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SilvaJ, etal. BMJ Open 2024;14:e082538. doi:10.1136/bmjopen-2023-082538
Open access
Knowledge and attitudes towards
cervical cancer and screening among
migrant women: a qualitative study
in Portugal
Joana Silva ,1 Ana Gama,1,2 Inês Fronteira ,1,2 Patrícia Marques,1,2
Sónia Dias1,2
To cite: SilvaJ, GamaA,
FronteiraI, etal. Knowledge
and attitudes towards cervical
cancer and screening among
migrant women: a qualitative
study in Portugal. BMJ Open
2024;14:e082538. doi:10.1136/
bmjopen-2023-082538
►Prepublication history
and additional supplemental
material for this paper are
available online. To view these
les, please visit the journal
online (https://doi.org/10.1136/
bmjopen-2023-082538).
Received 27 November 2023
Accepted 12 November 2024
1National School of Public
Health, Universidade NOVA de
Lisboa, Lisbon, Portugal
2CHRC, LA- REAL, National
School of Public Health, NOVA
University of Lisbon, Lisboa,
Portugal
Correspondence to
Dr Joana Silva;
js. silva@ ensp. unl. pt
Original research
© Author(s) (or their
employer(s)) 2024. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Objective To explore the perceptions of migrant women,
healthcare professionals and community workers
regarding migrant women’s knowledge and attitudes
about cervical cancer (CC) and screening and how these
inuence cervical cancer screening (CCS) uptake.
Design Qualitative study with seven focus groups, using a
semistructured guide.
Setting Five focus groups were conducted online and two
in community associations in Lisbon, Portugal.
Participants This study included 23 migrant women, 12
healthcare professionals and 10 community workers.
Results A lack of knowledge and negative attitudes
towards screening among migrants were discussed
as important factors leading to a lower CCS uptake.
For participants, many migrant women are unaware of
the disease and CCS. Feelings of uneasiness related to
screening and reservation from their husbands towards
consultations underlie negative attitudes towards CCS.
Disparities among migrant women regarding uptake of
CCS rooted on sociocultural factors were highlighted, with
women from African origin and older tending to engage
less. Healthcare professionals were identied as the
preferred source of information; nevertheless, difculties
in delivering information on sensitive topics were reported
by professionals. Additionally, participants agreed that
peers and social networks may play a role in promoting
screening among communities.
Conclusions Healthcare professionals and community
actors are paramount to promote CCS among migrant
women, especially through culturally adapted awareness
interventions and health- promoting activities engaging
local communities and social networks of women. Training
on cross- cultural communication skills of healthcare
professionals may contribute to improving migrant
women’s knowledge and uptake of CCS.
INTRODUCTION
Cervical cancer (CC) remains one of the most
common cancers among women globally. In
Portugal, it is the third- most common and
deadliest cancer occurring in women aged
between 15 and 64 years, accounting for 484
new cases and 203 deaths in 2020.1 Cervical
cancer screening (CCS) is an efficient
preventive measure to reduce mortality
due to CC,2 with many countries devel-
oping screening programmes and awareness
campaigns targeting women.3 Nevertheless,
inequities in access to early diagnosis still
prevail.
In Portugal, CCS is performed for
free, opportunistically in public health-
care services or through population- based
screening programmes, where women are
invited to be screened in the primary health-
care centre where they are registered.4
Yet CCS uptake remains insufficient, with
remarkable disparities in the coverage and
uptake across different geographic regions
and socioeconomic groups, affecting socially
vulnerable populations, including migrant
women (MW).5 6 Portugal has long been the
host country of many migrants, who account
for 7.6% of the total population.7 The most
common nationalities include those from
Portuguese- speaking countries (eg, Cape
Verde, Angolan, Guinea Bissau, São Tomé
and Principe), with Indian, Nepali and
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒A qualitative approach was used to understand mi-
grant women’s knowledge and attitudes towards
cervical cancer and screening, which may help to
identify effective strategies to promote screening
uptake among underserved populations.
⇒This focus group study allowed to gain insights from
the perspectives of diverse stakeholders, including
migrant women, healthcare professionals and com-
munity workers, contributing to a comprehensive
view of the issue.
⇒Some focus groups were conducted in the virtual
setting, which may have limited group dynamics.
⇒Other nationalities of migrants living in Portugal (eg,
from European countries) and more socially exclud-
ed groups (eg, with low education) were missing;
therefore, important inputs may lack.
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Open access
Chinese nationalities on the rise.7 Estimates indicate that
16.7% of MW do not participate in national population-
based CCS programmes, compared with 12.8% of native-
born women.5
Multiple underlying factors and barriers for low CCS
uptake among MW have been described, including
economic, cultural, religious, geographical and linguis-
tical.8 Individual knowledge and attitudes towards CC
and screening have also been shown to influence partic-
ipation in CCS.8–10 Understanding MW’s knowledge and
attitudes towards CC and screening may help to identify
effective strategies to promote CCS uptake. Additionally,
the perceptions of healthcare professionals (HCP) and
community workers (CW) that interact with MW are also
important to tackle existing inequities. Obtaining the
perspectives of all these stakeholders can contribute to
comprehensively understand what MW know about CC
and screening, how they feel about getting screened and
how those psychosocial aspects influence their screening
uptake.
This study aimed to explore the perceptions of MW,
HCP and CW regarding MW’s knowledge and attitudes
about CC and screening and understand how these
aspects influence CCS uptake.
METHODS
Study design
This phenomenology qualitative study used focus groups,
an appropriate technique to explore the variety of perspec-
tives, opinions and experiences of a group regarding a
topic.11 This paper follows the consolidated criteria for
reporting qualitative research (COREQ) guidelines.12
The study was approved by the Ethics Committee for
Health of the Regional Health Administration of Lisbon
and Tagus Valley (Reference: 8431/CES/2019).
Participants
Participants were MW, HCP and CW. MW were included
based on the following criteria: being 25–64 years old;
being born in Brazil, Portuguese- speaking African coun-
tries, East European or South Asian countries; not having
been screened for CC in the last 5 years; not having
undergone a hysterectomy. HCP included doctors or
nurses with previous experience in CCS clinical practice.
CW were included based on their working experience
with migrant communities.
Participants were purposively recruited via email/
telephone. Migrant associations and non- governmental
organisations doing outreach work with migrant commu-
nities collaborated by disseminating the study within their
social network and recruiting eligible women to partici-
pate, regardless of their level of knowledge or awareness
on CCS. CW were also invited through the collaborating
community organisations. HCP were recruited from
healthcare units located in areas with a high density of
migrant populations.
Setting
Focus groups with HCP and CW were conducted through
the online videoconference platform Zoom, while those
with MW were held in- person in community- based
organisations.
Data collection
Data were collected through seven focus groups
conducted between July 2020 and November 2021—two
with MW (10 and 13 participants, respectively), three
with HCP (two focus groups with three participants each
and one focus group with six participants) and two with
CW (five participants each). The HCP and CW groups
were relatively homogenous. One group of MW included
women from São Tomé and Principe, and another group
included women from other Portuguese- speaking African
countries and South Asian countries. All migrant partici-
pants, including Asian women, were moderately fluent in
Portuguese.
A semistructured topic guide was developed based on
literature and covered perceptions about MW’s knowl-
edge and attitudes towards CC and screening, sources of
information, CCS attendance and strategies to promote
CCS uptake.
Focus group discussions were conducted by a moder-
ator and co- moderator (AG and PM), who were both
females, Portuguese and experienced in using focus
groups methods in research with migrants.
All focus groups were conducted in Portuguese. Prior to
each session, the moderator introduced the team and the
project, describing its goals and procedures. All partici-
pants gave their informed consent, including audio-
recording of the sessions. Focus groups lasted between 1
hour 30 min and 2 hours. Focus groups with MW were set
to be longer to provide the opportunity for all women to
share their perspectives. Data collection was concluded
when saturation of themes was reached.
Patient and public involvement
No patients (ie, women diagnosed with CC) were involved
in this study. Migrant associations and non- governmental
organisations, which included professionals with a
migrant background, were consulted about the semistruc-
tured guide besides collaborating in the study dissemina-
tion and participants recruitment.
Data analysis
Focus groups were audio- recorded, transcribed verbatim
and anonymised. Written notes were also taken during
the sessions. Data analysis was conducted using a deduc-
tive content analysis approach.13 A codebook with themes
and subthemes was developed (see online supplemental
material) outlining the core dimensions of ‘Knowledge
about cervical cancer and screening’, ‘Attitudes towards
screening’ and ‘Bridging the gap’, within which the main
codes were defined and drawn from the data. Each tran-
script was analysed separately. The text segments were
categorised into the codes defined using a text processor.
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Two researchers (AG and PM) coded the transcripts and
validated the codification. Relevant quotes that illustrated
the diversity of emerged subthemes were translated from
Portuguese into English.
RESULTS
All MW were ≥25 years old, more than half had completed
high school and 10 had participated previously in CCS
(table 1). Most women were from São Tomé and Prín-
cipe (n=10), followed by Nepal (n=3), Cape Verde (n=2)
and India (n=2). HCP were all doctors, aged 25–45 years,
mostly women, and two- thirds had 6–15 years of experi-
ence with CCS. CW were mostly women ≥25 years of age.
Knowledge about CC and screening
MW were generally unaware of what CC was or how it
evolves. They tended to identify CC as a transmissible
disease that resulted from minor deformations associ-
ated with polyp growth, which was identified as a major
risk factor: ‘It starts with polyps (…) can cause internal and
external bleeding’ (MW- FG1- P6). While some MW correctly
associated CC with a viral infection and highlighted its
asymptomatic development, others confused it with
breast cancer: ‘It’s like breast cancer, no? Oh Sorry! (…) It’s
nearby the bladder’ (MW- FG2- P16).
The perception of a low level of knowledge about CC
that emerged from focus groups with MW was somehow
confirmed by HCP and CW: ‘There is a lack of literacy among
women regarding what cervical cancer is, when it can be detected,
from what age, and why’ (CW- FG1- P3).
When asked about CCS, almost a half of MW reported
having ever been screened, some expressed it is a method
that reassures women about their health status and a
few described the procedure: ‘It’s this deeper smear that
is collected, in which the doctor uses the speculum and collects
the fluid from there. It probably brings up something that helps
to elucidate, right? Whether it could evolve into cancer in the
uterus. No (…) in the cervix’ (MW- FG1- P7).
All HCP considered that MW do not have enough
information about CCS. MW, HCP and CW agreed that
many MW neither recognise the purpose nor benefits of
screening: ‘Most of them probably do not have enough infor-
mation’ (CW- FG2- P6); ‘They become very confused about what
they are going to do’ (HCP- FG3- P1); ‘Not everyone is informed’
(MW- FG2- P43).
The role of knowledge was remarkably perceived by
MW, HCP and CW as paramount to CCS adherence as
women’s low level of knowledge of the disease and rele-
vance of CCS would lead them to underrate the impor-
tance of early diagnosis: ‘If they are not informed (…) they
won't pursue it, but if they have the information, they will
undoubtedly be more receptive’ (MW- FG2- P43); ‘If I don’t know
what the benefits (of screening) are, I won’t go’ (HCP- FG2- P2).
Several MW and HCP reported that information
regarding CC and screening is primarily conveyed by
healthcare professionals. Those participants specified
paediatricians, gynaecologists and family planning
Table 1 Characteristics of migrant women, healthcare
professionals and community workers included in the study
Characteristics
Migrant
women
(n=23)
Healthcare
professionals
(n=12)
Community
workers
(n=10)
Age
<25 years 0 0 1
25–45 years 12 12 5
>45 years 11 0 2
Missing 0 0 2
Sex
Female 23 9 9
Male 0 3 1
Education level
None 4 NA NA
Elementary school 1
Middle school 3
High school 3
Higher education 9
Missing 3
Country of origin
São Tomé and
Príncipe
10 NA NA
Nepal 3
Cape Verde 2
India 2
Angola 1
Missing 5
Having ever been screened for cervical cancer
Yes 9 NA NA
No 10
Does not know 2
Missing 2
Years of experience with underserved groups
<6 years NA NA 2
6–15 years 2
Missing 6
Professional occupation
Sociocultural
mediator
NA NA 2
Psychologist 1
Social worker 2
Other 5
Category of healthcare work
Physician/doctor NA 12 NA
Nurse 0
Other 0
Years of experience with cervical cancer screening
2–5 years NA 3NA
6–15 years 8
Missing 1
Continued
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doctors as key sources of information: ‘There is the family
planning consultation’ (HCP- FG3- P1). Another valuable
source of information identified by HCP was MW’s social
networks and trustworthy circle of people: ‘They may
discuss with neighbours, acquaintances (…) being the primary
source of information’ (HCP- FG3- P2). To a lesser extent, the
internet was mentioned by HCP as a source used by MW.
Attitudes towards CCS
Women in general expressed feelings of uneasiness,
discomfort and fear with the CCS procedure, in line with
some HCP and CW opinions: ‘I think that, for start, this is
an extremely invasive appointment (…). We know that we must
go, but we avoid going there. I know that I must go there and that
it’s extremely unpleasant’ (MW- FG1- P14).
MW and CW highlighted that many women felt a nega-
tive attitude towards CCS due to their husbands’ reserva-
tion with regards to consulting a gynaecologist and family
planning: ‘In our community, there are men who won’t let their
wife go to family planning appointments. (…) Some men think
that a woman who is going to family planning appointments
wants to avoid getting pregnant (…). And those who don’t have
access to family planning appointments, will not have this infor-
mation (about the importance of screening)’ (MW- FG1- P16).
Different attitudes towards CCS were identified across
MW according with their country of origin. From the HCP
view, women from Latin America and Eastern Europe have
generally a proactive attitude towards healthcare inter-
ventions, which is perceived to be associated with higher
screening attendance among these groups: ‘Migrant popu-
lations from Brazil, (…) they are more informed about screening
and have a concept that they should go to the gynaecologist’
(HCP- FG1- P1). In contrast, some HCP noted that women
originally from an African cultural background often do
not seek screening spontaneously.
Age also emerged as playing a role in women’s attitudes
towards screening. Some CW mentioned that CCS is not a
priority, particularly among older women, and some feel
resistance to exposing their body to a younger healthcare
professional: ‘It’s more difficult for elder women to be observed
by younger ones’ (CW- FG2- P1). For an HCP, younger women
usually have a higher degree of education and are more
conscious about the importance of healthcare, thus show
less resistance towards CCS.
Bridging the gap
MW expressed the need for prior explanation about the
CCS, especially in terms of the procedure by HCP. This
was felt as important to address questions and fears and
facilitate acceptance of the CCS: ‘It’s necessary to explain the
whole mechanism (of CCS) so that people feel comfortable taking
care of their bodies’ (MW- FG1- P1). However, HCP admitted
struggling to explain to MW what CC is and the relevance
of screening in the absence of symptoms. According to
HCP, the main reasons for this are that many of these
topics are taboo and there is low availability of resources,
including time, to undertake healthcare promotion activ-
ities. CW agreed that information is scarcely provided
outside healthcare settings, suggesting a lack of invest-
ment in health education: ‘Information (about screening) is
centralized (…) we only have contact when we go to healthcare
centres’ (CW- FG1- P3).
As a result, MW advocated for a greater investment
in sexual education from an early age and suggested
that ‘There should be (…) teams (…) of medical students who
visit schools to provide information in a more personal way’
(MW- FG1- P7). MW also mentioned the role of informa-
tion campaigns targeting adults; for that, understanding
the rationale for the resistance and motivations to partic-
ipate in CCS was considered crucial for well- designed
health- promoting campaigns: ‘We have to call them, and we
have to have a meeting with them so they can also speak what’s
going in their mind, so we get to know why they are not going, why
they are feeling shy’ (MW- FG2- P4). This idea was somehow
supported by HCP who mentioned that the development
of tailored awareness campaigns would be beneficial to
provide women with the knowledge required to attend
CCS. One HCP specifically suggested that informative
flyers should be translated into different languages to
reach different migrant groups.
A summary of the main findings is illustrated in figure 1.
DISCUSSION
CC is the fourth most frequent cancer and one of the
deadliest among women globally, including in Portugal.14
Although CC is highly preventable through regular
screening, inequities in CCS uptake persist. We provided
an overview of the perspectives of MW, HCP and CW on
knowledge and attitudes about CC and screening among
migrants living in Portugal and its influence on CCS
uptake.
Underlying all participants’ discourses was the idea
that MW have a low level of knowledge about CC and
screening, which translates into a lower uptake of CCS.
Low level of knowledge on CC may lead women to under-
value the disease and screening, increasing the risk of
postponed diagnosis, delayed treatment and the prob-
ability of poor outcomes.15 This knowledge gap may be
related to language difficulties, ineffective interpersonal
communication and cultural differences.8 16 17
Lack of knowledge by MW and low uptake of CCS were
raised as concerns by HCP who participated in the study.
Doctors seem to be the key actors in providing informa-
tion about screening to MW, as observed in two studies
conducted in Scandinavia, one focussing on the perspec-
tive of migrant women18 and other on the perspective of
HCP.19 However, HCP tended to engage less than needed
in health promotion activities, given the sensitiveness of
Characteristics
Migrant
women
(n=23)
Healthcare
professionals
(n=12)
Community
workers
(n=10)
NA, not applicable.
Table 1 Continued
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the topic and the lack of resources, including time. On
the other hand, MW seeking information among peers
and social networks indicates the important role that
community actors have in strengthening communities’
knowledge on the matter.
A previous study conducted in the USA points out an
alarmingly low level of knowledge on CCS among MW.20
Surprisingly, in our study, most MW were aware of CCS,
with almost half of them having been screened and
some being able to describe the procedure. However,
women mentioned the need for further information
and confessed that MW are generally less informed and
willing to be screened, which might be partially explained
by the profile of the participants included: high educa-
tional level and recruited through organisations that
work with migrants, thus with more access to services and
information. Another explanation might be related to
the Portuguese National Health Service and legal frame-
work on migration that offers free access to sexual and
reproductive health services.
Nevertheless, HCP and CW tended to perceive low
adherence to CCS by MW, which they attributed to a
greater extent to lack of knowledge on CC and nega-
tive attitudes towards screening, rooted in sociocultural
factors, as described in other European studies with
diverse migrant groups.21 22 A previous study report that
women from South and Central America, where preven-
tive healthcare is promoted, have a higher CCS uptake.23
In contrast, other groups of women, as from African
origin, seem to be less aware of screening, only uptaking
when invited by the doctor, as suggested in other studies
on CCS attendance among migrant women.19 23 24 Indeed,
cultural background and social norms may influence
preventive health behaviours.16 25 Other reasons for low
CCS uptake are structural barriers in accessing healthcare
services in the host country, lack of culturally and linguis-
tically appropriate information, psychosocial factors, such
as shame related to gynaecological exams, or low health
literacy.8
The perception that women’s knowledge and atti-
tudes towards CC and screening are key for CCS atten-
dance was consensual among participants, leveraging
the importance of health literacy for health decision-
making.18 22 26 Among the strategies discussed in the focus
groups to increase MW’s knowledge, the role of HCP and
the provision of informative services were highlighted by
all participants. HCP stated that they struggle to explain
women the importance of screening, whereas women
expressed they would appreciate prior explanation of
the CCS procedure to help address questions and fears.
These findings show that efforts to improve cross- cultural
communication skills of HCP may be promising, which
were also highlighted in previous studies with migrants
in the European context.19 22 Supportive educational
training may include communication techniques for
improving cultural competency in delivering sensitive
information, considering the diverse characteristics of
migrant patients.19 22
The development of tailored interventions with cultur-
ally adapted information about CC and screening and
the investment in sexual education could raise awareness
among communities.27 These strategies could provide
information in a more engaging way, fostering the discus-
sion about CCS, and therefore should be explored as a
potential alternative for informing migrant communities.
LIMITATIONS
This study gathered the perspectives from different key
informants, providing a more comprehensive view of the
issue. Nevertheless, the limitations of this study must be
acknowledged. Focus groups with MW had a large number
of participants (10 and 13), which might limit the oppor-
tunity of all women to express their views. To overcome
Figure 1 Main results of the study. CW: community workers. HCP: healthcare professionals. MW: migrant women.
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this, the focus groups with MW were made longer to
assure every woman had a chance to share their perspec-
tives, and indeed all participants vigorously contributed
to the discussion. Some migrants were under- represented
in the focus groups (eg, from European countries, with
low education), which might bias the results of this study
towards higher represented migrants. Two focus groups
with HCP included a small number of participants (three
each). This resulted from difficulty in recruiting HCP
during the pandemic crisis and several dropouts among
those who initially accepted to participate in the study.
However, theoretical saturation was reached in focus
groups with HCP, similarly to focus groups with MW
and CW. Some of the focus groups were conducted in a
virtual setting, which creates a different dynamic for that
observed in focus groups conducted in- person, and this
should be accounted for while considering the results of
this study.
CONCLUSION
This study reinforces that knowledge and attitudes
are perceived determinants of CCS behaviour among
MW. Developing tailored health promotion activities is
important to increase CCS uptake in this group. Further
research is needed to understand which strategies are
most effective to increase health literacy and improve
CCS uptake among migrants.
X Inês Fronteira @Ines Fronteira
Acknowledgements The authors wish to thank the study participants for their
contribution to the research. The authors thank Sousan Al Hamwi for her assistance
in revising the draft of the manuscript and Maria J. Marques for assisting in the
focus group implementation. This paper was developed from the project ‘EarLy
dEtection of cerVical cAncer in hard- to- reach populations of women through
portable and point- of- care HPV Testing’. The ELEVATE project is supported by
the European Union’s Horizon 2020 Framework Programme for Research and
Innovation Action (project number 825747).
Contributors SD and AG conceived and designed the study. AG and PM conducted
the guides preparation, data collection and analysis. JS assisted in the data
analysis and wrote the rst draft of the manuscript. All authors contributed to the
interpretation of data. AG and PM commented on initial versions of the manuscript.
IF and SD critically revised the manuscript for important intellectual content and
contributed to the nal version of the paper. AG is the guarantor of this study. All
authors read and approved the nal manuscript.
Funding The present publication was funded by Fundação Ciência e Tecnologia, IP
national support through CHRC (UIDP/04923/2020).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Consent obtained directly from patient(s).
Ethics approval This study involves human participants and was approved by
Ethics Committee for Health of the Regional Health Administration of Lisbon and
Tagus Valley (Reference: 8431/CES/2019) Participants gave informed consent to
participate in the study before taking part.
Provenance and peer review Not commissioned; externally peer- reviewed.
Data availability statement All data relevant to the study are included in the
article or uploaded as supplementary information.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer- reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See:http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
JoanaSilva http://orcid.org/0000-0003-0121-517X
InêsFronteira http://orcid.org/0000-0003-1406-4585
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