Exploring factors influencing the decision-making regarding cervical cancer screening participation and HPV vaccination uptake among Syrian-Dutch women: a qualitative interview study

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Stein, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7934683/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background In the Netherlands, a free of charge national cervical cancer (CC) screening program is available for women aged 30 to 60 years. Participation rates in the CC screening programme are lower among women with a migration background compared to the general population, as shown for the Turkish- and Moroccan-Dutch women. However, specific data on Syrian-Dutch women is lacking. It is unclear how Syrian-Dutch women make decisions regarding participating in CC screening and HPV vaccination in the Dutch context. This study aims to explore how and why Syrian-Dutch women decide to participate in the Dutch national CC screening program and whether to vaccinate their children against HPV. Methods Twelve semi-structured interviews were held with Syrian-Dutch women aged 30–60 or having a daughter between 9–26 years, between March and July 2023. The interview guide was based on the Health Belief Model, the Reasoned Action Approach, and Betancourt's Model of Culture and Behaviour. The interviews were audio recorded, transcribed verbatim and thematically analysed. Results Overall, participants had a positive attitude towards CC screening and HPV vaccination. Participants indicated barriers for participation like a lack of knowledge about HPV, misconceptions about CC, safety concerns about the HPV vaccination, shame, fear, and practical obstacles including language and procedural anxiety. However, participation of CC screening and HPV-vaccination was facilitated by advantages of early detection, self-testing, protection of health, and trust in the government. Conclusion This study provides insights into the factors that influence the decision-making to participate in CC prevention programs among Syrian-Dutch women. These factors highlight the importance of addressing awareness and cultural and social factors to overcome the barriers Syrian-Dutch women experience. Future initiatives should develop accessible and culturally relevant tailored interventions that address these barriers to improve decision-making and participation in CC prevention programs. Cervical cancer screening HPV vaccination decision-making barriers and facilitators immigrant women interviews Figures Figure 1 2. Background Worldwide, cervical cancer (CC) is the fourth most frequently diagnosed cancer in women in 2020 ( 1 ). In the Netherlands, each year around 800 women are diagnosed with CC and around 200 women die because of this disease ( 2 ). It is estimated that without a nationwide screening program for CC, this number would be up to 500 women dying each year ( 2 ). The CC prevention programs (i.e. CC screening and human papillomavirus (HPV) vaccination) have been implemented free of charge for many years in the Netherlands. Since 1996, women aged 30 to 60 years are invited to participate in CC screening every five years ( 2 ). The HPV vaccination that protects against HPV 16 and 18 infections is since 2010 available for 13-year-old girls and since 2022 available for 10-year-old girls and boys in the Netherlands ( 3 ). Despite the availability of these free of charge CC prevention programs, 50.3% of the women do not participate in the CC screening program in the Netherlands ( 4 , 5 ). Specifically, individuals with a low socioeconomic position and/or a migration background are known to participate less often in CC prevention programs ( 6 ). For example, Turkish- and Moroccan-Dutch women, who represent the two largest immigrant groups in the Netherlands, have lower participation rates in CC screening compared to native Dutch women, with rates of 64% and 53% versus 79%, respectively ( 6 , 7 ). In addition, HPV vaccination rates are also lower among Turkish- and Moroccan-Dutch immigrants compared to individuals without a migration background and those from other immigrant populations, thereby increasing the likelihood of future development of CC among these women ( 8 ). Multiple studies have investigated the barriers and facilitators regarding CC screening participation among Turkish- and Moroccan-Dutch women in the Netherlands ( 9 ). Perceived barriers of participating in CC screening among these women were a lack of knowledge about CC and its screening, an insufficient command of the Dutch language, fear, fatalism, shame, and taboo ( 9 ). Perceived facilitators among these women were a high perceived severity of the disease, social support, and a short procedure time ( 9 ). Furthermore, our recently submitted manuscript examines the information needs and preferences among Turkish-, Moroccan-, and Syrian-Dutch women to support informed decision-making. This interview study takes an overarching approach across all three populations, but with a different focus (manuscript under review). However, there is still a lack of insight into how and why the new immigrant population in the Netherlands, the Syrian immigrants, decide to participate or not in the current Dutch CC prevention programs. In 2022, there were a total of almost 150,000 (0.8% of the Dutch population) Dutch inhabitants born in Syria ( 10 ). This immigrant population is still growing, but to date, there are no participation rates, and no research has been done about their participation in the CC prevention programs. This is concerning, because of the ongoing war in Syria and Syria’s deteriorating health system, it is expected that Syrian women are at an increased risk of developing CC ( 11 ). This is because many of these women did not have access to preventive measures such as CC screening and HPV vaccination before. Moreover, we do know that Syrian women in Syria were found to have limited understanding of CC prevention programs ( 12 , 13 ). It was also shown that these women and Syrian refugees in Greece and Turkey had a lack of knowledge regarding CC screening and HPV vaccination ( 14 – 16 ). To participate in CC prevention programs, informed decision-making is important. Through informed decision-making, individuals can consider the benefits of prevention programs against the risks of adverse effects when deciding whether to participate or not ( 17 ). Informed decision-making regarding CC screening among native Dutch women is found to be limited due to a lack of decision-relevant knowledge ( 18 ). There are currently no studies about the participation of Syrian-Dutch women in CC prevention programs. This is concerning, as previous research shows that Turkish- and Moroccan-Dutch women in the Netherlands often do not thoroughly consult available information materials, which negatively affects their decision-making ( 9 ). These information materials are also not customized to the needs of Turkish- and Moroccan-Dutch women, as present information materials are focused on medical facts, while these women indicated a need for information about the emotional, practical, religious, and cultural aspects of CC screening as well ( 9 ). The Centre for population screening (part of the National Institute for public health and the environment, RIVM) is currently actively addressing this issue by providing culturally sensitive educational video to facilitate informed decisions on CC screening among Turkish- and Moroccan-Dutch women ( 19 ). The reasons for (non)participation of Syrian-Dutch women may be comparable with the findings reported among Turkish- and Moroccan-Dutch women, as most of the Syrian-Dutch women share the same culture and religion ( 17 ). Therefore, the aim of this study is to explore how and why Syrian-Dutch women decide to participate or not in the Dutch national CC screening program and whether to vaccinate their children against HPV. 3. Methods Study design From April to June 2023, semi-structured interviews were held to learn more about how and why Syrian-Dutch women participate or not in CC prevention programs. This qualitative approach was chosen, since it allows participants to explore and clarify their knowledge, attitudes, feelings, beliefs, and experiences regarding their decision-making to participate or not in CC prevention programs. Prior to the start of our interviews, we used a short questionnaire about socio-demographic characteristics to gain insight into the diversity within our group of participants. This information helped us to later interpret the different perspectives of Syrian-Dutch women in relation to their backgrounds. The reporting of this study is in adherence to the Consolidated criteria for Reporting Qualitative research (COREQ) checklist (see supplemental material 1). Study population and recruitment The study population included ( 1 ) Syrian-Dutch immigrant women aged 30 to 60 years, and ( 2 ) Syrian-Dutch immigrant women having a daughter aged 9 to 26 years. Both women from the first- (women born in Syria) and second-generation (women born in the Netherlands, of which at least one of the parents was born in Syria) were included ( 20 ). We purposefully invited women between the age of 30 and 60 years, because this is the group that receives an invitation for CC screening every five years. We also invited women having a daughter aged 9 to 26 years who received the invitation for the HPV vaccination before. Snowball sampling was used to increase our sample size and reach the (more hidden) peers of our participants ( 21 ). We started with a small number of women who met the inclusion criteria and invited them to participate in the interviews. These participants were then asked to recommend other contacts who meet the inclusion criteria and may be willing to participate, who in turn recommended other potential participants. Participants were invited through various community centres, mosques, social media channels, and the project team's social networks. They were approached face-to-face, via telephone or e-mail. During recruitment, we aimed for diversity in age, educational level, geography, marital status, number of children, number of years residing in the Netherlands, and command of the Dutch language. Educational level was categorized as 1, 2, and 3 based on the classification of Statistics Netherlands (CBS) ( 22 ). Participants were included until data saturation was reached at the level of themes, i.e. no new themes or relevant information emerged during the last interviews among a diverse group of participants. ( 23 ). Interview guide The interview guide was developed based on previous literature and models, see supplemental material 2. We primarily employed the Health Belief Model (HBM) as the main conceptual framework. To provide a more comprehensive understanding, selected constructs from the Reasoned Action Approach (RAA) and Betancourt’s Model of Culture and Behaviour were integrated into the model. The HBM posits that health behaviour is influenced by perceived susceptibility, severity, benefits, barriers, self-efficacy, and cues to action ( 24 , 25 ). These constructs suggest that individuals are more likely to engage in health actions if they feel at risk, believe the disease has serious consequences, perceive benefits of the action, believe benefits outweigh barriers, feel capable of performing the action, and receive cues to act. However, the HBM does not account for social and cultural influences comprehensively. That is why we also included the RAA and the Betancourt's Model of Culture and Behaviour. Our model includes the RAA’s constructs of attitude toward behaviour and perceived norms ( 26 ). Previous research indicates that social networks significantly impact decision-making in health contexts ( 27 – 29 ). Additionally, the Betancourt's Model of Culture and Behaviour highlights the impact of cultural/religious beliefs, values and health practices on health behaviour ( 30 ). Cultural factors, such as traditional habits and religious views, are crucial in shaping attitudes towards health interventions ( 28 , 31 , 32 ). Incorporating these elements into the main conceptual model, the HBM, results in an extended version of the HBM, which addresses gaps in the original model by adding social, cultural, and religious factors, subjective norms and safety (see Fig. 1 ). This comprehensive approach provides a nuanced understanding of the decision-making processes of Syrian-Dutch women regarding participation in CC screening and HPV vaccination for their children. The main subjects included in the interview guide were ( 1 ) current awareness, knowledge and attitude, and ( 2 ) influencing factors like culture, religion, social factors, practical factors, and emotional factors. Current awareness and knowledge were chosen based on previous research indicating that these factors play a crucial role in informed decision-making for participation in CC prevention programs among immigrant populations ( 9 ). Additionally, influencing factors like culture, religion, social factors, practical factors, and emotional factors were chosen based on our conceptual model outlined in Fig. 1 . The concepts are shown in different colours: concepts derived from the HBM are shown in blue, those from the RAA in orange, and those from Betancourt’s Model of Culture and Behavior in green. Data collection A short online questionnaire assessing women's socio-demographic characteristics was sent to the participants prior to the interview. For participants who experienced difficulties with reading the Dutch language or accessing the online questionnaire, the questionnaire was filled out offline in Dutch by the participant and verbally translated to Arabic by the researcher if needed. The interviews were conducted in Dutch or Modern Standard Arabic (based on the participant’s preference) by a female bilingual interviewer (NA, MSc). Interviews were conducted in-person or via video conferencing using MS Teams, depending on the participant's preference and availability. The interviews were audio-recorded and lasted approximately one hour. Field notes were made during and after the interview. The data was stored on the RIVM’s secure server, which could only be accessed by authorized individuals; the interviewer and supervisors. Data analysis The interviews were transcribed verbatim. The interviews conducted in Arabic were directly transcribed into Dutch by the bilingual researcher (NA) ( 33 ). The transcripts were read until there was a deeper understanding of the data to identify patterns ( 34 ). Using the qualitative software tool MAXQDA (version 18.0.5) and thematic analysis approaches, transcripts were analysed inductively. Different coding styles were used: open, axial, and selective coding ( 34 ). Open coding was used to code transcripts by labelling significant text segments with concepts extracted from the text. Then, we detected categories and subthemes by systematic comparison of coded text (also known as axial coding). Finally, selective coding was used to define core categories and themes that appeared from axial coding by describing the relationship and theories of various categories ( 34 ). Furthermore, a second coder (TV) independently analysed a random sample (approximately 33%) to guarantee the veracity of the data interpretation. Discrepancies were resolved until agreement between NA, TV and NH was reached on the codes, categories, and (sub)themes assigned. Ethical considerations This study was conducted in accordance with the Declaration of Helsinki. Ethical clearance was obtained from the Medical Ethics Review Committee (NedMec) of the University Medical Centre Utrecht (23–090/DB). The Committee confirmed that the Medical Research Involving Human Subjects Act (WMO) does not apply to this study. Prior to the start of the interviews, participants were sent an online information letter and an informed consent for this study. The informed consent was the first page of the online questionnaire. After they read it, they could click on a button to give their digital consent and start the questionnaire. For the participants that could not read Dutch or had difficulties with the digital informed consent, they filled and signed the informed consent offline prior to the interview. At the start of the interview, the participants were again given a brief explanation of the study's purpose and were given the opportunity to ask questions. After the interviews, each participant received an eighteen-euro gift voucher as a token of our appreciation for their participation. 4. Results Socio-demographics A total of 12 Syrian-Dutch women were interviewed (see Table 1 ). One participant was born in the Netherlands, 11 participants were born in Syria and immigrated to the Netherlands between 1990–2023. The participants' ages ranged from 30 to 60 years. We interviewed women living in different areas of the Netherlands, with most of them residing near cities like Enschede, Edam, Amersfoort, and Amsterdam, and with various educational levels. Furthermore, most of the women (n = 7) reported that they have never participated in the CC screening program before. Most women (n = 9) had children, together accounting for 23 children (8 sons and 15 daughters), who were the subjects of the HPV vaccination questions. Of these children, 4 were fully vaccinated, 1 was partially vaccinated, 12 were not vaccinated, and for 6, the vaccination status was unknown. The vaccination status of the participants’ children is presented in the supplemental material 3. Table 1 Socio-demographics of the sample Syrian-Dutch participants (n = 12) Age group; n (%) 30–40 years 5 (41.5) 40–50 years 2 (17.0) 50–60 years 5 (41.5) Number of years residing in the Netherlands; n (%) 0–3 years 3 ( 25 ) 4–10 years 4 ( 33 ) 10 + years 5 (41.5) Educational level*; n (%) 1 5 (41.5) 2 1 ( 8 ) 3 6 (50) Women with children n (%) 9 (75) Self-reported command of the Dutch language: reading; n (%) Insufficient 5 ( 42 ) Sufficient 4 ( 33 ) Good 3 ( 25 ) Self-reported CC screening participation; n (%) Every 5 years 2 ( 17 ) Not every 5 years 2 ( 17 ) Never 7 (58) I do not know 1 ( 8 ) *Educational level ( 22 ): ( 1 ) primary education, secondary education: VMBO, the first 3 years of HAVO/VWO or the assistant training (mbo-1) , ( 2 ) upper years of HAVO/VWO, basic vocational training (mbo-2), vocational training (mbo-3) and specialist training (mbo-4) ( 3 ) bachelor/master levels of education Thematic analysis We identified eight main themes from our thematic analysis in relation to CC prevention program participation of Syrian-Dutch women. The identified themes focus on the following main subjects regarding CC screening and HPV vaccination: current knowledge and awareness, attitudes towards CC screening and HPV vaccination, cultural barriers, the influence of religious beliefs, influence of social environment, practical barriers and facilitators, influence of emotional factors, and desire for protection of health. Current knowledge and awareness regarding CC screening and HPV vaccination Most women had heard of CC and retrieved their knowledge of CC prevention programs from the invitation letter and informational leaflet from the Dutch government. A few women mentioned that they had learned about CC from the Syrian TV. They were aware that CC can develop later in life and lead to death. Most women also knew what the symptoms of CC were, and that the diagnosis of CC was simple. They also knew how a cervical smear test was done. However, there were considerable misconceptions regarding the cause of CC. Many women indicated that they believe that the disease is inherited and did not know that HPV is the cause of CC and that it can be transmitted through sexual contact. Some women wrongly indicated that CC is developed through a poor lifestyle, such as unhealthy food choices and not exercising. Many women were also unaware that CC can develop in 10–15 years after acquiring HPV. Most women were unaware of the HPV vaccination. Women who had recently arrived in the Netherlands had no information about the HPV vaccination; they said that the vaccination did not yet exist in Syria, so they knew little about it. When they arrived in the Netherlands, some of the women had received information about the HPV vaccination in the asylum centre. Despite hearing about it, most participants were still unfamiliar with this vaccination. ‘’When we came to the Netherlands, no one really explained to us what the HPV vaccination is. We were scared, because we thought we cannot get every vaccination without knowing what is in it. Maybe there are also bad side effects, so we were scared and unaware too.’’ – 50–60 years, educational level 3 Attitude towards CC screening and HPV vaccination Attitude towards CC screening Most of the women indicated having a positive attitude towards the CC screening. For example, they believed that the CC screening is beneficial and that it helps for early detection of CC. They also thought that the CC screening was accessible and not painful. Most of the women wanted to recommend the smear test to all women. Overall, women were positive about the CC screening and trusted the smear test. The only negative feedback was that it might hurt. Attitude towards HPV vaccination Many women were also enthusiastic about the HPV vaccination. Women that were not long in the Netherlands yet had a positive attitude. They felt happy that their children could be protected from CC and saw the HPV vaccination as beneficial and effective. As a result, they mentioned to trust the vaccine and recommended the HPV vaccination to others. Women who had lived in the Netherlands for a longer period regretted not vaccinating their daughters sooner. ‘’Of course, seeing that your child is not carrying a disease and receiving a vaccination makes you very happy that your child is safe. It is undoubtedly beneficial to them and has a positive impact; otherwise, they would not give vaccinations.‘’ – 40–50 years, educational level 1 However, some women had a negative attitude towards the HPV vaccination. For example, they believed the vaccination was still in its early stages and indicated doubts about the safety of the vaccine. They believed that the vaccination's long-term effects were still unknown. They mentioned that they would not be able to trust the vaccination for another generation. A few participants mentioned to not trust the government and the reason why they provide the vaccination. Furthermore, some women explained that rumours about the HPV vaccination, such as concerns about its safety, possible side effects, and potential impact on fertility, led them to hesitate or decide against vaccinating their children. At the time the HPV vaccination was introduced, these women heard misinformation from their social environment, such as claims that the vaccine could cause serious side effects or negatively affect fertility. This misinformation still influences their decision-making today. As a result, they were opposed to the HPV vaccination and chose not to vaccinate their children. ‘’Perhaps the vaccination is not safe and trustworthy after all, and there are many side effects, or the vaccination can cause something else; perhaps it is also due to politics or the government, which makes us more hesitant to vaccinate.’’ – 50–60 years, educational level 3 Cultural barriers that influence women’s participation in CC prevention programs For some women, culture played a role in their decision, as they claimed that if a woman is not married, she should not be exposed to sexual diseases or be tested for CC, because her intimate parts should be kept private. Furthermore, most women indicated that there is a taboo surrounding CC. They stated that because it is related to sexual diseases, people do not discuss it. They also stated that they do not tell others that they have cancer, because it makes them appear pathetic. However, some women stated that culture had no impact on their participation. Many women mentioned the impact of norms and values. They mentioned that it was not common practice for them to go to the doctor without a specific reason. It also emerged that, according to norms and values, a woman does not simply go outside, because people around her would gossip about her leaving the house often. Women also reported being told that, according to cultural norms and values, the man was in charge and therefore decided whether or not they were allowed to visit a doctor outside the home. An intriguing finding was that women who moved after the war gave up these norms and values. They stated that because they came close to death during the war, many people have given up their norms and values and are now enjoying their lives more. They also stated that because people have moved, their Syrian culture and the western culture have become mixed, as have norms and values. ‘’After the war, everyone appears to be distancing themselves from the Syrian norms and values. People lived between life and death, so, many people's perspectives have shifted. It also has to do with the fact that people moved to other places and countries where there are different norms and values, and they are now more mixed with other types of Syrians from other cities and people from other countries.'' – 50–60 years, educational level 2 Religious beliefs reducing the perceived need to participate in CC prevention programs Most women indicated that their religion (Islam and Christianity) does not influence their decision-making regarding participation in CC prevention programs. Most women indicated that it is allowed by their religion. Furthermore, most women said that based on their religion a male doctor is allowed to take the smear, since it has to do with their health. However, many women did state that their religion protects them from CC. Women mentioned that in their religion, it is forbidden to have sexual contacts before marriage, and once married, you can only have a sexual relationship with your partner. This ensures that the risk of contracting the HPV virus is extremely low, which was the reason that most women mentioned to not participate in CC screening and vaccinate their children against HPV. However, women recognized that those without religious beliefs or “Western” children might require the vaccination, because among these groups it is more common to have multiple bed partners. For their own children, most women felt that the vaccination was not necessary, as they believed this situation did not apply to them. In addition, a fatalistic belief was expressed by several women, who stated that if you get sick, it is God's will and cannot be prevented. ‘’Women are protected from this disease by the Islam. Because a woman only sleeps with one partner, she is protected from the disease… So, a virgin is protected in any case, and a married person is also protected. Unlike in the West, where people sleep with multiple partners.’’ – 50–60 years, educational level 3 Influence of social environment: taboo, support, and negative perception towards the HPV vaccination Women stated that the topic of CC was rarely discussed within the women's social environment, primarily due to the taboo that was mentioned earlier. However, among the few women who did engage in discussions about CC, they acknowledged that their social environment played a significant role in shaping their decision-making process. Individuals in their social circles held positive views regarding CC screening. These people believed that undergoing CC screening was a commendable choice that offered protection. Some individuals in their environment hesitated and deemed CC screening unnecessary, resulting in their non-participation. These women expressed that their social environment failed to provide the necessary encouragement. Moreover, some women indicated that their personal knowledge of someone affected by CC sometimes influenced their decision, while other times it did not. Notably, most women chose to discuss their participation in CC screening solely with their partners. Regarding HPV vaccination, the women's social environment played a significant role. Often, the women's surroundings held a negative perception of the vaccination, particularly influenced by their families. The general sentiment in the environment was that the vaccination was unnecessary, as neither their mothers nor grandmothers had received it and had not developed CC. Additionally, women mentioned that family in Syria had a strong influence, emphasizing the importance of listening to and obeying elderly. However, since living in the Netherlands, they felt that family had less influence due to a greater emphasis on privacy. Children, according to the women, did not have a major impact on the decision-making process due to their young age. However, with older children, a greater influence was indicated. Ultimately, most women made the decision to vaccinate their children in consultation with their partners. ‘’My surroundings told me to not vaccinate my daughter, because the vaccination is still new. That is why I did not vaccinate her, now I think that it was a stupid action of mine. Other Syrian women said things like, 'This vaccination is nonsense, you just shouldn't believe it.’" – 40–50 years, educational level 2 Women’s practical barriers and facilitators towards participation in CC prevention programs The first practical factor refers to barriers in receiving information regarding CC prevention programs to be able to participate. Women mentioned a language barrier, especially for those who had poor proficiency in Dutch. Additionally, some women mentioned difficulties in reading information due to illiteracy in Dutch and Arabic, which resulted in that they did not understand the invitation letter and did not participate because of that. Furthermore, most women stated that they did not prioritize the screening and did not make the time for it. Others highlighted benefits of the CC screening, such as its convenience, being free of charge, and the ability to detect (precursors of) CC early. Some women did express that it would be easier for them if the screening could be done at their homes. Most of the women were not aware of the option of the self-sampling test, which can be done at home. They generally appreciated the availability of this option, but most also indicated that they would find it intimidating and would not know how to use it properly. Lastly, many emphasized the preference for the screening to be conducted by a female doctor or assistant. Furthermore, women shared that receiving accurate information and being reminded were key factors that motivated their participation. Lastly, most women agreed that knowing their personal data would be handled confidentially made them feel more comfortable and encouraged them to take part in the programs. The influence of emotional barriers and facilitators towards participation in CC prevention programs Most women expressed a fear for the CC screening, primarily due to the disease itself and the screening results. Many women also described it as an unpleasant experience, based on past experiences with the screening, which they found painful and uncomfortable. The same barrier was also found for their children. Most women mentioned that the vaccination might cause pain and fever. Furthermore, women found it too nerve-wracking to wait for the screening results, leading to anxious thoughts. Many women viewed the screening as an intimate examination and preferred not to have someone looking at their intimate areas due to feelings of shame. Some women mentioned reluctance or not making the time as a reason for not going to the doctor. On the other hand, some women expressed the experienced regret as a specific facilitator. They regretted not vaccinating their daughters earlier due to their initial doubts. As the vaccine has been around for many years now and has gained more trust, women developed feelings of regret for not taking the vaccine. This regret has convinced them to vaccinate their daughters now. Desire for health protection as a facilitator of women’s participation in CC prevention programs According to most women, protection against CC was the most important facilitator. The existence of CC prevention programs brought joy to many women, especially among those who recently arrived in the Netherlands. They appreciated the government's dedication to their well-being and inclusion. Moreover, women stressed the need to prioritize their health and take necessary actions. Another facilitator mentioned by almost all women was the reassurance they would get from having undergone the screening. They explained that once they receive the results, they have more certainty about their health. On the other hand, most of the women mentioned a low perceived susceptibility as a barrier. They considered the CC screening and the HPV vaccination unnecessary, perceiving the risk of acquiring HPV as small. This was particularly the case for women who had no symptoms and were not sexually active. 5. Discussion Main findings This is the first study that explores how and why Syrian-Dutch women decide to participate or not in the current Dutch national CC screening program and whether to vaccinate their children against HPV. Most women were aware of CC, but had misconceptions about its cause, with many believing it was inherited or caused by lifestyle factors rather than the HPV. In addition, not many of the interviewed women were aware of the HPV vaccination, particularly due to recent arrivals in the Netherlands. Overall, women had a positive attitude towards the CC prevention programs. Several barriers towards participation in the CC screening were identified, such as fear for the test results, pain from the procedure, and cultural beliefs that prevent women from participating, such as discussing sexual diseases within the social network and getting tested if unmarried or being a virgin. Barriers that were identified in relation to the HPV vaccination were a lack of trust in the vaccine, concerns about safety and long-term effects, rumours such as potential impact on fertility, and fear of pain and fever. On the other side, there were also facilitators for participation in CC prevention programs, such as protection from CC, the government's commitment to their well-being, prioritizing health, fear of CC, receiving accurate information, and privacy on their personal data. Furthermore, some religious beliefs had an influence on the decision-making of women, as most women believed their religious practices protected them from CC and that it was unnecessary for them to participate in CC prevention programs. Moreover, the social environment also influenced women's decision-making. Due to the associated taboo and the resulting rarity of discussions about CC, women's choices were influenced, whereas positive attitudes and peer encouragement facilitated participation, hesitation and negative perceptions served as barriers. Finally, there were a couple of barriers found for accessing information, such as language barriers, illiteracy, time constraints, difficulty accessing information, embarrassment, and fear of the screening procedure and the test results. Comparison with other studies This study’s main influencing factors also align with existing research on immigrant women’s decision-making regarding participation in CC prevention programs in the Dutch context. Firstly, our findings about misconceptions regarding CC are in line with those found in other studies. Some women in our study, as well as in other research, incorrectly associated CC with infertility rather than recognizing it as being primarily caused by HPV ( 9 , 28 , 35 ). Secondly, Syrian-Dutch women in this study reported feelings of shame and taboo around discussing sexually transmitted diseases like CC, which can hinder open conversations and awareness about CC prevention. This finding is consistent with other studies that have highlighted the impact of taboos on health behaviours in similar immigrant groups ( 9 , 31 , 32 ). This study showed that most Syrian-Dutch women were positive about the HPV vaccination, which is in line with another study done under different immigrant groups in the Netherlands that were positive about the Dutch national vaccination campaign ( 36 ). Positive perceptions of HPV vaccination were linked to a sense of protection against CC, and this served as a motivating factor for participating in HPV vaccination. This is in line with another study in which Turkish- and Moroccan-Dutch women who indicated protection against CC as a facilitator for participation in the CC screening program ( 9 ). Moreover, barriers identified in this study such as language difficulties, illiteracy, time constraints, and limited access to accurate information, are consistent with barriers faced by Turkish- and Moroccan-Dutch women ( 9 ). In terms of awareness and knowledge, this study is in line with previous research among Arabic-speaking women in Australia ( 37 ). Both studies showed little awareness and knowledge of the cause of CC. Women did not know that CC is caused by a virus and thought it was heredity. The same holds for limited awareness about the HPV vaccination ( 37 , 38 ). Furthermore, the result of experiencing a language barrier in understanding the provided information was also found among immigrant groups like Turkish- and Moroccan-Dutch women ( 9 , 36 ). This study provided a new perspective of Syrian-Dutch women dropping their norms and values by the time they leave Syria due to the war. Participants expressed that surviving the war in Syria and having a new start in the Netherlands led some Syrian individuals to let go of certain cultural norms and values. This shift was partly due to the distance from family, which reduced traditional influences, and it was also a result of feeling free to make new choices in a safer environment. In addition, this study adds valuable insights by exploring the role of religion in decision-making regarding participation in CC prevention programs among Syrian-Dutch women, similar to findings previously reported for Turkish- and Moroccan-Dutch women ( 39 , 40 ). Our qualitative analysis highlights that the influence of religion among Syrian-Dutch women appears to be more diverse, which may reflect the religious heterogeneity within the Syrian population, including Muslims, Christians, and atheists ( 41 ). By providing an in-depth understanding of how religious background can shape attitudes toward CC prevention programs in this group, our study offers an important contribution to the literature. Strengths and limitations This study is the first that investigated the influencing factors among Syrian-Dutch women for their decision-making regarding CC prevention programs, which makes it unique and gives new insights regarding this population. Another strength of our study is that we used an in-depth qualitative approach via semi-structured interviews, allowing for a deep understanding of Syrian-Dutch women's decision-making processes regarding CC prevention programs. Furthermore, the study included a diverse sample with individuals of various ages, places, and lengths of residence in the Netherlands. This variety increased the findings' validity by capturing a wide range of opinions and experiences within this immigrant population. The study also benefited from the conceptual framework. This framework provided structure to the research and aided in interpretation and analysis of the findings. Lastly, this study benefited from the researcher being bilingual and sharing the same cultural background as the Syrian-Dutch participants. This provided a trusted relationship between the participants where they could share all their opinions. However, there are also limitations, such as reliance on self-reported information from the participants. While this fits with the study aim to explore the lived experiences of these women, it might also lead to recall bias or social desirability bias. Participants' answers may have been impacted by their desire to produce socially acceptable responses or their ability to recall detailed information accurately. In addition, a potential selection bias should be considered, as women with more positive attitudes toward screening and vaccination may have been more likely to participate in the interviews than those with more negative attitudes. Despite these limitations, the study gives helpful insights into the decision-making processes of Syrian-Dutch women regarding two CC prevention programs, the CC screening and the HPV vaccination. Implications and recommendations for practice and future research The barriers found in this study range from misconceptions, cultural and religious influences, practical challenges, and fear of the CC programs' procedures such as pain form the smear-test and HPV vaccination. These barriers emphasize the necessity of tailored interventions that target these barriers to improve decision-making regarding CC prevention programs. The study also emphasizes the importance of accessible and culturally relevant health communication. Misconceptions regarding the cause of CC indicate that education campaigns should address cultural beliefs and misconceptions regarding the HPV's transmission in addition to increasing women's awareness of the HPV vaccination. Using culturally appropriate materials or community leaders and developing information to recognize the importance of cultural and social norms could increase engagement and trust. While emphasizing the importance of prevention, healthcare professionals and educators should think about incorporating cultural competence into their outreach initiatives to ensure that they respect sensitivities associated with sexual health discussions. Furthermore, according to our study, some women were hesitant to take part in CC prevention programs, because they were uncomfortable in medical settings and afraid of procedures. The availability of the HPV self-test offers a potential solution to overcome reluctance towards medical settings and fears of privacy-invading procedures. For women who might feel ashamed or anxious about screening, it is important to offer reassurance by clearly outlining privacy measures and informing them that they can always request a female healthcare practitioner to perform the test. Future public health initiatives should also prioritize providing translated materials, bilingual support, and easily navigable digital resources, given the identified language barriers and challenges in accessing information. Offering educational materials in the native languages of immigrant communities, such as Arabic for Syrian-Dutch women, could improve the accessibility and understanding of CC prevention programs. The RIVM is already taking steps to address this issue by providing culturally sensitive educational videos to support informed decision-making on CC screening among Turkish- and Moroccan-Dutch women and providing translated information online. However, such efforts could be expanded to reach other communities as well and make it more accessible ( 19 ). Furthermore, there is a need for interventions to boost vaccine trust, because of the low awareness and safety concerns surrounding the HPV vaccination, particularly among recent immigrants. These interventions might involve eliminating misconceptions, showing the safety and effectiveness of vaccines, and reassuring people of their advantages by providing information gatherings. Including support in these information gatherings from trustworthy community members, like medical professionals, religious authorities, or other Syrian-Dutch mothers who have vaccinated their children may help eliminate myths and promote informed decision-making. Future research should focus on developing and evaluating tailored interventions for Syrian-Dutch women. 6. Conclusion Awareness, cultural norms, religious views, social environment, and emotional and practical factors all have a role in Syrian-Dutch women's decision-making processes about CC prevention programs. Within this study, we found several barriers for participation in CC prevention programs, such as a lack of knowledge about HPV, misconceptions about CC, fear of the procedure, and practical obstacles including language and procedural anxiety. Participation was facilitated by privacy of personal data, advantages of early detection, and trust in the government. Healthcare professionals could overcome these barriers by tailoring interventions to the cultural and emotional context, for example through healthcare practitioner training and information gatherings supported by trusted community members such as medical professionals, religious authorities, or Syrian-Dutch mothers who have vaccinated their children, as their involvement may help address myths. By implementing these recommendations, healthcare initiatives can support informed decision-making regarding CC prevention programs among Syrian-Dutch women. Abbreviations CBS: Statistics Netherlands CC: cervical cancer COREQ: Consolidated criteria for Reporting Qualitative research HPV: Human papillomavirus HBM: Health Belief Model RAA: Reasoned Action Approach RIVM: National Institute for Public Health and the Environment Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki. Ethical clearance was obtained from the Medical Ethics Review Committee (NedMec) of the University Medical Centre Utrecht (23-090/DB). The Committee confirmed that the Medical Research Involving Human Subjects Act (WMO) does not apply to this study. Consent for publication Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article and its supplementary information files. Competing interests No potential conflict of interest was reported by the authors. Funding This work was supported by ZonMw under [grant number 2477411. Authors' contributions TV and NH conceived and designed the study. NA conducted the interviews, and NA, TV, and NH analysed the interviews. NA wrote the first draft of the manuscript. All authors provided critical revisions on the interview guide and the manuscript. All authors read and approved the final manuscript. Acknowledgements We would like to thank all participants for taking part in the interviews and for inviting others to participate as well. The authors would like to thank their own network, key community figures, and community centres that helped with the recruitment of Syrian-Dutch women. The authors are thankful to the Foundation Hammurabi for their support in the recruitment of Syrian-Dutch women. Authors' information Nadien H.S. 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16:01:24","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":137842,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7934683/v1/c34ced974dba4ab6b2d35fc8.html"},{"id":96454509,"identity":"6bcef447-4bf6-46e5-9cc8-d2cad159808b","added_by":"auto","created_at":"2025-11-21 10:02:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":63453,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eExtended Health Belief Model for understanding the decision-making process for CC prevention programs among Syrian-Dutch women\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7934683/v1/ad051e17e394fdc65d4854b8.png"},{"id":96456955,"identity":"833cb6a4-12a7-431c-9f59-dd1be16705cc","added_by":"auto","created_at":"2025-11-21 10:08:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":566250,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7934683/v1/3d5429a0-54bb-4d3d-9603-e6e4d8d248e1.pdf"},{"id":96399646,"identity":"4b74cf49-e01e-4d1d-9735-d1faada387cc","added_by":"auto","created_at":"2025-11-20 16:01:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":516685,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementalmaterial1COREQChecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7934683/v1/0e0b8f2968b8c09550f2d51d.pdf"},{"id":96399648,"identity":"90ae5d12-9029-4354-bfc9-852a086aa091","added_by":"auto","created_at":"2025-11-20 16:01:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":106907,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementalmaterial2InterviewguideENGNHS.docx","url":"https://assets-eu.researchsquare.com/files/rs-7934683/v1/b72f9bc2a61368f12f043bf9.docx"},{"id":96454501,"identity":"14d5c16d-54de-4054-81ac-a513b6a0c443","added_by":"auto","created_at":"2025-11-21 10:02:50","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15025,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementalmaterial3vaccinationstatus23102025.docx","url":"https://assets-eu.researchsquare.com/files/rs-7934683/v1/7327d17802cdc9c055d2cdf0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring factors influencing the decision-making regarding cervical cancer screening participation and HPV vaccination uptake among Syrian-Dutch women: a qualitative interview study","fulltext":[{"header":"2. Background","content":"\u003cp\u003eWorldwide, cervical cancer (CC) is the fourth most frequently diagnosed cancer in women in 2020 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In the Netherlands, each year around 800 women are diagnosed with CC and around 200 women die because of this disease (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It is estimated that without a nationwide screening program for CC, this number would be up to 500 women dying each year (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The CC prevention programs (i.e. CC screening and human papillomavirus (HPV) vaccination) have been implemented free of charge for many years in the Netherlands. Since 1996, women aged 30 to 60 years are invited to participate in CC screening every five years (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The HPV vaccination that protects against HPV 16 and 18 infections is since 2010 available for 13-year-old girls and since 2022 available for 10-year-old girls and boys in the Netherlands (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite the availability of these free of charge CC prevention programs, 50.3% of the women do not participate in the CC screening program in the Netherlands (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Specifically, individuals with a low socioeconomic position and/or a migration background are known to participate less often in CC prevention programs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). For example, Turkish- and Moroccan-Dutch women, who represent the two largest immigrant groups in the Netherlands, have lower participation rates in CC screening compared to native Dutch women, with rates of 64% and 53% versus 79%, respectively (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In addition, HPV vaccination rates are also lower among Turkish- and Moroccan-Dutch immigrants compared to individuals without a migration background and those from other immigrant populations, thereby increasing the likelihood of future development of CC among these women (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMultiple studies have investigated the barriers and facilitators regarding CC screening participation among Turkish- and Moroccan-Dutch women in the Netherlands (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Perceived barriers of participating in CC screening among these women were a lack of knowledge about CC and its screening, an insufficient command of the Dutch language, fear, fatalism, shame, and taboo (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Perceived facilitators among these women were a high perceived severity of the disease, social support, and a short procedure time (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Furthermore, our recently submitted manuscript examines the information needs and preferences among Turkish-, Moroccan-, and Syrian-Dutch women to support informed decision-making. This interview study takes an overarching approach across all three populations, but with a different focus (manuscript under review). However, there is still a lack of insight into how and why the new immigrant population in the Netherlands, the Syrian immigrants, decide to participate or not in the current Dutch CC prevention programs.\u003c/p\u003e\u003cp\u003eIn 2022, there were a total of almost 150,000 (0.8% of the Dutch population) Dutch inhabitants born in Syria (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This immigrant population is still growing, but to date, there are no participation rates, and no research has been done about their participation in the CC prevention programs. This is concerning, because of the ongoing war in Syria and Syria\u0026rsquo;s deteriorating health system, it is expected that Syrian women are at an increased risk of developing CC (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This is because many of these women did not have access to preventive measures such as CC screening and HPV vaccination before. Moreover, we do know that Syrian women in Syria were found to have limited understanding of CC prevention programs (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). It was also shown that these women and Syrian refugees in Greece and Turkey had a lack of knowledge regarding CC screening and HPV vaccination (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo participate in CC prevention programs, informed decision-making is important. Through informed decision-making, individuals can consider the benefits of prevention programs against the risks of adverse effects when deciding whether to participate or not (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Informed decision-making regarding CC screening among native Dutch women is found to be limited due to a lack of decision-relevant knowledge (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). There are currently no studies about the participation of Syrian-Dutch women in CC prevention programs. This is concerning, as previous research shows that Turkish- and Moroccan-Dutch women in the Netherlands often do not thoroughly consult available information materials, which negatively affects their decision-making (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These information materials are also not customized to the needs of Turkish- and Moroccan-Dutch women, as present information materials are focused on medical facts, while these women indicated a need for information about the emotional, practical, religious, and cultural aspects of CC screening as well (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The Centre for population screening (part of the National Institute for public health and the environment, RIVM) is currently actively addressing this issue by providing culturally sensitive educational video to facilitate informed decisions on CC screening among Turkish- and Moroccan-Dutch women (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The reasons for (non)participation of Syrian-Dutch women may be comparable with the findings reported among Turkish- and Moroccan-Dutch women, as most of the Syrian-Dutch women share the same culture and religion (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Therefore, the aim of this study is to explore how and why Syrian-Dutch women decide to participate or not in the Dutch national CC screening program and whether to vaccinate their children against HPV.\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e\u003cp\u003eFrom April to June 2023, semi-structured interviews were held to learn more about how and why Syrian-Dutch women participate or not in CC prevention programs. This qualitative approach was chosen, since it allows participants to explore and clarify their knowledge, attitudes, feelings, beliefs, and experiences regarding their decision-making to participate or not in CC prevention programs. Prior to the start of our interviews, we used a short questionnaire about socio-demographic characteristics to gain insight into the diversity within our group of participants. This information helped us to later interpret the different perspectives of Syrian-Dutch women in relation to their backgrounds. The reporting of this study is in adherence to the Consolidated criteria for Reporting Qualitative research (COREQ) checklist (see supplemental material 1).\u003c/p\u003e\u003cp\u003eStudy population and recruitment\u003c/p\u003e\u003cp\u003eThe study population included (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Syrian-Dutch immigrant women aged 30 to 60 years, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Syrian-Dutch immigrant women having a daughter aged 9 to 26 years. Both women from the first- (women born in Syria) and second-generation (women born in the Netherlands, of which at least one of the parents was born in Syria) were included (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). We purposefully invited women between the age of 30 and 60 years, because this is the group that receives an invitation for CC screening every five years. We also invited women having a daughter aged 9 to 26 years who received the invitation for the HPV vaccination before. Snowball sampling was used to increase our sample size and reach the (more hidden) peers of our participants (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). We started with a small number of women who met the inclusion criteria and invited them to participate in the interviews. These participants were then asked to recommend other contacts who meet the inclusion criteria and may be willing to participate, who in turn recommended other potential participants.\u003c/p\u003e\u003cp\u003eParticipants were invited through various community centres, mosques, social media channels, and the project team's social networks. They were approached face-to-face, via telephone or e-mail. During recruitment, we aimed for diversity in age, educational level, geography, marital status, number of children, number of years residing in the Netherlands, and command of the Dutch language. Educational level was categorized as 1, 2, and 3 based on the classification of Statistics Netherlands (CBS) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Participants were included until data saturation was reached at the level of themes, i.e. no new themes or relevant information emerged during the last interviews among a diverse group of participants. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInterview guide\u003c/p\u003e\u003cp\u003eThe interview guide was developed based on previous literature and models, see supplemental material 2. We primarily employed the Health Belief Model (HBM) as the main conceptual framework. To provide a more comprehensive understanding, selected constructs from the Reasoned Action Approach (RAA) and Betancourt\u0026rsquo;s Model of Culture and Behaviour were integrated into the model. The HBM posits that health behaviour is influenced by perceived susceptibility, severity, benefits, barriers, self-efficacy, and cues to action (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). These constructs suggest that individuals are more likely to engage in health actions if they feel at risk, believe the disease has serious consequences, perceive benefits of the action, believe benefits outweigh barriers, feel capable of performing the action, and receive cues to act. However, the HBM does not account for social and cultural influences comprehensively. That is why we also included the RAA and the Betancourt's Model of Culture and Behaviour. Our model includes the RAA\u0026rsquo;s constructs of attitude toward behaviour and perceived norms (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Previous research indicates that social networks significantly impact decision-making in health contexts (\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Additionally, the Betancourt's Model of Culture and Behaviour highlights the impact of cultural/religious beliefs, values and health practices on health behaviour (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Cultural factors, such as traditional habits and religious views, are crucial in shaping attitudes towards health interventions (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIncorporating these elements into the main conceptual model, the HBM, results in an extended version of the HBM, which addresses gaps in the original model by adding social, cultural, and religious factors, subjective norms and safety (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This comprehensive approach provides a nuanced understanding of the decision-making processes of Syrian-Dutch women regarding participation in CC screening and HPV vaccination for their children.\u003c/p\u003e\u003cp\u003eThe main subjects included in the interview guide were (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) current awareness, knowledge and attitude, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) influencing factors like culture, religion, social factors, practical factors, and emotional factors. Current awareness and knowledge were chosen based on previous research indicating that these factors play a crucial role in informed decision-making for participation in CC prevention programs among immigrant populations (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Additionally, influencing factors like culture, religion, social factors, practical factors, and emotional factors were chosen based on our conceptual model outlined in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The concepts are shown in different colours: concepts derived from the HBM are shown in blue, those from the RAA in orange, and those from Betancourt\u0026rsquo;s Model of Culture and Behavior in green.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003eA short online questionnaire assessing women's socio-demographic characteristics was sent to the participants prior to the interview. For participants who experienced difficulties with reading the Dutch language or accessing the online questionnaire, the questionnaire was filled out offline in Dutch by the participant and verbally translated to Arabic by the researcher if needed. The interviews were conducted in Dutch or Modern Standard Arabic (based on the participant\u0026rsquo;s preference) by a female bilingual interviewer (NA, MSc). Interviews were conducted in-person or via video conferencing using MS Teams, depending on the participant's preference and availability. The interviews were audio-recorded and lasted approximately one hour. Field notes were made during and after the interview. The data was stored on the RIVM\u0026rsquo;s secure server, which could only be accessed by authorized individuals; the interviewer and supervisors.\u003c/p\u003e\u003cp\u003eData analysis\u003c/p\u003e\u003cp\u003eThe interviews were transcribed verbatim. The interviews conducted in Arabic were directly transcribed into Dutch by the bilingual researcher (NA) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The transcripts were read until there was a deeper understanding of the data to identify patterns (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Using the qualitative software tool MAXQDA (version 18.0.5) and thematic analysis approaches, transcripts were analysed inductively.\u003c/p\u003e\u003cp\u003eDifferent coding styles were used: open, axial, and selective coding (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Open coding was used to code transcripts by labelling significant text segments with concepts extracted from the text. Then, we detected categories and subthemes by systematic comparison of coded text (also known as axial coding). Finally, selective coding was used to define core categories and themes that appeared from axial coding by describing the relationship and theories of various categories (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Furthermore, a second coder (TV) independently analysed a random sample (approximately 33%) to guarantee the veracity of the data interpretation. Discrepancies were resolved until agreement between NA, TV and NH was reached on the codes, categories, and (sub)themes assigned.\u003c/p\u003e\u003cp\u003eEthical considerations\u003c/p\u003e\u003cp\u003e This study was conducted in accordance with the Declaration of Helsinki. Ethical clearance was obtained from the Medical Ethics Review Committee (NedMec) of the University Medical Centre Utrecht (23\u0026ndash;090/DB). The Committee confirmed that the Medical Research Involving Human Subjects Act (WMO) does not apply to this study.\u003c/p\u003e\u003cp\u003ePrior to the start of the interviews, participants were sent an online information letter and an informed consent for this study. The informed consent was the first page of the online questionnaire. After they read it, they could click on a button to give their digital consent and start the questionnaire. For the participants that could not read Dutch or had difficulties with the digital informed consent, they filled and signed the informed consent offline prior to the interview. At the start of the interview, the participants were again given a brief explanation of the study's purpose and were given the opportunity to ask questions. After the interviews, each participant received an eighteen-euro gift voucher as a token of our appreciation for their participation.\u003c/p\u003e"},{"header":"4. Results","content":"\u003cp\u003eSocio-demographics\u003c/p\u003e\u003cp\u003eA total of 12 Syrian-Dutch women were interviewed (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). One participant was born in the Netherlands, 11 participants were born in Syria and immigrated to the Netherlands between 1990\u0026ndash;2023. The participants' ages ranged from 30 to 60 years. We interviewed women living in different areas of the Netherlands, with most of them residing near cities like Enschede, Edam, Amersfoort, and Amsterdam, and with various educational levels. Furthermore, most of the women (n\u0026thinsp;=\u0026thinsp;7) reported that they have never participated in the CC screening program before. Most women (n\u0026thinsp;=\u0026thinsp;9) had children, together accounting for 23 children (8 sons and 15 daughters), who were the subjects of the HPV vaccination questions. Of these children, 4 were fully vaccinated, 1 was partially vaccinated, 12 were not vaccinated, and for 6, the vaccination status was unknown. The vaccination status of the participants\u0026rsquo; children is presented in the supplemental material 3.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSocio-demographics of the sample\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSyrian-Dutch participants (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge group; \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u0026ndash;40 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (41.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u0026ndash;50 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (17.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u0026ndash;60 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (41.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of years residing in the Netherlands; \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;3 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u0026ndash;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (41.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducational level*; \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (41.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen with children \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-reported command of the Dutch language: reading; \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInsufficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSufficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-reported CC screening participation; \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEvery 5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot every 5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (58)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eI do not know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003e*Educational level\u003c/em\u003e (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e):\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) \u003cem\u003eprimary education, secondary education: VMBO, the first 3 years of HAVO/VWO or the assistant training (mbo-1)\u003c/em\u003e,\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) \u003cem\u003eupper years of HAVO/VWO, basic vocational training (mbo-2), vocational training (mbo-3) and specialist training (mbo-4)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) \u003cem\u003ebachelor/master levels of education\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThematic analysis\u003c/p\u003e\u003cp\u003eWe identified eight main themes from our thematic analysis in relation to CC prevention program participation of Syrian-Dutch women. The identified themes focus on the following main subjects regarding CC screening and HPV vaccination: current knowledge and awareness, attitudes towards CC screening and HPV vaccination, cultural barriers, the influence of religious beliefs, influence of social environment, practical barriers and facilitators, influence of emotional factors, and desire for protection of health.\u003c/p\u003e\u003cp\u003eCurrent knowledge and awareness regarding CC screening and HPV vaccination\u003c/p\u003e\u003cp\u003eMost women had heard of CC and retrieved their knowledge of CC prevention programs from the invitation letter and informational leaflet from the Dutch government. A few women mentioned that they had learned about CC from the Syrian TV. They were aware that CC can develop later in life and lead to death. Most women also knew what the symptoms of CC were, and that the diagnosis of CC was simple. They also knew how a cervical smear test was done. However, there were considerable misconceptions regarding the cause of CC. Many women indicated that they believe that the disease is inherited and did not know that HPV is the cause of CC and that it can be transmitted through sexual contact. Some women wrongly indicated that CC is developed through a poor lifestyle, such as unhealthy food choices and not exercising. Many women were also unaware that CC can develop in 10\u0026ndash;15 years after acquiring HPV.\u003c/p\u003e\u003cp\u003eMost women were unaware of the HPV vaccination. Women who had recently arrived in the Netherlands had no information about the HPV vaccination; they said that the vaccination did not yet exist in Syria, so they knew little about it. When they arrived in the Netherlands, some of the women had received information about the HPV vaccination in the asylum centre. Despite hearing about it, most participants were still unfamiliar with this vaccination.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026rsquo;When we came to the Netherlands, no one really explained to us what the HPV vaccination is. We were scared, because we thought we cannot get every vaccination without knowing what is in it. Maybe there are also bad side effects, so we were scared and unaware too.\u0026rsquo;\u0026rsquo; \u0026ndash; 50\u0026ndash;60 years, educational level 3\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAttitude towards CC screening and HPV vaccination\u003c/p\u003e\u003cp\u003e\u003cem\u003eAttitude towards CC screening\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMost of the women indicated having a positive attitude towards the CC screening. For example, they believed that the CC screening is beneficial and that it helps for early detection of CC. They also thought that the CC screening was accessible and not painful. Most of the women wanted to recommend the smear test to all women. Overall, women were positive about the CC screening and trusted the smear test. The only negative feedback was that it might hurt.\u003c/p\u003e\u003cp\u003e\u003cem\u003eAttitude towards HPV vaccination\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMany women were also enthusiastic about the HPV vaccination. Women that were not long in the Netherlands yet had a positive attitude. They felt happy that their children could be protected from CC and saw the HPV vaccination as beneficial and effective. As a result, they mentioned to trust the vaccine and recommended the HPV vaccination to others. Women who had lived in the Netherlands for a longer period regretted not vaccinating their daughters sooner.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026rsquo;Of course, seeing that your child is not carrying a disease and receiving a vaccination makes you very happy that your child is safe. It is undoubtedly beneficial to them and has a positive impact; otherwise, they would not give vaccinations.\u0026lsquo;\u0026rsquo; \u0026ndash; 40\u0026ndash;50 years, educational level 1\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHowever, some women had a negative attitude towards the HPV vaccination. For example, they believed the vaccination was still in its early stages and indicated doubts about the safety of the vaccine. They believed that the vaccination's long-term effects were still unknown. They mentioned that they would not be able to trust the vaccination for another generation. A few participants mentioned to not trust the government and the reason why they provide the vaccination. Furthermore, some women explained that rumours about the HPV vaccination, such as concerns about its safety, possible side effects, and potential impact on fertility, led them to hesitate or decide against vaccinating their children. At the time the HPV vaccination was introduced, these women heard misinformation from their social environment, such as claims that the vaccine could cause serious side effects or negatively affect fertility. This misinformation still influences their decision-making today. As a result, they were opposed to the HPV vaccination and chose not to vaccinate their children.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026rsquo;Perhaps the vaccination is not safe and trustworthy after all, and there are many side effects, or the vaccination can cause something else; perhaps it is also due to politics or the government, which makes us more hesitant to vaccinate.\u0026rsquo;\u0026rsquo; \u0026ndash; 50\u0026ndash;60 years, educational level 3\u003c/em\u003e\u003c/p\u003e\u003cp\u003eCultural barriers that influence women\u0026rsquo;s participation in CC prevention programs\u003c/p\u003e\u003cp\u003eFor some women, culture played a role in their decision, as they claimed that if a woman is not married, she should not be exposed to sexual diseases or be tested for CC, because her intimate parts should be kept private. Furthermore, most women indicated that there is a taboo surrounding CC. They stated that because it is related to sexual diseases, people do not discuss it. They also stated that they do not tell others that they have cancer, because it makes them appear pathetic. However, some women stated that culture had no impact on their participation.\u003c/p\u003e\u003cp\u003eMany women mentioned the impact of norms and values. They mentioned that it was not common practice for them to go to the doctor without a specific reason. It also emerged that, according to norms and values, a woman does not simply go outside, because people around her would gossip about her leaving the house often. Women also reported being told that, according to cultural norms and values, the man was in charge and therefore decided whether or not they were allowed to visit a doctor outside the home. An intriguing finding was that women who moved after the war gave up these norms and values. They stated that because they came close to death during the war, many people have given up their norms and values and are now enjoying their lives more. They also stated that because people have moved, their Syrian culture and the western culture have become mixed, as have norms and values.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026rsquo;After the war, everyone appears to be distancing themselves from the Syrian norms and values. People lived between life and death, so, many people's perspectives have shifted. It also has to do with the fact that people moved to other places and countries where there are different norms and values, and they are now more mixed with other types of Syrians from other cities and people from other countries.'' \u0026ndash; 50\u0026ndash;60 years, educational level 2\u003c/em\u003e\u003c/p\u003e\u003cp\u003eReligious beliefs reducing the perceived need to participate in CC prevention programs\u003c/p\u003e\u003cp\u003eMost women indicated that their religion (Islam and Christianity) does not influence their decision-making regarding participation in CC prevention programs. Most women indicated that it is allowed by their religion. Furthermore, most women said that based on their religion a male doctor is allowed to take the smear, since it has to do with their health. However, many women did state that their religion protects them from CC. Women mentioned that in their religion, it is forbidden to have sexual contacts before marriage, and once married, you can only have a sexual relationship with your partner. This ensures that the risk of contracting the HPV virus is extremely low, which was the reason that most women mentioned to not participate in CC screening and vaccinate their children against HPV. However, women recognized that those without religious beliefs or \u0026ldquo;Western\u0026rdquo; children might require the vaccination, because among these groups it is more common to have multiple bed partners. For their own children, most women felt that the vaccination was not necessary, as they believed this situation did not apply to them. In addition, a fatalistic belief was expressed by several women, who stated that if you get sick, it is God's will and cannot be prevented.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026rsquo;Women are protected from this disease by the Islam. Because a woman only sleeps with one partner, she is protected from the disease\u0026hellip; So, a virgin is protected in any case, and a married person is also protected. Unlike in the West, where people sleep with multiple partners.\u0026rsquo;\u0026rsquo; \u0026ndash; 50\u0026ndash;60 years, educational level 3\u003c/em\u003e\u003c/p\u003e\u003cp\u003eInfluence of social environment: taboo, support, and negative perception towards the HPV vaccination\u003c/p\u003e\u003cp\u003eWomen stated that the topic of CC was rarely discussed within the women's social environment, primarily due to the taboo that was mentioned earlier. However, among the few women who did engage in discussions about CC, they acknowledged that their social environment played a significant role in shaping their decision-making process. Individuals in their social circles held positive views regarding CC screening. These people believed that undergoing CC screening was a commendable choice that offered protection. Some individuals in their environment hesitated and deemed CC screening unnecessary, resulting in their non-participation. These women expressed that their social environment failed to provide the necessary encouragement. Moreover, some women indicated that their personal knowledge of someone affected by CC sometimes influenced their decision, while other times it did not. Notably, most women chose to discuss their participation in CC screening solely with their partners.\u003c/p\u003e\u003cp\u003eRegarding HPV vaccination, the women's social environment played a significant role. Often, the women's surroundings held a negative perception of the vaccination, particularly influenced by their families. The general sentiment in the environment was that the vaccination was unnecessary, as neither their mothers nor grandmothers had received it and had not developed CC. Additionally, women mentioned that family in Syria had a strong influence, emphasizing the importance of listening to and obeying elderly. However, since living in the Netherlands, they felt that family had less influence due to a greater emphasis on privacy. Children, according to the women, did not have a major impact on the decision-making process due to their young age. However, with older children, a greater influence was indicated. Ultimately, most women made the decision to vaccinate their children in consultation with their partners.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026rsquo;My surroundings told me to not vaccinate my daughter, because the vaccination is still new. That is why I did not vaccinate her, now I think that it was a stupid action of mine. Other Syrian women said things like, 'This vaccination is nonsense, you just shouldn't believe it.\u0026rsquo;\" \u0026ndash; 40\u0026ndash;50 years, educational level 2\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWomen\u0026rsquo;s practical barriers and facilitators towards participation in CC prevention programs\u003c/p\u003e\u003cp\u003eThe first practical factor refers to barriers in receiving information regarding CC prevention programs to be able to participate. Women mentioned a language barrier, especially for those who had poor proficiency in Dutch. Additionally, some women mentioned difficulties in reading information due to illiteracy in Dutch and Arabic, which resulted in that they did not understand the invitation letter and did not participate because of that. Furthermore, most women stated that they did not prioritize the screening and did not make the time for it.\u003c/p\u003e\u003cp\u003eOthers highlighted benefits of the CC screening, such as its convenience, being free of charge, and the ability to detect (precursors of) CC early. Some women did express that it would be easier for them if the screening could be done at their homes. Most of the women were not aware of the option of the self-sampling test, which can be done at home. They generally appreciated the availability of this option, but most also indicated that they would find it intimidating and would not know how to use it properly. Lastly, many emphasized the preference for the screening to be conducted by a female doctor or assistant.\u003c/p\u003e\u003cp\u003eFurthermore, women shared that receiving accurate information and being reminded were key factors that motivated their participation. Lastly, most women agreed that knowing their personal data would be handled confidentially made them feel more comfortable and encouraged them to take part in the programs.\u003c/p\u003e\u003cp\u003eThe influence of emotional barriers and facilitators towards participation in CC prevention programs\u003c/p\u003e\u003cp\u003eMost women expressed a fear for the CC screening, primarily due to the disease itself and the screening results. Many women also described it as an unpleasant experience, based on past experiences with the screening, which they found painful and uncomfortable. The same barrier was also found for their children. Most women mentioned that the vaccination might cause pain and fever. Furthermore, women found it too nerve-wracking to wait for the screening results, leading to anxious thoughts. Many women viewed the screening as an intimate examination and preferred not to have someone looking at their intimate areas due to feelings of shame. Some women mentioned reluctance or not making the time as a reason for not going to the doctor.\u003c/p\u003e\u003cp\u003eOn the other hand, some women expressed the experienced regret as a specific facilitator. They regretted not vaccinating their daughters earlier due to their initial doubts. As the vaccine has been around for many years now and has gained more trust, women developed feelings of regret for not taking the vaccine. This regret has convinced them to vaccinate their daughters now.\u003c/p\u003e\u003cp\u003eDesire for health protection as a facilitator of women\u0026rsquo;s participation in CC prevention programs\u003c/p\u003e\u003cp\u003eAccording to most women, protection against CC was the most important facilitator. The existence of CC prevention programs brought joy to many women, especially among those who recently arrived in the Netherlands. They appreciated the government's dedication to their well-being and inclusion. Moreover, women stressed the need to prioritize their health and take necessary actions. Another facilitator mentioned by almost all women was the reassurance they would get from having undergone the screening. They explained that once they receive the results, they have more certainty about their health.\u003c/p\u003e\u003cp\u003eOn the other hand, most of the women mentioned a low perceived susceptibility as a barrier. They considered the CC screening and the HPV vaccination unnecessary, perceiving the risk of acquiring HPV as small. This was particularly the case for women who had no symptoms and were not sexually active.\u003c/p\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eMain findings\u003c/p\u003e\u003cp\u003e This is the first study that explores how and why Syrian-Dutch women decide to participate or not in the current Dutch national CC screening program and whether to vaccinate their children against HPV. Most women were aware of CC, but had misconceptions about its cause, with many believing it was inherited or caused by lifestyle factors rather than the HPV. In addition, not many of the interviewed women were aware of the HPV vaccination, particularly due to recent arrivals in the Netherlands. Overall, women had a positive attitude towards the CC prevention programs.\u003c/p\u003e\u003cp\u003eSeveral barriers towards participation in the CC screening were identified, such as fear for the test results, pain from the procedure, and cultural beliefs that prevent women from participating, such as discussing sexual diseases within the social network and getting tested if unmarried or being a virgin. Barriers that were identified in relation to the HPV vaccination were a lack of trust in the vaccine, concerns about safety and long-term effects, rumours such as potential impact on fertility, and fear of pain and fever. On the other side, there were also facilitators for participation in CC prevention programs, such as protection from CC, the government's commitment to their well-being, prioritizing health, fear of CC, receiving accurate information, and privacy on their personal data. Furthermore, some religious beliefs had an influence on the decision-making of women, as most women believed their religious practices protected them from CC and that it was unnecessary for them to participate in CC prevention programs. Moreover, the social environment also influenced women's decision-making. Due to the associated taboo and the resulting rarity of discussions about CC, women's choices were influenced, whereas positive attitudes and peer encouragement facilitated participation, hesitation and negative perceptions served as barriers. Finally, there were a couple of barriers found for accessing information, such as language barriers, illiteracy, time constraints, difficulty accessing information, embarrassment, and fear of the screening procedure and the test results.\u003c/p\u003e\u003cp\u003eComparison with other studies\u003c/p\u003e\u003cp\u003eThis study\u0026rsquo;s main influencing factors also align with existing research on immigrant women\u0026rsquo;s decision-making regarding participation in CC prevention programs in the Dutch context. Firstly, our findings about misconceptions regarding CC are in line with those found in other studies. Some women in our study, as well as in other research, incorrectly associated CC with infertility rather than recognizing it as being primarily caused by HPV (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Secondly, Syrian-Dutch women in this study reported feelings of shame and taboo around discussing sexually transmitted diseases like CC, which can hinder open conversations and awareness about CC prevention. This finding is consistent with other studies that have highlighted the impact of taboos on health behaviours in similar immigrant groups (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study showed that most Syrian-Dutch women were positive about the HPV vaccination, which is in line with another study done under different immigrant groups in the Netherlands that were positive about the Dutch national vaccination campaign (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Positive perceptions of HPV vaccination were linked to a sense of protection against CC, and this served as a motivating factor for participating in HPV vaccination. This is in line with another study in which Turkish- and Moroccan-Dutch women who indicated protection against CC as a facilitator for participation in the CC screening program (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Moreover, barriers identified in this study such as language difficulties, illiteracy, time constraints, and limited access to accurate information, are consistent with barriers faced by Turkish- and Moroccan-Dutch women (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn terms of awareness and knowledge, this study is in line with previous research among Arabic-speaking women in Australia (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Both studies showed little awareness and knowledge of the cause of CC. Women did not know that CC is caused by a virus and thought it was heredity. The same holds for limited awareness about the HPV vaccination (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Furthermore, the result of experiencing a language barrier in understanding the provided information was also found among immigrant groups like Turkish- and Moroccan-Dutch women (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study provided a new perspective of Syrian-Dutch women dropping their norms and values by the time they leave Syria due to the war. Participants expressed that surviving the war in Syria and having a new start in the Netherlands led some Syrian individuals to let go of certain cultural norms and values. This shift was partly due to the distance from family, which reduced traditional influences, and it was also a result of feeling free to make new choices in a safer environment. In addition, this study adds valuable insights by exploring the role of religion in decision-making regarding participation in CC prevention programs among Syrian-Dutch women, similar to findings previously reported for Turkish- and Moroccan-Dutch women (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Our qualitative analysis highlights that the influence of religion among Syrian-Dutch women appears to be more diverse, which may reflect the religious heterogeneity within the Syrian population, including Muslims, Christians, and atheists (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). By providing an in-depth understanding of how religious background can shape attitudes toward CC prevention programs in this group, our study offers an important contribution to the literature.\u003c/p\u003e\u003cp\u003eStrengths and limitations\u003c/p\u003e\u003cp\u003eThis study is the first that investigated the influencing factors among Syrian-Dutch women for their decision-making regarding CC prevention programs, which makes it unique and gives new insights regarding this population. Another strength of our study is that we used an in-depth qualitative approach via semi-structured interviews, allowing for a deep understanding of Syrian-Dutch women's decision-making processes regarding CC prevention programs. Furthermore, the study included a diverse sample with individuals of various ages, places, and lengths of residence in the Netherlands. This variety increased the findings' validity by capturing a wide range of opinions and experiences within this immigrant population. The study also benefited from the conceptual framework. This framework provided structure to the research and aided in interpretation and analysis of the findings. Lastly, this study benefited from the researcher being bilingual and sharing the same cultural background as the Syrian-Dutch participants. This provided a trusted relationship between the participants where they could share all their opinions.\u003c/p\u003e\u003cp\u003eHowever, there are also limitations, such as reliance on self-reported information from the participants. While this fits with the study aim to explore the lived experiences of these women, it might also lead to recall bias or social desirability bias. Participants' answers may have been impacted by their desire to produce socially acceptable responses or their ability to recall detailed information accurately. In addition, a potential selection bias should be considered, as women with more positive attitudes toward screening and vaccination may have been more likely to participate in the interviews than those with more negative attitudes. Despite these limitations, the study gives helpful insights into the decision-making processes of Syrian-Dutch women regarding two CC prevention programs, the CC screening and the HPV vaccination.\u003c/p\u003e\u003cp\u003eImplications and recommendations for practice and future research\u003c/p\u003e\u003cp\u003eThe barriers found in this study range from misconceptions, cultural and religious influences, practical challenges, and fear of the CC programs' procedures such as pain form the smear-test and HPV vaccination. These barriers emphasize the necessity of tailored interventions that target these barriers to improve decision-making regarding CC prevention programs. The study also emphasizes the importance of accessible and culturally relevant health communication. Misconceptions regarding the cause of CC indicate that education campaigns should address cultural beliefs and misconceptions regarding the HPV's transmission in addition to increasing women's awareness of the HPV vaccination. Using culturally appropriate materials or community leaders and developing information to recognize the importance of cultural and social norms could increase engagement and trust. While emphasizing the importance of prevention, healthcare professionals and educators should think about incorporating cultural competence into their outreach initiatives to ensure that they respect sensitivities associated with sexual health discussions. Furthermore, according to our study, some women were hesitant to take part in CC prevention programs, because they were uncomfortable in medical settings and afraid of procedures. The availability of the HPV self-test offers a potential solution to overcome reluctance towards medical settings and fears of privacy-invading procedures. For women who might feel ashamed or anxious about screening, it is important to offer reassurance by clearly outlining privacy measures and informing them that they can always request a female healthcare practitioner to perform the test.\u003c/p\u003e\u003cp\u003eFuture public health initiatives should also prioritize providing translated materials, bilingual support, and easily navigable digital resources, given the identified language barriers and challenges in accessing information. Offering educational materials in the native languages of immigrant communities, such as Arabic for Syrian-Dutch women, could improve the accessibility and understanding of CC prevention programs. The RIVM is already taking steps to address this issue by providing culturally sensitive educational videos to support informed decision-making on CC screening among Turkish- and Moroccan-Dutch women and providing translated information online. However, such efforts could be expanded to reach other communities as well and make it more accessible (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Furthermore, there is a need for interventions to boost vaccine trust, because of the low awareness and safety concerns surrounding the HPV vaccination, particularly among recent immigrants. These interventions might involve eliminating misconceptions, showing the safety and effectiveness of vaccines, and reassuring people of their advantages by providing information gatherings. Including support in these information gatherings from trustworthy community members, like medical professionals, religious authorities, or other Syrian-Dutch mothers who have vaccinated their children may help eliminate myths and promote informed decision-making. Future research should focus on developing and evaluating tailored interventions for Syrian-Dutch women.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eAwareness, cultural norms, religious views, social environment, and emotional and practical factors all have a role in Syrian-Dutch women's decision-making processes about CC prevention programs. Within this study, we found several barriers for participation in CC prevention programs, such as a lack of knowledge about HPV, misconceptions about CC, fear of the procedure, and practical obstacles including language and procedural anxiety. Participation was facilitated by privacy of personal data, advantages of early detection, and trust in the government. Healthcare professionals could overcome these barriers by tailoring interventions to the cultural and emotional context, for example through healthcare practitioner training and information gatherings supported by trusted community members such as medical professionals, religious authorities, or Syrian-Dutch mothers who have vaccinated their children, as their involvement may help address myths. By implementing these recommendations, healthcare initiatives can support informed decision-making regarding CC prevention programs among Syrian-Dutch women.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCBS: Statistics Netherlands\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCC: cervical cancer\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCOREQ: Consolidated criteria for Reporting Qualitative research\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHPV: Human papillomavirus\u003c/p\u003e\n\u003cp\u003eHBM: Health Belief Model\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRAA: Reasoned Action Approach\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRIVM: National Institute for Public Health and the Environment\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. Ethical clearance was obtained from the Medical Ethics Review Committee (NedMec) of the University Medical Centre Utrecht (23-090/DB). The Committee confirmed that the Medical Research Involving Human Subjects Act (WMO) does not apply to this study.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eNo potential conflict of interest was reported by the authors.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by ZonMw under [grant number 2477411.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eTV and NH conceived and designed the study. NA conducted the interviews, and NA, TV, and NH analysed the interviews. NA wrote the first draft of the manuscript. All authors provided critical revisions on the interview guide and the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe would like to thank all participants for taking part in the interviews and for inviting others to participate as well. The authors would like to thank their own network, key community figures, and community centres that helped with the recruitment of Syrian-Dutch women. The authors are thankful to the Foundation Hammurabi for their support in the recruitment of Syrian-Dutch women.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNadien H.S. Al-Rubaie\u003csup\u003e1\u003c/sup\u003e, Tharsini Veeravagu\u003csup\u003e1,2\u003c/sup\u003e, Mart Stein\u003csup\u003e1\u003c/sup\u003e, Josina L.I. van Wijk\u003c/em\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003cem\u003e, Rik Crutzen \u003csup\u003e1,3\u003c/sup\u003e, Aura Timen\u003csup\u003e2\u003c/sup\u003e Nora Hamdiui\u003csup\u003e4,5\u0026nbsp;\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eCentre for Communicable Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eDepartment of\u0026nbsp;Primary and\u0026nbsp;Community Care, Radboud University Medical Center, Nijmegen, The\u0026nbsp;Netherlands\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eDepartment of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eDepartment of Public and Occupational Health, Amsterdam University Medical Center, location University of Amsterdam, Amsterdam, The Netherlands.\u003cbr\u003e\u0026nbsp;\u0026nbsp;\u003csup\u003e5\u003c/sup\u003eAmsterdam Public Health Research Institute, Health Behaviours and Chronic Diseases, Amsterdam, The Netherlands. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO WHO. 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Plos one. 2022;17(5):e0266139. https://doi.org/10.1371/journal.pone.0266139 \u003c/li\u003e\n\u003cli\u003eRIVM. Wat doet het RIVM? [23-05-2023]. Available from: https://www.rivm.nl/hitte/wat-doet-rivm.\u003c/li\u003e\n\u003cli\u003eVos IM, Schermer MH, Bolt IL. Recent insights into decision-making and their implications for informed consent. Journal of Medical Ethics. 2018;44(11):734\u0026ndash;8. https://doi.org/10.1136/medethics-2018-104884 \u003c/li\u003e\n\u003cli\u003eDamen R, Huijnk W. Syrische statushouders op weg in Nederland De ontwikkeling van hun positie en leefsituatie Sociaal en Cultureel Planbureau: Sociaal en Cultureel Planbureau; 2020 [12-08-2025]. Available from: https://digitaal.scp.nl/syrische-statushouders-op-weg-in-nederland/religie/. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cervical cancer screening, HPV vaccination, decision-making, barriers and facilitators, immigrant women, interviews","lastPublishedDoi":"10.21203/rs.3.rs-7934683/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7934683/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIn the Netherlands, a free of charge national cervical cancer (CC) screening program is available for women aged 30 to 60 years. Participation rates in the CC screening programme are lower among women with a migration background compared to the general population, as shown for the Turkish- and Moroccan-Dutch women. However, specific data on Syrian-Dutch women is lacking. It is unclear how Syrian-Dutch women make decisions regarding participating in CC screening and HPV vaccination in the Dutch context. This study aims to explore how and why Syrian-Dutch women decide to participate in the Dutch national CC screening program and whether to vaccinate their children against HPV.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eTwelve semi-structured interviews were held with Syrian-Dutch women aged 30\u0026ndash;60 or having a daughter between 9\u0026ndash;26 years, between March and July 2023. The interview guide was based on the Health Belief Model, the Reasoned Action Approach, and Betancourt's Model of Culture and Behaviour. The interviews were audio recorded, transcribed verbatim and thematically analysed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOverall, participants had a positive attitude towards CC screening and HPV vaccination. Participants indicated barriers for participation like a lack of knowledge about HPV, misconceptions about CC, safety concerns about the HPV vaccination, shame, fear, and practical obstacles including language and procedural anxiety. However, participation of CC screening and HPV-vaccination was facilitated by advantages of early detection, self-testing, protection of health, and trust in the government.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis study provides insights into the factors that influence the decision-making to participate in CC prevention programs among Syrian-Dutch women. These factors highlight the importance of addressing awareness and cultural and social factors to overcome the barriers Syrian-Dutch women experience. Future initiatives should develop accessible and culturally relevant tailored interventions that address these barriers to improve decision-making and participation in CC prevention programs.\u003c/p\u003e","manuscriptTitle":"Exploring factors influencing the decision-making regarding cervical cancer screening participation and HPV vaccination uptake among Syrian-Dutch women: a qualitative interview study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-20 16:01:19","doi":"10.21203/rs.3.rs-7934683/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-09T12:10:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-03T11:59:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-25T21:23:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338956119625390337153617467016661228833","date":"2025-11-17T08:29:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T18:35:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339819621963722132077338144161272109038","date":"2025-11-11T13:54:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233031816188974685607834278872173260160","date":"2025-11-11T02:51:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-10T15:33:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-27T04:06:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-26T23:13:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-26T23:12:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-10-23T18:24:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2836fa5b-7a1b-44fc-8896-e7dd53f96d92","owner":[],"postedDate":"November 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-20T09:24:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-20 16:01:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7934683","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7934683","identity":"rs-7934683","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}