a mammography can lower the risk of dying and increase their chances of recovery (Bhargava, Hofvind, & Moen, 2019; Hippman et al., 2016). An early diagnosis was described as not as important as eating vegetables, fruits, organic foods and living in a healthy environment to decrease the risk of developing breast cancer (Suwankhong & Liamputtong, 2018). It was expressed by certain groups of women that if no one in their family had ever had breast cancer, there would be no risk for them to develop the disease (Hulme et al., 2016; Suwankhong & Liamputtong, 2018). It was also described that some women believed that they probably would not develop breast cancer during their lifetime (Hippman et al., 2016).

Knowledge and perception about breast cancer screening

Many women had heard about BCS, but some of them did not know about the biannual check-up (Kwok et al., 2020; Ogunsiji et al., 2017; Parajuli et al., 2019; Robinson et al., 2016). Older women showed less understanding of the reason for the screening (Tatari et al., 2020). In several studies, the women included were under the impression that a mammography was not necessary unless you had symptoms (Hulme et al., 2016; March et al., 2018; Parajuli et al., 2019; Tatari et al., 2020; Wang et al., 2019). Strengths and limitations with mammography were in some groups not clearly understood. Women expressed that after experiencing a mammography that they were cancer free with perfect health (Hulme et al., 2016). On the contrary, other women were under the impression that mammography is not good for their general health and could have a negative effect on their breasts (Suwankhong & Liamputtong, 2018; Tatari et al., 2020). Fears of participating in a mammography and being diagnosed with breast cancer was expressed and some women explained that they would rather die without knowing. It was also expressed that mothers had advised against having a mammography since they did not trust the procedure (Tatari et al., 2020). Lack of knowledge that not all lumps found in the breast were breast cancer were expressed and women described that the breast was always removed if a cancer was detected (Hippman et al., 2016).

Experience of breast cancer screening

In several studies, women described mammography as painful and uncomfortable but still many of them were willing to participate (Bhargava, Hofvind, & Moen, 2019; Hulme et al., 2016; Robinson et al., 2016; Suwankhong & Liamputtong, 2018; Tatari et al., 2020; Wang et al., 2019). The fear of pain was connected with previous experiences and aggressive or harsh care workers (Bhargava, Hofvind, & Moen, 2019; Hulme et al., 2016). Mammography was also described as embarrassing or shameful since they must undress (Parajuli et al., 2019; Robinson et al., 2016). Women who did not speak the language of the country described that not being able to express their worries or concerns during the procedure was unpleasant and weird (Parajuli et al., 2019). Sometimes the language barrier was due to time constraints. Healthcare workers stated that using an interpreter would be too time consuming (Wang et al., 2019).

The use of interpreters was not helpful for some groups since the interpreters gave unclear information, and often came from another region in their native country and thus did not have the right understanding regarding their language and culture (Suwankhong & Liamputtong, 2018). The option of bringing a younger relative to translate was expressed (Hulme et al., 2016; Parajuli et al., 2019), but it was also described as being uncomfortable sharing sensitive information with them (Parajuli et al., 2019). Fear and anxiety of receiving the results were also mentioned (Hulme et al., 2016).

DISCUSSION

In the majority of the studies, immigrant women had lower attendance rates than native women though several studies showed that attendance depends on the native country. Immigrant women from North and East Africa, South and Central Asia and India and Eastern Europe had the lowest attendance rates (Tsuruda et al., 2018; Vahabi et al., 2016; Woods et al., 2018), which indicates that these are groups where interventions should be carried out to increase participation. Previous studies, aimed at targeting religious or ethnic groups in order to increase attendance in screening, have been carried out and have shown to have a positive impact on attitudes towards BCS and immigrant women's intentions of participating in the programme (Cullerton et al., 2016; Kwok & Lim, 2016; Pratt et al., 2017). Another interesting result is that even though women attend the screening when they are invited for the first time, many do not return the next time they are invited for the biannual check-up. The result showed a difference in the participant frequency between first-time screening (37%–39%) and follow-up screenings (7%–66%). It may therefore be important not only to focus on raising the first-time attendance rates for immigrant women, but also making sure to identify reasons for this and finding methods that enable women to return biannually.

When immigrant women described their experiences with BCS, some stated that they found the examination painful or uncomfortable (Bhargava, Hofvind, & Moen, 2019; Hulme et al., 2016; Robinson et al., 2016; Suwankhong & Liamputtong, 2018; Tatari et al., 2020; Wang et al., 2019), experienced language difficulties (Lam et al., 2018; March et al., 2018; Suwankhong & Liamputtong, 2018) and in some cases experienced rude behaviour by the healthcare workers (Bhargava, Hofvind, & Moen, 2019; Hulme et al., 2016). Describing mammography as painful and uncomfortable is not exclusive to immigrant women. It is expressed by women in general (Andrews, 2001; Whelehan et al., 2017), but in combination with language problems, it might lead to increased non-participation of immigrant women in the future compared to native women. Verbal communication has been shown to have a significant impact on the experience of pain and discomfort during mammography examination (Shrestha & Poulos, 2001). One study compared the difference in mammography discomfort between a group who received verbal information before the study and a group who did not receive information. Information about the procedure, the importance of compression, and the expected pain experience was offered verbally. The women who received verbal information beforehand reported a significantly lower degree of discomfort than the women who did not receive information (Shrestha & Poulos, 2001). Improving verbal communication is thus appropriate. The use of an interpreter was shown not to be completely problem-free since women describe a feeling of loss in confidentiality in these situations (March et al., 2018; Suwankhong & Liamputtong, 2018). Alternative methods of interpretation should be considered. Digital language translation using an app has been tested in several studies where the results have shown that it might function with both text–text, text–speech and speech–speech, but with inconsistent quality since the accuracy of the translation can be affected by several different variables such as differences in dialect and pitch in speech–speech translation (Dew et al., 2018).

Sociodemographic factors such as age, employment status, level of education and area of residence were identified as factors that can have an influence on attendance. However, these factors have also been identified as barriers for native women and can therefore not be linked exclusively to the group of immigrant women (Lagerlund et al., 2021).

Many years as an inhabitant in the new country was connected with higher attendance rates (Kwok et al., 2020; Lam et al., 2018; Le et al., 2019; Tsuruda et al., 2018; Vahabi et al., 2016; Wang et al., 2019). Previous studies of refugees' barriers and facilitators to seeking healthcare show that there are many barriers such as language difficulties, a lack of confidence or capacity to find the right parts in the healthcare system and lack of knowledge about what services that are available (Parajuli & Horey, 2020). In this study, the lack of knowledge was shown to be a factor that influenced intentions in terms of participation in screenings and that a recommendation from a doctor had a positive effect on participation (Hulme et al., 2016), while it was also found that immigrant women who had an already established contact with healthcare had a higher tendency to participate in the screening programme (Vahabi et al., 2016, 2017; Woods et al., 2018). It is important to reach out with suitable information to these immigrant women and find suitable channels to do so. Previous studies have shown that healthcare professionals, family and friends, and the Internet were the most popular sources of information for immigrant women (Ahn & Chae, 2019; Zimmerman & Beam, 2020). Non-profit organizations such as humanitarian or social services agencies have also shown to be suitable sources of information for immigrants (Bianco et al., 2016). Maternity care centres are also places where it is possible to reach out with information to women about breast cancer and screenings. It is a place where women meet healthcare workers and breast health can be discussed, for example, when discussing breast-feeding. Although many women who are pregnant are not old enough for screening, the information given can be useful for the future and may also be passed on to friends and relatives.

Logistics was described as a barrier and desires for shorter distances to mammography centres was expressed. This was partly because it could not only be difficult to get around without a car or get time off from work, but also due to difficulties in getting childcare (Hulme et al., 2016; Suwankhong & Liamputtong, 2018). Mobile mammography units could make it easier for these women and have been described in previous studies to have a positive impact on the participation of women from minority groups (Phillips et al., 2011).

Limitations

In this study, the articles that were not about population-based screening were excluded. The reason for this is that the conditions for participation between opportunistic screening and population-based screening makes it difficult to make generalizations regarding attendance rates and factors influencing participation. Most articles fell into the category of ‘barriers and facilitators’ (n = 17) and the least were about ‘incidence and tumor biology’ (n = 3). The reason for the small number of studies on tumour biology and incidence may be that the keywords used were about participation in screening and not incidence or biology. The reason why this information was included was because they also contained results on participant frequency and barriers/facilitators. In order to be able to describe differences in breast cancer incidence between immigrant women and native women, the keywords and inclusion criteria should be adapted for this. The choice of how many databases to include can be discussed. After searching in PubMed, Web of science and CINAHL, the next three searches in Google Scholar, Oatd and Oalster only generated an additional five resources. Had the search been conducted in a larger number of databases, it might have generated additional resources. However, the hand search conducted in the included resources reference lists and citing articles broadened the search field and the possibility of additional articles. The choice to include grey literature opens up the possibility of a larger number of resources and a broader prospective, although in this study, the search for grey literature did not generate any additional resources.

CONCLUSION

This study contains 23 articles with various methods and results, which makes it difficult to draw a general conclusion. It is obvious that immigrant women are not a homogeneous group. It includes highly educated academic individuals as well as illiterate women without an education, women from different parts of the world and with different religions and cultures. The conclusions that can be drawn from this study are that immigrant women need to receive tailored information about breast cancer and BCS. When information is provided, it should be tailored according to the woman's migrant background, country of origin, religion, length of stay in the new home country and sociodemographic factors. Information should also be provided by physicians or other organizations that meet immigrant women in various cases. Since attendance rates, barriers and facilitators, knowledge and experience differ between different ethnic groups, any measures put in place should be tailored to different specific groups. Research on how to reduce language barriers should also be conducted in order to improve care in breast cancer screening.

AUTHOR CONTRIBUTIONS

All four authors have met the four criteria's of the ICMJE definition of authorship. ‘Have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. Been involved in drafting the manuscript or revising it critically for important intellectual content given final approval of the version to be published. Each author should have participated sufficiently in the work to take responsibility for appropriate portions of the content. Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved’. (International committee of medical journal editors [19 August 2022]. Defining the Role of Authors and Contributors. https://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html).

ACKNOWLEDGEMENTS

We would like to thank Solveig Lundgren for useful comments and feedback during the planning of this study.

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

CONFLICT OF INTEREST STATEMENT

The authors have no conflict of interest to declare.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.