Cervical cancer screening among urban immigrants by region of origin: A population-based cohort study Aisha K. Lofters a,b,c,d, ⁎, Stephen W. Hwang c,g , Rahim Moineddin a,e,f , Richard H. Glazier a,b,c,e,f a Department of Family & Community Medicine, University of Toronto, Toronto, Canada b Department of Family & Community Medicine, St. Michael's Hospital, Toronto, Canada c Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada d Primary Health Care System Research Fellow, London, Canada e Institute for Clinical Evaluative Sciences, Toronto, Canada f Dalla Lana School of Public Health, University of Toronto, Toronto, Canada g Department of Medicine, University of Toronto, Toronto, Canada abstract article info Available online 7 October 2010 Keywords: Cervical cancer Cancer screening Immigrants Objectives. We compared the prevalence of appropriate cervical cancer screening among screening- eligible immigrant women from major geographic regions of the world and native-born women. Methods. We determined the proportion of women who were screened during the three-year period of 2006–2008 among 2.9 million screening-eligible women living in urban centres in Ontario, Canada. In multivariate analyses, we adjusted for numerous variables including age, neighbourhood-level income, and prenatal visits during the study period. Results. 61.3% of women were up-to-date on cervical cancer screening. Screening rates were lowest among women from South Asia when compared to the referent group (Canadian-born women and immigrants who arrived before 1985) (adjusted rate ratio 0.81, 95% CI [0.80–0.82] among women aged 18– 49 years, adjusted rate ratio 0.67 [0.65–0.69] among women aged 50–66 years). Of the older South Asian women living in the lowest-income neighbourhoods and not in a primary care enrolment model, 21.9% had been appropriately screened. In contrast, among Canadian-born women living in the highest-income neighbourhoods and in a primary care enrolment model, 79.0% had been appropriately screened. Conclusion. Efforts to reduce cervical cancer screening disparities should focus on women living in the lowest-income neighbourhoods and women from South Asia. © 2010 Elsevier Inc. All rights reserved. Introduction Cervical cancer is the second most common cancer among women worldwide, with incidence rates almost twice as high in less developed than more developed countries (Kamangar et al., 2006). This difference in incidence rates is believed to be largely due to regular and widespread use of the Papanicolaou (Pap) test as a screening measure in more developed countries through either organized or opportunistic screening programs (Kamangar et al., 2006). The World Health Organization has estimated that 95% of women in less developed countries have never been screened, and therefore that screening just once every five to ten years can significantly reduce global cervical cancer mortality (2006). Although the Canadian province of Ontario has an opportunistic screening program and is moving toward an organized program, we have previously found that immigrant women in the Canadian province of Ontario have lower cervical cancer screening rates than would be expected with adherence to provincial and national guidelines, which recommend a Pap test at least once every three years (CancerCareOntario; Morrison, 1994; McLachlin et al., 2005; Lofters et al., 2010). They have significantly lower rates than their peers, suggesting that patterns of low screening often continue after immigration. Although Ontario has the highest proportion of immigrants in Canada, this finding is not unique to the province; similar inequities in cervical cancer screening for immigrant women have been found throughout Canada, as well as the US, Australia, the UK and parts of Europe (Taylor et al., 2003; Webb et al., 2004; van Leeuwen et al., 2005; McDonald and Kennedy, 2007; Woltman and Newbold, 2007; Wang et al., 2008). However, existing literature in this area have either focussed on particular ethnic groups or have looked at foreign-born women as a homogeneous group. In this study, we aimed to compare the prevalence of appropriate cervical cancer screening in Ontario among immigrant women from major geographic regions of the world and Canadian-born women. Preventive Medicine 51 (2010) 509–516 ⁎ Corresponding author. St. Michael's Hospital, Department of Family & Community Medicine, 30 Bond St., Toronto, ON M5B 1W8, Canada. Fax: +1 416 867 7498. E-mail address: Aisha.lofters@utoronto.ca (A.K. Lofters). 0091-7435/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2010.09.014 Contents lists available at ScienceDirect Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed