Social support and cervical cancer screening among sub‑Saharan African immigrant (SAI) women

Abstract

Background

Low rates of Papanicolaou (Pap) screening among sub-Saharan African immigrant (SAI) women in the US contribute to cancer diagnoses at late stages and high mortality rates. This study was conducted to examine if social support, positively associated with preventive health practices, was predictive of Pap screening in a sample of SAI women.

Methods

We conducted a cross-sectional study with SAI women who recently immigrated to the US. Participants completed a survey to assess ever having had Pap screening and social support using the Medical Outcomes Study Social Support Survey.

Results

Among the 108 SAI women in our study, Pap screening uptake was 65.7%. Affectionate and positive social support were each associated with Pap screening [adjusted odds ratio (AOR) = 1.73 (1.05, 2.87) and 1.68 (1.01, 2.78), respectively].

Discussion

These findings suggest that consideration should be given to strengthening certain aspects of social support to increase uptake of Pap screening among SAI women.

The rates of cervical cancer among sub-Saharan African women are among the highest in the world. At > 40 per 100,000, these rates are more than three times the global rates of 13.1 per 100,000 [1, 2]. The high rates of cervical cancer are of concern not only to the international community but to the US where from 1980 to 2018 migration of sub-Saharan African immigrants (SAIs) increased from 130,000 to approximately 2 million [3]. A coinciding concern is the low rates of cervical cancer screening among SAI women. In accord with US. Preventive Services Task Force guidelines, women aged 21–29 years who are of average risk should undergo Papaniculaou (Pap) screening every 3 years. Alternatively, women age 30–65 years may choose dual human papillomavirus (HPV) and Pap screening every 5 years [4]. Adherence to these recommendations allows for early detection of precancerous abnormalities and early-stage treatable cancer, leading to greater than 80% reduction in incidence and 85% reduction in mortality due to cervical cancer [5]. Despite the tremendous benefits of screening, recent surveys indicate that only 26.4% of SAI women living in the US have ever been screened compared to approximately 85% of US-born Black and White women [6, 7].

Because few studies of SAI women in the US have been conducted, factors associated with the low rates of screening are not well understood. Evidence available on factors that influence general health in this and other immigrant populations, however, suggests that social support is critical to the ability to adapt to a new environment and is associated with improved health outcomes [8]. This is unsurprising given the growing body of evidence that suggests that in the general population, social support is positively associated with health-protective behaviors [9] including engagement in breast, prostate, and colorectal cancer screening [10–14]. Research findings also suggest that social support influences cervical cancer-screening uptake. In a study conducted among non-Hispanic Black and White women, Documet and colleagues [10] found that, after controlling for age, race, having a healthcare provider, and health insurance status, women with education less than or equal to a high-school diploma who had strong social support had nearly two times the odds of engaging in cervical cancer-screening behavior compared to those with low social support.

Social support, defined as the extent to which an individual views his or her social relationships as available to provide aid in times of need [15], may be a particularly strong predictor of protective health behaviors among immigrants who often rely on social support systems to inform use of healthcare systems [16]. At the same time, associations between social support and self-care behaviors have been shown to vary according to the type of social support. For example, results of a study of a national sample of postmenopausal women indicated that lower levels of emotional/informational support and lower positive social interactions were associated with lower engagement in mammogram, annual clinical breast examinations, or monthly breast self -examinations after controlling for all other influences on breast cancer screening. Other forms of social support were not associated with cancer screening in this sample [17]. In a study conducted in a sample of Latinas, a strong association between recommendations from family and friends and mammogram intention and use was found [18]. Similarly, in a study among nurses in Brazil, positive social interaction and affective social support increased the odds of having a Pap smear done, with the odds of Pap completion 70% higher among individuals who had intermediary levels of social support and 84% higher for those with highest levels of social support compared to workers with the lowest positive social interaction/affective social support [19].

These associations between social support and social interactions and cancer-screening concur with the PEN-3 cultural model that provides an organizing framework in which culture is recognized as being central to health and health determinants [20]. The model highlights three interacting domains, Cultural Identity, Relationships and Expectations, and Cultural Empowerment, which guide approaches to understanding health problems and developing interventions [20, 21]. Among these, there is an identification within the Relationships and Expectations domain of the critical influence of family and kin on people’s perceptions of and attitudes toward health behaviors.

While there is substantial literature on the relationship between social support and engagement in health-protective behaviors, associations between social support and Pap screening among SAI women has not been well studied. Guided by the PEN-3 model, the purpose of this study, therefore, was to examine the relationship between social support and Pap screening in a sample of SAI women.

Methods

This was a cross-sectional study conducted with 108 SAI women in Kentucky. Data were collected between October 2016 and January 2017.

Participants

For this study, a convenience sample of 108 sub-Saharan African women was recruited. Eligibility included ability to speak English, self-identification as a SAI woman, and being age 21 and older. Because the purpose of the study was to examine associations between social support and Pap screening, women who had a hysterectomy with cervix removal or cervical cancer were excluded.

Data collection

All data were self-reported. After providing informed consent, participants completed either a hard copy survey or an electronic survey on a password-protected iPad, depending on participant preference. All participants were offered a $30 cash incentive for their participation. The University of Kentucky Institutional Review Board approved research procedures prior to commencement of all procedures.

Measures

Demographic data

Participants completed a sociodemographic questionnaire that included age and education in years. Marital status was assessed by asking if participants were married, cohabitating, single, separated, divorced, or widowed. Data were recoded into 2 categories: “married/cohabitating” or “not married” for those who indicated they were single, separated, divorced, or widowed. Financial comfort was assessed with the question, “Considering the amount of money that comes into your household for you to live on, would you say that you are: (a) very financially comfortable, having more than enough to make ends meet; (b) financially comfortable, having enough to make ends meet; or (c) not financially comfortable because you do not have enough to make ends meet.” The values were recoded into a dichotomous variable with responses categorized as “not financially comfortable” or “financially comfortable,” with the latter representing those who self-identified as “very financially comfortable” or “financially comfortable.” Additional data collected were country of origin, length of residence in the US in years, health insurance status coded as having or not having health insurance, and having a primary care provider.

Pap screening

Participants were asked if they had ever had a Pap screening, with response options of “yes,” “no,” or “don’t know.” Women who answered “don’t know” were grouped with women who answered “no.”

Social support

Social support was measured using the Medical Outcomes Study Social Support Survey (MOS-SS) [22]. The MOS-SS is a 19-item instrument that consists of four subscales used to assess four domains of support as well as overall functional social support, or the social support index. The four subscales include emotional/informational support defined as the availability of someone to share expressions of positive affect and offer advice and information; tangible/instrumental support, defined as the presence of someone to provide material or behavioral assistance; affectionate support that includes the behavioral manifestation of love and having someone to make you feel wanted; and positive social interactions that addresses the availability of someone with whom to do enjoyable activities [17, 22]. Likert-scale response options for items in the survey range from none of the time (1) to all of the time (5). Scores are averaged for each subscale with possible scores ranging from 8 to 40 for emotional/informational support, 4–20 for tangible/instrumental support, and 3–15 for affectionate support and for positive social interactions. The possible scores for the social support index range from 0 to 100, calculated based on the subscales and additional item scores by averaging the individual scores for all 19 items. Scores are transformed to a 0–100 scale by averaging non-missing items subtracting one and multiplying by 100. $100\times \frac{\left\{meansubscalescore-1\right\}}{4}$ For the index and subscales, a higher score indicates more support. The instrument is psychometrically sound and considered universally applicable for social support measurement [22]. In our sample, the instrument reliability was 0.95.

Analyses

Chi-square test of independence and independent sample t test analyses was conducted to describe sample characteristics and to assess between-group sociodemographic differences between those who had ever had and those who had never had Pap screening. To examine if each form of social support and the social support index were predictive of Pap screening, we conducted multiple logistic regression analyses controlling for age, education, marital status, length of stay in the US, financial comfort, and health insurance status. All analyses were conducted using IBM SPSS, version 26 (2017, New York) with an alpha of < 0.05 set a priori as indicative of statistical significance.

Results

The 108 SAI women who participated in the study represented 14 different countries of origin. Among these, there were Nigeria (38%), Cameroon (21.3%), Ghana (13%), Congo (9.3%), and Kenya (5.6%). Of the remaining 12.8% of participants, 9 different countries of origin were represented with no one country representing greater than 8% of the sample. Table 1 describes participants characteristics.

Table 1.

Sample characteristics by Pap screening status (n = 108)

Variable	Total (n = 108) Mean (SD); n (%)	Ever screened n = 71 Mean (SD); n (%)	Never screened n = 37 Mean (SD); n (%)	p value
Age	34.5 ± 9.5	34.8 ± 8.5	33.9 ± 11.2	0.044
Education in years	14.2 ± 6.6	14.6 ± 6.5	13.3 ± 6.8	0.365
Marital status
Married/cohabitating	57 (52.8%)	40 (56.3%)	17 (45.9%)	0.319
Not married	51 (47.2%)	31 (43.7%)	20 (54.1%)
Length of US residence (years)	6.7 ± 5.9	8.0 ± 6.2	4.1 ± 4.3	0.028
Financial comfort	38 (35.2%)	30 (42.3%)	8 (21.6%)
Not financially comfortable	70 (64.8%)	41 (57.7%)	29 (78.4%)	0.026
Health insurance	40 (37.0%)	19 (26.8%)	21 (56.8%)
No health insurance	68 (62.9%)	52 (73.2%)	16 (43.2%)	0.002
Primary care provider	44 (40.7%)	26 (37.0%)	18 (49.0%)
No primary provider	64 (59.2%)	45 (63.3%)	19 (51.4%)	0.302

Statistically significant at p < .05 bolded

Regarding Pap screening history, 34.3% of the women reported that they had never been screened or did not know if they had ever been screened. There were several significant differences between the SAI women in our sample who had ever been screened and those who had not or who were unsure if they had been screened. Compared to women who had never been or who were unsure if they had ever been screened, women who had undergone Pap screening were significantly older [t(106) = 0.64, p = 0.04], had longer length of residency in the US [t(106) = 3.44, p = 0.028], and were more likely to have health insurance [x²(1) = 9.39, p = 0.002], and to be financially comfortable [x²(1) = 3.58, p = 0.030].

We found higher odds of having Pap screening among women who had greater affectionate support [adjusted odds ratio (AOR) = 1.73, 95% CI = 1.05, 2.87] and those with more experiences of positive social interactions and (AOR = 1.68, 95% CI = 1.01, 2.78) (Tables 2 and 3 respectively). Emotional/informational support and tangible/instrumental support were not associated with Pap screening. Of sociodemographic variables for which we controlled, longer time of residence in the US and having financial comfort were also predictive of having obtained a Pap screening in all the models.

Table 2.

Logistic regression model to examine affectionate support as predictive of Pap screening (n = 108)

Characteristics	B	S.E	Odds ratio (95% CI)	p value
Age	0.03	0.03	1.03 (0.97, 1.09)	0.335
Education	0.02	0.04	1.02 (0.95, 1.10)	0.574
Marital status (Married as reference)	0.11	0.59	1.11 (0.35, 3.54)	0.855
Length of US stay	0.17	0.06	1.18 (1.05, 1.34)	0.008
Financial comfort (Financially comfortable as reference)	1.35	0.59	3.85 (1.22, 12.20)	0.022
Healthcare insurance (Has health insurance as reference)	− 0.91	0.55	0.40 (0.14, 1.79)	0.097
Affectionate support	0.55	0.26	1.73 (1.05, 2.87)	0.032

Statistically significant at p < 0.05 bolded

Table 3.

Logistic regression models to examine positive social interaction as predictive of Pap screening (n = 108)

Characteristics	B	S.E	Adjusted odds ratio (95% CI)	p value
Age	0.03	0.03	1.03 (.97, 1.09)	0.380
Education	0.03	0.04	1.02 (.95, 1.11)	0.552
Marital status (Married as reference)	0.87	− 0.09	.91 (.31, 2.72)	0.867
Length of U.S. stay	0.17	0.06	1.19 (1.05, 1.35)	0.006
Financial comfort (Financially comfortable as reference)	1.51	0.60	4.51 (1.39, 14.62)	0.012
Healthcare insurance (Has health insurance as reference)	− 0.79	0.55	.45 (.16, 1.33)	0.148
Positive social support	0.52	0.26	1.68 (1.01, 2.78)	0.046

Statistically significant at p < 0.05 bolded

Discussion

This is one of the first studies to report on social support related to Pap screening among SAI women in the US. We found that affectionate support and positive social interactions were both associated with Pap screening. The higher odds of Pap screening among women who report having affectionate support and positive social interactions, while not robust likely due to the small sample size, indicate the need for further investigation. This is further suggested by similar findings in studies among US-born Blacks and foreign-born Blacks in which social support has been shown to influence cancer-screening uptake [11, 12, 23, 24]. Also in accord with our findings, affectionate support has been positively associated with self-care in other studies. For example, Silva et al. [19] found that higher levels of affectionate support were associated with greater likelihood of completing breast and cervical cancer screening [19]. Similarly, Bajunirwe et al. [25] found that affectionate support was significantly positively correlated to physical health and mental health among 330 patients attending the HIV/AIDS clinic at two government hospitals in Western Uganda.

Affectionate support (the manifestation of love, sense of being cared about, feeling wanted and loved, esteemed, valued as a person, and having someone who cares about you and your problems) [17, 22] would likely come from a personal relationship with significant other or marital relationships. Receiving affectionate support can provide a conducive and enabling environment for women, which may encourage preventive behaviors like Pap screening. Several theories suggest that social support (especially from marital relationships) provides interpersonal connections that could be an important source of affectionate support [26], make available greater economic resources to promote access to health care, and promote adoption of healthy behaviors (adherence to medical regimens and the seeking of follow-up care). In addition, affectionate support may foster a sense of meaning and shift the focus from immediate self-interest gains to longer-term gains [27], which may drive the need to remain healthy and promote preventative behaviors.

Affectionate support may encourage and promote communication about health preventive habits including Pap screening and HPV infection prevention. The importance of affectionate support should be leveraged to promote Pap screening among SAI women by designing cervical cancer programs for SAI women with a dyadic approach that includes men or significant others in interventions for cervical cancer prevention in other to gain support for Pap screening. Single women may benefit from support from other close relationships that may provide affectionate support. Identifying respected individuals in the community, who are willing to provide support especially for those SAI women who are new to the US and may lack support or knowledge of how to navigate needed screening opportunities will be beneficial.

Positive social interaction [17, 22] was also significantly associated with Pap screening. Research has shown that individuals will alter their behavior based on the behavior of those around them, in what is known as modeling [28]. In the context of cancer screening, positive social interactions may take the form of engaging in cancer preventative behaviors such as Pap screening with others in one’s social circle. Similarly, talking to friends about issues related to health is associated with a more adequate frequency of having the Pap smear test [19, 29]. From this perspective, Pap screening is relevant to women who are within the same age group, friends can facilitate information gathering and clarify doubts about the screening [29]. Also positive social interactions may foster social influence and environment to establish Pap screening as an acceptable behavior, encourage discussion about screening, and promote access to healthcare services. Supportive social networks may provide women with information about screening, the means to enable them to make use of screening services, and the encouragement and reinforcement to use screening services [17, 30]. Social support may provide women with more assistance to overcome barriers such as childcare and transportation. Moreover, it provides women with more opportunities to learn about the value of cancer screening. Finally, it influences personal risk perception through information that becomes available to the individuals and advice offered by influential other [31].

We did not find significant relationships between tangible, emotional, or overall social support and Pap screening. This is in consonance with findings from Jatoi et al. [32]; in their study, they did not find significant association between any subscale of social support and better cancer survival. Tangible support is the most probable source to alleviate financial stress [33] that may be associated with Pap screening completion. Among SAI women, cost of Pap screening and additional cost associated with screening completion (such as arrangement for child care and losing income due to time off from work, etc.) have been reported as barriers to screening completion [34], provision of financial succor may eliminate these barriers. Based on the importance of tangible and emotional support, more research is warranted on tangible and emotional support among SAI women. The lack of a relationship between Pap screening and overall social support was in contrast to results from other studies in which significant associations were found [35, 36], but highlights the importance of considering the role of specific sources of support in developing interventions to increase engagement in Pap screening among SAI and other immigrant populations.

Associations of age, length of US residence, financial comfort, and insurance status with ever having had Pap screening are similar to the findings of other studies [7, 35, 36]. Further exploration of Pap screening patterns of younger, uninsured, recently arrived, and financially disadvantaged SAI women are warranted. Considering the growing size of SAIs in the US, public health interventions targeted at the SAIs may help identify at risk women and lead to early detection and prevention of cervical cancer.

These findings suggest that dimensions of social support should be incorporated into interventions to promote cancer screening among SAI women. Africans belong to a collectivist society where the focus is on the well-being of the group or family [37] and value is placed on support from family and groups. The PEN-3 cultural model emphasizes the role of the collective (family/community) in defining the health experiences of individuals and underscores its importance in influencing health-related decisions [21]. It is thought that availability of social support can be an enabler and nurturer that could enhance an individual’s decision to screen for cancer. Obtaining preventive health care in the US can pose a plethora of challenges to SAIs. Such challenges include but are not limited to language/communication, legal status, stigma, reduced access to health insurance, and socioeconomic status [20, 24, 38]. Having social support may reduce some of these health-seeking challenges among SAI population. As suggested by Airhihenbuwa [39], understanding cultural context is more important than focusing on the individual [39]; hence, it is important to recognize that promoting healthy behavior like Pap screening is a collective responsibility. Congruent with the PEN-3 model, our findings indicate that affectionate and positive social interaction with family and kin influence SAI women’s Pap screening behaviors. Future research should consider the use of PEN-3 framework as a guide in the development of innovative culturally relevant multicomponent approaches to improve cancer screening among SAI women. Researchers could leverage the strength of African cultural patterns of social and collateral ties and extended community relationships [40] to design culturally relevant interventions to promote and facilitate increased Pap screening. In addition, researchers could explore the development of interventions that activate different forms of social support within the society. The use of community-based participatory research approaches may leverage existing social networks among SAI women, thereby improving the rate of pap screening. Given that (41%) of our sample lacked a primary care provider and a medical home, engaging community health workers from the SAI community may be a useful strategy to navigate SAI women to the US healthcare and to available community resources such as free screenings.

In addition, community health workers will provide information on possible screening opportunities available at extended period so that women who might not be able to take time off work may leverage on such opportunities and not lose income. The importance of affectionate and positive social interaction can be leveraged to promote Pap screening among SAI women. Designing cervical cancer-screening programs for SAI women using an approach that includes others whom women identify as their greatest sources of support may be of particular importance. Community-wide programs and programs to educate religious leaders in immigrant communities may also be beneficial given the importance of community and religious social connections as sources of support. In many immigrant communities, community health workers serve as important sources of health information and support. Recent evidence from a Community Preventive Services Task Force systematic review shows that community health worker-led group education significantly increases engagement in cervical cancer screening [41].

New contribution to the literature

This study was among the first to examine the association between social support and Pap screening among SAI women and suggests that certain aspects of social support play an important role in the promotion of Pap screening among SAI women. Evidence is scarce concerning the use of validated social support scale to describe influence of social support on Pap screening among SAIs. Understanding the influence of social support among SAIs is crucial to designing culturally tailored behavioral interventions to promote screening among this population who may be outside the mainstream by virtue of being immigrants to the US.

Study limitations

Although our findings provide important data regarding associations between dimensions of social support and Pap screening, it is not without limitations. The use of a convenience sample and cross-sectional design limits the generalization of results to other SAI women, especially given the small sample size and limited inclusion to women who could complete surveys in English. In addition, we collected self-report responses for prior completion of Pap screening, which may be subjected to recall bias or social desirability. Also, given that there are other methods for cervical cancer screening (visual inspection with acetic acid, HPV DNA test, or colposcopy) [42] in the countries where the women in the study migrated from, the question on Pap screening history may exclude women who completed their screening using other methods. It is also important to recognize that SAI populations are quite heterogeneous, including people from many countries and cultures.

Despite these limitations, our study contributes to the literature by highlighting social support characteristics unique to SAI women. This study contributes to the emerging evidence of the role of varied dimensions of social support among SAI. It is imperative that cancer intervention programs are implemented by leveraging the social support systems available to SAI women, as well as addressing other important determinants among this group of women.

Data availability

Due to privacy or ethical restrictions, the data that support the findings of this analysis are not publicly available.