Our study showed that immigrants, especially those from 'other countries' (countries outside Western Europe, Northern America, Australia and New Zealand) had lower attendance in BreastScreen Norway than Norwegian-born women in all county areas in the period 1996–2015. Attendance was lower in Oslo than in other county areas for both Norwegian-born women and the two immigrant groups.
These findings are consistent with results from previous studies from BreastScreen Norway (study period 1996–2015) and the CervicalScreen Norway (study period 2008–12), which have also found lower attendance among immigrant women than among Norwegian-born women
(4, 16). Sociodemographic factors such as education and marital status have been shown to have an impact on attendance, for immigrant as well as Norwegian-born women (11). Our findings support results from studies from Denmark and Sweden, which have shown lower attendance among women who are unmarried or live alone and have long higher education or have completed only the primary/lower secondary level (5, 6).
The results from this study are important in a public-health perspective. They show that immigrant women, irrespective of country of birth and place of residence, had low attendance for a preventive healthcare measure recommended for women in Norway in the age group 50–69 years, irrespective of their country of birth or place of residence. Women residing in Oslo had low attendance, irrespective of country of birth. This is relevant since Oslo has a higher proportion of immigrants than the other counties, and negative factors related to place of residence may thus affect immigrants to a greater extent than Norwegian-born women.
Groups of immigrants have been shown to have higher prevalence of diabetes, HIV, tuberculosis, physical inactivity, obesity and smoking – diseases and conditions for which prevention and early detection are important
(17). GPs play a key role in the management of these diseases and conditions, and studies have shown that some groups of immigrants consult a GP less often than Norwegian-born persons (18). Studies such as this, combined with qualitative studies, may help provide a better understanding of underlying causes of inequality in health-seeking behaviour.
During the ongoing COVID-19 pandemic, inequalities in sociodemographic conditions, communication problems and trust in public authorities have been highlighted as contributory factors of the higher prevalence and worse outcomes of COVID-19 among 'non-Western' immigrant groups compared to other people
(19). It is conceivable that the same factors also contribute to the low attendance among immigrants from 'other countries', as described in this study.
We believe that the reasons for these variations in attendance are varied and complex. Variations in health literacy and awareness of breast cancer and screening are potentially relevant. Information on preventive healthcare measures intended for the entire population should be adapted to everyone, including groups that face challenges in terms of health literacy, such as immigrants and persons without higher education, as well as persons with long higher education
(20). Public statistics show that Oslo not only has a higher proportion of immigrants, but also of single-person households and persons with long higher education (21, 22). Furthermore, immigrants from 'other countries' are born in countries with a relatively lower prevalence of breast cancer (15). It is therefore conceivable that they regard mammographic screening as less relevant for them than other women do. Combined with more access to private clinics in the capital city of Oslo, these factors may conceivably have contributed to the lower attendance in BreastScreen Norway among women in Oslo than among women in other county areas.
Our methodological choices had some limitations. The broad division of immigrants into two groups did not take into account the major differences in attendance among immigrant women from different countries
(4). We only had data that link country of birth to attendance for the years 1996–2015, while the results from BreastScreen Norway in recent years have shown a general increase in attendance. Updated data would be able tell us whether this increase has occurred among both immigrant and Norwegian-born women. Our county areas were based on the county boundaries that existed until 2020. We believe that an approach using the current county boundaries would not have had a significant effect on the results and objective of this study. Our study is also limited by our lack of access to some factors that may possibly affect attendance, for instance pre-migratory factors, use of private clinics and post-migratory challenges.
Women residing in Oslo had lower attendance in BreastScreen Norway than women in all other county areas, irrespective of whether they were immigrants or not. Having Oslo as the place of residence had a stronger negative effect on attendance among immigrant women born outside Western Europe, Northern America, Australia and New Zealand than among other women.