Health Education Research Advance Access originally published online on November 30, 2006
Health Education Research 2007 22(5):665-676; doi:10.1093/her/cyl132
Beliefs, recommendations and intentions are important explanatory factors of mammography screening behavior among Muslim Arab women in Israel
1 School of Social Work, Bar-Ilan University, Ramat-Gan 52900, Israel
2 Hadassah—Hebrew University School of Public Health, Jerusalem 91120, Israel
3 Shalvata Mental Health Center, Hod-Hasharon 45100, Israel
* Correspondence to: V. Soskolne. E-mail: varda{at}vms.huji.ac.il
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Abstract |
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The rates of mammography screening by Muslim Arab women in Israel are lower compared with the general population. The current study aimed to examine factors related to screening mammography behavior among Arab women by employing components from the Health Belief Model and the Theory of Reasoned Action. Sociodemographic factors, knowledge, beliefs about breast cancer and mammography, self-efficacy, cues to action, norms and intention to perform mammography were examined as explanatory variables for mammography use. Face-to-face interviews with a random sample of 510 Muslim Arab women, aged 50–69 years, were conducted. The women had limited knowledge about breast cancer and mammography, and the rate of mammography screening behavior (at the recommended interval) was only 20%. The women who were significantly more likely to undergo mammography were those who received a recommendation from a health professional or from family/friends, perceived themselves as vulnerable to getting breast cancer, believed in the efficacy of the test, perceived it as not painful, were younger, were more educated and were only of borderline significance among those who expressed an intention to undergo mammography. The findings indicate that professional recommendation and beliefs sets are essential factors for developing effective mammography screening interventions in this unique population.
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Introduction |
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Breast cancer remains a major public health issue across the world. To facilitate its early detection and improve prognosis, mammography and clinical breast examinations are widely used [1]. Although there is controversy over effectiveness of mammography screening [2], it still remains the main screening tool, with evident data that mammography reduces breast cancer mortality by 22–35% for women aged 50 years or older [1, 3]. Nevertheless, many women remain unscreened, even where mammography is generally available [4]. Older age, lower education and income and ethnic origin were linked to lower screening behavior [5, 6]. Differences may be explained by culturally based norms, beliefs and values [6], including tendencies to give low priority to self-care in the presence of competing demands [7].
Theoretical sociocognitive models of health behavior have been extensively used to explain the determinants of behavior patterns. These frameworks attest that besides sociodemographic characteristics and knowledge, cognitive characteristics of the individual are important determinants of preventive behavior. Two of the leading conceptual frameworks, the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA), have guided studies on mammography screening.
The original HBM included constructs of perceived susceptibility, seriousness, benefits, barriers and cues to action [8], and self-efficacy (the person's perceived ability to perform the behavior) represents a later-added component [9]. The model suggests that, in addition to the effects of sociodemographic background and knowledge, the chances of performing a certain behavior increase when the person believes that she/he is susceptible, believes in the severity of the problem and its results, believes that the behavior is beneficial and that the barriers are few, feels she/he has the self-efficacy to perform the action and responds to cues to action. There is substantial empirical support for explanatory utility of the HBM for mammography screening, in particular the components of susceptibility to breast cancer and perceived benefits and barriers, but there are various cultural differences in perceived barriers or in the relative importance of the HBM components [10, 11]. Minority women feel less susceptible to cancer and exhibit specific barriers, such as fatalistic views of cancer, language barriers, culturally based embarrassment [12]. Low self-efficacy and low breast cancer knowledge [7] were important determinants of low screening mammography.
The HBM has been criticized for its emphasis on individual perceived beliefs and its relative neglect of social factors, such as social norms [13]. These were incorporated in the TRA [14]. According to the TRA, health behaviors arise from behavioral intention that is influenced by a set of attitudes toward performing a behavior along with perceptions about subjective social norms. The emphasis on norms adds a culturally based perspective of behavior, and intention includes the most proximate determinant of the behavior. Few studies of mammography screening were based on the TRA, and showed it to be a useful model [15], yet explaining more of the variance of intentions than that of actual behavior [16].
An attempt to empirically examine the utility of the two models in predicting health behavior suggested the overlap of the components of perceived severity, barriers and benefits of the HBM with behavioral attitude of the TRA, while perceived susceptibility and self-efficacy of the HBM, and group norms and behavioral intention of the TRA, do not overlap [13]. The addition of social norms to HBM components improved the effect of a mammography screening intervention [17]. Others have also recommended examining the usefulness of the HBM in combination with other theoretical frameworks [10], in particular its adaptation and examination in traditional, non-Western populations [18]. This recommendation is relevant for understanding screening behavior in the traditional population of aging Muslim Arab women in Israel.
The Arab minority in Israel comprises 19% of the population, most of them Muslims [19]. Age-adjusted incidence rates for breast cancer are consistently and significantly lower among Arab women than among Jewish women (41.25/100 000 and 96.49/100 000, respectively, in 2002 [20]), but while the incidence increased by 35% among Jewish women, it doubled among Arab women during the past 25 years [21]. The Israel Cancer Association recommends mammography every 2 years for women >50 years, and it is available to all women at this age under the free ‘basket of services’ provided via the National Health Insurance Law. Although the rates of mammography screening (in the previous 2 years) have increased in recent years, they remain lower among Arab Israeli women (49%) compared with the total population (60%) in 2001 [22]. The sociocultural context of Arab Israeli women plays a central part in their underutilization of health services [23]. Older Arab women have substantially lower education and income than Jewish women [23], live in extended family units [24] and hold traditional values and norms that stress the centrality of the family in a woman's life, which takes precedence over individual needs [25]. Many women report barriers such as feeling vulnerable when physically exposed in medical encounter and difficulties in communicating with male physicians [23].
Using the HBM as a conceptual framework, perceived barriers were the most significant components associated with mammography screening among Jewish Israeli women [26, 27]. Among Arab women, one qualitative study identified the fear that breast cancer screening may lead to cancer diagnosis, potentially preventing women from fulfilling their traditional roles, as a major barrier [28]. Yet, no studies guided by a sociocognitive theoretical framework were carried out among Arab Israeli women.
The current study attempted to extend the understanding of factors related to mammography screening behavior among Israeli Arab women by employing components from the HBM and TRA frameworks. Specifically, the objective of the study was to examine the components of beliefs, self-efficacy, cues to action and social norms related to breast cancer and mammography and intention to perform mammography, in addition to sociodemographic factors and knowledge, as explanatory variables for screening behavior.
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Sample
The participants in this cross-sectional study were Muslim Arab women, aged 50–69 years, Israeli citizens residing in one city and one large village in the central region of Israel. A random sample was selected from the voters' rolls by choosing six out of every 10 women from the list (a total of 935 women). The number of women in this sample was proportional to the size of each community. Women who reported that they had been diagnosed with breast cancer or were mentally or cognitively unable to be interviewed were excluded. The initial sample included 560 women, to allow for
10% exclusion of ineligible women or non-response. Of the 523 eligible women, 510 (97.5%) agreed to be interviewed. The sample size of 500 women was calculated to enable assessing the association between correct use of mammography and a dichotomous variable (e.g. perceived barriers) under the following assumptions: correct use of mammography is 13% in one group comprising one-third of the population and 23% in the other group (comprising two-thirds of the population), alpha is 5% in a two-sided test and the power is 80%.
Procedures
The study was approved by the municipality and local council of the two locations which provided the voters' lists and by the Human Subjects Ethical Committee of Hadassah Medical Center. The data were collected in 2001 by female Arab interviewers, using a structured questionnaire for face-to-face interviews in Arabic that lasted 20 min each.
Questionnaire
Mammography screening behavior
For the current study, the dependent variable was defined as ‘correct use of mammography’. It was constructed from the responses to three questions regarding ever having a mammography, frequency of screening and having had a mammography in the past year. In order to ensure that women who conform to the Israel Cancer Association's recommendation (mammography screening every 2 years for women aged 
50 years) are included, the variable was defined as ‘had a mammography in the past year’ for women aged 50–52 years and ‘had a mammography at least every 2 years’ for women >52 years of age.
Background variables
Age, years of education, marital status, monthly family income, number of children, literacy in Arabic (mother tongue), fluency in Hebrew (the major language in Israel and the formal language used by health services) and religiosity.
Knowledge about breast cancer and mammography
This included 11 questions adapted from previous studies in Israel [26, 27], such as the likelihood of having breast cancer over age 50, breast cancer is a higher cause of mortality than lung cancer among women, genetic risk for breast cancer, changes in size or color of the breast as cancer symptoms, the recommendations for early detection of breast cancer, frequency and type of testing, recommended age, etc. The total score was calculated as the sum of correct answers.
HBM components
Questions from previous studies among Jewish Israeli women [26, 27], originally based on several sources [29–31] were adapted and others were added to specifically suit the Arab population. Although all the components included several items, with four-point response categories, none formed reliable scales (Cronbach's alpha values ranged from 0.39 to 0.58). Therefore, the single items for each scale were examined individually, in line with the recommendation of Janz et al. [10] against aggregating items into scales because items, particularly barriers, can have low inter-item correlation. Responses were grouped into ‘agree’ and ‘disagree’. ‘Perceived susceptibility’ included four items, ‘perceived seriousness’—two items, ‘perceived benefits’—three items. ‘Perceived barriers’ included eight items, four of which were specifically constructed for this population (e.g. inability to be absent from home and family, needs an escort to get to a health center/clinic, performing mammography brings bad luck—‘the evil eye’). ‘Self-efficacy’ was measured by three items specifically constructed for the study (e.g. being able to ask the doctor for information, to make an appointment for mammography). ‘Cues to action’ included recommendations from family, friends or health care workers and knowing a close family member or friend with breast cancer.
TRA components
‘Subjective social norm’ regarding mammography was measured by a single question about the general belief of family and friends in the efficacy of mammography. ‘Behavioral intention’ was measured by a single question about intention to ask a physician for a referral to mammography. The four-point response categories of both items were dichotomized into ‘agree’ and ‘disagree’.
Statistical analyses
Based on the distribution, several variables were grouped into categories: age (50–55, 56–61 or 62–69 years), education (0, 1–7 or 8+ years), marital status (married or unmarried), monthly family income (<NIS3000, 3000 or >3000; at the time of data collection, NIS3000 was comparable to $800), number of children (0–5, 6–7 or 8+ children) and religiosity (religious /non-religious). To evaluate the effect of the independent variables on the odds of correct use of mammography, univariate logistic regression analysis was carried out, adjusting for age (due to the strong association between age and use of mammography). Variables that were found to be significantly related to correct use of mammography were entered into a multivariate model which also included age. While other variables measuring socioeconomic position were significantly associated with mammography use, the multivariate model included only education to avoid multicollinearity. Finally, the significance of each independent variable in the multivariate model was assessed by a Wald-type chi-square test.
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Description of the population
The study population was characterized by low education level—39% never attended school and 46% had 1–7 years of schooling. Most women (55%) were illiterate in Arabic and were not fluent in Hebrew, and the majority (57%) reported an average monthly family income of <NIS3000. Sixty-two percent classified themselves as religious and fertility level was high (Table I).
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Screening behavior
Of the 510 respondents, 259 (51%) reported ever undergoing a mammography and 47% reported having been checked in the past year. However, the overall rate of correct use of mammography was only 20%. Among the women who reported never performing a mammography, the main reasons were ‘no need’—42%, ‘did not receive an invitation to perform it’—25% and ‘never heard about it’—14%.
Associations of sociodemogaphic characteristics with screening behavior
Age was strongly associated with mammography screening, with (unadjusted) odds ratios of 10.2 and 3.8, for correct use among the 50–55 and 56–61 age groups, respectively, compared with those aged 62–69 years. Higher education, literacy in Arabic, fluency in Hebrew and higher income were all significantly related to mammography screening (adjusting for age, Table II).
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HBM and TRA components and associations with screening behavior
The mean level of correct knowledge about breast cancer and mammography was low (Table III). None of the women answered correctly to all the 11 questions, and the mode of correct responses was 7 and the median was 6 (data not shown). While the majority of women perceived breast cancer as a severe disease, and agreed that mammography is beneficial for early detection, perception of personal susceptibility to cancer was lower. Between 25 and 70% reported various barriers and most women felt they could make an appointment for mammography (self-efficacy), received cues to action and believed that the prevailing norms toward mammography are positive. About 60% declared that they intend to ask for a mammography appointment (Table III).
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Knowledge about breast cancer and mammography was significantly associated with correct use where women with higher knowledge were more likely to undergo screening. Each of the HBM components included at least one item which was significantly associated with mammography use (Table III), with the exception of perceived severity and self-efficacy. Perception of personal susceptibility to having breast cancer compared with other diseases, perceived benefits (the efficacy of mammography for early detection and for treatment for breast cancer and its efficacy in detecting tumors), perceived emotional (embarrassment and pain) and physical (difficulties in reaching the testing center using public transportation) barriers, as well as cues to action were significantly related to mammography screening. Notably, a recommendation from a health professional had a larger effect than a recommendation from a family member or a friend. Of the TRA components, only intention to perform mammography was positively associated with actual performance.
Multivariate analysis
The effect of age on the likelihood of correct mammography use was slightly attenuated in the multivariate model, whereas no change was detected in the effect of education (Table IV). Knowledge did not have a significant contribution after adjusting for all other variables. A number of HBM components remained significant: the odds for correct use of mammography increased among those who perceived themselves as susceptible to having breast cancer compared with other diseases (OR = 2.10) and among those who perceived the process as beneficial due to its efficacy in early detection and better chances for treatment (OR = 2.31). Further, the odds for correct use of mammography were significantly higher (OR = 2.47) among women who perceived mammography to be painful compared with those who did not report this barrier. Recommendation to perform mammography had a strong contribution, where the odds of correct mammography use were 12 times higher among those for whom the recommendation was made by a health professional, and three times higher among those recommended to be tested by a family member or a friend, compared with those not recommended to be tested. Finally, the effect of intention to undergo mammography (a component of TRA) was of borderline significance (P = 0.06).
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Discussion |
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The findings of the current study, based on components of two theoretical models of (preventive) health behavior, indicated a low rate of mammography screening and combination of components as factors related to mammography screening among this unique minority population—Arab women in Israel. Women who were more likely to undergo mammography were younger, more educated, those who perceived themselves as vulnerable to get breast cancer, believed in the efficacy of the test, perceived the procedure as not painful, received a professional recommendation or—to a lesser extent—informal recommendation and only of borderline significance among those who expressed an intention to undergo mammography in the coming year.
The very low rate (20%) of correct mammography screening behavior of these women is alarming since access to screening services is universal and free for this age group in Israel. This rate is much lower than the 49% of mammography use (previous 2 years) in a national sample of Arab Israeli women 50 years of age or older [22]. Although this discrepancy may result from a narrower age range in the current study, it is mainly due to the low education level of the women in our study. This rate is also lower than those reported for diverse ethnic minorities in the United States, ranging from 64 and 47% among African American or English Caribbean women, respectively, to 33% in Haitian women (who have the lowest education level) [6] and 53% among Chinese Americans [32]. Comparison with mammography screening rates among Arab women in other countries is limited, because they referred to having ever being screened, which was as low as 10% [33], or used a small convenience sample of women already presenting for mammography [34].
Our results expand the understanding of the special factors that contribute to mammography screening behavior among Muslim Arab women. The main sociodemographic characteristics, younger age and higher education are consistent with previous findings [5, 6, 35]. As women get older, they may perceive more barriers to access mammography [36]. Those with very lower education, who cannot read or write, may feel embarrassed to admit that they experience difficulties in understanding a medical recommendation and in making appointments for mammography [37]. Our findings suggest that even an elementary level of education (8 years) increases the likelihood of correct use of mammography. Moreover, the non-significant association of knowledge about breast cancer and mammography in the multivariate analysis suggests that knowledge is necessary but not enough to change the behavior. Higher education represents important aspects, other than knowledge, that bring risk into consciousness and influence mammography use. Knowledge alone provides information and is an antecedent of health beliefs [8] and when these are controlled, it is often not sufficient to explain mammography use.
By using a theoretical framework based on components of both the HBM and TRA, the most salient factors related to mammography screening in this population were identified. The results, based on the individual items measuring HBM components, support previous evidence regarding the major HBM components associated with mammography screening—susceptibility, barriers, benefits and cues to action [10–12, 38], but contrast those which showed that self-efficacy [7] and subjective norms [39], a TRA component, are also related to mammography use.
The finding that the most powerful factor related to mammography screening was recommendation from a health care professional (cues to action), similar to other findings [5, 38], including Jewish women in Israel [26, 40], is somewhat obvious as a physician referral is needed in order to perform mammography. The significance of a recommendation from family members, found also among other Arab women [34], possibly reflects the importance that these women give to the views of the family regarding decisions about their own health. The Arab villages and small towns in Israel (represented by the two communities of the present study) comprise a small number of clans (‘Hamulas’), with familial or marital ties, often living in several extended family residences. The clan is still the potent basis of social structure, the size and economic status of each clan determines its local political power and is also a major force in shaping the health care experiences of Arab women [23]. These close contacts also elucidate the women's high personal exposure (71%) to someone with breast cancer, although it was not sufficient to explain the use of mammography in the multivariate analysis, as found in another close-knit community, the kibutzim in Israel [27] or other populations [5, 41].
The specific combination of the three additional individual items measuring HBM variables—perceived susceptibility, benefits and barriers, all with similar effect size—is consistent with some previous studies and contradicts others [11, 38]. This reflects differences in cultural backgrounds of the populations studied or in the measurement of the components [10]. For example, in our study, susceptibility, measured by ‘high personal risk to become ill with breast cancer compared with other diseases’ was the only susceptibility item related to mammography use. Others, using a scale of personal susceptibility, found it to be related to use among women in Spain [35], or unrelated to mammography use among African American [42], and Swedish [41] women. Notably, the low perceived susceptibility in the current study (27%) is probably related not only to low levels of education and knowledge but also to traditional beliefs. During the interview, the questions about susceptibility were perceived as threatening, and most women prefaced their answers with statements related to superstitions or expressions from the Kuran, such as ‘Evil is far away, what will come upon us is what God (Allah) has decided for us’. While these reactions could indicate a validity problem in this population, they may represent fatalism, a significant factor in mammography screening behavior [43].
Interestingly, the more universal measures of benefits (efficacy of mammography in early detection of breast cancer) and barriers (fear of pain) were the final significant determinants of use, while the selected culturally specific variables were either not related to use (e.g. belief that performing mammography brings bad luck) or related to use only at the univariate level (e.g. difficulties to get to a health centre/clinic by public transportation). Fear of pain has been found as a significant perceived barrier to mammography in various cultural and ethnic backgrounds [6, 41, 44], indicating that an emotional barrier is more significant than the physical barriers specific to this population (i.e. the need for an escort when going for testing or accessibility by public transportation). For these women, a low level of education, lack of economic independence and partial ability to communicate in Hebrew create strong dependence on their husbands and children with regards to escorting and transportation to tests or treatment in medical centers located in the big cities. But, when considered with other barriers and factors, the women may perceive these technical barriers as less important [28]. The barrier identified in a qualitative study [28], namely, the fear that mammography screening leads to cancer diagnosis was not confirmed by our findings.
The lack of association of self-efficacy with mammography, similar to that in Swedish women [41] may lie with the notion that mammography is not a complex preventive behavior and is characterized by performing a single behavior that repeats itself infrequently. In fact, Rosenstock et al. [9] claimed that self-efficacy was not part of the original HBM that was developed to explain compliance with simple preventive behaviors, such as immunization.
The additional components derived from the TRA made a negligible contribution to mammography use. We expected that perceived norms among these Arab older women, for whom community values are a major source of life meaning [45], would contribute to mammography compliance, but the association was not significant. It may be that norms are non-significant when HBM components are included [46]. Yet, previous evidence is contradictory [39], or suggested that norms were a better predictor of mammography intentions than of actual behavior [15, 16]. The marginal contribution of intentions to actual behavior, when adjusted for barriers and benefits, may also be explained by the specific context of the woman's role in Arab society. Intentions may be required, but not sufficient to explain behavior when other factors are considered, or they exert their influence on mammography use only in prospective studies [47].
Several limitations need to be addressed. The study is not representative of Muslim Arab women in Israel, particularly those with higher education, and should be considered as a study of a unique social group of Muslim women. While self-report may pose another limitation, we believe that it is negligible as accuracy of self-report for mammography is considered high [48]. As with all cross-sectional studies, the findings do not allow establishing causality. Finally, contrary to previous studies showing reasonable reliability of HBM scales in various ethnic/cultural groups [e.g. 32, 42], the study instruments of beliefs, self-efficacy and norms had poor reliability (low Cronbach's alpha values of the scales) in this population. The reliance on single items of these constructs, which—unlike barriers—are generally unidimensional, may raise some validity and reliability questions. Due to time constraint of the interview, it was not feasible to add items that might have captured other potential cultural beliefs and perceptions related to breast cancer and mammography. Replication and expansion of these measures are needed.
Nevertheless, the comprehensive conceptual framework of the study, coupled with methodological strengths—a large sample size, random sampling and face-to-face data collection by (all female) trained interviewers that increased response rate with no major problems of comprehension, allowed us to conclude that it provides broad insight into the factors related to mammography screening behavior among Muslim Arab women in Israel.
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Conclusions |
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The findings suggest that factors derived mainly from the HBM apply to this population, and should form the basis for screening interventions. When adapted to the target population such interventions may increase mammography rates compared with usual care [49]. This implies that health services delivery and the content of mammography promotion programs should consider the low educational level of older Arab women and the significant role of professional recommendation. If women know mammography screening is not as painful as they think, and its efficacy is stressed, the needs for an escort to go to the clinic and transportation problem lose their importance as perceived barriers. Even then, merely stressing the benefits of mammography, or sending written reminders (even in Arabic), may not be sufficient. Additional outreach methods, carried out by community nurses who many women already respect and rely on for support [23], need to be employed. The substantial role of family and friends' recommendation suggests training lay community leaders as health educators, a significant component in the implementation of successful health promotion programs [50]. In this traditional society, a respected female member of the clan may be an influential figure. Special efforts should be addressed to reach out to women who already intend to make appointment for mammography; they might be the agents for diffusion of change among these women.
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Conflict of interest statement |
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None declared.
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References |
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Received on February 8, 2006; accepted on August 22, 2006
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