The electronic database search identified 774 peer-reviewed studies. Following the removal of duplicates (n = 732), title and abstract screening were performed for 42 articles, and 13 articles were excluded. A total of 29 articles were reviewed in full detail, resulting in the exclusion of 10 articles. Finally, 19 articles were selected for data extraction, analysis, and synthesis. A review of the reference list of the 19 selected articles was also conducted. In this study, gray literature was not included in the final review (Fig. 1).
Selected studies characteristics
The characteristics of the selected studies are presented in Table 2. All 19 studies were conducted between 2012 and 2022. Most were conducted in the US (n = 7), followed by Canada (n = 3). The research methods used in the articles were qualitative (n = 9) and quantitative (n = 9). One study used a combination of qualitative and quantitative methods. Data collection methods and sources included focus groups, surveys (questionnaires, databases, internet-based), in-depth interviews, semi-structured focus group interviews, group interventions, and evaluations.
Thematic analysis of CCS barriers
Based on the social-ecological model, CCS barriers were divided into four categories: individual, relationship, community, and social barriers [25]. Barriers in the individual category included sociodemographic factors, economic, language, cognitive, and emotional reactions. The relationship barrier was lack of time. Community barriers included the healthcare system, whereas culture and religion were considered social barriers. Barriers identified in each article are presented in Additional file 1. The themes of the identification results are summarized in Table 3.
Theme 1: individual barriers to CCS
Sociodemographic factors
Low education and being single were considered substantial barriers to CCS. The results showed that immigrant Muslim women in Australia with low levels of education tended to have no knowledge of cervical cancer; therefore, they had a high probability of not attending the screening test [24]. In contrast, women in the US with a lower educational level than a bachelor’s degree were found to have a high desire to undergo CCS [2]. The results of this study highlight successful counseling to Muslim immigrant communities by community-based clinics and organizations [2]. In contrast, age of the target population is rarely mentioned as a relevant factor in the reviewed articles. Only one study conducted in the US found that age was a barrier to screening. According to this study, CCS was deemed necessary and tended to be accepted by women under 50 years of age [2].
Economic barriers
Low economic status is a significant barrier to screening. Lack of health insurance and immigration status were identified as barriers to CCS, as well as the cost and length of stay or immigrant status. Low economic status and lack of insurance are significant barriers among immigrant Muslim women in the US. Although many participants had health insurance, they did not undergo a cancer screening test if additional payment was required [12]. Economic difficulties were also experienced by immigrant women in a study in Oslo, which found that immigrant women directed their focus towards meeting their family’s basic needs rather than their own health concerns [6]. The lack of health insurance significantly reduced the desire of immigrant women in the US and Australia to attend a screening site [21, 22]. Moreover, Islam et al. (2017) reported that immigration status and fear of being deported often acted as barriers preventing many women from undergoing screening in the US [17].
Language barrier
Difficulty in communicating effectively caused by inadequate language skills in host countries or English is a major barrier to screening according to many studies. Language was reported as an obstacle by immigrant women in the US when communicating with health workers, although the relationship was not significant; furthermore, the study reported that women who spoke English fluently still experienced obstacles when communicating about medical issues [12]. Language barriers were also experienced by most of the participants in Queensland, Australia, and European states such as Denmark and Norway, where limited language skills made it difficult for women to access health services or health-related information, including CCS [6, 9, 19].
Cognitive and affective barriers
The main cognitive barrier is that many immigrants are unfamiliar with CCS. One obstacle faced by immigrant Muslims in the US limited access to information regarding CCS in their communities; consequently, they received insufficient information and did not understand the importance of the examination [17]. However, in Denmark and Norway, the lack of information was a result of the fact that information on CCS was only available in Norwegian [6, 19]. The insufficient information was primarily attributed to inadequate information received from health workers, followed by low perceived risks and lack of knowledge. Additionally, the absence of symptoms and lack of awareness are barriers to CCS [8, 14, 16, 26]. Conversely, affective obstacles are also a challenge to undergoing CCS and include ignoring invitations for CCS and the influence of previous screening experiences [9, 19].
Negative feeling
Most participants believed that CCS was embarrassing or shameful. Muslim women in the US reported that they felt embarrassed when discussing CCS because it involves sensitive areas of the body, which makes them reluctant to attend the examination site [12, 17]. Immigrant Muslim women from different ethnic backgrounds in European countries and Australia also described feeling shy when discussing CCS. This was also the experience of some Indian women and black women who perceived this as a barrier to screening, particularly among the older generation who feel that their body is a private and sensitive area [9, 20, 21]. Moreover, most women in the US, Canada, London, Scotland, and Dubai stated that pain during the CCS procedure and fear of cancer were major factors contributing to low CCS rates, followed by discomfort during the procedure [3, 6, 14, 18, 20, 26]. Fear of test results or bad news was also considered a barrier to CCS [6, 9, 19, 20].
Theme 2: family and work-related barriers to CCS
The majority of participants in the US and Australia mentioned lack of time due to work, childcare, and home duties as a challenge to undergoing screening [16, 17, 24]. Many women from low socioeconomic backgrounds earn their income from hourly wages; hence, taking time off to visit a healthcare provider for screening tests leads to a loss of income [16]. Moreover, most of the key participants also reported that sociocultural gender norms regarding women’s roles were also a barrier. According to the respondents, women are expected to prioritize the health of their families above their own. This is because the existing culture has shaped the perception that women prioritize their families over themselves [17]. However, Islamic religious rules oppose spatial injustice based on sex and do not curb women’s freedom to move and choose activities according to their passion. If women choose not to work and stay at home to care for their children rather than combine work and family, it is their right [27].
Theme 3: community barriers to CCS
Healthcare system
Not having a female physician was the most frequently identified barrier in the literature. Most immigrant Muslim women from the US, Canada, Scotland, Norway, and Dubai expressed their desire to be served by a female doctor [2, 3, 6, 7, 14, 16, 18, 20]. Some women in Canada and the US also stated a preference for a physician of the same ethnic group and healthcare providers with the same religion as Muslim when discussing screening tests and undergoing examinations [2, 3]. Distrust, complicated procedures, lack of accessibility to health care centers, and long waiting time are also challenges to regular screening tests [6, 7, 14, 16, 19, 26].
Theme 4: societal barriers to CCS
Norm
Studies found that there is a stigma associated with CCS among women in the US and Norway [14]. Some Muslim women in Dubai stated that Muslim norms in society regarding CCS were an obstacle to attending CCS [14]. Moreover, in European regions such as Norway and Denmark, discussions about the subject of female genitalia or sexuality are taboo and cultural practice of female circumcision, which remains a cultural practiced were considered an obstacle to undergoing CCS [6, 9, 19].
Religion
The main obstacle for CCS regarding religion is modesty, whereby an unmarried Muslim woman is seen as someone who is not yet sexually active, because sexual relations before marriage are prohibited in Islam. This is written in the Qur’an [9, 12, 16, 19]. Furthermore, most Muslim communities in the US, Denmark, and Norway believe that becoming ill and dying is the will of Allah, and their health problems are a punishment from God. These perceptions are barriers to Muslim women undergoing CCS [2, 6, 13, 16,17,18,19]. Research in Canada found a significant relationship between individuals born in a Muslim-majority country and a low desire to undergo CCS [7]. However, some immigrant Muslim women in the US reported that living in a country in which Muslims are a minority is an obstacle to undergoing CCS [13].
