Beyond knowledge: trust and the engagement of newly arrived refugee women in cervical cancer prevention

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Despite national efforts to reduce cervical cancer incidence, uptake remains disproportionately low among newly arrived refugee populations. This study explores the experiences, perceptions, and contextual factors shaping cervical cancer prevention behaviors among newly arrived refugee women in the United States. Methods: We conducted in-depth, semi-structured interviews with 17 refugee women within their first two years of resettlement in a Midwestern U.S. city. Participants were purposively sampled to ensure variation in age, country of origin, and screening history. Data were analyzed using Braun and Clarke’s thematic analysis, guided by the Socioecological Model. Trustworthiness was strengthened through intercoder agreement, member checking, and reflexive memoing. Results: Four themes emerged: trust as a gatekeeper, highlighting how healthcare-seeking depended on perceived safety and relational trust; communication as access, reflecting challenges with language, interpretation, and navigating fragmented care; concordance and comfort, emphasizing the role of gender, cultural, and religious alignment with providers; and structural disorientation, describing the confusion around where, when, and how to access preventive services. Despite low awareness of HPV vaccination, most participants expressed openness when information was provided by trusted messengers. Conclusion: Refugee women’s engagement with cervical cancer prevention is shaped not only by knowledge but also by cultural safety, provider concordance, and systemic trust. Interventions must prioritize community-rooted education, gender-concordant care, and culturally responsive communication to improve prevention outcomes. Introduction Each year, approximately 660,000 new cases of cervical cancer are diagnosed worldwide, with more than 350,000 deaths attributed to the disease [ 1 ]. Cervical cancer remains a significant global health challenge despite being largely preventable through early detection of human papillomavirus (HPV) - the primary cause of this type of cancer, vaccination to prevent HPV, or Pap tests to detect abnormal lesions in the cervix [ 2 ][ 3 ][ 4 ][ 5 ]. Cervical cancer can be prevented either through the uptake of the HPV vaccine and/or regular engagement in Pap tests [ 6 ]. The World Health Organization (WHO) has set a goal to eliminate cervical cancer as a public health concern, aiming for 90% of girls to be fully vaccinated with the HPV vaccine by age 15, 70% of women to be screened by age 35 and again by age 45, and 90% of women identified with cervical disease to receive treatment [ 7 ][ 8 ]. Despite these efforts, cervical cancer continues to pose a significant global challenge, particularly for women in low-income regions [ 9 ]. Most cervical cancer-related deaths occur in low- and middle-income countries (LMICs), where limited access to preventive healthcare exacerbates disparities in cervical cancer outcomes [ 10 ][ 11 ]. In high-income countries, advancements in screening technologies and vaccination have significantly reduced the incidence and mortality of cervical cancer [ 12 ][ 11 ]. However, within these countries, populations such as refugees, who face systemic barriers to healthcare, experience disproportionately high rates of cervical cancer and limited access to preventive services [ 13 ][ 14 ]. The United States is a leading resettlement country for refugees who arrive annually from regions such as Sub-Saharan Africa, the Middle East, and Southeast Asia [ 15 ]. Although initial resettlement processes provide some health screenings, refugee women often encounter significant barriers to accessing ongoing preventive care, including cervical cancer screening and HPV vaccination [ 13 ][ 16 ]. These barriers are multifaceted, including limited awareness, cultural stigma around reproductive health, mistrust of healthcare services, and systemic obstacles such as language barriers, transportation difficulties, and a lack of culturally responsive care [ 17 ][ 18 ][ 19 ][ 20 ][ 21 ]. While trust has been increasingly recognized as a determinant of engagement in cervical cancer prevention, available research remains limited and fragmented. Trust in healthcare can be understood as a patient’s belief that healthcare providers and systems will act in their best interest, prioritize their well-being, and deliver care competently, ethically, and respectfully [ 22 ]. In contrast, mistrust refers to a lack of confidence in healthcare providers or institutions, often stemming from prior experiences of discrimination, systemic failures, or perceived risks of harm [ 23 ]. Mistrust is not simply the absence of trust but reflects a rational and protective response to historical and structural inequities within healthcare systems [ 24 ] [ 25 ]. Trust is a critical determinant of cervical cancer screening uptake, particularly among marginalized populations [ 26 ]. Recent evidence shows that trust in healthcare providers, defined through perceptions of competence, respectful communication, and cultural understanding, significantly influences women’s willingness to engage in Pap testing and HPV vaccination [ 23 ][ 27 ][ 28 ]. Among immigrant and refugee women, mistrust is often fueled by experiences of discrimination, language barriers, and confusion about healthcare navigation, leading to lower participation in preventive services [ 29 ][ 30 ][ 31 ]. Building trust requires culturally safe, consistent, and community-based interactions, rather than isolated informational campaigns [ 32 ]. Addressing these relational and structural barriers is essential to advancing equitable cervical cancer prevention strategies. While quantitative studies have established associations between trust and screening behaviors [ 33 ], few qualitative investigations have explored how trust is relationally built or eroded across individual, interpersonal, community, and systemic levels, especially in the context of cervical cancer prevention. To our knowledge, this is the first study to qualitatively assess trust as a critical lens to understand cervical cancer preventive behaviors among a sample of newly arrived refugee women in the US. Drawing on in-depth interviews with refugee women resettled within the past two years, this study explores how trust, mistrust, and relational dynamics with healthcare systems shape engagement with Pap testing and HPV vaccination. Guided by the socioecological model (SEM) and the cultural safety framework (CSF), we examine trust-building at multiple levels, including individual, interpersonal, community, and systemic levels. In doing so, we offer new insights into the mechanisms through which trust fosters or impedes preventive care engagement, highlighting the importance of culturally concordant providers, linguistically appropriate communication, and community-rooted outreach strategies. By reframing cervical cancer prevention as fundamentally relational rather than solely informational, this study provides a deeper understanding of how to promote health equity among newly arrived refugee populations. Methods Methods Theoretical framework This study is guided by the Socioecological Model (SEM) and the Cultural Safety Framework (CSF). The SEM highlights the multi-level influences on cervical cancer prevention behaviors, spanning individual (e.g., knowledge, health literacy), interpersonal (e.g., family support, cultural norms), community (e.g., stigma, religious expectations), organizational (e.g., provider concordance, navigation challenges), and policy levels (e.g., immigration status, insurance access) [ 34 ][ 35 ][ 36 ][ 37 ]. Complementing the SEM, the Cultural Safety Framework (CSF) addresses power imbalances, systemic inequities, and the historical contexts that influence healthcare experiences. CSF emphasizes that culturally safe care is defined by the experiences of those receiving care, not the intentions of providers [ 38 ]. Together, the SEM and CSF informed the development of the interview guide, ensuring attention to multi-level determinants and the need for culturally safe, equity-driven approaches to cervical cancer prevention. Study design and methodology This study utilized a qualitative research design to explore community-rooted insights on cervical cancer prevention, including pap smear uptake and HPV vaccination acceptance, among newly arrived refugee populations. Semi-structured interviews that lasted 45 minutes to one hour were used to elicit narratives about study participants’ experiences, attitudes, and perceptions on Pap smear tests and HPV vaccination. This design was chosen to capture the complexity of lived experiences within a sociocultural context [ 39 ], aligning with the study’s goal to identify actionable insights for public health interventions. Study setting and participants: The study was conducted in partnership with a community-based organization (CBO) serving diverse and newly arrived refugee populations in Louisville, Kentucky. Study participants were recruited through convenience sampling, relying on the availability of individuals at the partnering CBO. As a result, the demographic composition of our sample was informed by participants at the CBO who were available and willing to participate at the time of recruitment. Eligibility criteria included being a refugee woman, newly arrived within the past two years, and between the ages of 21–65 years. A total of 17 participants were recruited, including women eligible for cervical cancer screening and caregivers of adolescents eligible for HPV vaccination. All individuals who were approached agreed to participate in the study, and there were no participant dropouts. This sample size allowed for the attainment of both code and meaning saturation [ 40 ]. Table 1 presents the socio-demographic breakdown of study participants. Table 1 Socio-demographic characteristics of participants (n = 17) Variables N (%) Age (years) * Age range Average age SD 21–56 years 34.2 years 10.9 years Country of origin Afghanistan 3 (20.0%) Congo 5 (26.7%) Rwanda 6 (40.0%) Brazil 1 (6.7%) Nepal 2 (6.7%) Insurance status Insured 17 (100%) Uninsured 0 Pap smear prior to migration 1 (5.9%) Educational attainment < High school 13 (76.5%) High school or equivalent 2 (11.8%) College degree or higher 1 (5.9%) *except for age, all data provides numbers (and percent) Data collection: Data were collected through semi-structured interviews conducted between January to May 2022. Interviews were designed to elicit narratives about participants’ healthcare experiences with Pap test uptake and HPV vaccination, focusing on knowledge, attitudes, practices, and systemic challenges. Open-ended questions encouraged participants to share their experiences with accessing cervical cancer screening and HPV vaccinations, participants’ perceptions of healthcare providers and health systems, cultural and religious influences on health decision-making, and study participants’ suggestions for improving service delivery. Interviews were conducted in participants' preferred language with the assistance of professional interpreter services provided by the partnering CBO, when necessary. Each interview lasted approximately 60 minutes, was conducted in person, and was audio-recorded with participants' consent. All interviews were conducted by the first author, who is trained in qualitative research methodologies, including semi-structured interviewing and thematic analysis. No external interviewers were hired. To ensure consistency in data collection, a structured interview guide was used, and the first author employed standardized qualitative interviewing techniques. All participants received a $ 25 gift card as compensation for their time. To minimize social desirability bias, participants were assured of confidentiality and anonymity before data collection began. Moreover, interviews were conducted in private settings in order to promote authentic participant responses. Data analysis : Thematic content analysis of study findings followed Braun and Clarke’s six-step framework [ 41 ]. Thematic analysis was conducted using an iterative approach, supported by Dedoose version 9.0.17, to systematically organize and code the data. Two researchers independently coded an initial subset of transcripts to develop a preliminary codebook, which was refined through discussion. To ensure reliability, intercoder agreement was assessed through double-coding, with discrepancies resolved through consensus meetings. An adequate level of inter-coder reliability was attained, with Cohen’s kappa calculated at 0.85 and bias-adjusted kappa reaching 0.95 across five training transcripts, using Dedoose. The finalized codes were then grouped into themes, which were reviewed and refined collaboratively to ensure they accurately represented the data and aligned with the study's objectives. Member checking was conducted by sharing preliminary themes with four study participants to ensure the accuracy and credibility of study findings. Ethical considerations Ethical approval for this study was obtained from the University of Louisville Institutional Review Board (IRB). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and the Belmont Report. The researchers implemented measures to ensure the confidentiality and anonymity of all participants. All research team members were trained in ethical considerations, including cultural sensitivity and confidentiality. To accommodate participants with limited literacy, professional translators provided verbal explanations of the study’s purpose, procedures, risks, and benefits in the participants’ preferred language. Verbal informed consent was obtained from all participants, ensuring their understanding before participation. Participants were encouraged to ask questions, and clarifications were provided as needed to confirm comprehension. Results As shown in Table 1 , participants ranged in age from 21 to 56 years, with an average age of 38.24 years (SD = 10.92). The majority of participants were from Rwanda (40.0%), followed by Congo (26.7%), Afghanistan (20.0%), Nepal (6.7%), and Brazil (6.7%). All participants (100%) were insured at the time of the study. However, only one participant (5.9%) reported having received a Pap smear prior to migration. Regarding educational attainment, most participants had less than a high school education (76.5%), while 11.8% had completed high school or an equivalent level of education, and 5.9% had obtained a college degree or higher. Trust emerged as a foundational factor influencing newly arrived refugee women's engagement with cervical cancer prevention. Findings from this study indicated that women’s feelings of trust in their personal experiences with providers and the larger healthcare system played a key role in whether they chose to engage in cervical cancer preventive measures (i.e., cervical cancer screening and HPV vaccination). This dynamic was reflected across four interrelated themes that emerged from participants’ experiences, highlighting the ways trust influenced decisions about cervical cancer screening and HPV vaccination for their children. Four interrelated themes illustrate this dynamic: (1) trust as a precondition for engagement, (2) trust in providers built through concordance, respect, and listening, (3) systemic mistrust shaped by experiences of confusion, vulnerability, and financial fear, and (4) pathways to rebuilding through community-based support systems. These themes offer insight into how trust shaped women’s decisions around cervical cancer screening and HPV vaccination for their children. Trust as a precondition for engagement Trust was consistently described as a necessary precondition for engaging with cervical cancer screening and HPV vaccination. Without trust in the safety of medical procedures, the good intentions of healthcare providers, and the trustworthiness of the healthcare system, many participants avoided preventive services. Women’s narratives revealed that mistrust often served as a protective factor against experiences of vulnerability, harm, and uncertainty. One participant reflected on how cultural associations between cancer and death shaped her avoidance of screening: “ In my country, when someone says ‘cancer’, it means you are going to die. There is no cure. The hospitals are not good, and people don’t survive. So, I don’t see the point of getting tested. If I have it, I have it. It’s better not to know. ” (Interview 12). Others described profound unease with medical procedures that felt invasive and unsafe: “ I don’t trust [doctors] putting tools inside my body. What if they touch something wrong and make me sick when I was fine before? I have heard stories that doctors here like to do unnecessary tests for money. ” (Interview 5). In some cases, the sense of risk extended beyond the procedures themselves to fears about being misunderstood, silenced, or treated with indifference: “Sometimes I feel like they don’t listen to what I am saying. They just decide what they want to do. It makes me afraid to ask too many questions.” (Interview 14). However, not all participants expressed complete distrust. Some, especially those with higher English proficiency or previous experiences with preventive care, described cautious willingness to engage: “ I was scared at first, but the nurse explained everything to me step by step. I trusted her because she took her time, and that made me feel better. ” (Interview 2) Another explained: “ If they explained it slowly, and they asked me if I was comfortable before doing anything, that might help me feel okay to continue. ” (Interview 9) These narratives demonstrate that trust is neither static nor binary; it could be conditional, shaped by communication, prior experience, and perceived safety. If healthcare providers demonstrate relational respect through clear communication, consent-seeking, and patience, then participants would be more open to considering cervical cancer prevention services. Building trust was a necessary precursor to women’s engagement with preventive care. Trust in providers built through concordance, respect, and listening Participants described trust in providers as relationally constructed, influenced by perceived cultural understanding, racial and gender concordance, and interpersonal respect. Women reported that they felt more comfortable and trusting when their doctors looked like them and understood their culture. As one participant emphasized: “ If a doctor looks like me and understands my culture, I will trust them more. I will believe what they say. It feels like they know my ways and won’t judge me. ” (Interview 5). The gender of providers also shaped perceived interpersonal safety. Some women reported discomfort when seen by male providers for reproductive services, emphasizing the cultural importance of gender concordance: “ I prefer female doctors because it feels more comfortable for me. I can talk more openly with a woman, but with a man, I keep things inside. ” (Interview 1). Active listening contributed meaningfully to building trust. One participant described feeling truly heard: “ My doctor looked at me, listened, and did not interrupt. That made me feel like my voice mattered. If doctors listen to me like that, I would not be afraid to ask questions or follow their advice. ”(Interview 9). Another woman reflected on an experience with a provider: “ One time I went to the doctor here and they kept asking me if I was OK and comfortable. They always ask me if I understood what was going on and if I had questions. That made me feel more willing to follow their advice. ” (Interview 7) These experiences demonstrate that for many refugee women, trust was not simply about information delivery but about relational dynamics that fostered culturally safe care. However, when providers relied on assumptions or stereotypes, trust was undermined. As such, participants expressed frustration when they felt unseen or dismissed: “ I feel like when they see me, they already have an idea in their head. They don't listen carefully because they think I don’t understand anything. ” (Interview 11) While some women described building positive relationships with providers across cultural differences, many emphasized the importance of provider responsiveness in building trust. Even when women had positive experiences with individual providers, broader systemic challenges, such as confusing processes, financial concerns, and communication barriers, continued to weaken their overall trust in healthcare. Systemic mistrust shaped by experiences of confusion, vulnerability, and financial fear Beyond individual relationships, participants described profound systemic mistrust shaped by experiences of confusion, inaccessibility, and unexpected financial burdens. Many women said the healthcare system in the U.S. felt confusing and hard to trust. Navigating healthcare services felt overwhelming for many: “ I don’t know where to go or how to start. It’s all very confusing for me here. There are too many steps, too many papers to fill out, and the hospital, when I went there, was really big and easy to just miss your way. Even making an appointment feels complicated sometimes. I also do not understand the insurance part, what they cover, and what they do not cover. Nobody explains it in an easy way. Even if they don’t explain it, it should be simple to understand.” (Interview 8). Language barriers compounded these feelings, despite the availability of interpreters. As one participant shared: “ Even with an interpreter, sometimes I don’t understand the medical words. I just say yes because I am too shy to ask again.” (Interview 14). Another participant described their experiences with an interpreter: “ Sometimes, it sounds like even the interpreter does not understand what the doctor is saying. When I first got here, I went to the hospital and got an interpreter… I remember that I kept asking for clarification on what the doctor said, and they kept asking the doctor over again. I’m not sure if it was the doctor or the interpreter, but I know I was so confused throughout”. (Interview 2). Financial uncertainty was a major source of mistrust. The fear of hidden costs led some women to avoid care entirely: “One time I went to see the doctor and they said it was free because of my insurance, but later I got a bill. Now, I am scared to go back. I don't want surprises that I cannot pay for.” (Interview 4). Another participant emphasized the cost of care as a cause for concern: “I always ask how much before doing anything, but they say, ‘insurance will cover.’ Later, a bill still comes. This happened to me when I went to the doctor for something small. I was a little bit angry, honestly.” (Interview 12) One of the women described transportation barriers as a structural obstacle: “ I rely on my husband for driving. If he is busy, I miss my appointments.” (Interview 6). Importantly, not all participants mistrusted the system equally. For some women, having social support provided reassurance: “ My [caseworker] explained everything about insurance and clinics here, so at least I can ask her if I have any questions about anything”. (Interview 10). Overall, participants’ experiences suggest that trust was shaped not only by provider behavior but also by the broader structures and systems that influenced access to care. Pathways to rebuilding trust through community-based support systems Participants identified community-based strategies as important pathways for rebuilding trust. While professional interpreters helped bridge some language barriers, trust was more often fostered through familiar, community-rooted relationships. Peer educators and trusted community figures were seen as trusted sources of information: “ If a woman from our own community, someone we know and trust, explains it to us, then more people will believe it and take it seriously. We listen to our own more than outsiders .” (Interview 6). Participants acknowledged that embedding health education into trusted spaces, like centers where ESL classes are held, would make prevention services feel more accessible: “ We already come here for English classes, like today. If they talk about health after our class, or even before, I think we will feel comfortable listening and asking questions. ” (Interview 7). Participants also reflected on past experiences with community-based outreaches in their countries of origin, suggesting that bringing healthcare into community settings could strengthen trust: “ Back home, we used to have healthcare workers come into the camps to talk to us about one thing or the other, like vaccines, health checks, those kinds of things. If we can do something like that here, it would be nice. It would make it easier because people already feel comfortable here ” (Interview 16). Participants also emphasized that building trust required relational proximity, cultural humility, and sustained engagement, not just information delivery. As one participant put it: “ Trust grows when you see the same faces, when people care about you, not just for one day, but over time. ” (Interview 13). Community trust also played an important role in shaping women’s willingness to engage with healthcare providers. As another participant explained: “Yes, if my friend tells me that this doctor is good, and another friend tells me the same thing, I would want to try them out. I can trust them because they have worked with my friends and my friends trust them. So it’s a community thing.” (Interview 5) Overall, participants’ narratives highlighted that rebuilding trust requires creating consistent, culturally informed, and community-centered approaches to care. Trust was not built through information alone but through sustained relationships, shared experiences, and the validation of trusted community networks. Discussion This study examined the role of trust as a determinant of engagement with cervical cancer prevention services amongst newly arrived refugee women. The findings show that trust operates along a continuum that is shaped by multilayered contextual influences. Guided by the SEM, our results demonstrate that cervical cancer prevention behaviors are affected by factors operating at the individual, interpersonal, community, organizational, and policy levels. Simultaneously, the CSF provided a lens to interpret how trust is built or eroded based on women’s experiences of power, respect, and cultural understanding within the healthcare system. Trust, or its absence, informed women’s decisions to engage in cervical cancer prevention services, with mistrust serving as a protective response against perceived lack of trustworthiness of providers and the healthcare system. Guided by the SEM, these findings reflect how individual, interpersonal, organizational, and policy-level factors interact to shape refugee women's engagement with preventive services. The CSF further contextualizes participants' mistrust as rooted in experiences where care environments failed to feel safe, empowering, or culturally respectful. Consistent with available evidence, and in alignment with the SEM's emphasis on individual-level and interpersonal influences, participants described trust as essential for navigating preventive services [ 42 ][ 43 ]. Mistrust was often rooted in cultural understandings of cancer as a fatal diagnosis, fears of invasive medical procedures, and skepticism about the financial motivations of healthcare systems. The CSF helps interpret these concerns as reflections of deeper systemic inequities and historical marginalization in healthcare contexts. Beyond individual interactions, trust was relationally constructed through perceived cultural, racial, and gender concordance, as well as through respect and attentive communication. Participants expressed greater comfort and willingness to engage when providers demonstrated cultural sensitivity, shared similar backgrounds, or adopted patient-centered communication strategies. Recent studies emphasize that cultural humility and shared decision-making practices are critical for building trust among marginalized populations [ 44 ][ 45 ][ 46 ]. In contrast, assumptions, stereotypes, and inattentive listening undermined trust, reinforcing existing barriers to care, as seen in other studies where marginalized groups disengaged when providers failed to offer individualized care [ 47 ][ 48 ]. These interpersonal dynamics mirror the SEM’s interpersonal layer and emphasize the CSF's principle that culturally safe care is determined by the patient's experience of being respected and empowered. Systemic mistrust also emerged as a significant barrier to engagement. Participants highlighted structural challenges, including the complexity of healthcare navigation, confusion about insurance, language barriers, and fears of hidden medical costs. These systemic concerns align with broader evidence showing that structural barriers, rather than individual factors alone, drive disparities in preventive healthcare uptake among refugee and immigrant populations [ 49 ][ 50 ][ 51 ]. Even when individual providers were trustworthy, system-related issues continued to erode overall confidence in the healthcare system. This systemic mistrust reflects both the organizational and policy-level barriers described in the SEM and highlights, through the CSF lens, how healthcare systems that are difficult to navigate or lack financial transparency may contribute to cultural unsafety for marginalized populations. Importantly, participants identified community-based pathways as essential for rebuilding trust. Peer educators, trusted community figures, and familiar spaces like English as a Second Language (ESL) centers were considered safe entry points for preventive health education and services. These findings align with recent calls for community-engaged approaches to health promotion that prioritize relational trust and cultural embeddedness over transactional interventions [ 52 ][ 53 ][ 54 ]. Trust was cultivated not through isolated informational campaigns but through ongoing relational proximity, cultural humility, and repeated, caring interactions. These findings underscore the SEM’s recognition of community-level influences and align with the CSF’s call for culturally rooted, community-led approaches to health promotion. Collectively, these findings suggest that rebuilding trust among refugee women requires multilevel interventions, with consideration for cultural safety principles during care delivery. At the provider level, sustained investments in culturally informed care, patient-centered communication, and relational continuity are essential. At the systemic level, healthcare institutions must simplify navigation processes, ensure financial transparency, and embed preventive care initiatives within trusted community infrastructures. Future interventions that integrate these relational and systemic dimensions are more likely to succeed in increasing cervical cancer screening and HPV vaccination rates among newly resettled refugee populations. Study limitations This study has several limitations that should be considered when interpreting the findings. First, the focus on one geographic location may not account for regional variations in healthcare access and cultural dynamics across different refugee communities. Second, reliance on self-reported data introduces the potential for recall bias or social desirability bias, where participants may provide responses they perceive as socially acceptable rather than entirely accurate, despite efforts to mitigate this through assurance of confidentiality and ensuring neutrality in interviewing. Additionally, self-selection bias may have influenced the sample, as individuals who participated may have had stronger opinions about healthcare access or more direct experiences with preventive care than those who declined participation. Interviewer influence is another potential limitation, as all interviews were conducted by the first author, whose presence and interviewing style, despite adherence to standardized protocols, could have shaped participant responses. Lastly, the study’s cross-sectional design captures a snapshot of experiences and perceptions at a single point in time, limiting its ability to explore changes in attitudes or behaviors over time. Future research should consider longitudinal approaches, diverse geographic sampling, and multiple interviewers to address these limitations and provide a more comprehensive understanding of the barriers and facilitators to cervical cancer prevention among newly arrived refugee populations. Implications for practice, policy, and research Findings from this study suggest the importance of integrated, community-based health education programs that address the unique cultural and structural barriers faced by refugee populations. While this study provides valuable insights, the qualitative nature and sample size limit the generalizability of the findings. However, participants' experiences highlight the potential benefits of culturally responsive care models that incorporate patient education, interpreter services, and trauma-informed approaches to mitigate medical mistrust. Additionally, expanding multilingual patient navigator programs and embedding healthcare resources within refugee-serving organizations may help bridge gaps in preventive care access. To support equitable cervical cancer prevention services, policymakers should consider systemic reforms that prioritize refugee communities' needs. Potential strategies include expanding interpreter services, developing community-based patient navigation programs, and implementing mobile screening units to address transportation barriers. Furthermore, while increasing the recruitment and retention of racially and culturally concordant healthcare providers could foster trust and engagement, further research is needed to evaluate its long-term impact. Strengthening collaborations between government agencies, healthcare institutions, and community organizations remains an essential step in advancing health equity. Future research should explore these approaches in larger and more diverse samples to build on the insights from this study. Conclusion This study highlights trust as a critical determinant of engagement with cervical cancer prevention services among newly arrived refugee women. Information delivery alone is insufficient, as trust should be built through cultural and systemic responsiveness. Women’s experiences revealed that trust must be cultivated across multiple levels, through culturally respectful provider interactions, clear communication, accessible systems, and community-rooted support. Efforts to improve cervical cancer prevention uptake must therefore prioritize relational trust-building alongside structural reforms that address systemic barriers. By centering trust as both a relational and structural imperative, healthcare systems can move toward more equitable, culturally safe, and effective models of care for refugee populations. Declarations Conflicts of Interest: The authors have no conflict of interest to declare. Funding Statement: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The study was conducted without external financial support. Data Availability Statement: The data supporting this study's findings are not publicly available due to ethical and privacy considerations. Participants were assured that their responses would remain confidential and would not be shared beyond the research team. De-identified excerpts relevant to the study's conclusions are available upon reasonable request, subject to approval from the institutional review board. Author’s Contribution Statement : XX conceptualized the study, led data collection and analysis, and was primarily responsible for writing the results section and overseeing the entire research process. XX. provided critical support throughout the research process, including contributing to the analysis and assisting in writing the results section. XX. contributed to writing and refining various sections of the manuscript. XX. provided additional writing support and assisted with manuscript revisions. All authors reviewed and approved the final version of the manuscript. References World Health Organization (WHO). Cervical cancer. Accessed: Mar. 05, 2025. [Online]. Available: https://www.who.int/news-room/fact-sheets/detail/cervical-cancer#:~:text=Globally%2C%20cervical%20cancer%20is%20the,%2D%20and%20middle%2Dincome%20countries Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries, CA Cancer J Clin , vol. 68, no. 6, pp. 394–424, Nov. 2018, 10.3322/caac.21492 World Health Organization. World Health Assembly adopts a global strategy to accelerate cervical cancer elimination. Accessed: Jan. 08, 2025. [Online]. Available: https://www.who.int/news/item/19-08-2020-world-health-assembly-adopts-global-strategy-to-accelerate-cervical-cancer-elimination American Cancer Society (ACS). Screening tests for cervical cancer., 2023. Accessed: Jan. 08, 2025. [Online]. Available: https://www.cancer.org/cancer/types/cervical-cancer/detection-diagnosis-staging/screening-tests.html Centers for Disease Control and Prevention. Cervical cancer, 2023a. Accessed: Jan. 08, 2025. [Online]. Available: https://www.cdc.gov/cervical-cancer/index.html Centers for Disease Control and Prevention. Screening for cervical cancer. Accessed: Jan. 08, 2025. [Online]. Available: https://www.cdc.gov/cervical-cancer/screening/index.html World Health Organization.. WHO updates recommendations on HPV vaccination schedule. Accessed: Jan. 08, 2025. [Online]. Available: https://www.who.int/news/item/20-12-2022-WHO-updates-recommendations-on-HPV-vaccination-schedule World Health Organization. Global strategy to accelerate the elimination of cervical cancer as a public health problem. Accessed: Jan. 08, 2025. [Online]. Available: https://www.who.int/publications/i/item/9789240014107 Canfell K, et al. Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries. Lancet. Feb. 2020;395:591–603. 10.1016/S0140-6736(20)30157-4 . Sung H, Global Cancer Statistics. 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries, CA Cancer J Clin , vol. 71, no. 3, pp. 209–249, May 2021. 10.3322/caac.21660 Arbyn M, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Glob Health. Feb. 2020;8(2):e191–203. 10.1016/S2214-109X(19)30482-6 . Vaccarella S, Lortet-Tieulent J, Plummer M, Franceschi S, Bray F. Worldwide trends in cervical cancer incidence: Impact of screening against changes in disease risk factors, Eur J Cancer , vol. 49, no. 15, pp. 3262–3273, Oct. 2013, 10.1016/j.ejca.2013.04.024 Morris MD, Popper ST, Rodwell TC, Brodine SK, Brouwer KC. Healthcare Barriers of Refugees Post-resettlement, J Community Health , vol. 34, no. 6, pp. 529–538, Dec. 2009, 10.1007/s10900-009-9175-3 Rosato I, Dalla Zuanna T, Tricarico V, Barbiellini Amidei C, Canova C. Adherence to Cervical Cancer Screening Programs in Migrant Populations: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. Jan. 2023;20(3):2200. 10.3390/ijerph20032200 . United Nations High Commissioner for Refugees (UNHCR). Global trends: Forced displacement in 2022., Accessed: Jan. 08, 2025. [Online]. Available: https://www.unhcr.org Walker PF, Settgast AM, DeSilva MB. Cancer Screening in Refugees and Immigrants: A Global Perspective, Am J Trop Med Hyg , vol. 106, no. 6, pp. 1593–1600, Jun. 2022, 10.4269/ajtmh.21-0692 Afsah YR, Kaneko N. Barriers to cervical cancer screening faced by immigrant Muslim women: a systematic scoping review. BMC Public Health. Nov. 2023;23(1):2375. 10.1186/s12889-023-17309-9 . Ozturk NY, Hossain SZ, Mackey M, Adam S, Brennan P. HPV and Cervical Cancer Awareness and Screening Practices among Migrant Women: A Narrative Review. Healthcare. Mar. 2024;12(7):709. 10.3390/healthcare12070709 . Sawadogo PM et al. Sep., Barriers and facilitators of access to sexual and reproductive health services among migrant, internally displaced, asylum seeking and refugee women: A scoping review, PLoS One , vol. 18, no. 9, p. e0291486, 2023, 10.1371/journal.pone.0291486 Vu M, et al. System-level factors influencing refugee women’s access and utilization of sexual and reproductive health services: A qualitative study of providers’ perspectives. Front Glob Womens Health. Dec. 2022;3. 10.3389/fgwh.2022.1048700 . Farajimakin O. Barriers to Cervical Cancer Screening: A Systematic Review. Cureus Jul. 2024. 10.7759/cureus.65555 . Birkhäuer J et al. Feb., Trust in the health care professional and health outcome: A meta-analysis, PLoS One , vol. 12, no. 2, p. e0170988, 2017, 10.1371/journal.pone.0170988 Benkert R, Cuevas A, Thompson HS, Dove-Meadows E, Knuckles D. Ubiquitous Yet Unclear: A Systematic Review of Medical Mistrust, 2019. 10.1080/08964289.2019.1588220 Jaiswal J. Whose Responsibility Is It to Dismantle Medical Mistrust? Future Directions for Researchers and Health Care Providers. Behav Med. 2019;45(2). 10.1080/08964289.2019.1630357 . Jaiswal J, Halkitis PN. Towards a More Inclusive and Dynamic Understanding of Medical Mistrust Informed by Science, 2019. 10.1080/08964289.2019.1619511 O’Donovan B, et al. Trust and cancer screening: Effects of a screening controversy on women’s perceptions of cervical cancer screening. Prev Med Rep. 2022;25. 10.1016/j.pmedr.2021.101684 . Toluwani Elizabeth A, Maysa A, Rima A. A Qualitative Study to Understand Cervical Cancer Awareness and Prevention among African Immigrant Women (AIW) in Iowa City, Iowa. Int J Womens Health Wellness. 2021;7(1). 10.23937/2474-1353/1510117 . Dean A, et al. HPV-Related Knowledge and Impact of Patient–Provider Communication on HPV-Associated Cervical Cancer Awareness and Pap Smear Completion in US Women Aged 21–65 Years. Cancers (Basel). Mar. 2025;17(7):1188. 10.3390/cancers17071188 . Lurgain JG, et al. Exploring self-care and cervical cancer prevention attitudes and practices among Moroccan and Pakistani immigrant women in Catalonia, Spain: a comparative qualitative study. BMC Public Health. 2024;24(1). 10.1186/s12889-023-17445-2 . Seo JY, Li J, Li K. Cervical Cancer Screening Experiences Among Chinese American Immigrant Women in the United States. J Obstetric Gynecologic Neonatal Nurs. Jan. 2018;47(1):52–63. 10.1016/j.jogn.2017.10.003 . Lee HY, Lee MH. Barriers to Cervical Cancer Screening and Prevention in Young Korean Immigrant Women: Implications for Intervention Development. J Transcult Nurs. 2017;28(4). 10.1177/1043659616649670 . Lansing AE, et al. Building trust: Leadership reflections on community empowerment and engagement in a large urban initiative. BMC Public Health. 2023;23(1). 10.1186/s12889-023-15860-z . Shelton RC, Brotzman LE, Johnson D, Erwin D. Trust and mistrust in shaping adaptation and de-implementation in the context of changing screening guidelines. Ethn Dis. 2021;31(1). 10.18865/ED.31.1.119 . Bronfenbrenner U. Toward an experimental ecology of human development. Am Psychol. 1977;32(7). 10.1037/0003-066x.32.7.513 . Bronfenbrenner U. Ecology of the Family as a Context for Human Development. Research Perspectives. Dev Psychol. 1986;22(6). 10.1037/0012-1649.22.6.723 . Mcleroy KR, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Health Educ Behav. 1988;15(4). 10.1177/109019818801500401 . Golden SD, Earp JAL. Social Ecological Approaches to Individuals and Their Contexts: Twenty Years of Health Education & Behavior Health Promotion Interventions. Health Educ Behav. 2012;39(3). 10.1177/1090198111418634 . Curtis E, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health. Dec. 2019;18(1):174. 10.1186/s12939-019-1082-3 . Knott E, Rao AH, Summers K, Teeger C. Interviews in the social sciences. Nat Reviews Methods Primers. Sep. 2022;2(1):73. 10.1038/s43586-022-00150-6 . Vasileiou K, Barnett J, Thorpe S, Young T. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. Dec. 2018;18(1):148. 10.1186/s12874-018-0594-7 . Braun V, Clarke V. Using thematic analysis in psychology, Qual Res Psychol , vol. 3, no. 2, pp. 77–101, Jan. 2006, 10.1191/1478088706qp063oa Correia T. Trust Building in Public Health Approaches: The Importance of a ‘People-Centered’ Concept in Crisis Response. Risk Manag Healthc Policy. Aug. 2024;17:1903–8. 10.2147/RMHP.S471250 . Lansing AE, et al. Building trust: Leadership reflections on community empowerment and engagement in a large urban initiative. BMC Public Health. Jun. 2023;23(1):1252. 10.1186/s12889-023-15860-z . Theodosopoulos L, Fradelos EC, Panagiotou A, Dreliozi A, Tzavella F. Delivering Culturally Competent Care to Migrants by Healthcare Personnel: A Crucial Aspect of Delivering Culturally Sensitive Care. Soc Sci. Oct. 2024;13(10):530. 10.3390/socsci13100530 . Paige SR, Alber JM, Stellefson ML, Krieger JL. Missing the mark for patient engagement: mHealth literacy strategies and behavior change processes in smoking cessation apps. Patient Educ Couns. May 2018;101(5):951–5. 10.1016/j.pec.2017.11.006 . Ngondwe P, Tefera GM. Barriers and Facilitators of Access to Healthcare Among Immigrants with Disabilities: A Qualitative Meta-Synthesis, Healthcare , vol. 13, no. 3, p. 313, Feb. 2025, 10.3390/healthcare13030313 Riza E et al. Apr., Community-Based Healthcare for Migrants and Refugees: A Scoping Literature Review of Best Practices, Healthcare , vol. 8, no. 2, p. 115, 2020, 10.3390/healthcare8020115 Zaidi M, Fantasia HC, Penders R, Koren A, Enah C. Increasing U.S. Maternal Health Equity Among Immigrant Populations Through Community Engagement, Nurs Womens Health , vol. 28, no. 1, pp. 11–22, Feb. 2024, 10.1016/j.nwh.2023.09.004 Korn AR et al. Sep., Social determinants of health and US cancer screening interventions: A systematic review, CA Cancer J Clin , vol. 73, no. 5, pp. 461–479, 2023, 10.3322/caac.21801 Dadson YA, Bennett-Gayle DM, Ramenzoni V, Gilmore EA. Experiences of Immigrants During Disasters in the US: A Systematic Literature Review. J Immigr Minor Health. Feb. 2025;27(1):134–48. 10.1007/s10903-024-01649-8 . Hossain MA, Khanam SJ, Khan MN, Oldroyd J, Islam RM. Barriers to cervical cancer screening among refugee women: A systematic review. PLOS Global Public Health. Mar. 2025;5(3):e0004225. 10.1371/journal.pgph.0004225 . Redvers N et al. Jun., Relational community engagement within health interventions at varied outcome scales, PLOS Global Public Health , vol. 4, no. 6, p. e0003193, 2024, 10.1371/journal.pgph.0003193 Birgel V, Decker L, Röding D, Walter U. Community capacity for prevention and health promotion: a scoping review on underlying domains and assessment methods. Syst Rev. Aug. 2023;12(1):147. 10.1186/s13643-023-02314-1 . Holden K et al. Dec., Community Engaged Leadership to Advance Health Equity and Build Healthier Communities, Soc Sci , vol. 5, no. 1, p. 2, 2015, 10.3390/socsci5010002 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6558601","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":452261639,"identity":"cc8dfb6a-0c23-456d-837a-dacf44ce0e7a","order_by":0,"name":"Toluwani Adekunle","email":"data:image/png;base64,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","orcid":"","institution":"Calvin University","correspondingAuthor":true,"prefix":"","firstName":"Toluwani","middleName":"","lastName":"Adekunle","suffix":""},{"id":452261640,"identity":"a6ffacfb-240d-4a3f-aac6-6a68137970e8","order_by":1,"name":"Tiwaladeoluwa Adekunle","email":"","orcid":"","institution":"Northwestern University","correspondingAuthor":false,"prefix":"","firstName":"Tiwaladeoluwa","middleName":"","lastName":"Adekunle","suffix":""},{"id":452261643,"identity":"8c675090-5d3c-4d90-923d-f3ae81505886","order_by":2,"name":"Esther Afolabi","email":"","orcid":"","institution":"Calvin University","correspondingAuthor":false,"prefix":"","firstName":"Esther","middleName":"","lastName":"Afolabi","suffix":""},{"id":452261644,"identity":"9090c79f-4da1-4da6-a7f8-f1b85dca372d","order_by":3,"name":"Ayooluwatomiwa Adekunle","email":"","orcid":"","institution":"Washington University in St. Louis","correspondingAuthor":false,"prefix":"","firstName":"Ayooluwatomiwa","middleName":"","lastName":"Adekunle","suffix":""}],"badges":[],"createdAt":"2025-04-29 17:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6558601/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6558601/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10903-025-01756-0","type":"published","date":"2025-08-13T15:57:25+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89310540,"identity":"835b4330-a7fd-4575-a186-dadc9ff4c18f","added_by":"auto","created_at":"2025-08-18 16:07:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":669132,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6558601/v1/b6796e0f-a399-4a34-a595-2165ae9a0ba6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond knowledge: trust and the engagement of newly arrived refugee women in cervical cancer prevention","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEach year, approximately 660,000 new cases of cervical cancer are diagnosed worldwide, with more than 350,000 deaths attributed to the disease [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Cervical cancer remains a significant global health challenge despite being largely preventable through early detection of human papillomavirus (HPV) - the primary cause of this type of cancer, vaccination to prevent HPV, or Pap tests to detect abnormal lesions in the cervix [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Cervical cancer can be prevented either through the uptake of the HPV vaccine and/or regular engagement in Pap tests [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe World Health Organization (WHO) has set a goal to eliminate cervical cancer as a public health concern, aiming for 90% of girls to be fully vaccinated with the HPV vaccine by age 15, 70% of women to be screened by age 35 and again by age 45, and 90% of women identified with cervical disease to receive treatment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite these efforts, cervical cancer continues to pose a significant global challenge, particularly for women in low-income regions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Most cervical cancer-related deaths occur in low- and middle-income countries (LMICs), where limited access to preventive healthcare exacerbates disparities in cervical cancer outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In high-income countries, advancements in screening technologies and vaccination have significantly reduced the incidence and mortality of cervical cancer [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e][\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, within these countries, populations such as refugees, who face systemic barriers to healthcare, experience disproportionately high rates of cervical cancer and limited access to preventive services [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e][\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe United States is a leading resettlement country for refugees who arrive annually from regions such as Sub-Saharan Africa, the Middle East, and Southeast Asia [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Although initial resettlement processes provide some health screenings, refugee women often encounter significant barriers to accessing ongoing preventive care, including cervical cancer screening and HPV vaccination [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e][\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These barriers are multifaceted, including limited awareness, cultural stigma around reproductive health, mistrust of healthcare services, and systemic obstacles such as language barriers, transportation difficulties, and a lack of culturally responsive care [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e][\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e][\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e][\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e][\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile trust has been increasingly recognized as a determinant of engagement in cervical cancer prevention, available research remains limited and fragmented. Trust in healthcare can be understood as a patient\u0026rsquo;s belief that healthcare providers and systems will act in their best interest, prioritize their well-being, and deliver care competently, ethically, and respectfully [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In contrast, mistrust refers to a lack of confidence in healthcare providers or institutions, often stemming from prior experiences of discrimination, systemic failures, or perceived risks of harm [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Mistrust is not simply the absence of trust but reflects a rational and protective response to historical and structural inequities within healthcare systems [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTrust is a critical determinant of cervical cancer screening uptake, particularly among marginalized populations [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Recent evidence shows that trust in healthcare providers, defined through perceptions of competence, respectful communication, and cultural understanding, significantly influences women\u0026rsquo;s willingness to engage in Pap testing and HPV vaccination [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e][\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e][\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Among immigrant and refugee women, mistrust is often fueled by experiences of discrimination, language barriers, and confusion about healthcare navigation, leading to lower participation in preventive services [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e][\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e][\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Building trust requires culturally safe, consistent, and community-based interactions, rather than isolated informational campaigns [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Addressing these relational and structural barriers is essential to advancing equitable cervical cancer prevention strategies.\u003c/p\u003e \u003cp\u003eWhile quantitative studies have established associations between trust and screening behaviors [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], few qualitative investigations have explored how trust is relationally built or eroded across individual, interpersonal, community, and systemic levels, especially in the context of cervical cancer prevention. To our knowledge, this is the first study to qualitatively assess trust as a critical lens to understand cervical cancer preventive behaviors among a sample of newly arrived refugee women in the US. Drawing on in-depth interviews with refugee women resettled within the past two years, this study explores how trust, mistrust, and relational dynamics with healthcare systems shape engagement with Pap testing and HPV vaccination. Guided by the socioecological model (SEM) and the cultural safety framework (CSF), we examine trust-building at multiple levels, including individual, interpersonal, community, and systemic levels. In doing so, we offer new insights into the mechanisms through which trust fosters or impedes preventive care engagement, highlighting the importance of culturally concordant providers, linguistically appropriate communication, and community-rooted outreach strategies. By reframing cervical cancer prevention as fundamentally relational rather than solely informational, this study provides a deeper understanding of how to promote health equity among newly arrived refugee populations.\u003c/p\u003e \u003cp\u003eMethods\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003eTheoretical framework\u003c/h3\u003e\n\u003cp\u003eThis study is guided by the Socioecological Model (SEM) and the Cultural Safety Framework (CSF). The SEM highlights the multi-level influences on cervical cancer prevention behaviors, spanning individual (e.g., knowledge, health literacy), interpersonal (e.g., family support, cultural norms), community (e.g., stigma, religious expectations), organizational (e.g., provider concordance, navigation challenges), and policy levels (e.g., immigration status, insurance access) [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. Complementing the SEM, the Cultural Safety Framework (CSF) addresses power imbalances, systemic inequities, and the historical contexts that influence healthcare experiences. CSF emphasizes that culturally safe care is defined by the experiences of those receiving care, not the intentions of providers [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e]. Together, the SEM and CSF informed the development of the interview guide, ensuring attention to multi-level determinants and the need for culturally safe, equity-driven approaches to cervical cancer prevention.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy design and methodology\u003c/h2\u003e\n \u003cp\u003eThis study utilized a qualitative research design to explore community-rooted insights on cervical cancer prevention, including pap smear uptake and HPV vaccination acceptance, among newly arrived refugee populations. Semi-structured interviews that lasted 45 minutes to one hour were used to elicit narratives about study participants\u0026rsquo; experiences, attitudes, and perceptions on Pap smear tests and HPV vaccination. This design was chosen to capture the complexity of lived experiences within a sociocultural context [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e], aligning with the study\u0026rsquo;s goal to identify actionable insights for public health interventions.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eStudy setting and participants:\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in partnership with a community-based organization (CBO) serving diverse and newly arrived refugee populations in Louisville, Kentucky. Study participants were recruited through convenience sampling, relying on the availability of individuals at the partnering CBO. As a result, the demographic composition of our sample was informed by participants at the CBO who were available and willing to participate at the time of recruitment. Eligibility criteria included being a refugee woman, newly arrived within the past two years, and between the ages of 21\u0026ndash;65 years. A total of 17 participants were recruited, including women eligible for cervical cancer screening and caregivers of adolescents eligible for HPV vaccination. All individuals who were approached agreed to participate in the study, and there were no participant dropouts. This sample size allowed for the attainment of both code and meaning saturation [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the socio-demographic breakdown of study participants.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSocio-demographic characteristics of participants (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e *\u003c/p\u003e\n \u003cp\u003eAge range\u003c/p\u003e\n \u003cp\u003eAverage age\u003c/p\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e21\u0026ndash;56 years\u003c/p\u003e\n \u003cp\u003e34.2 years\u003c/p\u003e\n \u003cp\u003e10.9 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry of origin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfghanistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCongo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRwanda\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBrazil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNepal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInsured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUninsured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePap smear prior to migration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational attainment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; High school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (76.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh school or equivalent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCollege degree or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e*except for age, all data provides numbers (and percent)\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eData collection:\u003c/h3\u003e\n\u003cp\u003eData were collected through semi-structured interviews conducted between January to May 2022. Interviews were designed to elicit narratives about participants\u0026rsquo; healthcare experiences with Pap test uptake and HPV vaccination, focusing on knowledge, attitudes, practices, and systemic challenges. Open-ended questions encouraged participants to share their experiences with accessing cervical cancer screening and HPV vaccinations, participants\u0026rsquo; perceptions of healthcare providers and health systems, cultural and religious influences on health decision-making, and study participants\u0026rsquo; suggestions for improving service delivery. Interviews were conducted in participants\u0026apos; preferred language with the assistance of professional interpreter services provided by the partnering CBO, when necessary. Each interview lasted approximately 60 minutes, was conducted in person, and was audio-recorded with participants\u0026apos; consent. All interviews were conducted by the first author, who is trained in qualitative research methodologies, including semi-structured interviewing and thematic analysis. No external interviewers were hired. To ensure consistency in data collection, a structured interview guide was used, and the first author employed standardized qualitative interviewing techniques. All participants received a \u003cspan\u003e$\u003c/span\u003e25 gift card as compensation for their time.\u003c/p\u003e\n\u003cp\u003eTo minimize social desirability bias, participants were assured of confidentiality and anonymity before data collection began. Moreover, interviews were conducted in private settings in order to promote authentic participant responses.\u003c/p\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e\u003cem\u003eData analysis\u003c/em\u003e:\u003c/h2\u003e\n \u003cp\u003eThematic content analysis of study findings followed Braun and Clarke\u0026rsquo;s six-step framework [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e]. Thematic analysis was conducted using an iterative approach, supported by Dedoose version 9.0.17, to systematically organize and code the data. Two researchers independently coded an initial subset of transcripts to develop a preliminary codebook, which was refined through discussion. To ensure reliability, intercoder agreement was assessed through double-coding, with discrepancies resolved through consensus meetings. An adequate level of inter-coder reliability was attained, with Cohen\u0026rsquo;s kappa calculated at 0.85 and bias-adjusted kappa reaching 0.95 across five training transcripts, using Dedoose. The finalized codes were then grouped into themes, which were reviewed and refined collaboratively to ensure they accurately represented the data and aligned with the study\u0026apos;s objectives. Member checking was conducted by sharing preliminary themes with four study participants to ensure the accuracy and credibility of study findings.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003efor this study was obtained from the University of Louisville Institutional Review Board (IRB). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and the Belmont Report. The researchers implemented measures to ensure the confidentiality and anonymity of all participants. All research team members were trained in ethical considerations, including cultural sensitivity and confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTo accommodate participants with limited literacy, professional translators provided verbal explanations of the study\u0026rsquo;s purpose, procedures, risks, and benefits in the participants\u0026rsquo; preferred language. Verbal informed consent was obtained from all participants, ensuring their understanding before participation. Participants were encouraged to ask questions, and clarifications were provided as needed to confirm comprehension.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, participants ranged in age from 21 to 56 years, with an average age of 38.24 years (SD\u0026thinsp;=\u0026thinsp;10.92). The majority of participants were from Rwanda (40.0%), followed by Congo (26.7%), Afghanistan (20.0%), Nepal (6.7%), and Brazil (6.7%). All participants (100%) were insured at the time of the study. However, only one participant (5.9%) reported having received a Pap smear prior to migration. Regarding educational attainment, most participants had less than a high school education (76.5%), while 11.8% had completed high school or an equivalent level of education, and 5.9% had obtained a college degree or higher.\u003c/p\u003e \u003cp\u003eTrust emerged as a foundational factor influencing newly arrived refugee women's engagement with cervical cancer prevention. Findings from this study indicated that women\u0026rsquo;s feelings of trust in their personal experiences with providers and the larger healthcare system played a key role in whether they chose to engage in cervical cancer preventive measures (i.e., cervical cancer screening and HPV vaccination).\u003c/p\u003e \u003cp\u003eThis dynamic was reflected across four interrelated themes that emerged from participants\u0026rsquo; experiences, highlighting the ways trust influenced decisions about cervical cancer screening and HPV vaccination for their children. Four interrelated themes illustrate this dynamic: (1) trust as a precondition for engagement, (2) trust in providers built through concordance, respect, and listening, (3) systemic mistrust shaped by experiences of confusion, vulnerability, and financial fear, and (4) pathways to rebuilding through community-based support systems. These themes offer insight into how trust shaped women\u0026rsquo;s decisions around cervical cancer screening and HPV vaccination for their children.\u003c/p\u003e\n\u003ch3\u003eTrust as a precondition for engagement\u003c/h3\u003e\n\u003cp\u003eTrust was consistently described as a necessary precondition for engaging with cervical cancer screening and HPV vaccination. Without trust in the safety of medical procedures, the good intentions of healthcare providers, and the trustworthiness of the healthcare system, many participants avoided preventive services. Women\u0026rsquo;s narratives revealed that mistrust often served as a protective factor against experiences of vulnerability, harm, and uncertainty. One participant reflected on how cultural associations between cancer and death shaped her avoidance of screening: \u0026ldquo;\u003cem\u003eIn my country, when someone says \u0026lsquo;cancer\u0026rsquo;, it means you are going to die. There is no cure. The hospitals are not good, and people don\u0026rsquo;t survive. So, I don\u0026rsquo;t see the point of getting tested. If I have it, I have it. It\u0026rsquo;s better not to know.\u003c/em\u003e\u0026rdquo; (Interview 12). Others described profound unease with medical procedures that felt invasive and unsafe: \u0026ldquo;\u003cem\u003eI don\u0026rsquo;t trust [doctors] putting tools inside my body. What if they touch something wrong and make me sick when I was fine before? I have heard stories that doctors here like to do unnecessary tests for money.\u003c/em\u003e\u0026rdquo; (Interview 5). In some cases, the sense of risk extended beyond the procedures themselves to fears about being misunderstood, silenced, or treated with indifference: \u003cem\u003e\u0026ldquo;Sometimes I feel like they don\u0026rsquo;t listen to what I am saying. They just decide what they want to do. It makes me afraid to ask too many questions.\u0026rdquo;\u003c/em\u003e (Interview 14). However, not all participants expressed complete distrust. Some, especially those with higher English proficiency or previous experiences with preventive care, described cautious willingness to engage: \u0026ldquo;\u003cem\u003eI was scared at first, but the nurse explained everything to me step by step. I trusted her because she took her time, and that made me feel better.\u003c/em\u003e\u0026rdquo; (Interview 2) Another explained: \u0026ldquo;\u003cem\u003eIf they explained it slowly, and they asked me if I was comfortable before doing anything, that might help me feel okay to continue.\u003c/em\u003e\u0026rdquo; (Interview 9)\u003c/p\u003e \u003cp\u003eThese narratives demonstrate that trust is neither static nor binary; it could be conditional, shaped by communication, prior experience, and perceived safety. If healthcare providers demonstrate relational respect through clear communication, consent-seeking, and patience, then participants would be more open to considering cervical cancer prevention services. Building trust was a necessary precursor to women\u0026rsquo;s engagement with preventive care.\u003c/p\u003e\n\u003ch3\u003eTrust in providers built through concordance, respect, and listening\u003c/h3\u003e\n\u003cp\u003e Participants described trust in providers as relationally constructed, influenced by perceived cultural understanding, racial and gender concordance, and interpersonal respect. Women reported that they felt more comfortable and trusting when their doctors looked like them and understood their culture. As one participant emphasized: \u0026ldquo;\u003cem\u003eIf a doctor looks like me and understands my culture, I will trust them more. I will believe what they say. It feels like they know my ways and won\u0026rsquo;t judge me.\u003c/em\u003e\u0026rdquo; (Interview 5). The gender of providers also shaped perceived interpersonal safety. Some women reported discomfort when seen by male providers for reproductive services, emphasizing the cultural importance of gender concordance: \u0026ldquo;\u003cem\u003eI prefer female doctors because it feels more comfortable for me. I can talk more openly with a woman, but with a man, I keep things inside.\u003c/em\u003e\u0026rdquo; (Interview 1).\u003c/p\u003e \u003cp\u003eActive listening contributed meaningfully to building trust. One participant described feeling truly heard: \u0026ldquo;\u003cem\u003eMy doctor looked at me, listened, and did not interrupt. That made me feel like my voice mattered. If doctors listen to me like that, I would not be afraid to ask questions or follow their advice.\u003c/em\u003e\u0026rdquo;(Interview 9). Another woman reflected on an experience with a provider: \u0026ldquo;\u003cem\u003eOne time I went to the doctor here and they kept asking me if I was OK and comfortable. They always ask me if I understood what was going on and if I had questions. That made me feel more willing to follow their advice.\u003c/em\u003e\u0026rdquo; (Interview 7)\u003c/p\u003e \u003cp\u003eThese experiences demonstrate that for many refugee women, trust was not simply about information delivery but about relational dynamics that fostered culturally safe care. However, when providers relied on assumptions or stereotypes, trust was undermined. As such, participants expressed frustration when they felt unseen or dismissed: \u0026ldquo;\u003cem\u003eI feel like when they see me, they already have an idea in their head. They don't listen carefully because they think I don\u0026rsquo;t understand anything.\u003c/em\u003e\u0026rdquo; (Interview 11)\u003c/p\u003e \u003cp\u003eWhile some women described building positive relationships with providers across cultural differences, many emphasized the importance of provider responsiveness in building trust. Even when women had positive experiences with individual providers, broader systemic challenges, such as confusing processes, financial concerns, and communication barriers, continued to weaken their overall trust in healthcare.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSystemic mistrust shaped by experiences of confusion, vulnerability, and financial fear\u003c/h2\u003e \u003cp\u003eBeyond individual relationships, participants described profound systemic mistrust shaped by experiences of confusion, inaccessibility, and unexpected financial burdens. Many women said the healthcare system in the U.S. felt confusing and hard to trust. Navigating healthcare services felt overwhelming for many:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI don\u0026rsquo;t know where to go or how to start. It\u0026rsquo;s all very confusing for me here. There are too many steps, too many papers to fill out, and the hospital, when I went there, was really big and easy to just miss your way. Even making an appointment feels complicated sometimes. I also do not understand the insurance part, what they cover, and what they do not cover. Nobody explains it in an easy way. Even if they don\u0026rsquo;t explain it, it should be simple to understand.\u0026rdquo;\u003c/em\u003e (Interview 8).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLanguage barriers compounded these feelings, despite the availability of interpreters. As one participant shared: \u0026ldquo;\u003cem\u003eEven with an interpreter, sometimes I don\u0026rsquo;t understand the medical words. I just say yes because I am too shy to ask again.\u0026rdquo;\u003c/em\u003e (Interview 14). Another participant described their experiences with an interpreter: \u0026ldquo;\u003cem\u003eSometimes, it sounds like even the interpreter does not understand what the doctor is saying. When I first got here, I went to the hospital and got an interpreter\u0026hellip; I remember that I kept asking for clarification on what the doctor said, and they kept asking the doctor over again. I\u0026rsquo;m not sure if it was the doctor or the interpreter, but I know I was so confused throughout\u0026rdquo;.\u003c/em\u003e (Interview 2).\u003c/p\u003e \u003cp\u003eFinancial uncertainty was a major source of mistrust. The fear of hidden costs led some women to avoid care entirely: \u003cem\u003e\u0026ldquo;One time I went to see the doctor and they said it was free because of my insurance, but later I got a bill. Now, I am scared to go back. I don't want surprises that I cannot pay for.\u0026rdquo;\u003c/em\u003e (Interview 4). Another participant emphasized the cost of care as a cause for concern: \u003cem\u003e\u0026ldquo;I always ask how much before doing anything, but they say, \u0026lsquo;insurance will cover.\u0026rsquo; Later, a bill still comes. This happened to me when I went to the doctor for something small. I was a little bit angry, honestly.\u0026rdquo;\u003c/em\u003e (Interview 12)\u003c/p\u003e \u003cp\u003eOne of the women described transportation barriers as a structural obstacle: \u0026ldquo;\u003cem\u003eI rely on my husband for driving. If he is busy, I miss my appointments.\u0026rdquo;\u003c/em\u003e (Interview 6). Importantly, not all participants mistrusted the system equally. For some women, having social support provided reassurance: \u0026ldquo;\u003cem\u003eMy [caseworker] explained everything about insurance and clinics here, so at least I can ask her if I have any questions about anything\u0026rdquo;.\u003c/em\u003e (Interview 10).\u003c/p\u003e \u003cp\u003eOverall, participants\u0026rsquo; experiences suggest that trust was shaped not only by provider behavior but also by the broader structures and systems that influenced access to care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePathways to rebuilding trust through community-based support systems\u003c/h2\u003e \u003cp\u003eParticipants identified community-based strategies as important pathways for rebuilding trust. While professional interpreters helped bridge some language barriers, trust was more often fostered through familiar, community-rooted relationships. Peer educators and trusted community figures were seen as trusted sources of information: \u0026ldquo;\u003cem\u003eIf a woman from our own community, someone we know and trust, explains it to us, then more people will believe it and take it seriously. We listen to our own more than outsiders\u003c/em\u003e.\u0026rdquo; (Interview 6).\u003c/p\u003e \u003cp\u003eParticipants acknowledged that embedding health education into trusted spaces, like centers where ESL classes are held, would make prevention services feel more accessible: \u0026ldquo;\u003cem\u003eWe already come here for English classes, like today. If they talk about health after our class, or even before, I think we will feel comfortable listening and asking questions.\u003c/em\u003e\u0026rdquo; (Interview 7). Participants also reflected on past experiences with community-based outreaches in their countries of origin, suggesting that bringing healthcare into community settings could strengthen trust:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eBack home, we used to have healthcare workers come into the camps to talk to us about one thing or the other, like vaccines, health checks, those kinds of things. If we can do something like that here, it would be nice. It would make it easier because people already feel comfortable here\u003c/em\u003e\u0026rdquo; (Interview 16).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants also emphasized that building trust required relational proximity, cultural humility, and sustained engagement, not just information delivery. As one participant put it: \u0026ldquo;\u003cem\u003eTrust grows when you see the same faces, when people care about you, not just for one day, but over time.\u003c/em\u003e\u0026rdquo; (Interview 13).\u003c/p\u003e \u003cp\u003eCommunity trust also played an important role in shaping women\u0026rsquo;s willingness to engage with healthcare providers. As another participant explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, if my friend tells me that this doctor is good, and another friend tells me the same thing, I would want to try them out. I can trust them because they have worked with my friends and my friends trust them. So it\u0026rsquo;s a community thing.\u0026rdquo;\u003c/em\u003e (Interview 5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOverall, participants\u0026rsquo; narratives highlighted that rebuilding trust requires creating consistent, culturally informed, and community-centered approaches to care. Trust was not built through information alone but through sustained relationships, shared experiences, and the validation of trusted community networks.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the role of trust as a determinant of engagement with cervical cancer prevention services amongst newly arrived refugee women. The findings show that trust operates along a continuum that is shaped by multilayered contextual influences. Guided by the SEM, our results demonstrate that cervical cancer prevention behaviors are affected by factors operating at the individual, interpersonal, community, organizational, and policy levels. Simultaneously, the CSF provided a lens to interpret how trust is built or eroded based on women\u0026rsquo;s experiences of power, respect, and cultural understanding within the healthcare system. Trust, or its absence, informed women\u0026rsquo;s decisions to engage in cervical cancer prevention services, with mistrust serving as a protective response against perceived lack of trustworthiness of providers and the healthcare system. Guided by the SEM, these findings reflect how individual, interpersonal, organizational, and policy-level factors interact to shape refugee women's engagement with preventive services. The CSF further contextualizes participants' mistrust as rooted in experiences where care environments failed to feel safe, empowering, or culturally respectful.\u003c/p\u003e \u003cp\u003eConsistent with available evidence, and in alignment with the SEM's emphasis on individual-level and interpersonal influences, participants described trust as essential for navigating preventive services [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e][\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Mistrust was often rooted in cultural understandings of cancer as a fatal diagnosis, fears of invasive medical procedures, and skepticism about the financial motivations of healthcare systems. The CSF helps interpret these concerns as reflections of deeper systemic inequities and historical marginalization in healthcare contexts.\u003c/p\u003e \u003cp\u003eBeyond individual interactions, trust was relationally constructed through perceived cultural, racial, and gender concordance, as well as through respect and attentive communication. Participants expressed greater comfort and willingness to engage when providers demonstrated cultural sensitivity, shared similar backgrounds, or adopted patient-centered communication strategies. Recent studies emphasize that cultural humility and shared decision-making practices are critical for building trust among marginalized populations [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e][\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e][\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In contrast, assumptions, stereotypes, and inattentive listening undermined trust, reinforcing existing barriers to care, as seen in other studies where marginalized groups disengaged when providers failed to offer individualized care [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e][\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. These interpersonal dynamics mirror the SEM\u0026rsquo;s interpersonal layer and emphasize the CSF's principle that culturally safe care is determined by the patient's experience of being respected and empowered.\u003c/p\u003e \u003cp\u003eSystemic mistrust also emerged as a significant barrier to engagement. Participants highlighted structural challenges, including the complexity of healthcare navigation, confusion about insurance, language barriers, and fears of hidden medical costs. These systemic concerns align with broader evidence showing that structural barriers, rather than individual factors alone, drive disparities in preventive healthcare uptake among refugee and immigrant populations [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e][\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e][\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Even when individual providers were trustworthy, system-related issues continued to erode overall confidence in the healthcare system. This systemic mistrust reflects both the organizational and policy-level barriers described in the SEM and highlights, through the CSF lens, how healthcare systems that are difficult to navigate or lack financial transparency may contribute to cultural unsafety for marginalized populations.\u003c/p\u003e \u003cp\u003eImportantly, participants identified community-based pathways as essential for rebuilding trust. Peer educators, trusted community figures, and familiar spaces like English as a Second Language (ESL) centers were considered safe entry points for preventive health education and services. These findings align with recent calls for community-engaged approaches to health promotion that prioritize relational trust and cultural embeddedness over transactional interventions [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e][\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e][\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Trust was cultivated not through isolated informational campaigns but through ongoing relational proximity, cultural humility, and repeated, caring interactions. These findings underscore the SEM\u0026rsquo;s recognition of community-level influences and align with the CSF\u0026rsquo;s call for culturally rooted, community-led approaches to health promotion.\u003c/p\u003e \u003cp\u003eCollectively, these findings suggest that rebuilding trust among refugee women requires multilevel interventions, with consideration for cultural safety principles during care delivery. At the provider level, sustained investments in culturally informed care, patient-centered communication, and relational continuity are essential. At the systemic level, healthcare institutions must simplify navigation processes, ensure financial transparency, and embed preventive care initiatives within trusted community infrastructures. Future interventions that integrate these relational and systemic dimensions are more likely to succeed in increasing cervical cancer screening and HPV vaccination rates among newly resettled refugee populations.\u003c/p\u003e \u003cp\u003eStudy limitations\u003c/p\u003e \u003cp\u003eThis study has several limitations that should be considered when interpreting the findings. First, the focus on one geographic location may not account for regional variations in healthcare access and cultural dynamics across different refugee communities. Second, reliance on self-reported data introduces the potential for recall bias or social desirability bias, where participants may provide responses they perceive as socially acceptable rather than entirely accurate, despite efforts to mitigate this through assurance of confidentiality and ensuring neutrality in interviewing. Additionally, self-selection bias may have influenced the sample, as individuals who participated may have had stronger opinions about healthcare access or more direct experiences with preventive care than those who declined participation. Interviewer influence is another potential limitation, as all interviews were conducted by the first author, whose presence and interviewing style, despite adherence to standardized protocols, could have shaped participant responses. Lastly, the study\u0026rsquo;s cross-sectional design captures a snapshot of experiences and perceptions at a single point in time, limiting its ability to explore changes in attitudes or behaviors over time. Future research should consider longitudinal approaches, diverse geographic sampling, and multiple interviewers to address these limitations and provide a more comprehensive understanding of the barriers and facilitators to cervical cancer prevention among newly arrived refugee populations.\u003c/p\u003e \u003cp\u003eImplications for practice, policy, and research\u003c/p\u003e \u003cp\u003eFindings from this study suggest the importance of integrated, community-based health education programs that address the unique cultural and structural barriers faced by refugee populations. While this study provides valuable insights, the qualitative nature and sample size limit the generalizability of the findings. However, participants' experiences highlight the potential benefits of culturally responsive care models that incorporate patient education, interpreter services, and trauma-informed approaches to mitigate medical mistrust.\u003c/p\u003e \u003cp\u003eAdditionally, expanding multilingual patient navigator programs and embedding healthcare resources within refugee-serving organizations may help bridge gaps in preventive care access. To support equitable cervical cancer prevention services, policymakers should consider systemic reforms that prioritize refugee communities' needs. Potential strategies include expanding interpreter services, developing community-based patient navigation programs, and implementing mobile screening units to address transportation barriers. Furthermore, while increasing the recruitment and retention of racially and culturally concordant healthcare providers could foster trust and engagement, further research is needed to evaluate its long-term impact.\u003c/p\u003e \u003cp\u003eStrengthening collaborations between government agencies, healthcare institutions, and community organizations remains an essential step in advancing health equity. Future research should explore these approaches in larger and more diverse samples to build on the insights from this study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights trust as a critical determinant of engagement with cervical cancer prevention services among newly arrived refugee women. Information delivery alone is insufficient, as trust should be built through cultural and systemic responsiveness. Women\u0026rsquo;s experiences revealed that trust must be cultivated across multiple levels, through culturally respectful provider interactions, clear communication, accessible systems, and community-rooted support. Efforts to improve cervical cancer prevention uptake must therefore prioritize relational trust-building alongside structural reforms that address systemic barriers. By centering trust as both a relational and structural imperative, healthcare systems can move toward more equitable, culturally safe, and effective models of care for refugee populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eConflicts of Interest:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflict of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding Statement:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The study was conducted without external financial support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Availability Statement:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this study's findings are not publicly available due to ethical and privacy considerations. Participants were assured that their responses would remain confidential and would not be shared beyond the research team. De-identified excerpts relevant to the study's conclusions are available upon reasonable request, subject to approval from the institutional review board.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor’s Contribution Statement\u003c/em\u003e:\u003c/p\u003e\n\u003cp\u003eXX conceptualized the study, led data collection and analysis, and was primarily responsible for writing the results section and overseeing the entire research process. XX. provided critical support throughout the research process, including contributing to the analysis and assisting in writing the results section. XX. contributed to writing and refining various sections of the manuscript. XX. provided additional writing support and assisted with manuscript revisions. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (WHO). Cervical cancer. Accessed: Mar. 05, 2025. [Online]. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/cervical-cancer#:~:text=Globally%2C%20cervical%20cancer%20is%20the,%2D%20and%20middle%2Dincome%20countries\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/cervical-cancer#:~:text=Globally%2C%20cervical%20cancer%20is%20the,%2D%20and%20middle%2Dincome%20countries\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries, \u003cem\u003eCA Cancer J Clin\u003c/em\u003e, vol. 68, no. 6, pp. 394\u0026ndash;424, Nov. 2018, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3322/caac.21492\u003c/span\u003e\u003cspan address=\"10.3322/caac.21492\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. World Health Assembly adopts a global strategy to accelerate cervical cancer elimination. Accessed: Jan. 08, 2025. [Online]. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news/item/19-08-2020-world-health-assembly-adopts-global-strategy-to-accelerate-cervical-cancer-elimination\u003c/span\u003e\u003cspan address=\"https://www.who.int/news/item/19-08-2020-world-health-assembly-adopts-global-strategy-to-accelerate-cervical-cancer-elimination\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Cancer Society (ACS). Screening tests for cervical cancer., 2023. Accessed: Jan. 08, 2025. [Online]. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cancer.org/cancer/types/cervical-cancer/detection-diagnosis-staging/screening-tests.html\u003c/span\u003e\u003cspan address=\"https://www.cancer.org/cancer/types/cervical-cancer/detection-diagnosis-staging/screening-tests.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. Cervical cancer, 2023a. Accessed: Jan. 08, 2025. [Online]. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/cervical-cancer/index.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/cervical-cancer/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. Screening for cervical cancer. Accessed: Jan. 08, 2025. [Online]. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/cervical-cancer/screening/index.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/cervical-cancer/screening/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization.. WHO updates recommendations on HPV vaccination schedule. Accessed: Jan. 08, 2025. [Online]. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news/item/20-12-2022-WHO-updates-recommendations-on-HPV-vaccination-schedule\u003c/span\u003e\u003cspan address=\"https://www.who.int/news/item/20-12-2022-WHO-updates-recommendations-on-HPV-vaccination-schedule\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global strategy to accelerate the elimination of cervical cancer as a public health problem. Accessed: Jan. 08, 2025. [Online]. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789240014107\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789240014107\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCanfell K, et al. Mortality impact of achieving WHO cervical cancer elimination targets: a comparative modelling analysis in 78 low-income and lower-middle-income countries. Lancet. Feb. 2020;395:591\u0026ndash;603. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(20)30157-4\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(20)30157-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSung H, Global Cancer Statistics. 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries, \u003cem\u003eCA Cancer J Clin\u003c/em\u003e, vol. 71, no. 3, pp. 209\u0026ndash;249, May 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3322/caac.21660\u003c/span\u003e\u003cspan address=\"10.3322/caac.21660\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArbyn M, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Glob Health. Feb. 2020;8(2):e191\u0026ndash;203. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2214-109X(19)30482-6\u003c/span\u003e\u003cspan address=\"10.1016/S2214-109X(19)30482-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaccarella S, Lortet-Tieulent J, Plummer M, Franceschi S, Bray F. Worldwide trends in cervical cancer incidence: Impact of screening against changes in disease risk factors, \u003cem\u003eEur J Cancer\u003c/em\u003e, vol. 49, no. 15, pp. 3262\u0026ndash;3273, Oct. 2013, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ejca.2013.04.024\u003c/span\u003e\u003cspan address=\"10.1016/j.ejca.2013.04.024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorris MD, Popper ST, Rodwell TC, Brodine SK, Brouwer KC. Healthcare Barriers of Refugees Post-resettlement, \u003cem\u003eJ Community Health\u003c/em\u003e, vol. 34, no. 6, pp. 529\u0026ndash;538, Dec. 2009, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10900-009-9175-3\u003c/span\u003e\u003cspan address=\"10.1007/s10900-009-9175-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosato I, Dalla Zuanna T, Tricarico V, Barbiellini Amidei C, Canova C. Adherence to Cervical Cancer Screening Programs in Migrant Populations: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. Jan. 2023;20(3):2200. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph20032200\u003c/span\u003e\u003cspan address=\"10.3390/ijerph20032200\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited Nations High Commissioner for Refugees (UNHCR). Global trends: Forced displacement in 2022., Accessed: Jan. 08, 2025. [Online]. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unhcr.org\u003c/span\u003e\u003cspan address=\"https://www.unhcr.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalker PF, Settgast AM, DeSilva MB. Cancer Screening in Refugees and Immigrants: A Global Perspective, \u003cem\u003eAm J Trop Med Hyg\u003c/em\u003e, vol. 106, no. 6, pp. 1593\u0026ndash;1600, Jun. 2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4269/ajtmh.21-0692\u003c/span\u003e\u003cspan address=\"10.4269/ajtmh.21-0692\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfsah YR, Kaneko N. Barriers to cervical cancer screening faced by immigrant Muslim women: a systematic scoping review. BMC Public Health. Nov. 2023;23(1):2375. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-023-17309-9\u003c/span\u003e\u003cspan address=\"10.1186/s12889-023-17309-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOzturk NY, Hossain SZ, Mackey M, Adam S, Brennan P. HPV and Cervical Cancer Awareness and Screening Practices among Migrant Women: A Narrative Review. Healthcare. Mar. 2024;12(7):709. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/healthcare12070709\u003c/span\u003e\u003cspan address=\"10.3390/healthcare12070709\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSawadogo PM et al. Sep., Barriers and facilitators of access to sexual and reproductive health services among migrant, internally displaced, asylum seeking and refugee women: A scoping review, \u003cem\u003ePLoS One\u003c/em\u003e, vol. 18, no. 9, p. e0291486, 2023, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0291486\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0291486\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVu M, et al. System-level factors influencing refugee women\u0026rsquo;s access and utilization of sexual and reproductive health services: A qualitative study of providers\u0026rsquo; perspectives. Front Glob Womens Health. Dec. 2022;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fgwh.2022.1048700\u003c/span\u003e\u003cspan address=\"10.3389/fgwh.2022.1048700\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarajimakin O. Barriers to Cervical Cancer Screening: A Systematic Review. Cureus Jul. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.65555\u003c/span\u003e\u003cspan address=\"10.7759/cureus.65555\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBirkh\u0026auml;uer J et al. Feb., Trust in the health care professional and health outcome: A meta-analysis, \u003cem\u003ePLoS One\u003c/em\u003e, vol. 12, no. 2, p. e0170988, 2017, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0170988\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0170988\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenkert R, Cuevas A, Thompson HS, Dove-Meadows E, Knuckles D. Ubiquitous Yet Unclear: A Systematic Review of Medical Mistrust, 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/08964289.2019.1588220\u003c/span\u003e\u003cspan address=\"10.1080/08964289.2019.1588220\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaiswal J. Whose Responsibility Is It to Dismantle Medical Mistrust? Future Directions for Researchers and Health Care Providers. Behav Med. 2019;45(2). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/08964289.2019.1630357\u003c/span\u003e\u003cspan address=\"10.1080/08964289.2019.1630357\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaiswal J, Halkitis PN. Towards a More Inclusive and Dynamic Understanding of Medical Mistrust Informed by Science, 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/08964289.2019.1619511\u003c/span\u003e\u003cspan address=\"10.1080/08964289.2019.1619511\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Donovan B, et al. Trust and cancer screening: Effects of a screening controversy on women\u0026rsquo;s perceptions of cervical cancer screening. Prev Med Rep. 2022;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.pmedr.2021.101684\u003c/span\u003e\u003cspan address=\"10.1016/j.pmedr.2021.101684\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToluwani Elizabeth A, Maysa A, Rima A. A Qualitative Study to Understand Cervical Cancer Awareness and Prevention among African Immigrant Women (AIW) in Iowa City, Iowa. Int J Womens Health Wellness. 2021;7(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.23937/2474-1353/1510117\u003c/span\u003e\u003cspan address=\"10.23937/2474-1353/1510117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDean A, et al. HPV-Related Knowledge and Impact of Patient\u0026ndash;Provider Communication on HPV-Associated Cervical Cancer Awareness and Pap Smear Completion in US Women Aged 21\u0026ndash;65 Years. Cancers (Basel). Mar. 2025;17(7):1188. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/cancers17071188\u003c/span\u003e\u003cspan address=\"10.3390/cancers17071188\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLurgain JG, et al. Exploring self-care and cervical cancer prevention attitudes and practices among Moroccan and Pakistani immigrant women in Catalonia, Spain: a comparative qualitative study. BMC Public Health. 2024;24(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-023-17445-2\u003c/span\u003e\u003cspan address=\"10.1186/s12889-023-17445-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeo JY, Li J, Li K. Cervical Cancer Screening Experiences Among Chinese American Immigrant Women in the United States. J Obstetric Gynecologic Neonatal Nurs. Jan. 2018;47(1):52\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jogn.2017.10.003\u003c/span\u003e\u003cspan address=\"10.1016/j.jogn.2017.10.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee HY, Lee MH. Barriers to Cervical Cancer Screening and Prevention in Young Korean Immigrant Women: Implications for Intervention Development. J Transcult Nurs. 2017;28(4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1043659616649670\u003c/span\u003e\u003cspan address=\"10.1177/1043659616649670\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLansing AE, et al. Building trust: Leadership reflections on community empowerment and engagement in a large urban initiative. BMC Public Health. 2023;23(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-023-15860-z\u003c/span\u003e\u003cspan address=\"10.1186/s12889-023-15860-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShelton RC, Brotzman LE, Johnson D, Erwin D. Trust and mistrust in shaping adaptation and de-implementation in the context of changing screening guidelines. Ethn Dis. 2021;31(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18865/ED.31.1.119\u003c/span\u003e\u003cspan address=\"10.18865/ED.31.1.119\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBronfenbrenner U. Toward an experimental ecology of human development. Am Psychol. 1977;32(7). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/0003-066x.32.7.513\u003c/span\u003e\u003cspan address=\"10.1037/0003-066x.32.7.513\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBronfenbrenner U. Ecology of the Family as a Context for Human Development. Research Perspectives. Dev Psychol. 1986;22(6). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/0012-1649.22.6.723\u003c/span\u003e\u003cspan address=\"10.1037/0012-1649.22.6.723\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcleroy KR, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Health Educ Behav. 1988;15(4). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/109019818801500401\u003c/span\u003e\u003cspan address=\"10.1177/109019818801500401\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGolden SD, Earp JAL. Social Ecological Approaches to Individuals and Their Contexts: Twenty Years of Health Education \u0026amp; Behavior Health Promotion Interventions. Health Educ Behav. 2012;39(3). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1090198111418634\u003c/span\u003e\u003cspan address=\"10.1177/1090198111418634\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCurtis E, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health. Dec. 2019;18(1):174. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12939-019-1082-3\u003c/span\u003e\u003cspan address=\"10.1186/s12939-019-1082-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnott E, Rao AH, Summers K, Teeger C. Interviews in the social sciences. Nat Reviews Methods Primers. Sep. 2022;2(1):73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s43586-022-00150-6\u003c/span\u003e\u003cspan address=\"10.1038/s43586-022-00150-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVasileiou K, Barnett J, Thorpe S, Young T. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. Dec. 2018;18(1):148. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12874-018-0594-7\u003c/span\u003e\u003cspan address=\"10.1186/s12874-018-0594-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology, \u003cem\u003eQual Res Psychol\u003c/em\u003e, vol. 3, no. 2, pp. 77\u0026ndash;101, Jan. 2006, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1191/1478088706qp063oa\u003c/span\u003e\u003cspan address=\"10.1191/1478088706qp063oa\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorreia T. Trust Building in Public Health Approaches: The Importance of a \u0026lsquo;People-Centered\u0026rsquo; Concept in Crisis Response. Risk Manag Healthc Policy. Aug. 2024;17:1903\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/RMHP.S471250\u003c/span\u003e\u003cspan address=\"10.2147/RMHP.S471250\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLansing AE, et al. Building trust: Leadership reflections on community empowerment and engagement in a large urban initiative. BMC Public Health. Jun. 2023;23(1):1252. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-023-15860-z\u003c/span\u003e\u003cspan address=\"10.1186/s12889-023-15860-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTheodosopoulos L, Fradelos EC, Panagiotou A, Dreliozi A, Tzavella F. Delivering Culturally Competent Care to Migrants by Healthcare Personnel: A Crucial Aspect of Delivering Culturally Sensitive Care. Soc Sci. Oct. 2024;13(10):530. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/socsci13100530\u003c/span\u003e\u003cspan address=\"10.3390/socsci13100530\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaige SR, Alber JM, Stellefson ML, Krieger JL. Missing the mark for patient engagement: mHealth literacy strategies and behavior change processes in smoking cessation apps. Patient Educ Couns. May 2018;101(5):951\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.pec.2017.11.006\u003c/span\u003e\u003cspan address=\"10.1016/j.pec.2017.11.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNgondwe P, Tefera GM. Barriers and Facilitators of Access to Healthcare Among Immigrants with Disabilities: A Qualitative Meta-Synthesis, \u003cem\u003eHealthcare\u003c/em\u003e, vol. 13, no. 3, p. 313, Feb. 2025, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/healthcare13030313\u003c/span\u003e\u003cspan address=\"10.3390/healthcare13030313\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiza E et al. Apr., Community-Based Healthcare for Migrants and Refugees: A Scoping Literature Review of Best Practices, \u003cem\u003eHealthcare\u003c/em\u003e, vol. 8, no. 2, p. 115, 2020, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/healthcare8020115\u003c/span\u003e\u003cspan address=\"10.3390/healthcare8020115\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaidi M, Fantasia HC, Penders R, Koren A, Enah C. Increasing U.S. Maternal Health Equity Among Immigrant Populations Through Community Engagement, \u003cem\u003eNurs Womens Health\u003c/em\u003e, vol. 28, no. 1, pp. 11\u0026ndash;22, Feb. 2024, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nwh.2023.09.004\u003c/span\u003e\u003cspan address=\"10.1016/j.nwh.2023.09.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKorn AR et al. Sep., Social determinants of health and US cancer screening interventions: A systematic review, \u003cem\u003eCA Cancer J Clin\u003c/em\u003e, vol. 73, no. 5, pp. 461\u0026ndash;479, 2023, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3322/caac.21801\u003c/span\u003e\u003cspan address=\"10.3322/caac.21801\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDadson YA, Bennett-Gayle DM, Ramenzoni V, Gilmore EA. Experiences of Immigrants During Disasters in the US: A Systematic Literature Review. J Immigr Minor Health. Feb. 2025;27(1):134\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10903-024-01649-8\u003c/span\u003e\u003cspan address=\"10.1007/s10903-024-01649-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHossain MA, Khanam SJ, Khan MN, Oldroyd J, Islam RM. Barriers to cervical cancer screening among refugee women: A systematic review. PLOS Global Public Health. Mar. 2025;5(3):e0004225. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pgph.0004225\u003c/span\u003e\u003cspan address=\"10.1371/journal.pgph.0004225\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRedvers N et al. Jun., Relational community engagement within health interventions at varied outcome scales, \u003cem\u003ePLOS Global Public Health\u003c/em\u003e, vol. 4, no. 6, p. e0003193, 2024, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pgph.0003193\u003c/span\u003e\u003cspan address=\"10.1371/journal.pgph.0003193\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBirgel V, Decker L, R\u0026ouml;ding D, Walter U. Community capacity for prevention and health promotion: a scoping review on underlying domains and assessment methods. Syst Rev. Aug. 2023;12(1):147. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13643-023-02314-1\u003c/span\u003e\u003cspan address=\"10.1186/s13643-023-02314-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolden K et al. Dec., Community Engaged Leadership to Advance Health Equity and Build Healthier Communities, \u003cem\u003eSoc Sci\u003c/em\u003e, vol. 5, no. 1, p. 2, 2015, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/socsci5010002\u003c/span\u003e\u003cspan address=\"10.3390/socsci5010002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6558601/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6558601/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Refugee women face unique challenges in accessing preventive healthcare services upon resettlement, particularly for cervical cancer screening and HPV vaccination. Despite national efforts to reduce cervical cancer incidence, uptake remains disproportionately low among newly arrived refugee populations. This study explores the experiences, perceptions, and contextual factors shaping cervical cancer prevention behaviors among newly arrived refugee women in the United States.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe conducted in-depth, semi-structured interviews with 17 refugee women within their first two years of resettlement in a Midwestern U.S. city. Participants were purposively sampled to ensure variation in age, country of origin, and screening history. Data were analyzed using Braun and Clarke’s thematic analysis, guided by the Socioecological Model. Trustworthiness was strengthened through intercoder agreement, member checking, and reflexive memoing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Four themes emerged: trust as a gatekeeper, highlighting how healthcare-seeking depended on perceived safety and relational trust; communication as access, reflecting challenges with language, interpretation, and navigating fragmented care; concordance and comfort, emphasizing the role of gender, cultural, and religious alignment with providers; and structural disorientation, describing the confusion around where, when, and how to access preventive services. Despite low awareness of HPV vaccination, most participants expressed openness when information was provided by trusted messengers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Refugee women’s engagement with cervical cancer prevention is shaped not only by knowledge but also by cultural safety, provider concordance, and systemic trust. Interventions must prioritize community-rooted education, gender-concordant care, and culturally responsive communication to improve prevention outcomes.\u003c/p\u003e","manuscriptTitle":"Beyond knowledge: trust and the engagement of newly arrived refugee women in cervical cancer prevention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 08:30:05","doi":"10.21203/rs.3.rs-6558601/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-25T20:24:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-23T21:04:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-23T20:19:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-18T09:13:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313687016686441958094452837217617633086","date":"2025-06-02T23:25:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285081821926369556720338933161130467858","date":"2025-06-02T18:25:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2632326540806996575437906365434492022","date":"2025-06-02T17:07:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165391807275293960170415558064836692473","date":"2025-05-02T21:05:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-30T19:12:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-30T03:50:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-30T03:48:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Immigrant and Minority Health","date":"2025-04-29T17:14:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"642faafd-0f02-47d6-b456-cf812e31a4eb","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-18T16:00:55+00:00","versionOfRecord":{"articleIdentity":"rs-6558601","link":"https://doi.org/10.1007/s10903-025-01756-0","journal":{"identity":"journal-of-immigrant-and-minority-health","isVorOnly":false,"title":"Journal of Immigrant and Minority Health"},"publishedOn":"2025-08-13 15:57:25","publishedOnDateReadable":"August 13th, 2025"},"versionCreatedAt":"2025-05-06 08:30:05","video":"","vorDoi":"10.1007/s10903-025-01756-0","vorDoiUrl":"https://doi.org/10.1007/s10903-025-01756-0","workflowStages":[]},"version":"v1","identity":"rs-6558601","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6558601","identity":"rs-6558601","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}