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The Association Between Immigrant Muslim Arab Women’s Health Beliefs, Knowledge, Fatalism, Modesty, Perceived Spousal Support and Their Mammogram Utilizations: A Mixed- Methods Approach



Breast cancer (BC) is the most commonly diagnosed cancer among females in the United States. Substantial evidence has shown that regular mammogram screenings are effective for early BC detection and mortality reduction. Immigrant Muslim Arab women (IMAW), however, are less likely to be engaged in breast cancer screening (BCS), particularly mammogram screening. Few studies have explored factors associated with low mammogram utilization among IMAW. Additionally, all have overlooked an important factor—a husband’s influence in adherence to mammography screenings. In Arab and Muslim cultures, a husbands’ influence and responsibilities extends to their wives’ healthcare-seeking behaviors, thus becoming an important factor in a woman’s health status.

Developing and implementing a qualitative and quantitative mixed-method study sought: 1) to investigate associations between levels of IMAW’s health beliefs, BC knowledge, BC fatalism, modesty, perceived spousal support, and receiving physician recommendations and mammogram utilization; and 2) to better understand IMAW’s experiences and perceptions of spousal influence on mammogram utilization within their sociocultural context.

Method.The quantitative portion of the study was guided by the health beliefs model utilizing online surveys in Arabic and English. Due to the COVID 19 pandemic, a convenience sample was recruited using social media methods. Independent variables measured five scales: 1) perceived spousal support, 2) modified Powe fatalism inventory, 3) modesty measure for Muslim women, 4) BC knowledge, and 5) Champion breast health beliefs. Questions regarding receiving a health care providers’ (HCPs) recommendation for mammography was measured by self-report. Logistic regression explored relationships between independent variables and two outcomes: 1) ever had a mammogram, and 2) had a mammogram in the past two years.

Guided by symbolic interactionism, the qualitative portion of the study was conducted on a purposive sample of IMAW. A semi-structured interview guide in Arabic and English was used during the one-on-one interviews. Arabic interviews were translated into English and then transcribed by professional employees. Interviews were analyzed utilizing thematic analysis (Braun and Clarke, 2008). ATLAS.ti was used for the data analysis.

The 184 IMAW participants in the quantitative study had an average age of 50 years (SD = 3.5, range = 45–58 years); 86.6% reported having at least one mammogram in their lifetime, and 32.6% within the past two years. In bivariate analyses, perceived self-confidence, BC knowledge, receiving HCP recommendation, and perceived spousal support were positively associated with both outcomes (having had a mammogram and having one in the past two years). Whereas, perceived mammogram barriers was negatively associated with both outcomes. Perceived mammogram benefits was positively associated with only having had a mammogram within the past two years. In the final multivariate model, level of knowledge and perceived mammogram barriers retained the significant prediction of both outcomes, and receiving HCP recommendation of having had a mammogram.


The 20 qualitative interviews, 16 in Arabic and four in English, produced five themes: (1) types of husbands’ support experienced by IMAW; (2) the impact of husbands’ support on their wives’ attitudes about mammograms; (3) the importance of husbands’ support for mammogram use; (4) reasons behind inadequate husbands’ support; and (5) notions of “individual and collective duty” of enhancing husbands’ support.


Investigating factors influencing IMAW’s BC screening behaviors has resulted in important findings that can guide medical providers and nurses to a better understating of the factors influencing IMAW’s health-seeking behaviors and thus assist in positive BC screening behaviors. Promoting biennial mammography among IMAW may require a culturally tailored intervention to improve IMAW’s BC knowledge and health beliefs. Muslim and Arab men should also be educated about the importance of their support to enhance mammogram utilization among IMAW.

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