High trust, but low attendance for mammography screening among Pakistani women in Norway – family life, GPs and the radiographer's gender affect

A study published in September 2019 on Pakistani women in Norway shows that consideration for everyday tasks, what the GP says, and whether a man or woman undertakes the mammography examination are key explanations for an apparent paradox that Pakistani women rarely attend the Mammography Programme, despite great confidence in the screening.

The study is part of a doctoral project on immigrant women's participation in the Mammography Programme. The first author is Sameer Bhargava, a doctoral candidate at the Cancer Registry of Norway and doctor at the cancer section at Bærum Hospital.

The study is based on interviews with 16 women of Pakistani background in Norway.

High trust in the health service and GPs

The study shows that the interviewed women had a high level of trust in both the Norwegian health service in general and mammography screening, and that they regarded breast cancer as a serious disease that is important to detect and treat.

Nevertheless, they chose to attend to varying degrees when they received an invitation to the Public Mammography Programme.

There were various reasons why they did not attend. What they had in common, however, was that the women wanted screening closer to everyday life.

According to Bhargava, the women in particular called for greater involvement of GPs.

"We found that the women had a high level of trust in their GPs, and regarded them as important persons in all contact with the health services," says Bhargava.

The women felt that it would be positive if the GPs were given an active role in informing them about mammography screening, answering questions and reminding them that it was time for a new examination.

The women's family life was also central. Caring for the family and family-related obligations could prevent them from attending, despite the fact that they believed the examination was important.

For others, family obligations had the opposite effect, and were an argument in favour of participating in mammography screening.

These women thought that if they did not show up for screening and then developed breast cancer that was difficult to treat, they would eventually not be able to follow up their family obligations.

Want a clear invitation to attend screening

The Mammography Programme provides equal information to everyone in the target group, and sends a letter of invitation and a fact sheet in Norwegian to all 600,000 women in the target group.

In total, the information is four pages, and the purpose of the information is to enable individuals to make an informed choice about participation.

Several said they had attended screening without having read the information they received.

"They thought the information was too comprehensive and complicated," Bhargava said. 

"They called for a simpler and more direct message, for example with only information about the time and place of the mammography examination, and a clear message that this is an important examination they should attend".

Bhargava points out that the information had not prevented the women from attending – nor did those who did not speak Norwegian, or could not read and write.

"These women had family or friends translate or read to them. Those who did not attend cited reasons other than language and information as the reason", says Bhargava.

The women still wanted to get information in Urdu. Bhargava believes one reason may be that getting information in one's native language can increase interest in the information and the services one receives.

"Overall, the study indicates that the women want to be informed in a different way than they are today, both through simple information with a clear message in their own language, but also through dialogue and cooperation, for example because the Mammography Programme should collaborate more with GPs. user organisations, NGOs and others who are part of women's everyday lives, in order to bring screening closer to their daily lives," says Bhargava.

Gender influences, but not religion

The study also revealed that all the interviewed women were negative to a male radiographer undertaking the mammography examination.

Some said that they would not take the survey at all if a man were to carry it out, and the women asked for information in the invitation letter that they could get a female radiographer.

"It was clear that gender plays an important role for these women," says Bhargava.

When asked why they were uncomfortable with a male radiographer, several replied that Pakistani women are not used to associating with strangers of the opposite sex.

There were also several who justified this on religious grounds.

However, the women did not regard religion in itself as an obstacle to participating in mammography screening.

On the contrary, the women believed that religion and science could work together, and that God has given them the opportunity to enjoy good health by accepting offers of preventive health examinations.

More projects implemented in the Mammography Programme

Solveig Hofvind at the Cancer Registry of Norway has led the study, and is also head of the National Mammography Programme.

She believes that the study provides new and important insight, and that the doctoral project itself has already contributed to the Mammography Programme strengthening cooperation with organisations and competence environments that work closely with immigrants.

The Cancer Registry of Norway cooperates with these on several measures, and is in the process of adapting and translating the information in the Mammography Programme into different languages.

Hofvind is also concerned that the radiographer's gender should not be an obstacle to attending screening.

"In fact, it is almost exclusively female radiographers who work in the Mammography Programme," says Hofvind.

Her experience is that the staff try to take the women's wishes into account as far as possible, regardless of country of origin, and this is something she thinks is important to convey to the women.

Hofvind also says that the Cancer Registry, together with the Mammography Programme in Oslo and Akershus, has initiated a project to facilitate information for Somali women, which the doctoral project has previously shown is the immigrant group with by far the lowest attendance in the Mammography Programme.

"Among other things, we will arrange an information meeting in Oslo on 9 November 2019 where two of our radiographers who speak Somali themselves will provide information about breast cancer and mammography," says Hofvind.

Other projects are also being planned, but Hofvind says effective measures are often resource-intensive and thus dependent on external funding.

Hofvind hopes that various measures in the long term will contribute to more immigrant women seeing the Mammography Programme as a relevant service for them, on a par with Norwegian-born women.

"Although this study is about Norwegian-Pakistani women and mammography screening, it is reasonable to believe that the findings are also of value both for other immigrant groups and in other health prevention measures," says Hofvind.

Low attendance and advanced breast cancer

Previous studies have shown that immigrants have significantly lower attendance rates in the Mammography Programme than Norwegian-born women.

Groups of immigrant women are also shown to have more severe breast cancer when the disease is detected than Norwegian-born women – even though they are initially affected less frequently than the Norwegian-born.

Women with a background from Pakistan are the immigrant group with the third lowest attendance in the Mammography Programme. 34% of invitations to Norwegian-Pakistani women result in attendance, compared to 78% among non-immigrants.