JOURNAL OF WOMEN’S HEALTH
Volume 23, Number 7, 2014
ª Mary Ann Liebert, Inc.
DOI: 10.1089/jwh.2013.4569
Breast Cancer Screening Practices
Among First-Generation Immigrant Muslim Women
Memoona Hasnain, MD, MHPE, PhD,1 Usha Menon, PhD, RN, FAAN,2
Carol Estwing Ferrans, PhD, RN, FAAN,3 and Laura Szalacha, EdD 4
Abstract
Background: The purpose of this study was to identify beliefs about breast cancer, screening practices, and
factors associated with mammography use among first-generation immigrant Muslim women in Chicago, IL.
Methods: A convenience sample of 207 first-generation immigrant Muslim women (Middle Eastern 51%;
South Asian 49%) completed a culturally adapted questionnaire developed from established instruments. The
questionnaire was administered in Urdu, Hindi, Arabic, or English, based on participant preference. Internalconsistency reliability was demonstrated for all scales (alpha coefficients ranged from 0.64 to 0.91). Associations between enabling, predisposing, and need variables and the primary outcome of mammography use
were explored by fitting logistic regression models.
Results: Although 70% of the women reported having had a mammogram at least once, only 52% had had one
within the past 2 years. Four factors were significant predictors of ever having had a mammogram: years in the
United States, self-efficacy, perceived importance of mammography, and intent to be screened. Five factors
were significant predictors of adherence (having had a mammogram in the past 2 years): years in the United
States, having a primary care provider, perceived importance of mammography, barriers, and intent to be
screened.
Conclusions: This article sheds light on current screening practices and identifies theory-based constructs that
facilitate and hinder Muslim women’s participation in mammography screening. Our findings provide insights
for reaching out particularly to new immigrants, developing patient education programs grounded in culturally
appropriate approaches to address perceived barriers and building women’s self-efficacy, as well as systemslevel considerations for ensuring access to primary care providers.
Introduction
B
reast cancer is a leading cause of death and disability globally and is the most commonly diagnosed
cancer in women, regardless of race or ethnicity, in the
United States.1 Early detection of breast cancer is a key to
reducing morbidity and mortality. Substantial increases in
mammography use in the 1990s resulted in up to 30% reduction in mortality attributed to breast cancer.2–8 Despite
these advances, segments of our population have not benefited from cancer prevention and control efforts, and disparities in breast cancer screening and health outcomes
persist for minority groups.1,9–15 Low mammography use has
been associated with a variety of factors, including not having
a medical home, not having health insurance, being a recent
immigrant, and having low levels of knowledge and awareness about breast cancer.16–18
Migration to Western countries and increased length of
stay are associated with increased risk of breast cancer,19
which in turn is attributed to a number of factors and is
compounded by barriers to timely screening.20 Ethnicminority women residing in Western countries are more
likely to be diagnosed with advanced-stage disease and hence
have higher mortality rates.21 This often results from lower
utilization of timely breast cancer screening services.22–26
Personalizing or tailoring education about mammography to
1
Department of Family Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois.
College of Nursing, The Ohio State University, Columbus, Ohio.
3
College of Nursing, University of Illinois at Chicago, Chicago, Illinois.
4
Center for Research and Transdisciplinary Scholarship, College of Nursing, The Ohio State University, Columbus, Ohio.
This research was presented at Women’s Health 2012: The 20th Annual Congress in Washington, DC, and received the First Place
Award in Community & Public Health Research from the Office of Research on Women’s Health, National Institutes of Health.
2
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BREAST CANCER SCREENING FOR MUSLIM WOMEN
patients’ culture and beliefs has the potential to increase
breast cancer prevention awareness and screening utilization.27–33
The purpose of this study was to identify beliefs about
breast cancer, screening practices, and factors associated with
mammography use among first-generation immigrant Muslim women (born outside the United States) in Chicago, IL. In
the United States, immigrant Muslim women represent a fastgrowing and understudied population whose healthcare behaviors and utilization of health services, including cancer
screening, are influenced by religious and cultural beliefs.34–38
There is a paucity of rigorous theory-based, descriptive,
and intervention research on this population, and few studies
have evaluated breast cancer incidence, stage, treatment, and
mortality rates for Muslim women. Preliminary evidence
suggests that Muslim women underutilize mammography.34,39–40 More importantly, lack of cultural accommodation hinders Muslim women’s utilization of mammography
services. When breast cancer screening programs are not
structured in a manner consistent with their beliefs and customs, Muslim women choose not to participate.34,39–40
The number of Muslims in the United States is estimated to
be 2–6 million (47% women) and growing.41–43 African
American Muslims indigenous to the United States comprise
the largest number of American Muslims. Apart from these,
immigrant Muslims are extremely varied ethnically, coming
from virtually every country where Muslims live. The largest
group of Muslim immigrants in the United States is from
South Asian (SA) countries (33%), followed by the Middle
Eastern (ME) countries (25%).44 Hence, these two immigrant
groups were the focus of our research.
The limited literature on ME women indicates that breast
cancer is a leading cause of cancer-related mortality in this
group in their home countries, as well as when they immigrate to Western countries.45–51 Within the United States,
breast cancer is the most frequently diagnosed cancer among
SA women in California.52 In the United Kingdom, the risk of
breast cancer among SA women differs according to their
specific ethnic subgroup; Muslim women from India and
Pakistan are almost twice as likely to develop breast cancer as
their counterparts.53 In Australia, immigrants from Pakistan,
a country with a predominantly (95%) Muslim population,54
present with the highest age-standardized breast cancer
mortality rate.55
Multiple factors, such as language barriers; lack of medical
insurance; geographical barriers; and limited knowledge,
education, and access to healthcare services, contribute to
barriers faced by immigrant women in accessing and utilizing healthcare.56 In order to identify factors that influence
Muslim women’s decision making to engage in breast cancer screening, our study had the following three primary
objectives:
1. Develop a culturally relevant survey to assess
screening practices and to identify factors associated
with mammography use by Muslim women.
2. Confirm psychometric properties of survey subscales
in differing languages.
3. Explore the associations between mammography use
and predisposing, enabling, and need variables.
Three theoretical models—the Andersen Behavioral
Model of Health Services Utilization,57,58 the Health Belief
603
Model,59–61 and the Transtheoretical Model62–64—were used
to guide the development of the study.
Materials and Methods
Study design and setting
A cross-sectional study design was used to survey 215
first-generation immigrant Muslim women. The study was
conducted in Chicago, IL, home to a large number of immigrant Muslims. According to estimates by the Council of
Islamic Organizations of Greater Chicago, approximately
400,000 Muslims live in the Chicago area. Recruitment sites
were several Chicago-based community agencies and faithbased institutions. Data collectors were bilingual or trilingual
females and were trained research interviewers. Survey development and translation took place in 2008 and 2009;
survey administration and data collection, in 2009 and 2010.
The Institutional Review Board of the University of Illinois at
Chicago approved this study.
Measures and survey development
A written survey was developed to collect information on
two sets of core measures:
1. Breast cancer screening practices, with mammography
the primary dependent variable. Participants were
asked about their past mammography use and future
intent to screen in order to assess stage of readiness.
Mammography use was categorized as (a) never having had a mammogram (never-screened group), (b)
having had at least one mammogram but none in the
past 2 years (overdue group), and (c) having had a
mammogram in the past 2 years (adherent group). For
our study, the National Cancer Institute recommendations for breast cancer screening were used to define
adherence: mammogram screening every 1–2 years,
beginning at age 40.64
2. Predictors of mammography screening, organized
into predisposing, enabling, and need categories (see
Table 1).
Three instruments—the Champion Breast Health Survey,65
Ferrans Cultural Beliefs Scale,66 and Suinn-Lew Asian SelfIdentity Acculturation Scale (SL-ASIA)67—were adapted,
combined into one survey, and translated into the study languages (Urdu, Hindi, and Arabic). Focus groups were conducted to confirm that the survey items were understandable
and culturally relevant to the target population (described later).
Champion Breast Health Survey. The widely used subscales for breast cancer screening beliefs (perceived susceptibility, perceived benefits, perceived barriers, and
perceived self-efficacy), with established reliability and validity,68 were included in our study. All subscales have good
internal consistency reliability (Cronbach’s alphas greater
than 0.70) and construct validity (demonstrated by confirmatory factor analysis; all subscales were unidimensional).
Ferrans Cultural Beliefs Scale. This scale, which measures cultural beliefs about breast cancer, has previously been
tested with African American, Hispanic, and Caucasian
women. The instrument focuses on beliefs in three content
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HASNAIN ET AL.
Table 1. Predictors of Mammography Use
Predisposing
a
Perceived risk (susceptibility) for
developing breast cancer
Perceived benefitsa— positive
outcomes associated with screening
for breast cancer
Perceived barriersa—obstacles
associated with breast cancer screening
Self-efficacya—self-confidence in one’s
ability to get a mammogram
Knowledgea—cognitive information
about breast cancer risk, screening
recommendations, causes, treatment,
and cure
Emotional factors—fear and shame
associated with breast cancer and
mammography screening
Cultural factorsb—cultural beliefs
regarding breast cancer
Global rating of importance of
mammography—self-perceived overall
importance of the need for getting a
mammogram
Enabling
Need
Education
Income
Insurance—third-party payer of
healthcare costs
Acculturationc—modification of
the culture of a group or individual as a result of contact with
a different culture
Self-perceived health status
Physician recommendation—
patients’ perception of
recommendation by their
respective providers to screen
a
Source: Champion Breast Health Survey65 modified/refined via focus groups.
Source: Ferrans Cultural Beliefs Scale.66
c
Source: Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA).67
b
areas: those that make women feel less vulnerable to breast
cancer, those that discourage participation in breast cancer
screening, and those about the lack of efficacy of breast
cancer treatment. Higher scores on the Ferrans scale indicated that more cultural myths inhibiting screening were
believed. The scale has demonstrated reliability (alpha =
0.73) and validity in the populations tested.69
Suinn-Lew Asian Self-Identity Acculturation Scale. The
SL-ASIA67 was originally modeled after the Acculturation
Rating Scale for Mexican Americans70 and has been developed for and extensively tested with East Asian groups. The
measurement approach recognizes the multidimensionality of the acculturation process and takes into account the
issue of bicultural development. The instrument assesses
cognitive, behavioral, and attitudinal areas, and its 21
multiple-choice questions yield five factors and a single
acculturation score that range from 1:00 (low acculturation)
to 5:00 (high acculturation). The scale demonstrated internal
consistency reliability (Cronbach’s alpha: 0.88–0.91 in two
studies) and concurrent validity.67 The questions in the scale
are generic; to make the scale more relevant to our study
population, we changed country/region names to represent
those of our study population.
Global rating of importance of mammography screening. A 10-point Likert-type scale measuring global rating of
the importance of regularly getting mammograms (ranging
from ‘‘not at all important’’ to ‘‘very important’’) developed
for this study was also included in the survey.
Cultural adaptation and refinement of survey via focus
groups. To account for regional and ethnic differences in
beliefs and to add culturally relevant content, two focus
groups were conducted (one each for SA and ME women),
with 10–12 participants in each group. To be eligible to
participate in the focus groups, participants had to be female,
Muslim (defined as those who self-identify with the Islamic
faith), aged 40 years or older, first-generation immigrants (18
years or older on arrival in the United States) from the Middle
East or South Asia and able to read, write, and speak English
and one of the study languages (Urdu, Hindi, Arabic). Two of
the study authors (Memoona Hasnain and Usha Menon, who
are fluent in Urdu and Hindi), moderated the focus groups. An
Arabic-language translator participated in the Middle Eastern
focus group. We used a semistructured format to refine survey items and to identify new items. The process was used to
confirm that the survey items were understandable and culturally relevant to the target population. Based on participant
input, the Champion scales were adapted; some of the items
were reworded, some items were removed, and others were
added. See Appendix 1 for the modified Champion scales. No
changes were made to the Ferrans Cultural Beliefs Scale and
SL-ASIA; both were determined to be understandable and
culturally appropriate by the focus groups in their original
form.
Translation of survey. To address language barriers, the
culturally adapted survey and other study documents (informational flyer and consent brochure) were translated into
Urdu, Hindi, and Arabic. The committee-translation method71 was utilized, as it is a more rigorous process than using a
single translator. A translation team consisting of three
translators and a language expert (adjudicator) was established for each language to guide the translation. This systematic development of study survey and other documents
BREAST CANCER SCREENING FOR MUSLIM WOMEN
increased the likelihood of developing a culturally appropriate and psychometrically sound survey.
Sample and data collection
Sample size. A sample size of 230 participants (115 per
ethnic group) was planned on the basis of recommendations
by Nunnally72 for measurement reliability. To account for
incomplete data, we planned to oversample by 9% for a total
250 participants.
First-generation immigrant Muslim women (same eligibility criteria as for those who participated in the focus
groups) were eligible for the study. Given the exploratory
nature of this study, self-reported mammography-screening
practices were not verified via medical records.
Recruitment and data-collection procedures. Participants
were selected from a purposive sample of Muslim women
residing in Chicago, IL. Participant recruitment and datacollection procedures were standardized and kept similar
for both SA and ME women. Study flyers, in English and
translated languages, inviting participation were circulated
electronically and posted in community agencies and
mosques. Trained research assistants approached women at
community sites and used snowball sampling to accrue
the proposed sample size. After obtaining full written informed consent, the in-person survey was administered to
eligible participants at data-collection sites. Participants
received a small monetary incentive to participate in the
study.
Statistical analyses
In addition to psychometric assessment (reliability and
validity) of the various scales used in each of the three
language groups, descriptive statistics, bivariate correlations, contingency-table analyses, analyses of variance
(ANOVAs), and hierarchically nested logistic regression
models were conducted. Owing to the significant differences in screening behavior based on ethnicity, we stratified by ethnicity for all bivariate analyses. For each
outcome—(1) ever having had a mammogram versus not
and (2) adhering to mammogram guidelines (mammogram
within the past 2 years) versus not—modeling began with
all sociodemographic characteristics. Model 2 contained
only cultural and health-related predictors. Model 3 included all sociodemographic and cultural and health-related
predictors significant in Models 1 and 2 at alpha = 0.10. We
then tested for statistical interactions as was necessary. The
sample size was insufficient to fit separate logistic models
for ME and SA women. Therefore, we tested for ethnicity
in the models. Finally, only one participant completed the
survey in Hindi, precluding psychometric analysis for data
collected in that language; hence, data from the Hindi
survey were not included in the analysis. Data analysis was
performed using SPSS v. 21 (IBM, New York).
Psychometric analyses
Each of the established scales, translated into Urdu and
Arabic from English, was examined for reliability (internal
consistency) and validity (correlations) within and across
each language group. More than one-third of the participants
605
completed the survey in English (38.2%, n = 79), one-third in
Arabic (35.3%, n = 73), and about one-fourth in Urdu (26.1%,
n = 54). Every subscale was internally consistent, with alpha
coefficients ranging from 0.72 to 0.92, and constructs expected to be related were significantly appropriately correlated (e.g., benefits and self-efficacy r = 0.53, p < 0.001,
barriers and cultural beliefs r = 0.39, p < 0.001). There were
no significant differences based on the language of the survey, so we analyzed the combined data.
Results
Sample characteristics
The 207 participants had emigrated from 13 South Asian
and Middle Eastern nations: The largest proportions were
from Pakistan (30%, n = 65), Palestine (21%, n = 45), and
India (17%, n = 37). Although 37% (n = 80) spoke primarily
English, 35% (n = 75) spoke primarily Arabic, and 27%
(n = 59) spoke primarily Urdu. The majority of participants
were married (85%, n = 183), with a mean age of 52 years
(standard deviation [SD] = 10.0). Almost one-third of the
participants (31%, n = 66) were college graduates, and onethird (30%, n = 65) had a high school diploma. More than
one-third (42%, n = 90) reported incomes less than $20,000,
and one-third (34%, n = 70) reported having health insurance.
In terms of mammography-screening practice (Table 2), 32%
(n = 66) had never had a mammogram (never-screened
group); 17% (n = 37) had had a mammogram but more than 2
years prior to the survey (overdue group); and 52% (n = 112)
had had a mammogram within the past 2 years (adherent
group). Only 20% (n = 44) reported a family history of breast
cancer.
Bivariate analyses
There were significant differences in mammographyscreening practice based on sociodemographic characteristics.
For both the ME and SA groups, women in the never-screened
group had been in the United States for significantly fewer
years than those in both the overdue group and the adherent
group (F(2,105) = 3.3, p < 0.05, F(2,102) = 3.1, p < 0.05). Fiftyseven (72.2%) ME and 36 (52.1%) SA women in the adherent
group reported having a primary care provider, in contrast to
only 15 (19%) ME and 20 (20.9%) SA in the never-screened
group (v2(df = 1) = 11.5, p < 0.01, v2(df = 1) = 11.0, p < 0.01).
In addition, adherent participants rated the importance of
being screened significantly higher than did the overdue and
never-screened groups (F(2,105) = 6.0, p < 0.001, F(2,102) = 5.5,
p < 0.001).
In the bivariate analyses, there also were significant differences in screening behavior based on ethnicity. First, only
26 (23.6%) ME women had never been screened, as compared to 40 (38.1%) SA women. Similarly, 69 (62.7%) ME
women were adherent to guidelines, as compared to only 43
(41.0%) of SA women (v2(df = 1) = 10.2, p < 0.01). Second,
only for SA women was greater acculturation significantly
associated with being screened (F(2,102) = 3.1, p < 0.05).
There were significant differences in mammographyscreening practices as a function of beliefs for SA women
(benefits, self-efficacy, and cultural beliefs; see Table 3).
However, significantly lower barriers were reported by adherent participants in both the ME and SA groups.
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Table 2. Health-Related Characteristics of Study Participants by Ethnicity
Adherent
Overdue
Never screened (mammogram (mammogram
within past
> 2 years
(never had
2 years)
ago)
mammogram)
n = 26
n = 16
n = 59
mean (SD)
mean (SD)
mean (SD)
Middle Eastern
Age
Years in United States
Acculturation score
Self-perceived general health
Global rating of importance of getting a mammogram
50.2
15.6
1.7
2.6
7.6
Have a primary care provider
Family history of breast cancer
(10.1)
(10.5)
(.56)
(1.2)
(2.9)
Have a primary care provider
Family history of breast cancer
(7.9)
(10.7)
(.43)
(1.4)
(1.4)
52.7
21.9
1.8
2.7
9.2
(10.0)
(10.9)
(.45)
(1.1)
(1.8)
ns
F(2,100) = 3.3a
ns
ns
F(2,107) = 6.0b
Count (%)
Count (%)
Count (%)
15 (19)
3 (17.6)
7 (8.9)
3 (17.6)
57 (72.2)
11 (64.7)
Overdue
n = 22
mean (SD)
Adherent
n = 43
mean (SD)
Test statistic
54.8
17.2
1.7
3.1
7.5
51.2
18.0
1.8
3.0
8.4
ns
F(2,92) = 3.6a
F(2,102) = 3.0a
ns
F(2,102) = 5.5b
Never screened
n = 40
mean (SD)
South Asian
Age
Years in United States
Acculturation score
Self-perceived general health
Global rating of importance of getting a mammogram
51.0
23.4
1.5
2.3
9.5
Test statistic
53.1
12.7
1.6
3.0
5.9
(11.3)
(8.7)
(.47)
(1.1)
(3.8)
(8.8)
(8.2)
(0.44)
(1.1)
(3.5)
(9.3)
(8.5)
(.40)
(1.0)
(3.0)
Count (%)
Count (%)
Count (%)
20 (29)
11 (40.7)
13 (18.8)
7 (25.9)
36 (52.2)
9 (33.3)
v2 = 11.5b
ns
v 2 = 11.0b
ns
a
p < 0.05.
p < 0.01.
ns, not significant; SD, standard deviation.
b
Multivariate analyses
To identify the predictors of ever having had a mammogram, women who had never been screened were compared
with those who had had at least one mammogram (both those
who were overdue and those who were adherent). As presented in Table 4, in Model 3, controlling for insurance and
income, there were four significant predictors of ever having
had a mammogram: (1) years in the United States (adjusted
OR [AOR] = 1.1), (2) perceived importance of being
screened (AOR = 1.3), (3) self-efficacy (AOR = 2.4), and (4)
intent to be screened (AOR = 2.2). Although the effect of time
since immigration was negligible, a positive difference of 1
point in perceived importance of mammograms was associated with 1.3 times the odds of being screened. Those who
reported greater self-efficacy by 1 point had 2.4 times the
odds of having had a mammogram, and those who indicated
intent to be screened had more than twice the odds of having
been screened in the past. Finally, there was no effect of
ethnicity. The model explained slightly more than a third of
the variance (Nagelkerke R2 = 0.36).
To identify the predictors of adherence, women who were
adherent were compared with those who had not had a
mammogram in the past 2 years (both those who had never
been screened and those who were overdue). As presented in
Table 5, in Model 3, controlling for insurance and income,
there were five significant predictors of being adherent: (1)
years in the United States (AOR = 1.1), (2) having a primary
care provider (AOR = 1.3), (3) barriers (AOR = –0.52), (4) the
perceived importance of screening (AOR = 1.2), and (5) intent to be screened (AOR = 2.2). Although the effect of time
since immigration was, again, negligible, those who had a
primary care provider had 1.3 times the odds of being adherent. A positive difference of 1 point in barriers was associated with half the odds of being adherent. Perceived
importance was associated with 1.2 times the odds of being
adherent, and those who indicated intent to be screened had
more than twice the odds of being adherent. There was no
effect of ethnicity. The model explained slightly less than a
third of the variance (Nagelkerke R2 = 0.28).
Discussion
The provision of culturally appropriate, patient-centered
cancer-screening education has not yet been fully explored for immigrant Muslim women in the United States, an
especially vulnerable population, given their increasing
numbers and unique cultural beliefs. This study sought to
explore breast cancer screening practices and factors associated with mammography screening among a study sample
BREAST CANCER SCREENING FOR MUSLIM WOMEN
607
Table 3. Self-Ratings on Beliefs Related to Breast Cancer Screening Behavior
Never screened
n = 62
mean (SD)
Middle Eastern
Champion subscales
Benefits
Barriers
Self-efficacy
Susceptibility
Fear/shame
Ferrans cultural beliefs
4.3
2.6
3.7
3.0
3.3
4.2
(.56)
(.44)
(.95)
(.91)
(.84)
(3.5)
4.2
2.3
4.2
2.8
2.8
5.3
n = 62
mean (SD)
South Asian
Champion subscales
Benefits
Barriers
Self-efficacy
Susceptibility
Fear/shame
Ferrans cultural beliefs
a
3.7
2.8
3.9
2.5
3.5
7.2
Overdue
n = 36
mean (SD)
Adherent
n = 109
mean (SD)
(.70)
(.49)
(.38)
(1.1)
(1.2)
(4.0)
4.1
2.2
4.1
3.0
3.4
4.0
n = 36
mean (SD)
(.92)
(.61)
(.65)
(.92)
(.92)
(3.8)
4.1
3.0
4.3
2.8
3.7
6.5
(.83)
(.60)
(.68)
(.95)
(.88)
(2.9)
F-test statistic
ns
F(2,102) = 3.4a
ns
ns
ns
ns
n = 109
mean (SD)
(.75)
(.78)
(.51)
(.78)
(1.3)
(4.4)
4.1
2.6
4.3
2.9
3.2
5.0
(.67)
(.58)
(.56)
(.90)
(1.0)
(3.2)
F(2,102) = 3.5a
F(2,102) = 3.4a
F(2,102) = 6.5b
ns
ns
F(2,102) = 3.6a
p < 0.05.
p < 0.01.
b
Table 4. Predictors of Ever Having Had a Mammogram
Model 1
AOR (CI)
Variable
Demographics
Partner
Income
< $20,000
$20,000–$75,000
> $75,000
Insurance
Education
High school or less
Bachelor degree or more
Years in the United States
Primary healthcare provider
Ethnicity
Language
English
Urdu
Arabic
Family history of breast cancer
Mammogram importance
Self–health assessment
Benefits
Barriers
Self-efficacy
Susceptibility
Fear
Cultural beliefs
Acculturation
Intent to be screened
a
Model 3
AOR (CI)
1.2 (0.43–3.4)
Referent
1.5 (0.67–3.4)
1.4 (0.43–4.8)
0.88 (0.38–2.0)
0.36 (0.06–2.17)
0.48 (0.09–2.71)
1.18 (.37–3.78)
Referent
2.0 (0.25–10.9)
1.1 (1.0–1.1)a
0.43 (0.20–0.93)
0.31 (0.08–1.2)
1.1 (1.0–1.1)a
1.1 (0.50–2.5)
Referent
2.4 (0.66–8.8)
2.7 (0.57–12.9)
p < 0.05.
p < 0.01.
c
p < 0.001.
Pseudo R2 = 36%.
AOR, adjusted odds ratio; CI, confidence interval.
b
Model 2
AOR (CI)
0.87
1.2
0.93
0.84
0.67
2.7
1.1
1.0
1.0
1.3
2.7
(0.38–1.9)
(1.08–1.33)b
(0.68–1.3)
(0.35–1.3)
(0.35–1.3)
(1.5–4.9)b
(0.78–1.9)
(0.73–1.5)
(0.90–1.1)
(0.56–2.9)
(1.4–5.4)b
1.3 (1.1–1.4)c
2.4 (1.4–4.4)b
2.2 (1.0–5.0)b
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HASNAIN ET AL.
Table 5. Predictors of Adherence to Screening Guidelines (Mammogram Within the Past 2 Years)
Variable
Demographics
Partner
Income
< $20,000
$20,000–$75000
> $75,000
Insurance
Education
High school or less
Bachelor degree or more
Years in the United States
Primary care provider
Ethnicity
Language
English
Urdu
Arabic
Family history of breast cancer
Mammogram importance
Self–health assessment
Benefits
Barriers
Self-efficacy
Susceptibility
Fear
Cultural beliefs
Acculturation
Intent to be screened
Model 1
Adjusted OR (CI)
Model 2
Unadjusted OR (CI)
Model 3
Adjusted OR (CI)
1.3 (0.48–3.2)
Referent
1.0 (0.48–2.2)
0.80 (0.27–2.4)
1.96 (0.91–4.2)
0.36 (0.06–2.17)
0.48 (0.09–2.71)
1.18 (0.37–3.78)
Referent
0.55 (0.12–2.5)
1.0 (1.0–1.12)a
1.3 (1.0–1.6)b
0.37 (0.12–2.5)
1.08 (1.03–1.14)c
1.3 (1.1–1.7)b
Referent
2.4 (0.66–8.8)
2.7 (0.57–12.9)
1.4
1.1
0.83
0.77
- 0.40
1.6
1.3
1.3
1.0
1.9
3.3
(0.64–3.0)
(1.0–1.3)a
(0.62–1.1)
(0.47–1.3)
(0.22–0.75)b
(0.92–2.38)
(0.89–1.8)
(0.93–1.9)
(0.90–1.1)
(0.87–4.2)
(1.7–6.4)b
1.2 (1.0–1.3)a
- 0.52 (0.31–0.89)a
2.2 (1.1–4.20)b
a
p < 0.05.
p < 0.01.
c
p < 0.001.
Pseudo R2 = 28%
b
that represented two of the largest groups of immigrant
Muslims in the United States: those from South Asia and the
Middle East. In our sample, only 52% of women reported
screening in the past 2 years, which is substantially lower
than the national figure of 67% (all women, not limited to
Muslims) for the data-collection period of 2009–2010.73 A
greater proportion of ME women had had a mammogram
within the past 2 years compared with their SA counterparts,
although ethnicity was not a significant predictor of adherence. Previous evidence from prevalence studies of Arab
American women in the Detroit region indicates mammographyscreening rates close to 70%.74–75 Lower mammography
rates, however, have been found when specifically looking at
Muslim women over age 40 in southern California,76 where
46% had not had a mammogram in the past 2 years.
In the multivariate analysis, the predictors of ever having
had a mammogram were years in the United States, selfefficacy, perceived importance of mammography, and intent
to be screened. Adherence to screening guidelines (screening
in the past 2 years) was predicted by three of those same
variables (years in the United States, perceived importance
of mammography, intent to be screened), along with two
additional predictors (having a primary care provider and
barriers to screening). Thus, our findings are similar to those
in previous studies reporting that physician recommendation,
acculturation and length of stay in the United States, and
barriers to mammography were significantly associated with
screening behavior.16,25,37,77–84
Self-efficacy is a key variable in the Health Belief Model
(HBM). Interestingly, self-efficacy was significant in distinguishing between women who had never had a mammogram
and those who had had at least one but was not a predictor for
adherence to screening guidelines. Thus, for this sample, the
findings indicate that ever having obtained a mammogram
made women confident in their ability to get one, but this
confidence was insufficient to produce adherent screening behavior that would take these women from the stage of ‘‘action’’
to that of ‘‘maintenance’’ in the Transtheoretical Model.
Barriers, another key variable of the HBM, was a significant predictor of adherence. This variable distinguished between those who were successful in timely screening and
those who did not, providing insights for future work focused
on reducing and eliminating barriers to mammography.
Implications
Immigrant Muslim women in the United States represent a
unique and fast-growing population whose healthcare behaviors, including breast cancer screening practices, are
significantly influenced by past beliefs and experiences.34–38
Considering that mammograms are not part of the routine
screening process in public hospitals in their home countries
BREAST CANCER SCREENING FOR MUSLIM WOMEN
and are usually recommended only as part of the diagnostic
workup after a lump has been detected, raising awareness of
the importance of routine and regular screening is vitally
important. When designing breast cancer screening programs
for immigrant Muslim women, our findings indicate that increasing both self-efficacy and intention to be screened is
essential, as well as ensuring the provision of a primary
healthcare provider. Our findings also highlight the need for
reaching out to recently migrated Muslim women and conveying the importance of regular screening, emphasizing the
message that it is not enough to get screened once or sporadically. This will require providing culturally sensitive and
specific information, as well as supportive services, such as
health care system navigation, to assist women in overcoming barriers and finding a medical home.
Study limitations
In any study of health behavior, there is always the possibility that self-reported health behavior may be over- or
underreported. In research settings, participants commonly
overreport health screening use; validity of self-report for
mammography ranges from 49% to 94%.85–86 This factor
should be taken into consideration when drawing conclusions
from self-reported breast cancer screening. For our study, this
means that actual participation in mammography for this
group of Muslim women may have been lower than our figures indicate. Further, the external validity of our study is
limited because of the moderate sample size, as well as the
fact that we used a convenience sample. For an exploratory
study, however, we believe that it was appropriate to test the
translated survey with a small sample, which has provided
information about moving forward with additional descriptive and interventional studies with larger, more representative samples of immigrant Muslim women.
Conclusions
Breast cancer screening rates for underserved and minority
women must be increased in the United States, as early and
regular mammography screening is critical to reducing breast
cancer–related morbidity and mortality. This study provides
the important and currently unavailable information about
theory-based factors associated with Muslim women’s participation in mammography screening. The findings of this
study are intended to encourage future research to develop
and test culturally appropriate, patient-centered strategies for
promoting timely and regular breast cancer screening and
therapeutic services for immigrant Muslim women, as well as
for other minority immigrant women in the United States.
Acknowledgments
This research was funded in part by Grant # P30
NR009014 to the University of Illinois at Chicago’s Center
for Reducing Risks in Vulnerable Populations (CRRVP), by
NINR/NIH. We gratefully acknowledge the contributions of
our community partners, translators, language experts, data
collectors, and UIC Department of Family Medicine research
staff.
Author Disclosure Statement
No competing financial interests exist for any of the authors.
609
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Address correspondence to:
Memoona Hasnain, MD, MHPE, PhD
Department of Family Medicine (MC 663)
College of Medicine
University of Illinois at Chicago
1919 W. Taylor Street
Chicago, IL 60612-7309
E-mail: memoona@uic.edu
(Appendix follows/)
612
HASNAIN ET AL.
Appendix 1. Culturally Adapted Champion Scales, Based on Focus-Group Input
Susceptibility
Benefits
Self-efficacy
Barriers
1.
2.
3.
1.
2.
3.
4.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Emotional
(fear and
shame)
a
1.
2.
3.
4.
You are likely to get breast cancer in the next few years.
You are likely to get breast cancer.
You will get breast cancer sometime during your life.
If you have regular mammograms, you won’t worry as much about dying from breast cancer.
If you have breast cancer found through regular mammograms, your chances of being cured are
good.
Having regular mammograms will help you find breast cancer early when it starts.a
Having regular mammograms will set your mind at ease.
You can ask your doctor for a mammogram even if the doctor does not mention it.a
You can get to the clinic to have a mammogram.a
You can make time in your life to have a mammogram.a
You can talk to people at the mammogram center if you have a problem.
You can go for a mammogram even if you are worried.
You can go for a mammogram even if you don’t know what to expect during the test.a
You can get a mammogram even if you can’t afford it.a
You can make an appointment for a mammogram.
You can get a mammogram if you really want to.
You can find a place to get a mammogram
The treatment for breast cancer is worse than breast cancer itself.
You are too old to have a mammogram.
You are afraid to get a mammogram because it may find a problem in your breast.a
Having a mammogram is too difficult.a
Having a mammogram would cause too much pain.
Having a mammogram would be too embarrassing.
Worry about being exposed to harmful radiation keeps you from having a mammogram.a
You have difficulty remembering to make an appointment for a mammogram.
You are worried about having a mammogram because you don’t understand how the test is done.a
It is difficult for you to get transportation to go for a mammogram.a
It is difficult for you to get child care to go for a mammogram.a
You don’t have time to get a mammogram.
You don’t have a convenient place to get a mammogram.
Compared with your other health problems, having a mammogram is not important.
You don’t want to get a mammogram because if you have breast cancer it is better not to know
about it.
You wouldn’t get a mammogram because it costs too much.
You are afraid to have a mammogram because it may show a problem.
You don’t want to get a mammogram because people you know don’t think it is necessary.
You don’t think a mammogram is necessary if you have a breast exam by a doctor.
You don’t think a mammogram is necessary because a doctor didn’t recommend one.
You don’t need a mammogram because your chances of getting breast cancer are low.
You wouldn’t want to go for a mammogram if it was done by a male provider.b
You wouldn’t want to go for a mammogram unless the clinic has private space for mammography
patients.b
When you think about breast cancer, you get scared.
When you think about breast cancer, you get worried.
When you think about breast cancer, you get depressed.
Thinking about breast cancer is shameful.b
Item reworded per input from focus group participants.
New items:
Susceptibility: reworded items (0), new items (0), deleted items (2). Your chances of getting breast cancer are higher than most women
your age. Your chances of getting breast cancer are lower than most women your age.
Benefits: reworded items (1), new items (0), deleted Items (0).
Self-efficacy: reworded items (5), new items (0), deleted items (0).
Barriers: reworded items (6), new items (2), deleted items (1). Getting a mammogram could cause breast cancer because the breasts are
squeezed.
Emotional (fear and shame): reworded items (0), new items (1), deleted items (4): When you think about breast cancer, you feel nervous.
When you think about breast cancer, you get upset. When you think about breast cancer, you get edgy. When you think about breast cancer,
your heart beats faster.
b
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