Factors associated with low screening for breast cancer in the Palestinian authority

Relations of availability, environmental barriers, and cancer-related fatalism

Authors


  • See editorial on pages 4436-9, this issue.

Abstract

BACKGROUND:

The current study was conducted to assess screening behaviors in relation to cultural and environmental barriers among Palestinian women in the West Bank.

METHODS:

The participants were 397 women, ages 30 to 65 years, residing in the Palestinian Authority, and a stratified sample method was used (98.3% participation rate). The participants completed questionnaires on breast examination behaviors and knowledge, on perceived cancer fatalism and health beliefs, and on environmental barriers scales.

RESULTS:

Greater than 70% of the women had never undergone mammography or clinical breast examination (CBE), whereas 62% performed self breast examination (SBE). Women were more likely to undergo mammography if they were less religious (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.47-0.81) and if they expressed lower personal barriers (OR, 0.59; 95% CI, 0.29-0.76) and lower fatalism (OR, 0.39; 95% CI, 0.28-0.63). A higher likelihood for CBE was related to being Christian (OR, 2.91; 95% CI, 1.49-5.73) and being less religious (OR, 0.32; 95% CI, 0.13-0.78), to perceived higher effectiveness of CBE (OR, 1.46; 95% CI, 1.20-1.79), and to perceived lower cancer fatalism (OR, 0.35; 95% CI, 0.28-0.60). Women were more likely to perform SBE if they were more educated, resided in cities, were Christian, were less religious, had a first-degree relative with breast cancer, perceived higher effectiveness and benefits of SBE, and perceived lower barriers and fatalism.

CONCLUSIONS:

Participants reported a combination of personal, cultural, and environmental barriers, which should be addressed by educational programs and followed by the allocation of resources for early detection and treatment of breast cancer. Cancer 2010. © 2010 American Cancer Society.

It is established that the early detection of breast cancer increases survival.1-3 The existing data suggest that a combination of clinical breast examination (CBE) and mammography increases detection rates.4 Official guidelines in the United States for asymptomatic, average-risk women include CBE by a physician starting at age 20 years. Annual mammography screening is recommended for women aged ≥40 years. Israeli guidelines differ, recommending regular biennial mammography for women aged ≥50 years.5 Self-awareness, defined as becoming familiar with one's breasts, recognizing any changes that occur, and promptly reporting them to the healthcare provider, also is recommended.6 Although the efficiency of self breast examination (SBE) is questionable,7, 8 periodic, consistent SBE may facilitate breast self-awareness.9

Many studies have assessed environmental, cognitive, and emotional facilitators and barriers to screening.10, 11 Health beliefs and perceptions reportedly act as principal barriers to attending screenings.12, 13 In recent years, awareness has risen of cultural barriers to screening in specific ethnic groups, especially in traditional societies.14-16 A prominent barrier that has been identified in traditional societies is cancer fatalism, defined as the belief that death is inevitable when cancer is diagnosed.17 Other studies have focused on low socioeconomic status18, 19 or living in low-income countries20 as major barriers to screening.

Breast Cancer Screening in Low-Income Countries

The International Agency for Research on Cancer reported that, although the incidence of breast cancer is lower in low-income countries than in high-income countries, the mortality-to-incidence ratio is much higher in these countries (0.43 vs 0.30, respectively).19 In addition, the greatest increase in the incidence of breast cancer is observed in low-income countries.21 Because of the dearth of mammography facilities and the inability of many women to afford them,21 the 2007 Breast Health Global Initiative Global Summit in Budapest recommended promoting breast self-awareness and CBE in low-income countries without resources.22

However, in low-income countries, the lack of facilities, lack of information, and environmental barriers (such as difficulties reaching the clinic and costs)21 cannot be distinguished from the cultural barriers of traditional societies.14-16 These factors have not yet been assessed among Palestinian women residing in the West Bank where, in addition to the difficulties described above, there also are barriers of accessibility to healthcare facilities because of the complex situation of political conflict.23

Background: The Health System and Screening for Breast Cancer in the Palestinian Authority

The population of the West Bank, the major part of the Palestinian Authority, consists of 2.4 million Palestinians.24 The population is young (46% are aged <15 7 years) because of a high fertility rate and decreasing infant mortality.23

Despite the complex political and economic situation, the standard of living and the standard of medical care generally are higher in the Palestinian Authority than in several Arab countries.25 This improvement results in a decrease in communicable diseases and an increase in noncommunicable diseases, such as cardiovascular diseases, hypertension, diabetes, and cancer.25

Three tracks of health insurance exist in the Palestinian Authority: government insurance, which encompasses 35% of the residents and is affordable but with partial coverage of health needs; the United Nations Relief and Work Agency insurance, which is only for the refugee population (43%); and private insurance, which covers just 2%. Another 20% of the population is uninsured.24, 26

The incidence rate of breast cancer in the West Bank is 60 per 100,000 women.27 Although this rate is lower than that in Western countries or in Israel, breast cancer is the second most common cause of death among women.25, 28 There are 4 mammogram facilities in the entire Palestinian Authority. Mammography is free for insured women, whereas uninsured women have to pay the equivalent of $5 for mammography in a government hospital28 and $30 in a nongovernment hospital, making mammography expensive in relation to the income of Palestinians.28 Therefore, Palestinian women often are diagnosed with breast cancer at an advanced stage, which reduces their chance of recovery.28

To our knowledge, the current study is the first to assess breast cancer screening performance among women in the Palestinian Authority, where cultural perceptions related to religion and social norms are intertwined with factors such as low income, under insurance, a health system that is unable to establish an appropriate early detection system, and environmental barriers of distance and accessibility. The objective of this study was to assess the rate of performance of breast examination and its relation to demographic characteristics, perceived fatalism, and personal and environmental barriers.

MATERIALS AND METHODS

Participants

Participants were 397 Palestinian women residing in the West Bank. The only inclusion criterion was ages 30 to 65 years. Four hundred women were approached, including 100 from each district in the West Bank (Bethlehem, Hebron, Nablus, and Ramallah). In each district, 50 participants were recruited from the main city, 25 were recruited from villages, and another 25 were recruited from the refugee camps outside the cities.

The mean age of participants (±standard deviation [SD]) was 41.7 ± 8.88 years (range, 30-65 years). Three hundred two women (76.1%) were married, 59 women (14.8%) were not married, 9 women (2.3%) were divorced, 27 women (6.8%) were widows, and 307 women (90.8%) had children. Ninety-five women (23.9%) had an elementary school education or no education, 143 women (36%) had a high school education, 56 women (14.1%) had a higher education or a professional diploma, and 103 women (25.9%) had a university degree. Only 151 women (38%) worked outside the home. Fifteen women (3.8%) reported high family income, 159 women (40%) reported an average income, and 223 women (56.2%) reported low or very low income. The majority of the women were Muslim (N = 312; 78.6%) and the remaining women (N = 85; 21.4%) were Christian, which is representative of the population of the Palestinian Authority.24 Most of the women were either religious or very religious (N = 227; 57.6%), 144 women (36.3%) were conservative, and only 23 women (5.8%) reported being nonreligious. One hundred ninety-nine women (50.1%) lived in cities, 98 women (24.7%) lived in villages, and 100 women (25.2%) lived in refugee camps.

Procedure

A pilot study (N = 10) was conducted to assess clarity and ease of answering the questions. Minor changes were made accordingly. Seven professionals (nurses, social workers, and teachers) were trained to conduct the interviews. In each selected city or village, the interviewers went to households in different parts of the locality to obtain a random sample. Then, they approached 1 eligible woman in each household and asked for her agreement to participate. Four participants refused and were replaced by another 4, and 3 participants failed to complete the questionnaire and were excluded. Thus, the participation rate was 98.3%. The study was approved by the Ethics Board of the University of Haifa.

Questionnaires

Demographic data included age, family status, education, employment, perceived economic status, religion, level of religiosity, and having a first-degree relative with breast cancer.

Breast Examinations

The frequency of mammography, CBE, and SBE were analyzed. Mammography attendance was analyzed only for women aged ≥50 years. SBE performance was defined according the conservative guidelines used in the Palestinian Authority. Knowledge of breast cancer screening recommended guidelines was assessed using a question regarding the recommended frequency of mammography, CBE, and SBE according to age.

The perceived cancer-related fatalism subscale is part of the Arab Culture-Specific Barriers (ACSB) questionnaire composed by Cohen and Azaiza.29 It consists of 2 items that probe the degree to which respondents believe that early detection increases chances of recovery and that breast cancer is a curable disease. Answers range from 1 (strongly agree) to 5 (strongly disagree). Internal consistency (Cronbach α) of the subscale was .57.

The environmental barriers subscale also is part of the ACSB questionnaire.29 It consists of 4 items, including 3 original items that assess barriers of distance, accessibility, and expenses and a fourth item that tracks situational barriers for women in the Palestinian Authority (“existence of the wall and the checkpoints”). Internal consistency (Cronbach α) of the subscale was .78.

The health belief questionnaire was adapted from Champion13 and translated into Arabic.30 That version of the questionnaire was used in 2 previous studies30, 31 in which internal consistency of the subscales ranged from .87 to .92. It assesses perceptions of 1) severity of breast cancer (1 item); 2) susceptibility to breast cancer (2 items); 3) benefits of mammography, CBE, and SBE (5 items on each subscale); and 4) personal barriers to examinations (7 items on each subscale). Internal consistency (α) of the scales in the current study ranged from .68 to .80.

Statistical Analyses

Analyses were conducted using SPSS software (SPSS Inc., Chicago, Ill). Frequencies, means (SD), and differences in demographic and study variables were calculated. Differences between means of variables by attendance at breast examinations were calculated with t tests. The distribution of nominal variables by performance of breast examinations was determined by using chi-square tests or Fisher exact tests when cells had an expected frequency <5. Two-sided significance levels were used in univariate analyses, and multiple logistic regression analyses were conducted subsequently to assess variables that were associated significantly with the performance of breast examinations. From the demographic variables, only those variables that were correlated significantly with at least 1 of the breast examinations were entered into the regression and adjusted for (education, place of residence, religion, religiosity, and [for CBE and SBE] having a first-degree relative with breast cancer). We assessed multiple collinearity, and found that education, employment, and income were highly correlated. Therefore, the variable of education alone was entered. Multiple collinearity for the other variables was ruled out. A significance level of P < .05 was used.

RESULTS

The participants were asked what, according to their knowledge, was the recommended frequency of the different breast examinations (Table 1). Approximately 41% gave a frequency of 1 to 2 years for CBE, and approximately 48% had no idea of the recommended frequency. Only women aged ≥50 years were asked about the recommended frequency of mammography (Table 1). Sixty percent estimated higher than the recommended frequency (every 6 months and even more), 31% answered that they did not know the needed frequency, and another 7% reported no need for mammogram screening. No participants gave the correct, recommended frequency. SBE frequency was reported correctly by almost 30% of the women, approximately 20% suggested higher than the recommended frequency, 17% suggested lower, and 32% did not know the recommended frequency of SBE.

Table 1. Undergoing Breast Examinations: Knowledge and Performance
VariableNo. of Women (%)
Mammography, N=87aCBE, N=397SBE, N=397
  • CBE indicates clinical breast examination; SBE, self breast examination.

  • a

    Women aged ≥50 years.

Accuracy of knowledge on recommended frequency of breast examinations
 More than recommended53 (60.9)30 (7.6)84 (21.1)
 As recommended164 (41.3)117 (29.5)
 Less than recommended5 (1.3)69 (17.4)
 By physician's reference4 (1.0)
 No need7 (8.1)3 (0.8)
 Do not know or are unfamiliar with27 (31)191 (48.2)127 (32)
Performance of breast examination   
 More than recommended28 (7.06)67 (16.88)
 As recommended16 (18.39)44 (11.08)117 (29.47)
 Less than recommended7 (8.46)38 (9.57)62 (15.62)
 Never64 (73.56)287 (72.29)151 (38.04)

Frequency of Performing Breast Examinations

Table 1 shows that >60% of the women (aged ≥50 years only) had never attended mammogram screening, and only 18% had ever attended. In addition, approximately 72% had never undergone CBE; and, among those who had, only 18% had undergone CBE as recommended or even more frequently. Forty-six percent performed SBE on time or more frequently than recommended, whereas approximately 38% never performed SBE.

Most of the women who underwent CBE (87%) also performed SBE (chi-square test with 1 degree of freedom[1] = 39.48; P < .001). Also, significantly more women aged ≥50 years who ever had attended mammography (73.9%) had performed CBE (chi-square[1] = 33.03; P < .001), and 65.2% had performed SBE; however, the association between mammography attendance and performing SBE was not statistically significant (chi-square[1] = 0.56; P >.05).

Breast Cancer Screening-Related Perceptions

Only 60.1% of participants agreed to venture an estimate of the lifetime risk that a Palestinian woman would have breast cancer. On average, they estimated a medium risk (mean ± SD, 2.6 ± 0.95 on a scale from 1 to 4). A much lower proportion of participants (22.4%) were willing to estimate their own lifetime risk, and the mean estimated risk was 2.1 ± 0.80. The remaining respondents could not make an estimate. The participants perceived breast cancer as a very severe disease (4.29 ± 0.90 on a scale from 1 to 5). Participants perceived mammography and CBE as highly effective in detecting breast cancer (3.96 ± 1.25 and 3.61 ± 1.38, respectively) but also had similar perceptions about SBE (3.53 ± 1.42).

The mean (±SD) fatalism score was 2.69 ± 0.64 on a scale from 1 to 5, indicating a medium degree of the perception that breast cancer is an incurable or fatal disease. The mean score for environmental barriers also was in the middle of the range: 2.42 ± 0.97 for distance from clinic, 2.81 ± 1.26 for existence of walls and checkpoints that may make traveling difficult, and 3.09 ± 1.26 for financial barriers.

Regarding health beliefs, the women perceived high benefits from breast screenings, especially mammography (mean ± SD, 4.24 ± 0.71), but also from CBE (3.88 ± 0.73) and SBE (3.69 ± 0.87). The mean scores for perceived personal barriers to the examinations were similar for the 3 types of examinations and were in the middle of the range (2.60 ± 0.71 for mammography, 2.70 ± 0.80 for CBE, and 2.43 ± 0.94 for SBE).

Differences in Study Variables by Mammography and CBE Attendance and SBE Performance

The characteristics of women who had ever undergone mammography and CBE, who had never undergone mammography (assessed only for participants aged ≥50 years) or CBE, and who had performed or not performed SBE regularly are presented in (Table 2). Women who had ever attended mammography or CBE and had performed SBE regularly were more educated and were less religious. More women who had undergone mammography were married. More Christian women than Muslim women and more women who lived in cities and villages than in camps had attended CBE and had performed SBE regularly, and more of them were employed and had a higher income. Women who had ever undergone mammograms or CBE and who had performed SBE reported knowing more women with breast cancer, and more of the women who had undergone mammography had received a recommendation from their physician to undergo mammography.

Table 2. Differences in Study Variables by Performance of Breast Examinations
VariableMammography, N=87aCBE, N=397SBE, N=397
No. of Women (%) or Mean±SD No. of Women (%) or Mean±SD No. of Women (%) or Mean±SD 
Ever Attended, n=23Never Attended, n=64Statistical TestbEver Attended, n=110Never Attended, n=287Statistical TestbPerformed, n=246cNever Performed, n=151Statistical Testb
  • CBE indicates clinical breast examination; SBE, self breast examination; SD, standard deviation; t, t test; χ2, chi-square test; Z, Fisher exact test.

  • a

    Women aged ≥50 years.

  • b

    bFor statistical tests, the subscript values in parentheses indicate degrees of freedom.

  • c

    Done in the preceding 3 months versus less frequently or not done.

  • d

    P < .05.

  • e

    P < .01.

  • f

    P < .001

  • g

    One hundred forty-one participants stated “impossible to know.”

  • h

    Two hundred eighty-two participants stated “impossible to know.”

Age, y54.57±4.0055.31±4.48t(85)=−0.7142.21±8.3241.45±9.02t(394)=0.7841.12 (8.50)42.27 (9.18)t(394)=1.75
Married11 (47.83)48 (75)χ2(1)=5.73d79 (71.82)222 (77.35)χ2(1)=0.77186 (75.60)116 (76.8)χ2(1)=0.08
Education  χ2(2)=13.17e  χ2(2)=16.04e  χ2(2)=33.48f
 None or elementary school8 (34.78)34 (53.13) 14 (12.73)80 (27.87) 39 (15.85)56 (37.09) 
 High school9 (39.13)17 (26.56) 49 (44.54)93 (32.40) 87 (35.37)56 (37.09) 
 Higher education6 (26.09)13 (20.31) 47 (42.73)114 (39.73) 120 (48.78)39 (25.82) 
Employed8 (34.78)14 (21.88)χ2(1)=1.4950 (45.45)100 (34.84)χ2(1)=4.37d111 (45.12)40 (26.49)χ2(1)=13.78f
Income, $2.74±1.212.34±1.11t(85)=1.422.63±0.992.34±1.08t(393)=2.44d2.61±1.092.19±0.98t(393)=3.98f
Religion  χ2(1)=1.81  χ2(1)=8.74e  χ2(1)=11.29e
 Muslim16 (69.56)53 (82.81) 74 (67.27)236 (82.22) 180 (73.17)132 (87.42) 
 Christian7 (30.44)11 (17.20) 36 (32.73)51 (17.78) 66 (26.83)19 (12.58) 
Religiosity, 1-4 scale2.22±0.672.83±0.63t(85)=−3.21e2.34±0.692.67±0.68t(392)=−4.35e2.47±0.702.77±0.66t(392)=−4.35e
Place of residence  χ2(1)=0.29  χ2(2)=12.93e  χ2(2)=27.71f
 City11 (47.82)30 (46.88) 56 (50.91)143 (49.83) 135 (54.88)63 (41.72) 
 Village6 (26.09)20 (31.25) 38 (34.54)60 (20.91) 71 (28.86)28 (18.54) 
 Camp6 (26.09)14 (21.87) 16 (14.55)84 (29.26) 40 (16.26)60 (39.74) 
Has first-degree relative with breast cancer1 (4.35)5 (7.81)Z=1.5813 (11.81)15 (5.26)χ2(1)=5.53d24 (9.76)4 (2.65)Z=1.76
Knows someone with breast cancer11 (47.83)13 (20.31)χ2(1)=6.41d44 (40.00)65 (22.65)χ2(1)=12.9f71 (34.30)37 (19.47)χ2(1)=12.9f
Received recommendation10 (43.48)4 (6.25)Z=15.16      
Perceived risk for Palestinian women, 1-5 scaleg3.94±1.663.32±1.92t(85)=2.48d3.40±1.783.89±1.91t(394)=−2.33d3.43±1.834.13±1.88t(394)=−3.77f
Perceived personal risk, 1-5 scaleh4.74±1.395.46±1.18t(35)=−2.40d4.65±1.565.46±1.19t(111)=−5.46f5.06±1.485.42±1.18t(111)=−2.65f
Perceived severity, 1-5 scale1.78±0.901.56±0.75t(84)=1.404.39±0.824.26±0.92t(395)=1.334.32±0.914.23±0.88t(395)=0.90
Perceived fatalism, 1-5 scale2.64±0.512.98±0.66t(85)=2.80d2.54±0.482.75±0.67t(394)=−3.47e2.75±1.402.74±0.67t(394)=−1.10
Perceived effectiveness, 1-5 scale4.19±1.003.91±1.30t(85)=1.764.11±1.143.42±1.42t(394)=4.51f3.11±1.143.16±1.38t(394)=4.10f
Environmental barriers, 1-5 scale         
 Overall2.53±0.892.83±0.98t(85)=−2.36d2.60±0.902.83±0.99t(393)=−2.06d   
 Distance2.23±1.042.46±1.08t(85)=1.652.32±0.962.44±1.11t(395)=−0.98   
 Checkpoints2.54±1.112.87±1.29t(84)=2.05d2.55±1.102.91±1.30t(394)=−2.54d   
 Expenses2.82±1.043.15±1.31t(85)=2.32c2.94±1.173.14±2.92t(394)=−1.41   
Personal barriers, 1-5 scale2.32±0.702.81±0.61t(83)=3.14d2.48±0.712.79±0.58t(394)=−3.29d2.48±0.712.79±0.58t(394)=3.96e
Perceived benefits, 1-5 scale4.43±0.804.09±0.72t(85)=1.933.99±0.583.84±0.78t(394)=2.103.84±0.813.45±0.89t(395)=4.22e

The women who attended mammography and CBE and the women who performed SBE perceived their own lifetime risk of breast cancer and that of Palestinian women in general as higher than that perceived by women in the nonattendees group but did not differ from the SBE nonperformers in perceived severity. The mammography and CBE attendees reported lower fatalism regarding breast cancer and experienced the checkpoints as a lower barrier to attending examinations. Regarding health beliefs, as measured by the health belief questionnaire, mammography and CBE attendees perceived significantly lower personal barriers to mammography but perceived its benefits. SBE performers and nonperformers reported levels of fatalism similar to the levels among nonperformers but reported lower personal barriers and higher benefits of SBE.

Predictors of Attending Mammogram and CBE and Performing SBE

Table 3 presents the results from a logistic regression analysis of the variables that predicted breast examinations. Only 3 of the variables that were included in the regression analysis increased the likelihood of attending mammography: a lower level of religiosity, lower perceived personal barriers, and a lower sense of fatalism. Similarly, the likelihood of undergoing CBE increased with lower religiosity and also with being Christian, with perceiving CBE as effective, and with lower fatalism. Undergoing both examinations was not associated with sociodemographic variables, perceived benefits of examinations, or environmental barriers.

Table 3. Multiple Logistic Regression Analysis Predicting Breast Examinations Among Women in the Palestinian Authority
VariableMammographyaCBEaSBEb
AOR95% CIAOR95% CIAOR95% CI
  • CBE indicates clinical breast examination; SBE, self breast examination; AOR, adjusted odds ratio; CI, confidence interval; df, degrees of freedom

  • a

    Ever done versus never done.

  • b

    Done in the preceding 3 months versus less frequently or not done.

  • c

    P < .01.

  • d

    P < .05.

  • e

    Analysis was not performed for mammography attendance because of small numbers.

  • f

    P < .001.

Education1.290.64-2.601.000.73-1.381.51c1.38-1.69
Place of residence      
 City1.00 1.00 1.00 
 Village0.260.03-1.595.072.47-10.390.39c0.19-0.77
 Camp0.190.03-1.141.231.23-2.630.76d0.68-1.02
Religion      
 Muslim1.00 1.00 1.00 
 Christian0.810.16-4.152.91c1.49-5.730.540.27-1.07
Religiosity0.59**0.47-0.810.32c0.13-0.780.44c0.24-0.56
First-degree relativee1.530.60-3.911.26d1.02-1.93
Perceived fatalism0.39*0.28-0.630.52c0.33-0.830.950.65-1.48
Perceived effectiveness0.950.59-1.521.46f1.20-1.791.24d1.04-1.46
Environmental barriers1.330.67-1.650.830.62-1.09  
Personal barriers0.59d0.29-0.760.770.54-1.080.43d0.24-0.70
Perceived benefits0.560.21-1.461.160.80-1.661.66c1.49-1.89
Chi-square model (df)29.50 (9)c 79.50 (10)f 113.85 (10)f 

SBE was associated with and predicted by a wide range of variables. Higher education, living in cities, religiosity, having a first-degree relative diagnosed with breast cancer, perceived efficacy, higher benefits, and lower personal barriers all were linked with SBE, but a sense of fatalism and religion were not.

DISCUSSION

To our knowledge, this is the first study among Palestinian women in the West Bank on breast cancer screening and on facilitators of and barriers to screening. The results indicate that most respondents could not recall the precise frequencies recommended for breast examinations. Rates of mammography and CBE attendance were very low, whereas a relatively high percentage of women performed SBE. When controlling for other variables, barriers of distance, cost, and the existence of checkpoints and walls did not predict mammography or CBE attendance.

Knowledge of guidelines for breast examinations is considered central for better consistency with examinations.21 Women who are knowledgeable about the examination recommendations according to age are better able to control and actively undergo the examinations.14 The current results indicated that very small numbers of women were aware of the needed frequency of CBE and mammography. Moreover, many women gave a much higher frequency of needed examinations, especially mammography, than actually recommended. Accurate knowledge about breast examinations can be achieved by the wide propagation of education programs.21

The low attendance rates reported in this study probably were caused by the insufficient number of mammography facilities, their remoteness, difficulty reaching them, and inadequate health insurance.23, 26 However, as indicated by the current results and in support of previous studies, low attendance rates also are caused by a lack of knowledge and by personal, social, and cultural barriers.14, 16, 29-32

In contrast to CBE and mammography attendance, a large portion of participants in the current study reported performing SBE (approximately 62%), and >15% reported performing a daily SBE. This finding may be indicative of high anxiety and high cancer worries, as reported previously.30, 33, 34 Over performance of SBE also may be an act of compensation—the reflection of a woman's desire to do something for her health—in light of the unavailability of more effective examinations. However, SBE overuse also may be the result of under dissemination of information about current guidelines, or health professionals may not even be aware of the recommended shift in focus toward educating women to acquire familiarity with their breasts and awareness of any change in them. Conducting SBE is important for enhancing this awareness in addition to CBE and mammography. However, health professionals and the women themselves should be aware that this procedure has low efficiency for the detection of small lumps6; and, because of the false reassurance women may gain from checking their breasts, if they are convinced that they are healthy, then they may not seek further examinations.6

In support of previous studies,19 lower education, not working outside the home, and lower income all were associated with an increased odds of not attending CBE and not performing breast examinations. These variables also were associated significantly with mammography; however, when other variables were controlled for, these variables were not significant predictors of mammography attendance. However, the reason fewer variables were identified that predicted ever attending mammography also may have been because of the small numbers of participants aged ≥50 years (N = 87) who were assessed for mammography attendance.

In support of previous studies in Arab participants,30, 31, 35 being more religious was associated with lower attendance to CBE and mammography and lower SBE performance. This also explains why more Christian women, who were less religious, participated in the examinations.

The health belief model for screening for breast cancer12 posits that the likelihood of women attending screenings depends on their perceptions of the severity of the illness and their susceptibility to it, of the benefits resulting from the examinations (eg, possibility of detecting the illness at an early stage, thereby preventing death), and of perceived personal barriers to them (eg, it is painful, time-consuming).13 Women who attended the examinations and those who performed SBE differed from the nonattending and nonperforming participants mostly in terms of personal barriers, as reported previously (such as fear of pain, fear of finding a lump)14, 30, 31, 34 and fatalism.15, 35 Regarding mammography and CBE, the nonattendees also reported more environmental barriers, namely, cost, distance, and the army checkpoints. These barriers are unique to the situation of living at the heart of a political conflict. However, when other variables were controlled for, these barriers did not increase the odds of attending mammography or CBE.

The predictors of SBE presumably differ from the predictors of CBE and mammography attendance because of the already widespread counter-recommendation on SBE.6-8 In contrast, similar to predictors of mammography and CBE attendance, higher SBE performance was predicted by higher education, employment, living in urban areas, lower religiosity, greater perception of SBE as effective and beneficial, and lower personal barriers. An explanation for these findings may be the lack of adequate educational programs for proper awareness of screening guidelines rather than only for SBE. Nevertheless, when access to screening facilities is difficult, performing SBE is the only action that can be applied. Perhaps the guidelines in Western countries should be adapted to the specific circumstances and possibilities in low-income countries.

Several studies have demonstrated that cultural perceptions and social norms often act as barriers to screening for breast cancer,29 and these factors have been related to lower screening rates among Arab Israeli women.14, 30-32 A central barrier that has been identified in traditional societies is cancer fatalism.17 The relations between cancer fatalism and screening performance in traditional societies may be explained by the belief in God's will and that the onset of disease and its course are in God's hands.16 These beliefs also have been related to external health locus of control.35 A previous study that assessed health locus of control in a random population-based sample of Jews and Arabs in Israel demonstrated that the Arab respondents, especially women, reported higher external health locus of control35; this locus of control predicted avoiding undergoing screening and screening intention, which were markedly lower among the Arab respondents.35

The high rate of death from cancer in the Palestinian Authority because of late diagnosis and insufficient treatment also may enforce the fatalistic view of cancer as a certain death. However, it is important to note that, in Muslim writings, illness also is viewed as a test from God.14, 16 This conveys the message that individuals are responsible for and must take action to preserve and promote their own health.14

To summarize, the current findings indicate that there is a combination of cultural and personal barriers to screening together with restricted facilities for breast examinations, barriers in cost and accessibility, and inaccurate knowledge. These factors together cause low attendance for mammography and CBE and encourage frequent SBE performance.

A change in this situation is needed to improve the early detection rate and, thus, increase the survival of women with breast cancer. This change should occur according to the financial and structural limits of the healthcare system in the specific country.21 Therefore, although more facilities and full coverage of CBE and mammography screening are prerequisites, these changes will take time. Educational programs should be constructed to enhance understanding of the value of early detection and knowledge of guidelines, to teach breast awareness, and to reduce cultural and social barriers. In addition, more rigorous implementation of CBE by physicians is needed. It also will be very important to increase physicians' awareness and motivation to perform CBE.

The casual screening practiced today in the West Bank is insufficient, because, of course, it does not reach high-risk women. Organized screening should be developed in which invitations to screening are extended to a defined target group. However, increasing the rate of early detection has little value if the healthcare system is incapable of providing access to efficient treatment for cancer, which is the current situation in the Palestinian Authority. Priority should go to allocating resources for developing treatment facilities.

The current study had several limitations that should be underscored. Several steps were taken to ensure that the participants constituted a representative sample; this was achieved by recruiting an equal number of women from each district and from the 3 main types of communities in each district (cities, villages, and refugee camps). Moreover, in each community, households were selected arbitrarily, and only 1 eligible woman from each household was interviewed. The high participation rate also increases the strength of the results and their implications for the changes suggested in public health policy. Nevertheless, it was not a random, population-based sample, which may limit the generalizability of the study to women in the West Bank. In addition, it was demonstrated previously that on-time attendance of screening should be assessed rather than probing for ever attending the examinations. Because of the low rates of attendance for mammography and CBE, it was not possible to assess variables related to on-time attendance rather ever attending the examination. Nevertheless, to our knowledge, this study is the first to report on screening for breast cancer behavior in Palestinian women in the West Bank and to reveal the personal, cultural, and environmental barriers to screening in face of the unique situation of insufficient healthcare and an enduring political conflict.

CONFLICT OF INTEREST DISCLOSURES

The authors made no disclosures.

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