Breast Cancer and Screening Experiences
According to the Public Health Agency of Canada, breast cancer is one of the common cancers affecting women in Canada Statistics indicate that in the 2017, an estimated 26,300 Canadian women had a higher chance of being diagnosed with breast cancer (Government of Canada, 2017). Out of the 26,300 diagnosed, about 5,000 women are expected to die from the disease or complications of it . The statistics indicate that approximately 26% of all deaths of women in Canada are due to breast cancer. 1 out of 8 women is expected to develop a cancer disease during her lifetime while 1 out of every 31 diagnosed female patients will die (Government of Canada, 2017). For that reason, breast cancer organizations across the country create partners with key stakeholders to support and enhance screening and early detection policy (Canadian Cancer Society, 2015). The Network focuses on improving patient experiences and making evidence-based recommendations so that patients have access to better services, which will lead to controlling cancer (Cancer view, 2017).
The principal strategy of breast cancer prevention in Canada is cancer screening. Screening takes several forms, including breast self-exam, clinical breast examination and regular mammography (Canadian Cancer Society, 2015). In fact, studies have shown that mammography reduces the risk of breast cancer death and improve survival rate (Gøtzsche, P.C & Nielsen, 2011; Schwartz et al., 2008; Madanat, 2002).
Screening Practices. Variations in culture and ethnicity influence behaviors such as cancer screening participation and have a significant impact on rates of developing and dying from breast cancer (Aziza, 2014). In Canada, marginalized and immigrant women have some of the lowest consumption rates of screening services and are more likely to face significant obstacles in accessing preventive services (Smith, Diana, Miglioretti, Nicole, Linn, Rachel, Jodi, Mark, William, Barlow, Cherry, Beasley, Karla, 2006). This poor involvement places them at a higher risk of developing advanced stages of breast cancer and reduces their chances of survival (Smith et al., 2006). Shields and Wilkins (2009) found that poor screening rates are associated with certain racial and immigrant groups in Canada. They also found that the screening participation level is low among immigrant women from Asia in comparison to those from Europe. Factors such as language, social isolation and cultural differences were identified as barriers to involvement in screening services (Shields and Wilkins, 2009). New immigrant women have a lower incidence of breast cancer than Canadian-born women, perhaps due to the process of the medical screening they undergo as part of the immigration process (Amin, 2008). However, their risk goes up ultimately, probably due to changes in lifestyle, environmental risk factors and other factors associated with a deterioration in their health condition (Salman. 2012). These other factors include smoking and drinking due to stress, low socioeconomic status and unemployment (Amin, 2008).
Among the studies that explored the utilization of breast health services among immigrant women, a small number looked at the association between acculturation and health behaviors related to breast health and screening. The findings have been relatively inconsistent. Some showed that acculturation, specifically English proficiency, is associated with going for screening (e.g., mammography and Pap smear) (Suarez, 1994). Schoueri, Campbell and Mai (2013) reviewed the Canadian Refugee and Family Classes to learn about the length of stay and utilization of health care services. They found that new immigrants had poor utilization of health care facilities compared to those who had lived in the country for a long time (Schoueri, Campbell & Mai, 2013). Researchers also suggested that a longer stay in Canada had some significant impact on levels of screening among ethnic minority women; perhaps that longer time gave them the opportunity to know about the services and learn how they are operated. With this knowledge, individuals who had lived in the country for more extended periods were capable of utilizing the services more efficiently (Remennick, 2006).
In contrast, earlier studies indicated that acculturation is not a consistent predictor of seeking screening or participating in breast health promotion services (Lipson and Meleis, 1990). Another more recent counter-argument was that acculturated or bicultural groups were not found to be healthier or better-educated about screening services (Lai, Tsang, Chappell, Lai, & Chau, 2007).
Pervious researchers have not examined the perceptions, behaviors, and barriers to breast screening among Arab women in Alberta, nor looked at these women’s health practice in relation to acculturation (e.g., length of stay in Canada and pro?ciency in English), education and knowledge, socioeconomic status and other factors. Arab Muslim women in Alberta are exposed to many disadvantages. They are exposed to social and economic challenges as explored above, and educational challenges that lower their ability to learn about local breast health services (Salman, 2012). With these challenges, it becomes difficult for MENA women in Alberta to access breast health care services equal to those available to other women in the province (Amin, 2008).
While the literature on racial groups’ consumption of health services in Canada is limited, it is on the rise in the United Kingdom (UK), United States (US) and Australia (Aziza, 2014). Research in those countries identified religious and socio-cultural factors, such as modesty and body covering, as impeding participation in screening programs among Asian Islamic immigrant women Rajaram & Rashidi, 1999). In Australia, immigrant women from the Middle East are shown to have poorer screening practices than Western-born women (Azaiza & Cohen 2006). Studies of determinant of mammogram screening behavior among Arab women in Israel have shown similar results (Soskolne, Marie, & Manor, 2006). Factors such as low income, unemployment, low education, and religious beliefs are among the major barriers to participation in mammography and other screening facilities. However, similar to all cross-sectional studies, the outcomes in Soskolne et al., (2006) study do not establish causation. On the other hand, Ivanov, Hu and Leak (2010) found that immigrant women from regions such as the former Soviet Union (FSU) are attentive and committed to taking care of themselves to ensure good health. However, these women lack an understanding and awareness of good health (Ivanov, Hu & Leak (2010). These immigrant women from former Soviet Union also describe health as the absence of disease, which perhaps explains their poor participation in health practices such as mammography and breast self-exam (Ivanov, Hu &Leak (2010).
In the United States, a telephone survey was conducted to study the prevalence of mammography screening as well as beliefs and practices regarding mammography screening among immigrant women from Middle East (Schwartz et al., 2008). The prevalence of mammography screening among these women was 57.8% (Schwartz et al., 2008). Of the women whose ethnic groups were surveyed, Lebanese women who lived in the US for more than 10 years, were50 years of age and older, and had health insurance were found to have the highest reporting rate, as they reported having a mammogram every 1–2 years (Schwartz et al., 2008). The above study valuated Arab women who share similar ethnicities, but did not take religious differences in consideration (Schwartz et al., 2008).
In other studies, factors affecting immigrant women’s decisions to undergo screening included the lack of a doctor’s recommendation, denial of personal risk, fear of diagnosis of BC and fear of becoming a burden on family members (Remennick, 2006). Additionally, in many traditional cultures, especially Islam, females’ actions are controlled by males in the family (husband, father, brother), and sometimes men are unaware of the consequences of objecting to breast screening (Remennick, 2006). Hence it is recommended to involve men in these traditional communities in efforts to address breast cancer screening disparities and also to include them in educational programs about cancer myths (Remennick, 2006).
According studies, factors associated with increased participation in screening services include a high level of education, past history of BC, older age and higher socioeconomic class (Salman, 2012). A qualitative study using face-to-face interviews was conducted in Israel to determine the rate of mammography screening behavior among Muslim Arab women (Soskolne et al., 2007). It was reported in this study that the mammography screening rate was only 22% among Arab women ages 50–69 compared to 71% among Israeli women (Soskolne et al., 2007). The study also indicated that Arab women were most likely to undergo screening if they had a high level of education, or had been advised to do so by a health professional, or were at risk of developing BC (e.g., had a family member with BC) (Soskolne et al., 2007).
However, we should recognize that even though Arab women have low level of participation in BC screening programs, they are eager to learn more about breast cancer risk and preventive services (Amin, 2008). Studies have shown that Arab women are often reluctant to seek screening when they want it (Amin, 2008, Salman, 2012). By way of explaining this, Salman used self-esteem theory to argue that some Arab women in Western society are hesitant to seek BC preventive care because they are concerned that their peers may find it unacceptable and may criticise them, which will lead to low self-esteem. It is important that health care providers and policymakers understand the complex factors that influence Arab women health decisions with respect to BC risks and outcomes including structural, organizational, psychological and sociocultural barriers.
Breast Cancer Outcomes. A well-built body of evidence demonstrates that there are cultural and ethnic inequalities in breast cancer outcomes. Evidence from the US revealed that black women have a greater possibility of dying from BC than white women, indicating prominent racial inequalities for female BC (Rajaram ; Rashidi, 1999). In the US, Hispanic and Asian Pacific American women with breast cancer have a poorer prognosis and lower survival rate than Caucasian women (Seiler et al., 2017). Data from the UK found that ethnic minority women (Black, South Asians, Chinese and Arabs) have an increased risk of diagnosis of advanced-stage BC and higher death rates compared to women from dominant ethnicities (Aziza, 2014). Madanat (2002) indicated a high prevalence of advanced BC and high mortality rate in the MENA region because of the progression of malignant tumors and late detection of cancer at the time of diagnosis. Madanat concluded that Jordanian women have a limited understanding of BC risk. He said that Jordanian women, including nurses, who performed breast self-exams on a regular basis were less than 19% of the total women population. Similarly, evidence from Australia showed that high cancer risk and poor survival rates are prominent among Indigenous populations living in remote parts of Australia (Heathcote ; Armstrong, 2007). A significant proportion of indigenous Australians are diagnosed at a later stage of cancer, have worse prognoses and higher mortality rates (Heathcote ; Armstrong, 2007). There is also evidence of treatment and medical care variations that could adversely affect the survival prospects of socio-economically disadvantaged patients living in rural and remote areas (Kricker, Haskill ; Armstrong, 2001). In remote and rural areas of North South Wales, women with BC were more likely to undergo mastectomies and less likely to have breast conserving surgery (Kricker, Haskill ; Armstrong, 2001).
From a broader perspective, these inequalities in BC outcomes are shaped by variations in culture and ethnicities. However, Aziza (2014) argued that the real disparities in BC prevalence and survival rates are concealed by overlooking the variations among the smaller groups and grouping them into larger categories. For example, the Middle Eastern region includes many smaller racial groups that are highly diverse in terms of demographics and social determinants of health. These differences between the smaller ethnic communities are masked by the larger groups. For example, statistics show that BC survival rate is going down for Arab women, but this data does not precisely reveal the drop in survival rates occurring among Saudi women (Azaiza ; Cohen, 2006).
Multiple factors including genetic, socio-behavioral, cultural and ecological are likely involved in the etiology of these inequalities (Heathcote ; Armstrong, 2007; Todd ; Hoffman, 2011). The health needs and outcomes of BC patients are greatly impacted by their diverse backgrounds including race, socioeconomic status and disease pathophysiology (Tan ; Li, 2016). A complex and multidimensional approach is needed to reduce and eliminate these disparities, improve health outcomes and enhance the quality of life among women from ethnic minorities (Seiler et al., 2017; Tan ; Li, 2016).
Historical Beliefs and Cultural Health Practices of the MENA Population
In the 1980s and early 1990s, a substantial number of refugees came to Canada from Middle East and North African (MENA) countries. These regions are sometimes collectively referred to as the Arab world since Arabic is widely spoken in the majority of the regions’ countries, including Lebanon, Egypt, Iraq, Somalia, Syria, Sudan, United Arab Emirates, Saudi Arabia, Libya, Tunisia, Maraca and Algeria (Barakat, 1993). The migration in the late twentieth century was due to political instability, conflicts, poverty and the pursuit of academic and work opportunities (Barakat, 1993). The MENA countries are home to several world religions and are both ethnically and politically diverse (Lazar, 2008). The countries have many unifying features and common characteristics, such as social behavior and relations, culture in arts (music, poetry), traditional clothing (Abiah, Hijab), food (falafel, shawarma) and architecture. However there are also some dissimilarities in their socio demographics and cultural values (Lazar, 2008).