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JOURNAL OF WOMEN’S HEALTHVolume 15, Number 5, 2006© Mary Ann Liebert, Inc.

Health Beliefs and Rates of Breast Cancer Screeningamong Arab Women

FAISAL AZAIZA, Ph.D., and MIRI COHEN, Ph.D.

ABSTRACT

Objectives: To examine the relationship between health beliefs and participation in breastcancer screening among Arab women in Israel.

Methods: A random sample of 568 Arab women, aged 20–60, belonging to three religiousgroups, Muslim, Christian, and Druze, was recruited. Participants answered a telephone ques-tionnaire regarding attendance for mammography screening and clinical breast examination(CBE) and health beliefs.

Results: Christian women had undergone more mammography screening and CBE thanDruze and Muslim women. They perceived more benefits and fewer barriers to screeningpractices and had greater perception of the severity of breast cancer. Perception of suscepti-bility was similar across groups. The barriers that were significant for the Druze and Mus-lim women were feelings of discomfort and embarrassment, the belief that there was no curein the case of a positive finding, perceiving mammography as hazardous to health, and per-ceiving CBE as painful. Logistic regression revealed that age, group, and having a first-de-gree relative with breast cancer predicted participation in early detection screening. Physi-cian’s recommendation predicted mammography, and level of participants’ religiositypredicted CBE.

Conclusions: Diversity in health beliefs and behaviors exists in religious subgroups. Healthcommunications should be modified to suit women in different groups in order to increaseparticipation in screening. In addition, physicians have to be made keenly aware of their piv-otal role in motivating women to participate in early detection screening.

INTRODUCTION

BREAST CANCER IS THE MOST COMMON invasivecancer in women, with more than 1 million

cases and nearly 600,000 deaths occurring world-wide annually.2 In Israel, some 3500 new cases and1000 deaths occur annually.1 Early detection ofbreast cancer in women through regular screeningmethods has been shown to decrease mortality.3–5

Early detection guidelines in Israel include clinical

breast examination (CBE) by a physician begin-ning at age 20 and mammography screening onceevery 2 years for average-risk women aged 50–74years and yearly for high-risk women aged �40.6

Nevertheless, high-risk women �40 years and av-erage-risk women �40 years are often referred tomammography screenings, as is the case with theAmerican Cancer Society (ACS) guidelines.7

Studies in western countries have found thatethnic minority groups are more likely to be di-

School of Social Work, Faculty of Health and Welfare Studies, University of Haifa, Haifa, Israel.This study was supported by grant 20040014-c from the Israel Cancer Society.

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agnosed with advanced-stage disease and largetumors and, hence, have higher mortality rates.8

This often reflects lower use of early detectionscreening.9–14 Subsequent to national programsdesigned to increase mammography screening bywomen, the percentage of women participatingin mammography has risen.4,15 In the UnitedStates, the rise was among white women, notblack women,16 although the rate of attendancefor early detection screening among minoritygroups is growing.8 This is mainly an outcome ofhealth providers’ efforts8 but has also been foundto be related to acculturation and modernizationprocesses, namely, the adoption of western atti-tudes toward health and prevention.13

The lower use by minority groups of early de-tection screening could be attributed to distanceand clinic inaccessability, unfamiliarity with thespoken language, lack of resources, and less ex-posure to health communications.9,12 Other stud-ies stress cultural factors, such as distrust of west-ern medicine, as well as a fatalistic view of healthand illness.9

Researchers found that a physician’s recom-mendation for mammography was strongly re-lated to mammography use,16–19 but recommen-dations tend to be given less frequently tominority or low-income women.12

Arab women in Israel, breast cancer incidence,and early detection

The Arab population in Israel constitutes 19.3%of the general population, of which Arab womenaged 20–60 comprise 4.3%. The Arab populationconsists of several religious groups (Muslims82.4%, Christians 8.9%, Druze 8.5%, and others).2

These groups speak the same language and sharesome likeness in historical background, culturalnorms, and values; some live in mixed commu-nities consisting of two or three of the sub-groups.20–23 Their society is more conservativeand religious than Jewish secular society in Is-rael,24,25 yet there is evidence that the Arabs liv-ing in Israel are undergoing major modernizationprocesses resulting from increasing urbanization,more education for men and women, more wo-men working outside the home, and greater useof health and other services.24 Arabs are under-going a transition from traditionalism to mod-ernization, although its pace differs among thethree subgroups.26 Christian Arab women expe-rience a faster rate of change toward moderniza-

tion than Muslim and Druze women as a resultof various factors. In particular, more ChristianArabs live in urban areas and are closer to andmore involved with the Jewish secular popula-tion, whereas more of the Muslims and Druze livein villages and maintain traditional ways of liv-ing.26,27

The incidence of breast cancer is considerablylower in Arab women than in Jewish women inIsrael and in women in western countries.28 Still,the incidence increased in Arab women in Israelby 93.7% from 1970 to 1995, compared with anincrease of only 31.7% among Israeli Jewish wo-men over the same period; the gap is narrowing.29

In those years, too, death from breast cancer in-creased by 12% in the Jewish female populationbut by 50% among Arab women.29 Survival ratesfrom breast cancer are notably lower among Arabwomen (63% compared with 71% in Jewish wo-men); this is attributed to diagnosis of the illnessat a later stage.30,31 Recent surveys report thatJewish women attend mammography screening1.2–2 times more than do Arab women.29,32 Thedifference tends to decrease in women aged50–75, to whom a national project offers mam-mography free of charge.6

Petro-Nustus and Mikhil33 investigated breastself-examination (BSE) among Arab women inJordan and found that about only a quarter ofthem practiced it and only 7% of them did so ona regular monthly basis. Also, Middle Eastern-born and Asian-born women living in Australiawere found to perform far fewer early detectionpractices than women born in western coun-tries.34 It has been reported previously that theArab population in Israel in general,35 and Arabwomen especially,36 make less use of medical ser-vices and do not frequently undergo examina-tions for the purpose of illness prevention, in con-trast to the Jewish population.

Health beliefs and seeking early breast cancer detection

The health belief model,37 adjusted to includeunderstanding early detection screening forbreast cancer,38,39 proposes that the likelihood ofappearing for screening depends on perceptionsof the severity of the illness, of one’s susceptibil-ity, of benefits accruing from the examination(e.g., the chances of detecting the illness at anearly stage, thereby preventing death), and ofbarriers to performance (e.g., it is painful, time

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consuming), as well as general health motiva-tion.39–41 Health beliefs may be affected by de-mographic factors, such as age34 and ethnicity,13

and such personal factors as having a first-degreerelative affected by breast cancer.42 Women witha family history of breast cancer have greater per-ceptions of susceptibility,42,43 which was found tobe related to attending detection screening ear-lier.42

To date, links between health beliefs and par-ticipation in breast cancer screening have notbeen studied or compared in different culturalminority groups that are transitioning from tra-ditionalism to modernization in various ways.The aim of this study was to reveal patterns ofearly detection practices among Arab women ofthree different religious groups and to determinethe effects of demographic background andhealth beliefs on those patterns.

MATERIALS AND METHODS

Participants and procedure

The present study is descriptive and compara-tive. It is part of a larger population-based studyaimed at detecting early breast cancer screeningpatterns among Israeli women.

The eligibility criteria included women aged20–60 years and excluded women with past can-cer diagnosis. Participants were 568 Arab womenliving in Israel; of these, 436 were randomly sam-pled from the total Arab population by means ofa random digit dialing method. The names of theother 132 women (80 Christians and 52 Druze)were randomly drawn from the university data-bases of respondents to previous surveys; thisdatabase sampling was undertaken to increasethe number of Christian and Druze women. Allthe women were contacted by telephone. The re-sponse rate in the random sample was 69% (436women agreed to take part in the telephone sur-vey, and 196 refused). In the database sample, theresponse rate was 70.5% (132 women agreed toparticipate, and 55 refused). For the women ap-proached through random digit dialing, a clustersample design was used in which householdswere selected and one woman was randomly cho-sen from the eligible women in each household.With those approached through the existing data-base, the sampling was on an individual basis.The demographic characteristics of the two sam-

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TABLE 1. COMPARISON OF RANDOM

AND DATA-BASED SAMPLES

Population-based Data-basedsample sample

Agea 38.4 (10.6) 38.9 (9.6)Educationa 10.5* (4.1) 12.4 (4.0)Economic statusa 2.7 (0.9) 2.7 (0.8)Marriedb 375 (86.0) 118 (89.4)Has first-degree relative 16 (3.7) 6 (4.5)

with breast cancerb

aMean (SD).bn (%)*p � 0.01.

ples were compared (Table 1). The only signifi-cant difference between the samples was in meanyears of education (t(566) � �4.3; p � 0.01), likelydue to the higher proportion of Christian women.In the absence of other significant differences, thetwo samples could be treated as one. The ques-tionnaire was translated into Arabic by expertsusing the back translation method, and contentvalidity was verified by three professionals.

Instruments

Demographic details included age, family sta-tus, education, employment, perceived economicstatus, level of religiosity, and having a first-de-gree relative with breast cancer.

Participation in early breast cancer screening,included questions on the regularity and fre-quency of mammography and CBE and physi-cian’s recommendation of mammography andCBE. A very small number of women recalled aphysician’s recommendation for CBE, so thesedata were not further analyzed.

The Health Beliefs Questionnaire were adaptedfrom Champion’s health belief model (HBM).38,39

In these studies, the reliability and validity of thequestionnaire were examined and found satis-factory. Internal reliability (�) of the question-naire in Champion’s study38 was 0.93. We ren-dered the questionnaire into Arabic by backtranslation, and its contents were reviewed bythree professionals. It consisted of five subscales:(1) Perceived susceptibility to breast cancer wasassessed by two items eliciting self-perceived sus-ceptibility (1, a very low chance, to 5, a very highchance) and self-susceptibility in relation to thegeneral population (1, much lower than the gen-eral population, to 5, much higher than the gen-

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eral population). (2) Perceived severity was a one-item question asking for a rating of the severityof breast cancer, from 1, not serious at all, to 5,very serious. (3) The benefits of mammographyand CBE were sought through five items each, re-ferring to self-assurance, reduced worry, benefitsfor the family, and better chances of survival incase of a positive result. Internal consistency (�)was 0.92 for mammography and 0.88 for CBE. (4)Barriers to mammography and CBE were eachmeasured by seven items, referring to time, avail-ability, costs, being painful, being embarrassing,causing anxiety, and possible harm to health. In-ternal consistency (�) was 0.90 and 0.87, respec-tively. (5) Five items measured health motivation,referring to degree of engagement in activities de-signed to improve or maintain health, physicalexercise, balanced diet, and regular checkups. In-ternal consistency (�) was 0.73. Answers to sub-scales 3, 4, and 5 ranged from 1, strongly agree,to 5, strongly disagree.

Data analysis

Descriptive statistics were used to assess dif-ferences among the groups in demographic, earlydetection screening, and health beliefs variables.Due to age differences among groups, chi-squareresults are presented separately for respondentsaged 20–40 and 41–60. For health beliefs, multi-variate analysis of variance (MANOVA) wasused, followed by univariate analysis and Scheffepost-hoc test. In addition, analysis of covariance(ANCOVA) was implemented, with age enteredas a covariate. Multiple stepwise logistic regres-sion, backward procedure, assessed the predic-tive value of the independent variables on mam-mography screening (done during the preceding5 years vs. done �5 years before or never done)and CBE (done during the preceding 2 years vs.less frequently or never). Independent variablesincluded demographic variables, age, group(Muslim, Christian, Druze), proximity to mam-mography unit (no mammography unit, mam-mography unit in the town, or mobile mammog-raphy unit reaches place of residence), and typeof community (Arab village, Arab town, mixedJewish/Arab town). Economic status and educa-tion were not associated with early detectionpractices, so they were not entered into the lo-gistic regression analyses: incentive factors (hav-ing a first-degree relative ill with breast cancerand, for mammography only, physician’s recom-

mendation) and health beliefs. Levels of signifi-cance are shown in the tables. A probability levelof 0.05 was accepted as significant.

RESULTS

Demographic characteristics of Muslim, Christian,and Druze women

Of the participants, 305 (53.7%) were Muslims,159 (28.0%) were Christians, and 104 (18.3%) wereDruze; their ages were from 20 to 60 years. Themean age of the Christian women (M 41.6, SD10.3) was significantly higher than that of theMuslim and Druze women (M 37.4, SD 10.1, andM 37.0, SD 10.1, respectively) (F(2, 565) � 10.1,p � 0.001). The Christians had on average 3.3 (SD1.4) children, compared with 4.2 (SD 1.8) for theMuslims and 4.1 (SD 1.2) for the Druze(F(3,488) � 104.8; p � 0.001). Additional demo-graphic characteristics of the three groups areshown in Table 2. Differences between Muslim,Christian, and Druze women were significant for education (chi-square(4) � 40.3 and 49.8, respectively, p � 0.001), work outside home (chi-square(2) � 19.5 and 9.6, p � 0.01), level of religiosity (chi-square(6) � 28.6 and 38.5, respec-tively, p � 0.001), and place of living (chi-square(4) � 71.7 and 22.2 respectively, p � 0.001).Family status (chi-square(6) � 18.3, p � 0.01) andhaving a relative affected by breast cancer (chi-square(2) � 7.1, p � 0.001) were different in therespective young age groups only.

Participation in early breast cancer screening

The differences between the groups in CBE at-tendance were significant (chi-square(4) � 13.5,p � 0.01). Participation in early detection screen-ing by the Muslim, Christian, and Druze womenis shown in Table 3. More Muslim and moreDruze women than Christian women had neverappeared for CBE. In addition, more Christianwomen had annual CBE regularly.

Significantly more Christian women aged �41had undergone mammography screening thanMuslim or Druze women (chi-square(4) � 12.7,p � 0.05). Significantly more Christian womenhad been referred by their physician to havemammography screening (chi-square(2) � 7.4,p � 0.05). Significantly more Christian womenlived in large towns with mammography units,

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but mobile units reached more towns and villageswith higher rates of Druze and Arab women (chi-square(4) � 13.4, p � 0.01). Nevertheless, no dif-ference was found in the rate of mammographyattendance in relation to proximity of a mam-mography unit (chi-square(4) � 2.0, p � 0.05).

Health beliefs in Muslim, Christian, and Druze women

MANOVA was performed for health beliefvariables; the overall model proved significant(F(14,1103) � 4.02; p � 0.001). Table 4 presentsmeans (�SD) and univariate analysis of varianceresults for each of the health beliefs variables. Theunivariate analysis revealed a significant differ-ence among groups for each of the health beliefs,except for perceptions of susceptibility to the dis-ease, benefits of CBE, and health motivation. Thesubgroup of women with a first-degree relative

affected by breast cancer rated their personal sus-ceptibility higher than did women without sucha relative (M 3.1, SD 0.86; F(1,561) � 3.47, p �0.0001) but reported similar perceptions of theseverity of the disease (F(1,561) � 0.03, p �0.005). Scheffe post-hoc test revealed that for sus-ceptibility, benefits, and barriers to mammogra-phy, the differences were significant among theChristian women and the Muslim and Druze. Forperceived benefits of mammography, a signifi-cant difference was found between the Christianand Druze women only.

In the next step, differences in health beliefswere analyzed again, using ANCOVA to controlfor the effect of age. We first checked for the ef-fect of possible interactions between the groupvariable and age as covariate, but none werefound. Significant main effects for age were foundfor barriers to mammography (F(1,564) � 7.9, p �0.01) and for health motivation (F(1,564) � 9.7;

TABLE 2. DEMOGRAPHIC CHARACTERISTICS OF MUSLIM, CHRISTIAN, AND DRUZE WOMEN

Muslims Christians Druze

20–40 years 41–60 years 20–40 years 41–60 years 20–40 years 41–60 years(n � 189) (n � 116) (n � 66) (n � 93) (n � 71) (n � 33)

n % n % n % n % n % n %

Education, years0–8 19.a 10.1 77 66.4 1 1.5 21 22.6 14 19.7 26 78.89–12 115 60.8 23 19.8 21 31.8 39 41.9 36 50.7 4 12.113� 55 29.1 16 13.8 44 66.7 33 35.5 21 29.6 3 9.1

Family statusMarried 165.b,** 87.3 108 93.1 54 81.8 85 91.4 52 73.3 29 87.9Divorced 0 0 1 0.9 0 0 1 1.1 2 2.8 1 3.0Widow 0 0 3 2.6 0 0 3 3.2 2 2.8 0 0Never married 24 12.7 4 3.4 12 18.2 4 4.3 15 21.1 3 9.1

EmployedYesc 58.a,** 30.7 24 20.7 41 62.1 37 39.8 28 39.4 8 24.2No 131 69.3 92 79.3 25 37.9 56 60.2 43 60.6 25 75.8

ReligiositySecular 17.a,* 9.0 8 6.9 26 39.4 19 20.4 15 21.1 4 12.1Mildly religious 92 48.7 34 29.3 32 48.5 61 65.6 44 62.0 12 36.4Very religious 80 42.3 74 63.8 8 12.1 13 14.0 12 16.9 17 51.5

Economic statusGood 81 42.9 34 29.3 33 50.0 31 33.3 32 45.1 8 24.2Intermediate 88 46.5 64 55.2 28 42.4 50 53.8 33 46.5 20 60.6Poor 20 10.6 18 15.5 5 7.6 12 12.9 6 8.4 5 15.2

CommunityTown 19.a,* 10.1 20 17.2 33 50.0 36 38.7 2 2.8 1 3.0Village 170 89.9 96 82.8 33 50.0 57 61.3 69 97.2 32 97.0

Has a first-degree relative 2.b,*** 1.1 5 4.3 6 9.1 5 5.4 2 2.8 2 6.1with breast cancer

aSignificant differences between the Muslim, Christian, and Druze in both age groups.bSignificant differences between the Muslim, Christian, and Druze in the young age group.cIncludes students.*p � 0.01; **p � 0.001.

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p � 0.01), with younger women perceivinggreater barriers and reporting greater health mo-tivation. Then, when controlling for age, benefitsof CBE proved significantly different amonggroups (F(2,564) � 2.1, p � 0.01).

The barriers to CBE and mammographyscreening were further analyzed, usingMANOVA, to assess whether the specific barri-ers differed (Table 5). The overall model provedsignificant (F(14,1101) � 3.21, p � 0.001). Regard-ing barriers to CBE, univariate analysis revealedsignificant differences in feelings of discomfort,that the examination was painful, and the notionthat there was no cure in the case of a positive re-sult. For mammography, differences were foundin the barriers stemming from the belief that there

was no cure and that the procedure was haz-ardous to health. Scheffe post-hoc test revealedthat Christian women reported lower barriersthan Muslim or Druze women. Differences in per-ceptions of barriers were again analyzed bymeans of ANCOVA to control for the effect ofage. First, a significant interaction between ageand group was found for perception of CBE aspainful (F(2, 562) � 3.8, p � 0.05), namely, moreyounger Druze and Muslim women tended toperceive CBE as painful. When age was con-trolled for, the differences in perception of mam-mography as causing feelings of discomfort andembarrassment became significant (F(3,564) �4.70; p � 0.01). Age main effects were found forthe belief that there was no cure in the case of a

TABLE 3. EARLY DETECTION SCREENING AMONG MUSLIM, CHRISTIAN, AND DRUZE WOMEN

Druze Christian Muslim

% n % n % n

Frequency of clinical BEa

Once a year 12.5 13 22.1 35 16.4 50Once in 2 or 3 years 21.1 22 33.9 54 17.7 54Never 66.4 69 44.0 70 65.9 201

Frequency of mammographyb

In preceding 1–2 years 18.2 6 40.9 38 28.4 333–4 years earlier 9.1 3 19.3 18 13.8 16�5 years before or never 72.7 24 39.8 37 57.8 67

Physician’s recommendationb

Yes 33.3 11 48.4 45 30.2 35Proximity to mammography unitb

Living in town with mammography unit 0 0 10.8 10 2.6 3Living in a town/village with no unit 48.5 16 31.2 29 28.4 33Mobile unit reaches town/village 51.5 17 58.0 69.0 80

aMuslim women: n � 305; Christian women: n � 159; Druze women: n � 104.bOnly for women �41 years (Muslim women: n � 116; Christian women: n � 93; Druze women: n � 33).

TABLE 4. HEALTH BELIEFS AMONG MUSLIM, CHRISTIAN, AND DRUZE WOMEN

Druze Christians Muslims

Variable M SD M SD M SD F (2,564)

Susceptibility 2.58 1.20 2.74 0.82 2.73 0.83 0.83Severity 1.75 0.96 1.95 0.83 1.76 0.85 3.95*,a

Benefits (CBE) 3.61 0.79 3.87 0.67 3.68 0.75 2.37Barriers (CBE) 1.72 0.81 1.52 0.78 1.78 0.84 5.21**,b

Benefits (mammography) 4.27 0.61 4.48 0.67 4.24 0.67 4.31*,a

Barriers (mammography) 2.94 0.93 2.10 0.77 2.40 0.73 15.75***,a

Health motivation 2.6 1.5 3.0 1.5 2.6 1.5 2.31

aSignificant difference between Christian vs. Muslim and Druze women.bSignificant difference between Christian and Druze women.*p � 0.05; **p � 0.01; ***p � 0.001.

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positive result (F(1,564) � 5.4, p � 0.05) and forfeelings of discomfort as a barrier to having CBE(F(1,564) � 4.4, p � 0.05).

Variables associated with attending for early detection

Table 6 shows the results of the logistic re-gression analyses, including the odds ratios (ORs)and their corresponding confidence intervals

(CIs) and the model’s chi-square. Both mam-mography screening and CBE were predicted by age (Wald chi-square(1) � 6.41, p � 0.001, and Wald chi-square(1) � 3.90, p � 0.05, respec-tively), belonging to the Christian subgroup(Wald chi-square(2) � 10.21, p � 0.01, and Waldchi-square(2) � 9.70, p � 0.01, respectively), hav-ing a first-degree relative (Wald chi-square(2) �13.47, p � 0.001, and Wald chi-square(2) �4.09, p � 0.05, respectively), and barriers (Wald

TABLE 5. BARRIERS TO EARLY DETECTION SCREENING AMONG MUSLIM, CHRISTIAN, AND DRUZE WOMEN

Druze Christians Muslims

Variable M SD M SD M SD F (2,564)

Barriers to CBEFeels uneasy and ashamed 2.11 1.65 1.57 1.16 1.88 1.43 4.82**,a

Availability difficulties 1.1.59 1.23 1.48 1.11 1.54 1.46 1.43Painful 1.38 0.93 1.21 0.79 1.54 1.05 5.30**,b

Afraid to find a lump 1.69 1.36 1.76 1.38 1.72 1.26 0.92No cure 2.25 1.59 1.74 1.13 2.24 1.35 8.08***,c

Barriers to mammographyFeels uneasy and ashamed 2.40 1.79 1.91 1.34 2.24 1.56 1.93Availability difficulties 1.91 1.61 1.75 1.11 1.88 1.26 0.96Painful 1.86 1.37 2.10 1.41 1.90 1.35 0.41Afraid to find a lump 2.18 1.68 2.08 1.53 2.06 1.44 0.80No cure 2.29 1.61 1.67 1.11 2.29 1.41 11.48***,c

Expensive 1.79 1.35 1.55 1.05 1.74 1.16 1.49Hazardous to health 3.08 1.56 1.95 1.21 2.28 1.33 20.59***,a

aSignificant difference between Christian and Druze women.bSignificant difference between Christian and Muslim women.cSignificant difference between Christian vs. Muslim and Druze women.*p � 0.05; **p � 0.01; ***p � 0.001.

TABLE 6. LOGISTIC REGRESSION ANALYSIS PREDICTING EARLY DETECTION PRACTICES

BEa Mammographyb

Variable 95% CI OR 95% CI OR

Age 1.05–1.63 1.03* 1.03–1.21 1.12*Group: Christian 1.35–8.65 3.42** 1.68–6.80 3.32*Group: Muslim 0.46–2.41 1.05 0.72–2.79 0.45Religiosity 1.29–2.14 1.98* 0.28–1.46 0.64First-degree relativec 0.88–5.44 2.19* 1.17–2.75 1.72*Physician’s recommendationc — — 3.90–27.67 10.39***Susceptibility 0.75–1.43 1.04 0.29–1.06 0.56Severity 0.75–1.54 1.08 0.38–1.33 0.72Benefits 0.57–1.06 0.78 0.49–1.92 0.97Barriers 1.05–2.22 1.52* 1.11–4.87 3.79*Health motivation 0.78–1.33 1.02 0.81–1.94 1.26Model chi-square (df) 23.25 (8)** 46.89 (9)***

aDone in the preceding 2 years vs. done less frequently or never.bEver done vs. done � 5 years before or never.cCategorical variable: 0 � no; 1 � yes.*p � 0.05; **p � 0.01; ***p � 0.001.

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chi-square(1) � 3.71, p � 0.05, and Wald chi-square(1) � 6.51, p � 0.05, respectively). In addi-tion, mammography screening was significantlypredicted by physician’s recommendation (Waldchi-square(1) � 21.93, p � 0.001), and lower reli-giosity predicted CBE attendance (Wald chi-square(1) � 4.40, p � 0.05). For mammography,the variables education, economic status, reli-giosity, type of community, and proximity of res-idence to mammography unit did not enter theequation. For CBE, variables not in the equationwere education, economic status, and type ofcommunity.

DISCUSSION

This study indicates that women of the Mus-lim, Christian, and Druze communities, whichconstitute the three major religious subgroups ofIsraeli Arabs, differ in rate of attendance for earlydetection of breast cancer and in perceptions ofthe benefits and barriers to screening. Christianwomen reported higher attendance rates at mam-mography and CBE, perceiving more benefitsfrom and lower barriers to these screenings.

Previous studies usually treated Arab womenas a single group,29,44 an approach that concealsthe significant differences among them. Severalfactors can explain the differences in the threegroups with respect to screening. Regardingmammography, more Muslim and Druze womenreported not receiving a physician’s recommen-dation. In the present study and in previous re-ports,17–19 physician’s recommendation was astrong and consistent predictor of having mam-mography, so its absence partially accounts forthe lower rate of attendance in these two groups.As previously shown, physicians seem to be in-fluenced in recommending or not recommendingmammography by various demographic charac-teristics of women patients, such as family status,level of education, and income.16 They are lesslikely to recommend it to women who they thinkwill not accept the advice or will not be able toappear for mammography because of cost and ac-cessibility barriers45,46 or considerations of mod-esty.47 Accordingly, there may be a tendency torecommend mammography less to Muslim andDruze women because of physicians’ perceptionof greater religiosity and conservatism as barri-ers. Also, physicians are less likely to impart in-formation to patients they perceive to be differ-

ent from themselves (in social class, ethnicity,gender, or age).47 Another explanation for thelower attendance by Muslim and Druze womenmay be their perception of fewer benefits fromand greater barriers to mammography screeningand CBE, as revealed in the present research.These perceptions were found related to lower at-tendance in this and previous studies.41,48 As theresults were controlled for age differences amonggroups, the effect of physician’s recommendationand health beliefs was still significant for pre-dicting early detection behaviors. Although in thepresent study accessibility and availability didnot account for differences in attendance, otherfactors related to delivery of health services maystill reflect the disparities between them. Thesecould be fewer Arabic-language health promo-tion projects, the lower number of Arab physi-cians and women physicians, or the limited useof Arabic. These factors may also affect the healthbeliefs. As these factors can be modified, healthproviders and health policymakers should paymore attention and allocate more resources to re-ducing their adverse impact.

The groups did not differ in their perceptionsof barriers related to time and cost. However, thedifference between the Christian women and theMuslim and Druze women in barriers concern-ing feelings of discomfort and embarrassmentand the belief in no cure in the case of a positiveresult may be understood in light of traditionalcultural and religious beliefs.49 The more reli-gious an Arab women is, the more she believesthat an illness is God’s will, which modern med-icine cannot change.37,50 In addition, modesty isrigorously maintained by women of traditionalArab society. Exposure of the body, especially thebreast, is perceived as a violation of modesty andmay arouse feelings of discomfort and embar-rassment,47 thus fostering avoidance of screening.

Level of religiosity accounted for low atten-dance at CBE screening but had no significant ef-fect on mammography screening. CBE involvesan invasion of a woman’s privacy and is usuallyperformed by a male physician (unlike mam-mography, usually administered by female tech-nicians). CBE thus causes greater feelings of em-barrassment, which might explain why religiouswomen avoid it more than mammography.

Modernization processes and their effect onhealth beliefs and practices are manifested in thedifferences found among the three groups. TheChristians generally reside in urban communi-

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ties, often in mixed Jewish/Arab towns; they usu-ally have more years of schooling and attainhigher levels of education than the Muslims andthe Druze.51 Accordingly, they are more influ-enced by modernization processes and by west-ern perceptions. Several aspects of modernizationmay exert effects on health beliefs and behaviors,such as a growing sense of individualism, sharperawareness of the future, and higher perceptions ofcontrol over the course of life and of active mea-sures to preserve health.51,52 For women, mod-ernization processes also involve more educationand more participation in the labor force,53 whichcreate openness to the media and receptivity tohealth knowledge as well as easier access tohealth services. The more pragmatic quality ofmodernization may also be responsible for thedifferences in attending early detection screening.Among them are a lower language barrier, closerproximity, and accessibility of health facilities,12

and, as mentioned, greater likelihood of receiv-ing a physician’s recommendation.16,45–47

Modernization processes affect people’s healthpositively and negatively. However, researchconsistently points to the effectiveness of screen-ing for early detection of breast cancer in better-ing the chances of survival. Mass health commu-nications to increase attendance for earlydetection should be modified to the Arab popu-lation, especially Muslim and Druze women.These efforts should focus on reducing culturalbarriers. The message should be careful not to runcounter to cultural beliefs (such as faith in God)but to augment them with the idea of each per-son assuming responsibility for her health.47

Health providers should be equally aware of andsensitive to the modesty requirements of women.

Another conclusion from the present study re-lates to physicians’ awareness of their pivotal rolein motivating women to attend regular early de-tection screening in accordance with their age andlevel of risk factors. This should be done in keep-ing with the particular culture. Screening exami-nations must always be recommended for all wo-men, but with the necessary adjustments to suiteach woman’s specific cultural and religious re-quirements. Physicians must apply culturallysensitive interventions that will not offend tradi-tional Arab women.

This study had several limitations. First, themean age differed in the three groups, and thiscould have affected the results. Age was con-trolled in the statistical analysis, but homogeneity

of the groups in age might contribute to the gen-eralizability of results. In addition, the study pop-ulation consisted of two differently sampledgroups (i.e., the random sample and samplingfrom an existing database). This was done to in-crease the number of Christian and Druze women.Although we demonstrated the similarity in mostdemographic characteristics between the differ-ently recruited women, caution should be exer-cised on this issue.

Another concern is the telephone survey. Itgrants access to a large number of women ran-domly selected, thus overcoming the bias of sam-pling from populations more easily approached.The drawback of a telephone survey is the diffi-culty in controlling for the validity and reliabil-ity of self-reports. A recent study, however,showed high, albeit not complete, concordancebetween self-reports and medical documentationregarding attendance for medical procedures.54

Still another concern is the inclusion of womenaged 41–60 in one group. Free mammography isoffered to all Israeli women over age 50, whereaswomen in the 40–49-year-old age group have topay for the screening. Thus, women of lower eco-nomic status may have less accessibility to theservice. This difference may influence attendancerates and their correlates. However, in the pres-ent study, economic status was not associatedwith any of the early detection practices.

Despite the foregoing limitations, this is thefirst study to explore participation in breast can-cer screening in culturally close subgroups expe-riencing different modernization processes. It of-fers an initial picture of the impact on women’shealth beliefs and behaviors.

REFERENCES

1. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancerstatistics. CA Cancer J Clin 2005;55:74.

2. Central bureau of statistics. Jerusalem: StatisticalYearbook of Israel. 2004.

3. de Koning HJ. Mammographic screening: Evidencefrom randomized controlled trials. Ann Oncol2003;14:1185.

4. Kerlikowske K, Grady D, Rubin SM, Sandrock C, Ern-ster VL. Efficacy of screening mammography: A meta-analysis. JAMA 1995;273:149.

5. Tabar L, Vitak B, Chen HHT, Yen MF, Duffy SW,Smith RA. Beyond randomized controlled trials: Organized mammographic screening substantiallyreduces breast carcinoma mortality. Cancer 2001;91:1724.

AZAIZA AND COHEN528

6174_10_p520-530 6/9/06 11:22 AM Page 528

23. Smooha S. Class, ethnic, and national cleavages anddemocracy in Israel. In: Sprinzak E, Diamond L, eds.Israeli democracy under stress. Boulder, CO: LynneRienner Publishers, 1993:309.

24. Azaiza F. Patterns of labor division among Palestinianfamilies in the West Bank. Global Dev Stud 2004;3:201.

25. Azaiza F, Brodsky J. Changes in the Arab world andthe development of services for Arab elderly in Israelduring the last decade. J Gerontol Soc Work 1996;27:37.

26. Lavee Y, Katz R. Division of labor, perceived fairness,and marital quality: The effect of gender ideology. JMarriage Fam 2002;64:27.

27. Ben-Ari, A, Lavee, Y. Cultural orientation, ethnic af-filiation, and negative daily occurrences: A multidi-mensional cross-cultural analysis. Am J Orthopsychi-atry 2004;74:102.

28. Israel National Cancer Registry. Survival of breastcancer patients in Israel. Jerusalem: Israel Ministry ofHealth, 2000.

29. Ifrah A. Women’s health in Israel, 1999–2000. IsraelCenter for Disease Control (ICDC). Publication No.219. Jerusalem: Israel Center for Disease Control,2000:55.

30. Israel National Cancer Registry. Survival of breastcancer patients in Israel. Jerusalem: Israel Ministry ofHealth, 2000.

31. Nisan A, Spira RM, Hamburger T, et al. Clinical pro-file of breast cancer in Arab and Jewish women in theJerusalem area. Am J Surg 2004;188:62.

32. Green M, Keinan-Boker L. Women’s health. Nationalhealth survey in Israel. Publication No. number 237.Jerusalem: Israel Center for Disease Control (ICDC),2004.

33. Petro-Nustus W, Mikhil BI. Factors associated withbreast self-examination among Jordanian women.Public Health Nurs 2002;9:263.

34. Siahpush M, Singh GK. Sociodemographic variationsin breast cancer screening behavior among Australianwomen: Results from 1995 National Health Survey.Prev Med 2002; 35:174.

35. Purple M, Yoval DJ. Jews’ and Arabs’ perception ofthe health system two and a half years after the im-plementation of the official health insurance law.Jerusalem: The National Center for the Investigationof Health Services and Health Policies (Hebrew),1999.

36. Elnekave E, Gross R. The healthcare experiences ofArab Israeli women in a reformed healthcare system.Health Policy 2004;69:101.

37. Becker HM. The health belief model and personalhealth behavior. Thorofare, NJ: Charles B. Slack, 1974.

38. Champion VL. Instrument development for thehealth belief model constructs. Adv Nurs Sci 1984;6:73.

39. Champion VL. Revised susceptibility, benefits, andbarriers scale for mammography screening. Res NursHealth 1999;22:341.

40. Ashton L, Karnilowicz W, Fooks D. The incidence andbelief structures associated with breast self-examina-tion. Soc Behav Pers 2001;29:223.

6. Israel Cancer Society. National Oncology Councilguidelines for early detection of cancer. Tel Aviv: Is-rael Cancer Association, 2005. Available at www.can-cer.org.il/default.asp?url�template/default.asp?maincat�4 Accessed August 11, 2005.

7. Smith RA, Cokkinides V, Eyre HJ. American CancerSociety guidelines for the early detection of cancer,2005. CA Cancer J Clin 2005;55:31.

8. Ghafoor A, Jemal A, Ward E, et al. Trends in breast can-cer by race and ethnicity. CA Cancer J Clin 2003;53:342.

9. Frisby CM. Messages of hope: Health communica-tions strategies that address barriers preventing blackwomen from screening for breast cancer. J Black Stud2002;32:489.

10. Hiatt RA, Pasick RJ. Unsolved problems in earlybreast cancer detection: Focus on the underserved.Breast Cancer Res Treat 1996;40:37.

11. Nerbs MV, Mark HF. Breast cancer among Asian wo-men. Med Health RI 1996;79:388.

12. O’Malley MS, Earp JA, Hawley ST, Chell MI, Math-ews HF, Mitchell J. The association of race/ethnicity,socioeconomic status, and physician recommendationfor mammography: Who gets the message aboutbreast cancer screening? Am J Public Health 2001;91:49.

13. Tang TS, Solomon LJ, Yeh CJ, Worden JK. The role ofcultural variables in breast self-examination and cer-vical cancer screening behavior in young Asian wo-men living in the United States. J Behav Med 1992;22:419.

14. Wilcox LS, Mosher WD. Factors associated with ob-taining health screening among women of reproduc-tive age. Public Health Rep 1993;108:76.

15. Steadman L, Rutter DR, Field S. Individually elicitedversus modal normative beliefs in predicting atten-dance at breast screening: Examining the role of be-lief salience in the theory of planned behavior. Br JHealth Psychol 2002:7:317.

16. Coleman EA, O’Sullivan P. Racial differences inbreast cancer screening among women from 65 to 74years of age: Trends from 1987–1993 and barriers toscreening. J Women Aging 2001;13:23.

17. Friedman LC, Neef NE, Webb JA. Early breast cancerdetection behaviors among ethnically diverse low-in-come women. Psychooncology 1996;5:283.

18. Lerman C, Rimer BK, Trock B, Balshem A, EngstromPF. Factors associated with repeat adherence to breastcancer screening. Prev Med 1990;19:279.

19. Rimer BK. Understanding the acceptance of mam-mography by women. Ann Behav Med 1992;14:197.

20. Florian V, Mikulincer M, Weller A. Does culture af-fect perceived family dynamics? A comparison ofArab and Jewish adolescents in Israel. J Comp FamStud 1993;24:189.

21. Haj-Yahia M. Culturally sensitive supervision of Arabsocial work students in Western universities. SocWork 1997;42:166.

22. Lavee Y, Ben-Ari A. Daily stresses and uplifts duringtimes of political tension: Jews and Arabs in Israel.Am J Orthopsychiatry 2003;7:65.

BREAST CANCER SCREENING AND ARAB WOMEN 529

6174_10_p520-530 6/9/06 11:22 AM Page 529

AZAIZA AND COHEN530

41. Champion VL, Miller TK. Variables related to breastcancer self-examination. Psychol Women Q 1992;16:81.

42. Cohen, M. First-degree relatives of breast-cancer pa-tients: Cognitive perceptions, coping and adherenceto breast self-examination. Behav Med 2002;28:15.

43. Finney LJ, Iannotti RJ. The impact of family historyof breast cancer on women’s health beliefs, salienceof breast cancer family history, and degree of in-volvement in breast cancer issues. Women Health2001;33:15.

44. Baron-Epel O, Granot M, Badarna S, Avrami S. Per-ception of breast cancer among Arab Israeli women.Women Health 2004;40:101.

45. Grady KE, Lemkau JP, Lee NR, Caddell C. Enhanc-ing mammography referral in primary care. Prev Med1997;26:791.

46. Weinberger M, Saunders AF, Samsa GP, et al. Breastcancer screening in older women: Practices and bar-riers reported by primary care physicians. J Am Geri-atr Soc 1991;39:22.

47. Rajaram SS, Rashidi A. Asian-Islamic women andbreast cancer screening: A sociocultural analysis. Wo-men Health 1999;28:45.

48. Erblich J, Bovbjerg DH, Valdimarsdottir HB. Psycho-logical distress, health beliefs, and frequency of breastself-examination. J Behav Med 2000;23:277.

49. Leininger M. Overview of Leininger’s culture caretheory. In: Transcultural nursing: Concepts, theories,

research and practices. New York: McGraw-Hill,1995:93.

50. Zahr L, Hattar-Pollara M. Nursing care of Arab chil-dren: Consideration of cultural factors. J Pediatr Nurs1998;13:349.

51. El-Ghannam AR. Modernization in Arab societies:The theoretical and analytical view. Int J Sociol SocPolicy 2001;21:99.

52. Chirot D. Social change in the modern era. New York:Harcourt Brace Jovanich, 1986.

53. Haj-Yahia M. Wife abuse and battering in the socio-cultural context of Arab society. Fam Process2000;39:237.

54. Gordon NP, Hiatt RA, Lampert DI. Concordance ofself-reported data and medical record audit for sixcancer screening procedures. J Natl Cancer Inst1993;85:566.

Address reprint requests to:Faisal Azaiza, Ph.D

School of Social WorkHaifa University

Mount CarmelHaifa 31905

Israel

E-mail: azaiza@research.haifa.ac.il

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