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Key findings
Our sequential mixed-methods study aimed to understand personal and religious meaning of breast cancer screening, and to identify barriers to and facilitators for mammogram uptake among Malay-Muslim women in the community. The IDI highlighted that decisions on mammogram uptake among the Malay-Muslim community in Singapore did not only depend on intrapersonal factors, but also their interpersonal relationships, community level factors such as their normative religious beliefs, and environmental factors such as screening facilities’ availability and access. Our nationwide survey results support the IDI findings, whereby mammography uptake was associated with multilevel factors. Factors that were associated with ever gone for mammogram were age, perceived benefits of saving lives from early detection, perceived importance of mammogram, cues from health care professionals and modesty concerns, appraisal of difficulties in life as a punishment from Allah (PMIR-PAR), and needing symptoms before deciding to go for mammogram. Factors associated with regular mammography uptake included household income, perceived structural barriers to screening, needing symptoms before deciding to go for mammogram, cues from health care professionals, and perceived susceptibility to breast cancer.
Interpretation of findings
To our knowledge this is the first study locally, to assess and compare factors associated with both ever gone for mammography, and regular mammography uptake. Most studies viewed mammography uptake as a single behavior and therefore assessed either uptake [12,13,14] or the intention to screen [42]. Of note, we found first and regular mammography uptake were only similar on two accounts in that, receiving cues from healthcare professionals facilitated both uptakes, and perception of needing symptoms prior to mammogram hindered both uptakes. Beyond this, ever gone for mammography and regular mammography uptake were facilitated and hindered differently. While ever gone for mammography was associated with perceptions of mammography and more deep-seated values such as PMIR-PAR and modesty concern, regular mammography was associated with household income, perceived structural barriers such as cost and ease of access, and one’s perceived susceptibility. One possible explanation for the differences in associations is that, positive perceptions on mammogram benefits and importance may encourage first uptake, but is insufficient to sustain regular uptake possibly due to a null result which may in turn reinforce belief of low susceptibility. On the other hand, deep-seated values may impede first uptake, however having overcome these initial barriers, affordability and ease of access matters more in decision for subsequent uptakes.
Such deep-seated values may have contributed to the observed interethnic disparity in mammography uptake too. Appraisal of difficulties in life as punishment from Allah (PMIR-PAR), and modesty concern relating to appearance have not been reported to be associated with mammography uptake or other cancer screening among other ethnic groups in Singapore – suggesting that these factors are likely to be unique to this community. Concerns on removal of clothing for medical tests [11] and preference for healthcare professional of certain gender [14] have been reported previously as barriers to screening among Asians in general. Both these factors were assessed in our survey but were outcompeted in our final multivariable logistic model by modesty concern relating to one’s dressing or appearance. Individuals holding a neutral perception towards modesty concerns in appearance, which is a core value of the Islamic faith [43], were most likely to attend screening compared to those that agreed to it. As the Islamic faith prohibits revealing of the aurat [10] with the exception of an emergency such as illnesses [44], our findings show that those that perceived this exception to include preventative health measures such as cancer screening were more likely to go for mammography. More importantly, our findings showed that those that place higher value on upholding modesty in their appearance were less likely to have ever gone for mammography screening, demonstrating that this religious priority does take precedence over mammography screening among many in this community. Prioritization of modesty in appearance over health is not limited to mammography screening and has been put forth to hinder Singaporean Malay women from taking part in physical activity in public spaces [15], despite physical activity being explicitly encouraged in the Islamic faith [45]. Compared to physical activity, cancer screening has not been directly addressed in religious guidance [44], potentially making the decision for cancer screening over preservation of modesty even harder, to the extent that breast cancer screening has been reported to be viewed as a taboo [10].
PMIR-PAR, or religious coping in general, has not been discussed in local or regional cancer screening literature. Hence, our finding which suggests, resigning to punishments given by Allah to lead to a deferment of mammography uptake among Muslims in Singapore, is a novel finding in this region. Notably, no association was found between PMIR-PAR and mammography uptake among Muslims in the US. Instead, positive religious coping (PMIR-PRC) was negatively associated with mammography uptake among Muslims in the US [18]. Taken together, our findings demonstrate strong association of religious coping with deferment of mammography uptake among Muslims, although the specific religious coping style differed with the regions. The reason for this difference in religious coping styles is unclear, but may be partly explained by differences in educational level and cultural background of women in the two studies. Of the respondents in the US, 65.0% were of tertiary education, compared to 13.3% in our study. Also, the study participants in the US comprised Muslim women of Arab, African and South Asian ethnicity with one third having only lived in US for the past 20 years, while our study comprised women of Malay ethnicity which are the original inhabitants of Singapore. Further qualitative inquiry is needed to understand the influence of religious coping on breast cancer screening, and the role of culture in this relationship. While household income and perceived structural barriers to screening are unlikely to be factors unique to this community, these factors may increase the interethnic disparity in mammography uptake, particularly regular uptake. This was confirmed by our study, which showed an independent significant association of household income with regular uptake. Additionally, those of Malay ethnicity report the lowest average household income in Singapore [46]. Given the availability of subsidies and facilities across Singapore, policy makers and health care providers may attribute perceived structural barriers to screening in this community, such as cost, inconvenience and lack of time, to a lack of knowledge on access and hence advocate for more public education on available subsidies and facilities. However, this action is unlikely to fully resolve the perceived barriers in this community. We found perceived structural barriers to be associated with regular screening but not with ever screening, suggesting that these women have acquired the knowledge, having gone for mammography for the first time. There could be other explanations such as Malay women prioritizing the needs of their loved ones over their health hence leading to them not attending screening regularly. This has been reported to hinder women from attending breast cancer screening in Jordan [17], and has been discussed elaborately in a series of in-depth interviews on heart health, whereby Singaporean Malay women described management of their heart health as “looking after their loved ones’ needs, no matter the strife” [47]. Given that these were qualitative studies, further investigation is needed to establish the relationship of prioritization the needs of loved ones with their health screening behaviour.
Study limitations and strengths
Our study had the following limitations. Despite efforts to maintain representativeness and reduce non-contactable individuals for the survey, number of households that remained uncontactable (12.1%) or have not completed contact attempts were relatively high (29.4%) (Fig. 1). We were not able to collect demographic variables from non-responders since verbal consent was not given, and therefore are not able to ascertain if non-responders significantly differed from responders. Also, the religious constructs were not validated in this region prior to data collection. However, these constructs were validated by the original authors, and were assessed as individual variables when found to be not unidimensional in EFA and scored low on inter-item reliability score. Finally, this research was conducted before the COVID-19 pandemic, hence potential barriers such as fear of attending health care facilities [48] due to COVID were not assessed. This might have changed some barriers and facilitators elucidated, but not the community-level norms relating to more deep-seated religious values.
Despite these limitations, our study has many strengths. First, our study assessed and demonstrated that different factors influenced the two behavioral outcomes, hence showing the need for different interventions and public health communication messages in targeting these behaviors. Second, using a qualitative inquiry before the quantitative survey ensured that we gained insights into all possible reasons for and against mammogram uptake before systematically determining factors that were associated with mammogram uptake in a representative sample in this community. Not only did the qualitative study prompt us to combine the Social Ecological Model with the individual-level Health Belief Model to assess multi-level factors associated with screening in the survey, it also helped explain prevalent misinformation. This is crucial in designing health communication messages specific for this community. Third, our findings on the influence of religion on mammography uptake that are potentially unique to the Malay-Muslim community helped to explain the persistent lower mammography uptake in this community compared to other ethnic groups despite equal access to health care services.
Public health and research implications
Our finding on cues from healthcare professionals to predict mammography uptake highlights the crucial role healthcare professionals play in encouraging screening in this community. Our finding on perception of needing symptoms prior to screening on the other hand, indicates the need for health education to specifically clarify that mammography can detect breast cancer prior to development of physical symptoms. Given the strong association observed between PMIR-PAR and mammography uptake and the high prevalence of such beliefs (29.4%), clearly, breast cancer screening interventions and its accompanying health messages should be jointly developed with religious leaders and the Islamic Religious Council of Singapore. We need to reduce perceptions on punishing appraisals, and clarify religious teachings on health preventive measures so as to reduce mental conflicts, particularly for those who highly value modesty in appearance (74.4%), and facilitate decision-making on cancer screening. We also need to encourage conversations among Malay women and among their loved ones, to emphasize prioritization of one’s own health and therefore foster a shift in norms with regards to women’s role in this community. In a multi-ethnic population in Singapore, ethnic-specific screening interventions should be part of the strategy to reach out to minority ethnic groups so as to increase equity in mammography uptake. Notably, our findings will have public health implications for our neighboring countries such as Malaysia and Indonesia, which not only share cultural roots with Malay-Muslims in Singapore, but also make up a larger proportion of their population. Mammogram uptake in Malaysia remains low, with approximately 25.0% having ever gone for mammogram in the general population [49]. In Indonesia, breast self-examination and clinical breast examination are currently still the recommended screening test, with one study reporting only 0.1% of its participants ever going for mammogram [50]. To promote mammography in these countries, it may be useful to conduct behavioral research on breast cancer screening that incorporates religious and cultural factors. This too applies to behavioral research on other cancer screening programs in Singapore. Finally, given our findings on the differences in factors related to ever gone for mammography and regular mammography, future behavioral research should assess these behaviors separately to facilitate development of differentiated strategies relevant to the differing needs of the two distinct (ever and regular) screener groups.
In summary, our study added significantly to the literature on mammography uptake behaviors among the Malay-Muslim community in Singapore. We identified factors that could have led to the ethnic disparity in mammogram uptake and also proposed actionable strategies to address this disparity. Notably, our study highlighted multiple key players that should be involved in future mammography promotion. As the Malay-Muslim community in Singapore shares its roots with Malaysia and Indonesia, community-level factors elucidated can be applied to the Muslim community there too.
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