Rebecca Haworth

Women’s health in resettlement: Assessing beliefs and practices for cervical cancer screening in a Midwestern Bhutanese refugee cohort

A refugee is someone who has fled his or her country to escape fear and persecution (1). Bhutanese refugees have a complicated history. Nepali by ethnicity, many of the refugees’ ancestors migrated to southern Bhutan in the late 1800’s in search of better farming. The Lhotsampas (“People of the South”) lived securely for many years, while maintaining their Nepali culture, language and religion. However, in the 1980’s, the ruling authorities became threatened by the growing Lhotsampa population and imposed policies restricting them from participating in their traditional cultural practices (2). With these policies came new laws regarding citizenship that excluded many ethnic Nepali people and took away their civil rights. In the 1990’s, the Lhotsampas protested the cultural impositions, thus leading to many arrests and reports of torture. Eventually many were expelled from the country after being forced to sign a ‘voluntary migration’ certificate (2). They fled to what are now seven Bhutanese refugee camps in eastern Nepal. After years of negotiation attempts and lack of acceptance by neither Nepal nor Bhutan, resettlement procedures began and Bhutanese refugees have started arriving in the United States since 2008 (3). The U.S. agreed to resettle at least 60,000 of the over 100,000 Bhutanese refugees (2). Through 2011, Nebraska has resettled over 300 Bhutanese refugees (3). This community continue to expand beyond 2012 and into this present year.
Human papillomavirus (HPV) is one of the most commonly transmitted sexually transmitted infections (STIs), and has been detected in 99% of cervical cancer incidences (4). Across the globe, cervical cancer is the second most common cause of cancer mortality among women with 80% of the over 500,000 new cases annually occurring in developing countries (5). The highest incidences occur in Africa, Asia, Central and South America (5). Bhutan and Nepal contribute to the high incidence of cervical cancer and mortality rates in South Central Asia (6), but information is not available for identifying HPV and cervical cancer incidence and prevalence among Bhutanese refugees. According to the Centers for Disease Control, the awareness of preventative healthcare is rare and most female Bhutanese refugees have never experienced cytological cancer screening and HPV testing (7). Research indicates that foreign-born women are more likely to have never experienced cervical cancer screening by three times the general U.S. female population (8). Gender-based violence, such as sexual assault, rape, trafficking, polygamy, domestic violence and child marriage have been reported in Bhutanese refugee camps (7). These factors may also contribute to increased risk for STIs. 
Certain barriers contribute to further disparity of refugee health: language, limited healthcare insurance, financial constraints, poor transportation, and distrust of healthcare providers or the government (9).  Social stigma and knowledge pertaining to certain health concerns, such as HPV and cervical cancer, may also be barriers to seeking treatment. Access to appropriate interpreters is also a concern for some (9).  Women may be apprehensive about discussing reproductive and sexual health issues with providers. 
This proposal would serve to assess attitudes, beliefs and practices for cervical cancer screening in a Midwestern Bhutanese refugee cohort and assist providers in better understanding the demographic characteristics of the Bhutanese refugee population. In addition, it would also serve to identify the community’s need and readiness for implementing a community health worker (CHW) model. CHWs are natural leaders from the community who are trained to provide basic health education and knowledge of how to access health resources, such as increasing cervical cancer screening.    

Specific Aims: 
1. Evaluate current knowledge of cervical cancer and screening in this population.
2. Assess current attitudes and beliefs about cervical cancer and screening practices.
3. Identify the community’s readiness for a community health worker (CHW) program for reducing disparities in cervical cancer screening and other health programs.
4. Identify natural leaders who could potentially be trained as community health workers.

1. The United Nations Refugee Agency. Refugees: Flowing across borders. Last accessed 1/2013 at
2. Cultural Orientation Resource Center: Center for Linguistics. Bhutanese refugees in Nepal (2007). Last accessed 1/2013 at
3. U.S. Department of Health and Human Services: Office of Refugee Resettlement. Refugee arrival data (July 17, 2012). Last accessed 1/2013 at
4. Broutet, N. Interventions for encouraging sexual behaviours intended to prevent cervical cancer (last revised: 1 April 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.
5. Arbyn, M., Castellsagué, X., De Sanjosé, S., Bruni, L., Saraiya, M., Bray, F., & Ferlay, J. (2011). Worldwide burden of cervical cancer in 2008. Annals of Oncology, 22(12), 2675-2686.
6. Noronha ,V., Tsomo, U., Jamshed, A., Hai, MA., Wattegama, S., Baral, RP., et al. A fresh look at oncology facts on south central Asia and SAARC countries. South Asian Journal of Cancer 2012; 1:1-4.
7. Centers for Disease Control. Refugee health profiles: Bhutanese refugee health profile. (last revised: 22 June, 2012). Accessed at
8. Tsui, J., Saraiya, M., Thompson, T., Dey, A., & Richardson, L. (2007). Cervical cancer screening among foreign-born women by birthplace and duration in the united states. Journal of Women's Health, 16(10), 1447-1457.
9. Davidson, N., Skull, S., Burgner, D., Kelly, P., Raman, S., Silove, D., . . . Smith, M. (2004). An issue of access: Delivering equitable health care for newly arrived refugee children in australia. Journal of Paediatrics and Child Health, 40(9‐10), 569-575.

Rebecca Haworth
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