Journal of Immigrant and Minority Health

https://doi.org/10.1007/s10903-018-0785-7

BRIEF COMMUNICATION

Uptake of Gynecological Cancer Screening and Performance of Breast

Self-Examination Among 50-Year-Old Migrant and Non-migrant
Women in Germany: Results of a Cross-Sectional Study (InEMa)
Eva‑Maria Berens1   · Lea‑Marie Mohwinkel2 · Sandra van Eckert5 · Maren Reder3,4 · Petra Kolip3 · Jacob Spallek5

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Our aim was to provide data regarding uptake of gynecological early detection measures and performance of breast self-
examinations among migrant women in Germany. Cross-sectional self-reported data were collected using paper-and-pencil
questionnaires. Descriptive analyses, Chi square-tests, and logistic regression were applied. Results were adjusted for edu-
cational level. Of 5387 women, 89.9% were autochthonous, 4.1% German resettlers, 2.8% Turkish, 3.1% other migrants.
Participation rates regarding cancer screening differed significantly, with the lowest proportion in Turkish migrants (65.0%),
resettlers (67.8%), other migrants (68.2%) and autochthonous population (78.2%). No differences in performance of breast
self-examinations were detected. When adjusted for education, results indicated only slight changes in the odds to partici-
pate in screening irregularly or not at all. Results support existing evidence by showing lower participation rates in cancer
screening among migrant women, but there were no differences regarding breast self-examinations. Migrant women form a
potential high-risk group for late-stage diagnosis of cervical or breast cancer.

Keywords  Migrants · Non-migrants · Cervical and breast cancer · Cancer screening · Participation · Performance · Uptake

Background including pap smear (from the age of 20 onwards) and

Persons with migration background account for 21% of the
German population [1], thus constituting a relevant target
group for cancer prevention.
Women in Germany are eligible for an annual gynecolog-
ical examination and cervical and breast cancer screening,
* Eva‑Maria Berens
eva‑maria.berens@uni‑bielefeld.de
1
Department of Health Services Research and Nursing
Science, Bielefeld School of Public Health, Bielefeld
University, Bielefeld, Germany
2
Department of Epidemiology and International Public
Health, Bielefeld School of Public Health, Bielefeld
University, Bielefeld, Germany
3 women (73.2%) and German resettlers (73.2%) [5], indicat-
Department of Prevention and Health Promotion, Bielefeld
School of Public Health, Bielefeld University, Bielefeld,
Germany
4
Institute of Psychology, University of Hildesheim,
Hildesheim, Germany
5
Department of Public Health, Brandenburg University
of Technology, Senftenberg, Germany
inspection and palpation of the breasts (from the age of 30
onwards). These check-ups are performed in outpatient care
by a gynecologist. In addition, women should be instructed
to perform breast self-examination on a regular monthly
basis. From the age of 50 to 69 years, they are also invited
every other year to the nationwide mammography screening
programme. This study focuses on the regular examination
by a gynecologist and the self-examination of the breast.
Previous findings from other European countries indicate
that women with migration background, especially of non-
Western origin, are less likely to participate in breast and
cervical cancer screening than autochthonous residents do
[2–4]. Results from Germany show lower intention to par-
ticipate in mammography screening among Turkish (60.6%)
and other (66.9%) migrants compared to autochthonous
ing barriers in access to mammography. However, to our
knowledge there are neither any studies concerning potential
differences of participation in gynecological cancer screen-
ing, nor studies regarding the performance of non-institu-
tional cancer prevention, such as breast self-examination
stratified for different migration backgrounds in Germany.

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 Journal of Immigrant and Minority Health

This study compares the uptake of cancer screening per-
formed by a gynecologist and the performance of breast self-
examination by different groups of migrant women and the
autochthonous population in Germany.
Methods
Women aged 50 years living in Westphalia-Lippe (a sub-
region of the German Federal State of North-Rhine West-
phalia) were invited to participate in the cross-sectional
InEMa study (Informierte Entscheidung zur Teilnahme am
Mammographie-Screening-Programm) 1–2 months after
their 50th birthday. Data were collected in a self-adminis-
tered paper–pencil questionnaire between October 2013 and
July 2014. The questionnaire was available in German and
Turkish language.
Migration background was defined by self-assigned
country of birth, as women in that age group are unlikely
to be second generation immigrants. Migrant women were
stratified into the two largest groups, German resettlers
(ethnic German return-migrants who lived in various East-
ern European countries) and Turkish women. Women with
other migrant background were grouped as ‘other migrant
women’. The group of resettlers was identified by their birth
in an Eastern European country and by reporting a resettler
status.
Uptake of gynecological cancer screening and perfor-
mance of systematic breast self-examination were assessed
by two questions. Women were asked whether they took
part in cancer screening performed by their gynecologist
‘regularly’, ‘occasionally’, ‘rarely’ or ‘never’. Performance
of breast self-examination was assessed as ‘regularly’, ‘occa-
sionally’ or ‘not at all’. In addition, their education level was
assessed [6].
The study was approved by the ethical committee of the
Medical Faculty of Muenster (2012-268-f-S) and the Data
Protection Officer of Bielefeld University. Women gave
their written consent to participate in the study.
Data were analyzed using SPSS 22.0. The characteri-
zation of the study population was done by descriptive
analyses. The proportions of women participating in
gynecological cancer screening or breast self-examina-
tion were described by migrant group (Turkish/German
resettler/autochthonous/other). Group differences for both
outcomes were assessed by Chi square tests. This was fol-
lowed by logistic regression analyses adjusted for educa-
tion level.
Results
In total, 5847 women aged 50 years participated in the study
(response: 33.7%). Excluding those with a missing value
on migration, 5837 women were included in the analyses.
While 78.2% of the autochthonous women participate in
gynecological cancer screening regularly, the proportion is
lower among German resettlers (67.8%), Turkish (65.0%)
and other migrant women (68.2%). Furthermore, while there
are differences in the uptake of gynecological cancer screen-
ing (p < .001), we found no differences in the performance
of breast self-examination by migration group (see Table 1).
About 30% of all groups regularly self-examine their breasts,
and 13–16% do not palpate their breasts at all.
The likelihood of participating in gynecological cancer
screening rarely or never is higher among German resettlers
(OR 1.71; 95% CI 1.28–2.27), Turkish women (OR 1.60;
95% CI 1.14–2.25) and other migrant women (OR 1.63;
95% CI 1.17–2.29) compared to autochthonous women
when adjusting for educational level. We found no signifi-
cant differences in the likelihood of performing breast self-
examination irrespective of adjustments for education level
(see Table 2).

Table 1  Uptake of German German reset- Turkish Others

gynecological cancer screening tlers
and performance of breast
self-examination stratified by % n % n % n % n χ2-test
migration background
Gynecological cancer screening
 Regularly 78.2 4099 67.8 162 65.0 106 68.2 122 χ2 = 69.566,
 Occasionally 13.4 703 21.3 51 26.4 43 15.1 27 df = 9, p < .001
 Rarely 6.2 324 5.9 14 4.3 7 10.1 18
 Never 2.3 119 5.0 12 4.3 7 6.7 12
Breast self-examination
 Regularly 30.1 1577 31.3 75 32.3 53 33.3 60 χ2 = 4.202,
 Occasionally 56.5 2958 54.6 131 53.0 87 50.0 90 df = 6, p = .649
 No 13.4 701 14.2 34 14.6 24 16.7 30
 Total 89.8 5252 4.1 241 2.8 164 3.1 180

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Journal of Immigrant and Minority Health

Table 2  Odds ratios for no Gynecological cancer screening Breast self-examination

or unregular versus regular
a
uptake of gynecological cancer OR 95% CI p-value ORa 95% CI p-value
screening and performance
of breast self-examination, Total N = 5826 N = 5820
unadjusted and adjusted for Migration < .001 .734
education level  German Ref Ref
 German resettlers 1.70 1.29–2.25 < .001 0.95 0.72–1.25 .709
 Turkish 1.92 1.39–2.67 < .001 0.90 0.65–1.26 .546
 Others 1.67 1.21–2.30 .002 0.86 0.63–1.18 .356
Adjusted for education N = 5757 N = 5750
Migration < .001 .762
 German Ref Ref
 German resettlers 1.71 1.28–2.27 < .001 0.95 0.71–1.26 .700
 Turkish 1.60 1.14–2.25 .007 0.96 0.68–1.35 .801
 Others 1.63 1.17–2.29 .004 0.85 0.61–1.17 .318
a
 OR > 1 means greater odds for no or unregularly screening or self-examination compared to regular per-
formance

Discussion by gynecologists. However, as numbers in some strata are

The aim of this article was to describe the uptake of gyneco-
logical cancer screening and the performance of breast self-
examination stratified by different groups of migrant women
in Germany.
In our study population, all groups of migrant women
participate less often in gynecological cancer screening.
This is in line with previous studies [2–4]. In contrast, there
are no differences in regards to breast self-examination.
An explanation for the lower uptake of the screening by a
gynecologist might be that migrant women face barriers,
such as poor German language skills or a lack of transporta-
tion, thus depending on others when seeing a doctor. These
barriers do not apply to self-examination of the breasts as
this is done alone at home. However, we could not include
these co-variates to our analyses. Interestingly, even German
resettlers, who are likely to have good German language
skills, had a higher likelihood of participating less often in
gynecological cancer screening. However, no difference
was found between German women and German resettlers
with regards to intention to participate in the mammography
screening programme [5]. One explanation could be that
German resettlers lack the knowledge about their eligibility
for gynecological cancer screening while they are invited
to the mammography screening program through an invi-
tation letter (from the age of 50 onwards). Additionally, it
is possible that the proposition of a fixed appointment as
in the mammography screening program could overcome
perceived barriers to attend a screening, thus leading to
equal intention rates. There are only slight changes in the
odds when adjusting for educational level. This indicates
that educational level does not influence the association
between migrant background and uptake of cancer screening
rather small, this should not be overrated.
Limitations
The response rate of this survey is rather low among migrant
women compared to the autochthonous population. This was
expected as it is known that the willingness of migrants,
particular Turkish individuals, to participate in research
studies is lower than among the general population [7].
Hence results should not be over-interpreted but still can
give important directions for further studies. Our study used
self-reported data on participation. In the context of health
behaviors, sensitivity of self-reporting is described consist-
ently high while specificity tends to be lower. This results
in an overestimation of the percentage of the population
actually adhering to recommended screening behavior [8].
However, this applies to all women and should not affect
differences among migrant groups. Nevertheless, differences
in the strength of social desirability effects between migrant
groups cannot be entirely ruled out. Some women may lack
the skills and knowledge necessary to answer survey ques-
tions about prior mammography screening properly. Another
possibility is that women who choose to answer the ques-
tionnaire differ from non-responders [9] in their screening
behaviors.
Conclusion
Compared to autochthonous women, a lower proportion of
migrant women performs gynecological cancer screening
on a regular basis, thus migrant women might be at a higher
risk of a late diagnosis of cervical or breast cancer. This

13

implies a need for measures to identify and reduce possible
barriers to accessibility of gynecological cancer screening
for migrant women. Regarding breast self-examination, it
remains unclear whether this is beneficial [10] and, there-
fore, the rather low performance rate in all migrant groups
may not be a public health concern.
Acknowledgements  This work was supported by the German Federal
Ministry of Health within Research for the National Cancer Plan, Grant
Number NKP-332-028. The content of this paper is solely the respon-
sibility of the authors and does not necessarily represent the official
views of the funders.
Compliance with Ethical Standards  on informed choice in the mammography screening programme in
Conflict of interest  The authors declare that they have no conflict of
interest. This study was not linked to a mammography screening or-
ganization.
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