Modesty matters: cultural sensitivity and cervical cancer prevention in muslim women in the United States

Coping with modesty during radiotherapy for breast cancer: a multicentric study

PURPOSE

Breast cancer is the most frequently diagnosed tumour, representing nearly 30% of all new cases in women. Radiotherapy (RT) plays a crucial role in the management of breast cancer. The objective of this study is to assess modesty in patients undergoing RT for breast cancer and take their suggestions and ideas into consideration to enhance the quality of treatment in this regard.

METHODS

The study enrolled 555 breast cancer patients undergoing adjuvant RT in three Italian centres. Patients completed a self-test questionnaire assessing their comfort level concerning modesty during therapy and their relationship with strangers and healthcare professionals. The impact of religious views and potential changes in sexuality were also examined.

RESULTS

Results showed that modesty was a common concern across the overall cohort of patients, with discomfort in being undressed during RT correlating with discomfort experienced in other daily life situations. Most patients felt more at ease with same sex healthcare workers. Age was also a major factor with younger patients generally feeling more comfortable with healthcare workers of the same age group. Interestingly, the surgical technique used (mastectomy vs. quadrantectomy) did not significantly influence modesty perceptions. Patients provided valuable suggestions to improve privacy and modesty during RT.

CONCLUSION

This study demonstrates that modesty is an important issue for women undergoing RT, which can be influenced by personal characteristics and hospital-related factors. A reflection about the need to address modesty concerns and to incorporate dedicated interventions for protecting patients' physical and emotional well-being is warranted. Initiatives to improve communication, involvement, and body image support should also be integrated into the care path of patients to better their overall therapeutic experience. This study paves the way for broader research and interventions in daily cancer care.

Experiences Relating to Sexual Well-Being Among Muslim Gynecological Cancer Survivors: A Systematic Review of Qualitative Studies

Background

Gynecological cancers are one of the most important threats to women's health worldwide. The objective of this review is to synthesize and present the best available evidence on the experiences relating to sexual well-being among Muslim women with gynecological cancer.

Methods

The databases searched included Web of Science, Scopus, SID, Google Scholar, ProQuest, MEDLINE, and CINAHL from the inception of the database until August 2021. The review was guided by the JBI methodology used for qualitative systematic reviews. Findings were collated using the meta-aggregation method through JBI SUMARI.

Results

Eight studies involving Muslim women cancer survivors were included in the review. Meta-synthesis of the eight included studies generated 59 findings, which were organized into 14 categories and combined into four synthesized findings.

Conclusions

Gynecological cancer and its treatment results in numerous challenges with sexual well-being among Muslim women cancer survivors. Providing information about sexual activity following gynecological cancer, better communication from health care professionals, and support from the husband is essential to overcome the struggle with intimacy and femininity experienced by the women, thus improving the sexual quality of life of Muslim gynecological cancer survivors.

A Culturally Adapted Breast and Cervical Cancer Screening Intervention Among Muslim Women in New York City: Results from the MARHABA Trial

We examine the efficacy of MARHABA, a social marketing-informed, lay health worker (LHW) intervention with patient navigation (PN), to increase breast and cervical cancer screening among Muslim women in New York City. Muslim women were eligible if they were overdue for a mammogram and/or a Pap test. All participants attended a 1-h educational seminar with distribution of small media health education materials, after which randomization occurred. Women in the Education + Media + PN arm received planned follow-ups from a LHW. Women in the Education + Media arm received no further contact. A total of 428 women were randomized into the intervention (214 into each arm). Between baseline and 4-month follow-up, mammogram screening increased from 16.0 to 49.0% in the Education + Media + PN arm (p < 0.001), and from 14.7 to 44.6% in the Education + Media arm (p < 0.001). Pap test screening increased from 16.9 to 42.3% in the Education + Media + PN arm (p < 0.001) and from 17.3 to 37.1% in the Education + Media arm (p < 0.001). Cancer screening knowledge increased in both groups. Between group differences were not statistically significant for screening and knowledge outcomes. A longer follow-up period may have resulted in a greater proportion of up-to-date screenings, given that many women had not yet received their scheduled screenings. Findings suggest that the educational session and small media materials were perhaps sufficient to increase breast and cervical cancer screening among Muslim American women. ClinicalTrials.gov NCT03081507.

Sexual Modesty in Sexual Expression and Experience: A Scoping Review, 2000 - 2021

Sexual modesty is the social, cultural, interpersonal, and psychological systems - defined by the tenets of Script Theory - that regulate individuals' sexual expression and experience at the social, legal, and interpersonal boundaries of acceptable/not-acceptable, private/public, and personal/social. Almost all aspects of sexual expression and experience are touched by the pervasive modesty standards for sexual communication, sexual display, sexual relations, and sexual behaviors. Sexual modesty influences an array of sexual and reproductive health outcomes. Many aspects of sexual modesty are enforced by legal as well as social, cultural, and religious proscriptions, including social shaming and ostracism as well as corporal and capital punishments. The purpose of this paper is to summarize a diverse literature related to sexual modesty from the years 2000 to 2021 in order to clarify its role in sexual health and sexual wellbeing and to identify directions for new research.

Promoting Colorectal Cancer Screening in South Asian Muslims Living in the USA

Colorectal cancer is one of the more common forms of cancer in South Asian men and women. Despite the rates of colorectal cancer (CRC) in South Asians, the CRC screening rates remain low in South Asians and Muslims compared with those in Whites and other ethnic minorities in the USA. Religious and cultural barriers have been examined in relation to other types of cancer such as breast and cervical cancers. However, few data are available about CRC screening among Muslims, particularly South Asian American Muslims. A community-based participatory research approach was used to assess attitudes toward CRC screening and various cultural, religious, and gender barriers that prevent CRC screening expressed by Muslim South Asian men and women in the larger San Francisco Bay Area. Six focus groups were conducted (three males and three females) with South Asian American Muslims. The focus groups consisted of a total sample size of n = 32, with 15 men and 17 women, with the average age of participants being 57 years old. This study highlighted key religious, cultural, and gender barriers to CRC screening including lack of awareness of CRC, the notion of fatalism as it relates to screening, lack of emphasis on preventive health, the need to preserve modesty, and stigma around certain CRC screening practices. Religiously tailored interventions and culturally sensitive healthcare providers are needed to better promote CRC screening in South Asian Muslim communities and to help inform the design of health interventions and outreach strategies.

Factors Influencing Mammography Uptake Following a Screening Intervention among Asian American Women: A Systematic Review

Asian American women, both immigrant and US-born, are known to have low mammography screening rates. To reduce health disparities and address community health needs, we undertook a systematic review to identify factors that affect mammography uptake among Asian American women following a mammography screening intervention. Following the PRISMA guidelines, we searched four databases and selected 12 studies that met our inclusion criteria. We identified 22 relevant factors and developed a new conceptual model that comprehensively captures these sociodemographic; cultural; knowledge, attitude, and perception; health history; health care accessibility and availability; and intervention factors, including components and mode of intervention. This conceptual model can be used to guide development of interventions that effectively promote mammography screening. Future research should focus on the effect of acculturation on screening behaviors and the importance of culturally tailored intervention and information-sharing elements to improving mammography screening among Asian Americans.

Case of Paradoxical Cultural Sensitivity: Mixed Method Study of Web-Based Health Informational Materials About the Human Papillomavirus Vaccine in Israel

BACKGROUND

Designing web-based informational materials regarding the human papillomavirus (HPV) vaccine has become a challenge for designers and decision makers in the health authorities because of the scientific and public controversy regarding the vaccine's safety and effectiveness and the sexual and moral concerns related to its use.

OBJECTIVE

The study aimed to investigate how cultural sensitivity (CS) is articulated in the explanatory informational materials on the HPV vaccine that are posted on the websites of the Israeli health authorities. In addition, the study examined the effect of transparency on the expression of CS in the informational materials.

METHODS

The study employed a quantitative and qualitative content analysis of the texts of explanatory informational materials published on the Arabic and Hebrew websites of the Israel Ministry of Health and the Clalit health maintenance organization (HMO).

RESULTS

The findings revealed the differences in the dimensions of CS (based on the CS model by Resnicow) between the informational materials targeting the majority Jewish population and those targeting the minority Arab population. Indeed, the research findings point to a paradox. On the one hand, the materials appealing to the conservative Arab population exhibited CS, in that the sexual context of the vaccine was missing. On the other hand, analysis of Resnicow's deep dimensions showed that disregarding the sexual context does not allow the relevant target audience to reflect on the barriers and concerns. In addition, the way the information was provided exhibited a lack of transparency regarding the CS dimensions (surface and deep).

CONCLUSIONS

The public health authorities have 2 main objectives in the context of vaccinations. One is to raise the vaccination rates and the other is to provide full and culturally sensitive information to give the public the tools to make intelligent decisions. The findings of this study indicated that despite the high uptake rate for HPV vaccination in the Arab population, the health authorities did not exercise full transparency and CS in transmitting the association between engaging in sexual relations and the necessity of the vaccination. Thus, the major challenge for the health authorities is to find ways to implement the objective of communicating information about the vaccination in a way that is transparent and culturally sensitive, even if this raises questions and fears among the public deriving from their culture.

Bedouin Women's Gender Preferences When Choosing Obstetricians and Gynecologists

Patients' preferences in choosing obstetricians/gynecologists are widely investigated, but studies among traditional populations are lacking. Bedouins comprise a traditional Arab Muslim society in the Arabian Peninsula (Saudi Arabia), The Levant (Syria, Jordan and Israel) and North Africa (Egypt). Most of the Bedouins in Israel populate several villages, mostly in the southern part of the country. This cross-sectional study compared 200 Bedouin and 200 Jewish women who responded to an anonymous questionnaire. Queried on gender alone, more Bedouin responders preferred female obstetricians/gynecologists (59.5 vs. 33% Jewish responders, p value <0.0001). Bedouin women preferred a female obstetrician/gynecologist for intimate procedures [feeling more comfortable (66.3%) and believing that females were more gentle (50%)]. However, they and the Jewish participants ranked ability, experience and knowledge as the top 3 qualities of an obstetrician/gynecologist, putting reputation in 4th place and gender in 5th place. Bedouin women strongly preferred female obstetricians/gynecologists, although professional skills were an important factor in their choice of caregiver. The ideal obstetrician/gynecologist for Bedouin women would be a skilled, knowledgeable, and experienced female.

Mixed Blessings? Religion/Spirituality Predicts Better and Worse Screening Behaviours

Some health research suggests that religious and spiritual variables positively predict health-screening behaviours. However, much of the literature on this topic has utilized exclusively religious samples, or has sampled from populations without uniform access to health care. Either of these issues may have artificially inflated the relationship between religion/spirituality and health-screening behaviours. The current study used data from the 2012 Canadian Community Health Survey to examine a general sample of women from New Brunswick and Manitoba (N > 1200). Results indicated that lower levels of church attendance were positive predictors of papanicolaou tests and mammograms, while higher levels of attendance were generally associated with poorer screening behaviours. Religiosity was a uniformly non-significant predictor of screening behaviours. Finally, religious affiliation was inconsistently related to screening behaviours, but tended to favour religious non-affiliation when it was. Religion/spirituality does not appear to have a uniformly positive nor linear effect in predicting health-screening behaviours in women.

Integrative review of cervical cancer screening in Western Asian and Middle Eastern Arab countries

Population-based screening programs have resulted in minimizing mortality and morbidity from cervical cancer. The aim of this integrative review was to explore the factors influencing access of women from Western Asian and Middle Eastern Arab countries to cervical cancer screening. A systematic search for studies conducted in Arab countries in those regions, and published in English between January 2002 and January 2017, was undertaken. Thirteen papers were selected and subjected to quality appraisal. A three step analysis was used, which involved a summary of the evidence, analysis of both quantitative and qualitative data, and integration of the results in narrative form. Few population-based cervical cancer screening programs had been implemented in the relevant countries, with low knowledge of, and perceptions about, cervical screening among Arab women, the majority of whom are Muslim. Factors affecting the uptake of cervical cancer screening practices were the absence of organized, systematic programs, low screening knowledge among women, healthcare professionals' attitudes toward screening, pain and embarrassment, stigma, and sociocultural beliefs. Policy changes are urgently needed to promote population-based screening programs. Future research should address the promotion of culturally-sensitive strategies to enable better access of Arab Muslim women to cervical cancer screening.

Depression Among Arab American and Arab Immigrant Women in the United States

The difficult and tense political climate Arab populations are currently facing may be exacerbating mental health issues, reducing forms of social support in friend circles, and decreasing the desire to seek health care. There is room to better understand the mental health needs of Arab women residing in the United States and to develop policies and interventions that keep these women safe and in care. This column reviews two recent studies; the first examines barriers to reporting intimate partner violence and depression among Arab American women and the second highlights stressors and social support for Arab women immigrants throughout their immigration experience.

Supporting Muslim Patients During Advanced Illness

Religion is an important part of many patients' cultural perspectives and value systems that influence them during advanced illness and toward the end of life when they directly face mortality. Worldwide violence perpetrated by people identifying as Muslim has been a growing fear for people living in the US and elsewhere. This fear has further increased by the tense rhetoric heard from the recent US presidential campaign and the new presidential administration. For many, this includes fear of all Muslims, the second-largest religious group in the world with 1.6 billion adherents and approximately 3.5 million in the US alone. Patient-centered care requires health professionals to look past news headlines and unchecked social media so they can deliver high-quality care to all patients. This article explores areas of importance in the context of advanced illness for practitioners of Islam. These include the conditions needed for prayer, the roles of medical treatment and religious authority, the importance of modesty, the religious concordance of clinicians, the role of family in medical decision making, advance care planning, and pain and symptom management. Initial recommendations to optimize care for Muslim patients and their families, informed by the described tenets of Muslim faith, are provided for clinicians and health systems administrators. These include Islamic cultural awareness training for staff, assessment of patients and families to determine needs, health education and decision-making outreach, and community health partnerships with local Islamic institutions.

Barriers to Cervical Cancer and Breast Cancer Screening Uptake in Low-Income and Middle-Income Countries: A Systematic Review

Background:

Cervical cancer (CCa) and breast cancer (BCa) are the two leading cancers in women worldwide. Early detection and education to promote early diagnosis and screening of CCa and BCa greatly increases the chances for successful treatment and survival. Screening uptake for CCa and BCa in low and middle - income countries (LMICs) is low, and is consequently failing to prevent these diseases. We conducted a systematic review to identify the key barriers to CCa and BCa screening in women in LMICs.

Methods:

We performed a systematic literature search using Ovid MEDLINE, EMBASE, PsycINFO, SCOPUS, CINHAL Plus, and Google scholar to retrieve all English language studies from inception to 2015. This review was done in accordance with the PRISMA-P guidelines.

Results:

53 eligible studies, 31 CCa screening studies and 22 BCa screening studies, provided information on 81,210 participants. We found fewer studies in low-income and lower - middle - income countries than in upper - middle - income countries. Lack of knowledge about CCa and BCa, and understanding of the role of screening were the key barriers to CCa and BCa screening in LMICs. Factors that are opportunities for knowledge acquisition, such as level of education, urban living, employment outside the home, facilitated CCa and BCa screening uptake in women in LMICs.

Conclusions:

Improvements to CCa and BCa screening uptake in LMICs must be accompanied by educational interventions which aim to improve knowledge and understanding of CCa and BCa and screening to asymptomatic women. It is imperative for governments and health policy makers in LMICs to implement screening programmes, including educational interventions, to ensure the prevention and early detection of women with CCa and BCa. These programmes and policies will be an integral part of a comprehensive population-based CCa and BCa control framework in LMICs.

Ethnic Variations in Perception of Human Papillomavirus and its Vaccination among Young Women in Nepal

BACKGROUND

The Human Papillomavirus (HPV) is strongly associated with cervical and other cancers. In women, cervical cancer is the third most common cancer. HPV infection can be largely prevented through vaccination of (adolescent) girls. At the same time, Nepal is a low-income country experiencing a cultural change in attitudes towards sex and sexual behaviour. However, in the adolescent population knowledge about HPV, factors associated with an increased risk of HPV and the existence of the vaccination is often low.

MATERIALS AND METHODS

This was a cross-sectional study with female students enrolled in health and non-health science courses in Pokhara, Nepal. The questionnaire included demographic details, knowledge and attitude questions related to HPV, associated risk behaviour and its vaccination. Descriptive statistics, including Chi-Square test, were used to identify statistically significant relationships. Ethical approval was granted by the relevant authority in Nepal.

RESULTS

Hindu religion (75.0 %; 95% CI: 70.9, 78.6) and Newari caste (75.5%; CI: 61.1, 86.7) were more aware about HPV, HPV vaccination. Hindus religion (55.6%; 95% CI: 51.2, 60.0) and Dalit caste (61.6%, 95% CI: 53.3, 69.4) more willing to be vaccinated than other religions and other castes, respectively. Not unsurprisingly, students on health-related courses had a greater awareness of HPV, HPV vaccination and were more willing to be vaccinated than students on other courses. Similar patterns of association arose for knowledge related to those sexually active at an early age; HPV risk and multiple sex partners; and fact that condoms cannot fully prevent the transmission of HPV.

CONCLUSION

Knowledge about the link between HPV and (a) early sexual initiation, (b) having multiple sexual partners, and (c) the limited protection of condoms and other birth control measures was poor in our study compared to similar research conducted in other parts of the world. One key implication is the need for education campaigns in Nepal to educate young women and their parents about HPV, its risk factors and the benefits of vaccination. .

Breast and Cervical Cancer Screening among US and non US Born African American Muslim Women in New York City

PURPOSE

Health disparities related to breast and cervical cancer among African American and African-born Muslim women in the United States have been identified in previous literature. Our study aimed at exploring the breast and cervical screening rates and factors that influence this population's disposition to adhere to cancer screening exams.

METHODS

Mixed methods were used to collect data with African American and African-born Muslim women in New York City. Data were collected from a total of 140 women; among them, 40 participated in four focus groups.

FINDINGS

Focus groups revealed nine themes: healthcare practices; lack of knowledge/misconceptions; negative perceptions and fear; time; modesty; role of religion; role of men; role of community; stigma and shame. Among 130 women who reported their cancer screening status, 72.3% of those age 21 and over were adherent to cervical cancer screening; 20.0% never had a Pap test. Among women age 40 and over, 80.2% reported adherence to recommended mammogram; 12.8% never had one. Among women under age 40, 52.2% had their last clinical breast exam (CBE) less than three years ago. Among women age 40 and over, 75.0% were adherent to yearly CBE.

CONCLUSIONS

While rates of screenings were above the national average and higher than expected, specific barriers and facilitators related to religious and health beliefs and attitudes that influence the decision to adhere to screening were revealed. These factors should be further explored and addressed to inform future research and strategies for promoting regular breast and cervical cancer screenings.

Nursing Care of Pregnant Muslim Women During Ramadan

There are approximately 3.3 million people of the Muslim faith living in the United States. This article explores how Muslim women observe their religious beliefs during pregnancy and discusses implications for nursing care of pregnant Muslim women during Ramadan. Although pregnant Muslim women can be exempt from fasting, many still choose to fast during Ramadan. Factors that influence a woman's decision to fast include gravity and parity, maternal education, maternal age, body mass index, comprehension of Islamic Law, and gestational trimester. Nurses can tailor their care of pregnant Muslim women to include episodes of fasting and help them make informed decisions regarding fasting during Ramadan.

Qualitative study of barriers to cervical cancer screening among Nigerian women

OBJECTIVES

To explore the barriers to cervical cancer screening, focusing on religious and cultural factors, in order to inform group-specific interventions that may improve uptake of cervical cancer screening programmes.

DESIGN

We conducted four focus group discussions among Muslim and Christian women in Nigeria.

SETTING

Discussions were conducted in two hospitals, one in the South West and the other in the North Central region of Nigeria.

PARTICIPANTS

27 Christian and 22 Muslim women over the age of 18, with no diagnosis of cancer.

RESULTS

Most participants in the focus group discussions had heard about cervical cancer except Muslim women in the South Western region who had never heard about cervical cancer. Participants believed that wizardry, multiple sexual partners and inserting herbs into the vagina cause cervical cancer. Only one participant knew about the human papillomavirus. Among the Christian women, the majority of respondents had heard about cervical cancer screening and believed that it could be used to prevent cervical cancer. Participants mentioned religious and cultural obligations of modesty, gender of healthcare providers, fear of disclosure of results, fear of nosocomial infections, lack of awareness, discrimination at hospitals, and need for spousal approval as barriers to uptake of screening. These barriers varied by religion across the geographical regions.

CONCLUSIONS

Barriers to cervical cancer screening vary by religious affiliations. Interventions to increase cervical cancer awareness and screening uptake in multicultural and multireligious communities need to take into consideration the varying cultural and religious beliefs in order to design and implement effective cervical cancer screening intervention programmes.

Lack of Understanding of Cervical Cancer and Screening Is the Leading Barrier to Screening Uptake in Women at Midlife in Bangladesh: Population-Based Cross-Sectional Survey

BACKGROUND

Cervical cancer (CCa) is the second most common cancer among women in Bangladesh. The uptake of CCa screening was less than 10% in areas where screening has been offered, so we investigated the awareness of CCa and CCa screening, and factors associated with women's preparedness to be screened.

METHODS

A nationally representative, cross-sectional survey of women aged 30-59 years was conducted in 7 districts of the 7 divisions in Bangladesh, using a multistage cluster sampling technique. Factors associated with the awareness of CCa and screening uptake were investigated separately, using multivariable logistic regression.

RESULTS

On systematic questioning, 81.3% and 48.6% of the 1,590 participants, whose mean age was 42.3 (±8.0) years, had ever heard of CCa and CCa screening, respectively. Having heard of CCa was associated with living in a rural area (adjusted odds ratio [OR]: 0.42; 95% confidence interval [CI]: 0.26-0.67), being 40-49 years old (OR: 1.59; 95% CI: 1.15-2.0), having no education (OR: 0.25; 95% CI: 0.16-0.38), and being obese (OR: 2.04; 95% CI: 1.23-3.36). Of the 773 women who had ever heard of CCa screening, 86% reported that they had not been screened because they had no symptoms and 37% did not know screening was needed. Only 8.3% had ever been screened. Having been screened was associated with being 40-49 years old (OR: 2.17; 95% CI: 1.19-3.94) and employed outside the home (OR: 3.83; 95% CI: 1.65-8.9), and inversely associated with rural dwelling (OR: 0.54; 95% CI: 0.30-0.98) and having no education (OR: 0.29; 95% CI: 0.10-0.85).

CONCLUSION

Lack of awareness of CCa and of understanding of the concept of screening are the key barriers to screening uptake in women at midlife in Bangladesh. Targeted educational health programs are needed to increase screening in Bangladesh with the view to reducing mortality.