Mammogram Screening Among Arab American Women

By Sarah Alkhaifi-Gonzalez. RN. WHNP. PhDc.

Since 2007, I have been working as a nurse and women’s health nurse practitioner in Saudi Arabia and the United States. This experience has made me question a variety of women’s behaviors toward preventive health.¹ Many complicated health problems could be prevented by adhering to secondary screenings. As a nurse, my responsibility is not limited to providing health care; it extends to utilizing scientific research to facilitate women’s use of secondary screening, particularly mammograms.

Breast cancer is the most common cancer afflicting women worldwide.² In 2012, there were 1.7 million women with breast cancer around the world.³ Despite the health risk of breast cancer, immigrant women of ethnic minorities in the United States, such as Arab American Women (AAW), are less likely to undergo mammogram screenings.⁴ Consequently, they have a greater risk of being diagnosed with breast cancer in the advanced stages, and they have a higher mortality rate than nonimmigrant women.⁵

Low breast cancer screening attainment among AAW has resulted from two sets of factors. First, health practices and beliefs in their countries of origin, such as breast cancer stigma; religious beliefs (e.g., fatalism); political conflicts; exposure to physiological stressors associated with war, health literacy, health beliefs, women’s image and status, family responsibilities; and health infrastructure all have an impact on screening rates. Second are immigration-related factors. After migration to the United States, AAW have to deal with a host of different factors that have also been found to influence their breast cancer screening utilization, such as immigration status, understanding and navigating a new health care system, language barriers, financial instability, discrimination in health care settings, and social isolation.⁶

Another factor that may affect AAW’s mammogram utilization is the influence of their family members, particularly that of their husbands. In Arab and Muslim cultures, the influence of husbands over their wives extends to personal matters such as health care-seeking behaviors, finances, and education.⁷ Results from the literature suggest that husbands may have a negative or a positive influence on AAW’s mammogram utilization.⁸

Compared to single AAW, married AAW could be influenced by their husbands to increase mammogram utilization.⁹ However, it is still unclear whether this increase would be due to the husband’s influence or whether it would occur because of the recommended age for mammograms, which starts at 40. In addition, if husbands play a positive role, the nature of their support from Arab women’s perspective is still unclear, as is how different forms of spousal support would influence AAW’s mammogram utilization and adherence to breast cancer screening guidelines within AAW’s sociocultural and religious contexts after immigration.

To answer these questions, I will conduct my dissertation research among married AAW living in California. This study will employ two methods. First, the quantitative part of the study is a cross-sectional design aimed to (a) investigate how AAW’s health beliefs, breast cancer and mammogram knowledge, fatalism, modesty, and husbands influence their mammogram utilization, and (b) explore the influence of AAW’s perceptions of the support received from their husbands regarding their mammogram utilization. Second, the qualitative part of the study aims to understand AAW’s experiences and their perception of the influence of their husbands in relation to mammograms, within their sociocultural context before and after immigration to the United States.

This study will explore the factors influencing AAW’s breast cancer screening utilization from interpersonal and familial perspectives, including understanding spousal influence (negative or positive) on AAW’s mammogram utilization, as well as AAW’s health practices, level of breast cancer and mammogram knowledge, and religious beliefs (fatalism and modesty). Results from this study would help to tailor an educational program for AAW and their husbands regarding breast cancer and mammograms, with the aim of increasing mammogram utilization among this minority population.

As a novice researcher in women’s health at the UCLA School of Nursing, my academic and personal reward will be to see the results from my research improve women’s preventive health practices in general, especially regarding breast-cancer screening.

Sarah Alkhaifi-Gonzalez is a PhD candidate at the UCLA School of Nursing. Her research focused on improving Arab American women adherence to secondary screenings. She is a Fall 2019 recipient of the CSW Travel Grant.

1. For this article, the term “women” is used in reference to people who are born female and identify as cisgendered heterosexual women.
2. American Cancer Society, “American Cancer Society Recommendations for the Early Detection of Breast Cancer 2017,” accessed February 4, 2019, http://www.aaiusa.org/pages/demographics/.
3. “Cost effectiveness and strategic planning (WHO-CHOICE): Eastern Mediterranean Region,” World Health Organization, 2016, http://www.who.int/choice/demography/emed_region/en/.
4. Center for Disease Control and Prevention, “ Breast Cancer Screening Guidelines for Women 2016.,” https://www.cdc.gov/cancer/breast/basic_info/screening.htm.

   Center for Disease Control, “Health, United States, 2017: With Chartbook on Long-term Trends in Health,” 314–317, https://www.cdc.gov/nchs/data/hus/hus16.pdf#056%0Ahttps://www.cdc.gov/nchs/data/hus/hus16.pdf%23listtables%0Ahttps://www.cdc.gov/nchs/data/hus/hus16.pdf%23019.

5. American Cancer Society, American Cancer Society Recommendations for the Early Detection of Breast Cancer 2017,” accessed February 4, 2019, http://www.aaiusa.org/pages/demographics/.

   Hasnain, M., U. Menon, C. E. Ferrans and L. Szalacha, “Breast cancer screening practices among first-generation immigrant muslim women,” Journal of Women’s Health (Larchmt) 23, no. 7 (2014), 602–612, http://doi.org/10.1089/jwh.2013.4569.

   Padela, A. I., S. Murrar, B. Adviento, C. Liao, Z. Hosseinian, M. Peek and F. Curlin, “Associations between religion-related factors and breast cancer screening among American Muslims,” Journal of Immigrant and Minority Health 17, no. 3 (2015), 660–669, http://doi.org/10.1007/s10903-014-0014-y.

   Reeder-Hayes, K. E., S. B. Wheeler and D. K. Mayer, “Health disparities across the breast cancer continuum,” Seminars in Oncology Nursing, 31, no. 2 (2015), 170–7, http://doi.org/10.1016/j.soncn.2015.02.005.

   Schwartz, K., M. Fakhouri, M. Bartoces, J. Monsur and A. Younis, “Mammography screening among Arab American women in metropolitan Detroit,” Journal of Immigrant and Minority Health 10, no. 6 (2008), 541–549, http://doi.org/10.1007/s10903-008-9140-8.

   Snyder, R., N. Lyon, E. Hertel, S. Moran, C. Miller, S. Lyon-Callo, C. Fussman, S. Weir and K. Hekman, “2013 Arab Behavioral Risk Factor Survey,” Michigan Department of Health and Human Services, 2013, http://www.michigan.gov/mdhhs/0,5885,7-339-71550_5104_5279_39424_39429-134736–,00.html.

6. Aboul-enein, B., “The cultural gap delivering health care services to Arab American populations in the United States,” Journal of Cultural Diversity 17, no. 1 (2010): 20-23, https://search.proquest.com/openview/642bda2425fa.

   “Cross-cutting gender issues in women’s health in the Eastern Mediterranean Region,” World Health Organization, WHO-EM/WHD/011/E/02.07/500 (2007): 1–20.

7. Donnelly, T. T., A. H. Al-Khater, S. B. Al-Bader, M. G. Al-Kuwari, M. A. A. Malik, N. Al-Meer and R. Singh, “Perceptions of Arab men regarding female breast cancer screening examinations—Findings from a Middle East study,” PLoS ONE 12, no. 7 (2017), 1–24, https://doi.org/10.1371/journal.pone.0180696.

   Elias, N., I. R. Bou-Orm and S. M. Adib, “Patterns and determinants of mammography screening in Lebanese women,” Preventive Medicine Reports 5 (2017), 187–193, https://doi.org/10.1016/j.pmedr.2016.12.015.

   Kawar, L., “Barriers to breast cancer screening participation among Jordanian and Palestinian American women,” European Journal of Oncology Nursing 17, no. 1 (2013), 88–94, http://doi.org/10.1016/j.ejon.2012.02.004.

8. Hasnain, M., U. Menon, C. E. Ferrans and L. Szalacha, “Breast cancer screening practices among first-generation immigrant muslim women,” Journal of Women’s Health (Larchmt) 23, no. 7 (2014), 602–612, http://doi.org/10.1089/jwh.2013.4569.

   Padela, A. I., S. Malik, H. Din, S. Hall and M. Quinn, “Changing Mammography Related Beliefs Among American Muslim Women : Findings from a Religiously-Tailored Mosque-Based Intervention,” Journal of Immigrant and Minority Health 21 (2019): 1–9, http://doi.org/10.1007/s10903-018-00851-9.

   Schwartz, K., M. Fakhouri, M. Bartoces, J. Monsur and A. Younis, “Mammography screening among Arab American women in metropolitan Detroit,” Journal of Immigrant and Minority Health, 10, no. 6 (2008), 541–549, http://doi.org/10.1007/s10903-008-9140-8.

9. Hasnain, M., U. Menon, C. E. Ferrans and L. Szalacha, “Breast cancer screening practices among first-generation immigrant muslim women,” Journal of Women’s Health (Larchmt) 23, no. 7 (2014), 602–612, http://doi.org/10.1089/jwh.2013.4569.

   Padela, A. I., S. Malik, H. Din, S. Hall and M. Quinn, “Changing Mammography Related Beliefs Among American Muslim Women : Findings from a Religiously-Tailored Mosque-Based Intervention,” Journal of Immigrant and Minority Health 21 (2019): 1–9, http://doi.org/10.1007/s10903-018-00851-9.

   Schwartz, K., M. Fakhouri, M. Bartoces, J. Monsur and A. Younis, “Mammography screening among Arab American women in metropolitan Detroit,” Journal of Immigrant and Minority Health, 10, no. 6 (2008), 541–549, http://doi.org/10.1007/s10903-008-9140-8.