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ONLINE EXCLUSIVE
The Determinants of Breast Cancer Screening
Behavior: A Focus Group Study of Women
in the United Arab Emirates
Abdulbari Bener, PhD, MFPHM, FRSS, Gladys Honein, MPH,
Anne O. Carter, MD, MHSc, Zahra Da'ar, MPH, Campbell Miller, MB, ChB, MSc,
and Earl V. Dunn, MD
Key Points . . .
Purpose/Objectives: To explore perceptions, knowl-
edge, attitudes, and beliefs about breast cancer and its
screening among Emirati national women in Al Ain,
Women have encouraging and deterring factors that affect their
United Arab Emirates.
breast cancer screening practices.
Design: A qualitative study using focus group methods.
Setting: Primary healthcare centers and a community-
Healthcare providers must identify and account for women's
based women's association in the United Arab Emirates.
encouraging and deterring factors when planning and imple-
Sample: 41 women, aged 2545 years.
menting breast cancer screening programs.
Methods: Four 90-minute focus group discussions ex-
Focus group methods can be used successfully to identify fac-
ploring perceptions, knowledge, attitudes, beliefs, and
practices regarding breast cancer were audiotaped,
tors that affect women's breast cancer screening practices.
transcribed, translated, and analyzed.
Main Research Variables: Social and cultural themes
related to breast cancer and its screening.
reast cancer is the most commonly diagnosed cancer in
B
Findings: Focus group methodology worked well in this
women and the second leading cause of mortality and
setting. The women's perceptions, knowledge, attitudes,
morbidity in women in western countries (Caplan,
and beliefs regarding cancer and screening, together
Wells, & Haynes, 1992; Davis, Arnold, Berkel, & Nandy, 1996;
with aspects of the healthcare system and social milieu,
appeared to strongly influence the women's preventive
practices. Some of these factors had an encouraging ef-
At the time this study was conducted, Abdulbari Bener, PhD,
fect on the women's practices, and others had a deter-
MFPHM, FRSS, was a professor in the Department of Community
ring effect. The encouraging factors included feelings of
Medicine in the Faculty of Medicine at United Arab Emirates (UAE)
susceptibility, high levels of knowledge in some women,
University in Al Ain. Gladys Honein, MPH, is a course manager in
attitudes and beliefs about personal responsibility for
the Department of Health Policy Management and Evaluation at the
health, and a supportive social milieu. Deterring factors
University of Toronto in Canada, and Anne O. Carter, MD, MHSc, is
included anxiety and fear leading to denial; lack of
an associate professor in the Department of Community Medicine in
knowledge about cancer and the screening program;
the Faculty of Medicine at UAE University. At the time this study was
fear, embarrassment, and mistrust of health care; and
conducted, Zahra Da'ar, MPH, was a health educator in the Depart-
belief in predestination.
ment of Preventive Medicine in the Ministry of Health in Al Ain.
Conclusions: Health planners and healthcare provid-
Campbell Miller, MB, ChB, MSc, is an assistant professor in the De-
ers must capitalize on encouraging factors and minimize
partment of Family Medicine in the Faculty of Medicine, and Earl V.
deterring factors to optimize breast cancer screening
Dunn, MD, is a professor in the Department of Family Medicine in
practices among these women.
the Faculty of Medicine, both at UAE University. This work was sup-
Implications for Nursing: Identifying and accounting
ported by a grant (NP/99/5) from the Faculty of Medicine and Health
for the factors that encourage or deter women in their
Sciences, UAE University, Al Ain, Abu Dhabi, UAE. (Submitted July
breast cancer screening practices will help to optimize
2001. Accepted for publication March 30, 2002.)
screening programs.
Digital Object Identifier: 10.1188/02.ONF.E91-E98
BENER VOL 29, NO 9, 2002
E91
This focus group study was designed to explore the deter-
Jemal, Thomas, Murray, & Thun, 2002). Screening and early
minants of breast cancer screening behavior and assist in the
detection of breast cancer through a combination of monthly
development of the program. Because healthcare services are
breast self-examination (BSE), regular clinical breast examina-
free to all Emirati nationals, the cost of screening was not
tion, and annual mammography beginning at age 40 are the
explored as a determinant. The perceptions, knowledge, atti-
best ways to limit morbidity and mortality from breast cancer
tudes, beliefs, and practices of the women in relation to
(Fletcher, Black, Harriss, Rimer, & Shapiro, 1993; Pearlman,
breast cancer and breast cancer screening were the specific re-
Clark, Rakowski, & Ehrich, 1999; Schweitzer, 1988).
search issues addressed. This study was approved by the re-
Lack of knowledge about the benefits of breast cancer
search ethics committee of the Faculty of Medicine and
screening is a significant barrier for some women (McPhee et
Health Sciences at UAE University.
al., 1997; Pham & McPhee, 1992; Philips, Cohen, & Moses,
1999; Remennick, 1999; Yi & Prows, 1996). In particular,
lack of knowledge has been associated with underuse of
Methods
screening services in low-income, poorly educated minori-
Participants in the focus groups were Emirati women volun-
ties and the elderly (Gotay, Issell, Hernandez, & Serxner,
teers who were 2545 years of age. For three of the four focus
1996; Morgan, Park, & Cortes, 1995; Rakowski et al., 1992;
groups, women were recruited by personal invitation of the
Suarez, Roche, Nichols, & Simpson, 1997; Sung, Blu-
nurses who worked in their primary healthcare (PHC) centers.
menthal, Coates, & Alema-Mensah, 1997; Vietri, Poskitt, &
Two of these three centers are in semirural areas, and one is in
Slaninka, 1997).
an urban area. Because the breast cancer screening program al-
Recently, some studies have reported that improved
ready had been implemented in these centers at the time of re-
knowledge and attitudes positively affect the screening be-
cruitment, the women most likely were exposed to the program
havior of women (McPhee et al., 1997; Pearlman et al., 1999;
prior to their participation in the focus group. However, this
Suarez et al., 1997; Tang, Solomon, Yeh, & Worden, 1999;
was not a requirement for group membership. The fourth focus
Underwood, Shaikha, & Bakr, 1999). In their study, Erblich,
group consisted of women attending a social and educational
Bovbjerg, and Valdimarsdottir (2000) suggested that exam-
center for Emirati women in urban Al Ain. They were less
ining the impact and role of psychological distress on the
likely to have been exposed to the breast cancer screening pro-
practice of BSE may be particularly important.
gram than those recruited from the PHC centers.
Focus groups and surveys have been used extensively to
T h e four group meetings were held in the PHC and
study breast cancer screening behavior and barriers to screen-
women's centers because the settings were familiar. The fo-
ing among Anglo American women (Zapka & Berkowitz,
cus groups met for 6090 minutes, and participants spoke in
1992), African American women (Hoffman-Goetz & Mills,
Arabic. The purpose of the first three focus group meetings
1997; Philips et al., 1999; Tessaro, Eng, & Smith, 1994),
was to generate data and identify key concepts that emerged
Vietnamese American women, Mexican women (Suarez et al.,
from the discussions. These concepts then were tested and re-
1997), Russian immigrants in Israel (Remennick, 1999), Na-
fined in the fourth focus group, which was held in the urban
tive American women (Coughlin, Uhler, & Blackman, 1999),
PHC center.
and Asian American women (Tang et al., 1999). These stud-
A semistructured guide was designed to focus the discus-
ies offer explanations for mammography screening in women
sion on the following issues: perceptions related to cancer
and emphasize the strength of naturally existing sources of
and screening for cancer; knowledge about the etiology of
social support for designing interventions to increase breast
breast cancer, its symptoms, and the screening techniques
cancer screening.
used for early detection; attitudes and beliefs concerning
Focus group interviewing has been used extensively to ex-
screening and treatment services; and practices and barriers
amine a variety of healthcare-related issues, belief, attitudes,
related to screening. The discussion was not limited to the
and practices. Focus group methodology is particularly effec-
guide; new ideas were welcomed and encouraged. The dis-
tive in collecting information about sensitive topics, such as
cussion guide was modified for the last focus group to test the
breast cancer, because it breaks barriers of shyness and silence
concepts that emerged from preliminary analysis of the first
through group interaction (Philips et al., 1999; Tessaro et al.,
three focus groups.
1994). Usually, small group discussions of 412 individuals
Two bilingual investigators attended the focus group
are held in neutral and nonthreatening settings to allow for the
meetings: One acted as a facilitator, and the other took notes
collection of subject-generated data that are not captured by
and observed. An additional individual, who had been in-
quantitative techniques (Morgan et al., 1995). However, focus
volved in recruiting the women, attended the discussions to
group findings are directional and nondefinitive and, therefore,
help create an atmosphere of trust and openness. Each focus
may not be generalizable (Krueger, 1994).
group session was taped using a multidirectional micro-
A breast cancer screening program was introduced at the
phone placed in the center of the group, which was capable
beginning of 1998 in the inland desert city of Al Ain in the
of recording all voices. At the beginning of each session, the
United Arab Emirates (UAE). The age-standardized inci-
facilitator introduced herself and the other investigators,
dence of breast cancer for 1998 in this population was 15.5
stated the aim of the meeting, and asked for consent to audio-
per 100,000 (Denic & Bener, 2001). By way of comparison,
tape the discussion. The women then were asked to complete
the age-standardized incidence of breast cancer for 1998 in
a brief questionnaire regarding their basic demographic in-
Kuwait was 31.8 per 100,000 and 18.6 per 100,000 in Saudi
formation (illiterate women were assisted). The facilitator
Arabia (Denic & Bener). One of the main target groups of this
followed the discussion guide beginning with broad ques-
screening program is traditional, Muslim Bedouin women
tions to initiate discussion. Probing questions were used to
more than 40 years old who are citizens of the UAE (i.e.,
gain a deeper understanding of participants' initial responses.
Emirati nationals).
ONF VOL 29, NO 9, 2002
E92
Audiotapes of all focus group discussions were transcribed
cer screening program. Thirteen women had experienced
in Arabic and translated into English because three of the
screening mammography at least once.
The focus group approach was effective in collecting in-
study's investigators could not read Arabic. The audiotapes
usually were transcribed by the person involved in recruiting
formation from participants by breaking barriers through
the women under the supervision of the investigator who ob-
group interaction. After an initial period of limited communi-
cation, they began to express their thoughts freely and al-
served the discussion at each focus group session. Two inves-
most every woman participated actively.
tigators independently reviewed and manually analyzed the
transcripts by dissecting each line into ideas. Similar ideas
Perceptions of Cancer
were grouped together into concepts. The investigators then
met to compare their findings. Differences were resolved by
Personal perceptions of susceptibility to breast cancer ap-
returning to the Arabic transcripts to clarify issues of mean-
peared to have a positive impact on the women's screening
ing. After the third focus group session, a complete list of
behaviors.
concepts was generated and used to prepare the discussion
We heard that this disease is spreading too much in the
guide for the fourth focus group where the concepts were
country, so we are afraid, and we want to treat it early be-
tested and refined. The concepts that emerged from the fourth
fore it spreads.
focus group session were integrated into a conceptual frame-
work.
Some women are thinking that they may have problems
with their breast and go to do tests.
Results
In addition, fear of cancer, in some, led to a positive attitude
toward prevention.
Forty-one Emirati women participated in the study; their
sociodemographic characteristics are presented in Table 1.
If I know that I have any tumor, I want to get treatment.
They ranged in age from 2545 years, with a mean age of 40
I do not want to neglect myself.
years and a median age of 38.4 years. None of the partici-
pants had more than a middle school education. They were
If I feel signs and symptoms that the television program
married at a young age (on average at age 17), and 14 had
told us about, I will feel afraid that I may have the dis-
more than 10 children. Seven women had relatives who had
ease without knowing it.
experienced breast cancer, and 30 had heard of the breast can-
I imagine that there was pain, here and there, after which
I go to the hospital for treatment and for examination.
Table 1. Sample Demographics
Religious faith attenuated the women's fear and reduced the
threat of the disease.
Variable
%
Many problems may happen but one must have patience
Age (years)
like Job.
--
X = 40 + 6.05
Median = 38.4
God is wonderful, and we depend on him.
Marital status
Married
083
A person is always afraid of getting sick but the treat-
Single/divorced/widow
017
ment or getting better is from God.
Number of children
This trust in divine providence may have had a positive effect
< 10 children
066
in giving women more courage; however, it also may have
> 10 children
034
reduced the incentive to seek screening.
Education
No formal education
058
Various perceptions of breast cancer and screening ap-
Formal education
043
peared to negatively affect women's screening behavior. Can-
Occupation
cer was an enigma to them and a source of anxiety.
Unemployed
088
It is a dangerous disease and a bad one. . . . It is a big dis-
Employed
012
Ethnicity
ease.
United Arab Emirates national
100
From its name, we do not like this disease; we feel sad.
Religion
Muslim
100
This led to avoidance associated with a desire for reassuring
Living area
evidence of their lack of susceptibility.
Urban
076
Semi-urban
024
Thank God we do not have anybody who had cancer.
Clinic visits per year
There is no need to go and search for and look around
< 10 visits
072
for it.
> 10 visits
029
Monthly income in dirhamsa
When I feel that I do not have anything, why would I
< 5,000
029
take precautions?
5,00010,000
044
> 10,000
027
We are breastfeeding so we are not afraid.
a
1 U.S. dollar = 3.68 dirhams
For some, fear of finding out that they may have cancer had
a negative effect.
Note. Because of rounding, percentages may not total 100.
BENER VOL 29, NO 9, 2002
E93
If they tell me, I will go.
I feel afraid when I have no disease and have an exami-
nation and after that, they will tell me that I have a dis-
If something is related to my health and future, why not
ease. . . . It is better if they do not discover it.
do it?
Knowledge About Breast Cancer
We are interested to know more.
and Screening Tests
Once you know how to do breast self-examination at
The knowledge demonstrated by the participants ranged
home, you know how to do it, no problem.
from little or none at all to adequate knowledge. Misconcep-
Despite the fact that most women in the sample were not
tions about etiology, symptoms, and screening tests existed.
well informed about screening methods, those who were in-
These factors appeared to have both positive and negative
formed complied willingly and according to recommenda-
effects on preventive behavior. Women who were appropri-
tions.
ately aware of the etiology of the disease and symptoms had
a positive approach to seeking prevention.
We are doing yearly examinations.
The disease may start without pain. First the nodes, then
I do it periodically.
the pain.
What the doctor is telling us, we are doing.
Breastfeeding decreases the risk of having breast cancer.
We do it for precaution, and when we feel anything, we
It will take time before it spreads; therefore, the lady
go to the doctor.
should be examining herself to find it early.
Mammography is normal. I do it regularly.
I know it could be treated if discovered early.
They also were open to discussion about the disease and
Lack of knowledge and misconceptions about etiology,
screening tests.
symptoms, and screening methods were deterring factors for
We discuss our health problems.
appropriate preventive behavior.
We are warning each other about this cancer disease.
The reasons [for cancer] are an injury in the breast and
pollution and she did not go for treatment.
These attitudes had a positive effect on preventive behavior.
Mammography may cause disfigurement.
Women should listen to their physician and go on time
to see her, and if she tells her to do a test, she should
Bleeding causes infection, infection causes cancer.
quickly go and do it.
A lady had 14 children and yet got breast cancer.
However, fear and embarrassment created barriers to health-
If the girl treated her forearm following the trauma, she
seeking behavior.
would not have had cancer.
She is afraid of the doctor.
Many were aware of their lack of knowledge.
The doctor is the one making fear inside me.
We do not know what causes cancer.
I feel shy with the doctor.
No one [in the group] has any idea what are certain signs
and symptoms for cancer.
Beliefs About Cancer and Screening
Women knew that treatment is possible but cure may not be.
Participants were unanimous in their belief in patients'
rights to informed decision making about health care. They
She is taking chemotherapy but the effect is only tempo-
wanted to be told about diagnoses so they could have input
rary.
into management decisions.
If the disease spreads, one can do nothing about it.
We feel sad because they made a mistake and did not
Such misconceptions may have discouraged women from
tell us about the disease, and they were giving him [a
seeking screening and treatment.
participant's acquaintance] different treatment (than we
Sources of knowledge for the informed women included
would have wanted).
both healthcare providers and the media.
Yes, they should inform us.
I heard about the disease on the television.
Yes, they should tell us. Why should they hide things
Yes, we read about it in magazines.
related to my health?
The nurse teaches us how to do BSE and what to feel.
The women strongly believed in personal responsibility re-
garding cancer prevention and management.
She told us to do it every month.
The self-exam we make at home; the nurse taught it to
I have responsibility to look for treatment.
us.
Because she was careless with her health and this is not
the mistake of the doctor but herself only.
Attitudes Toward Cancer and Screening
I have responsibility to look for treatment. . . . We shall
An encouraging feature identified in this study was the
women's eagerness to learn about the disease and participate
examine ourselves, and if we find a lump, we should go
in screening.
to the doctor.
ONF VOL 29, NO 9, 2002
E94
They viewed the government's provision of care positively,
They also believed that screening led to better outcomes.
including screening tests: "The government provided every-
If discovered early, it could be treated.
thing." These factors seemed to positively affect screening
behaviors. However, certain services or options were not avail-
If one takes the treatment, he [sic] will be well. If he ne-
able in all locations, such as female doctors and women's clin-
glects it, he will deteriorate.
ics: "There must be female doctors." One woman said, "The
One relative had cancer in the blood. They took him,
well-woman clinic is now closed," which may mean that some
and now he is cured.
women required transport to an alternative screening location.
Some women complained about a lack of confidence in
If discovered early, it could be treated.
the healthcare system.
They believed that God could act through screening.
Why are the doctors outside more qualified than the
Doctors are messengers from God for treatment.
doctors here?
"Act and I will act with you," said God.
They advised me to go abroad because treatment there is
better.
These beliefs may have a positive effect on their screening
practice. However, the same faith made some women pas-
I feel that the second physician opinion is better than the
sive.
first.
I am not afraid. Everything is in the hand of God.
One woman had pus and blood in her breast; she was not
treated until her breast was swollen and told she had
The disease is from God.
cancer.
People should accept God's action.
They also complained that lack of educational services within
It is from God that this disease will not happen to us.
the healthcare facilities led them to neglect their health.
If her life is long, she will live but if short, she will die.
We heard about those tests but we thought that sick ones
had to do them.
God is curing all the people, and we depend on Him.
I delivered 10 children. Nobody told me to do those tests.
Life from God.
These deficits in the availability of services, confidence of
Death is by the hand of God.
the women, and in health education were deterring factors
Some women believed in turning to folk medicine for treat-
that affected screening behavior in participants.
ment.
Discussion
Some people are doing cauterization [i.e., similar to acu-
puncture, except that a hot metal rod is used to cauterize
This study provided new insights into the perceptions,
the skin].
knowledge, beliefs, attitudes, and practices of the Emirati
My sister's son was affected by the disease.
women of Al Ain with respect to breast cancer and the breast
cancer screening program. Many features were encouraging,
They went for cauterization.
and many perceptions were positive. Some of the women
These beliefs and practices may have had a negative effect
were very knowledgeable, many attitudes and beliefs sup-
on screening practice.
ported the program, and the local social milieu and healthcare
system supported the program. However, many deterring fac-
Health Services and Social Milieu
tors also were found: Some perceptions, attitudes, and beliefs
Study participants received support from their husbands,
were negative or led the women to avoid the program, and
family members, and friends in seeking screening and treat-
some aspects of the social milieu and healthcare system dis-
ment.
couraged good practices. Healthcare planners from the Min-
istry of Health, who initiated the breast cancer screening pro-
She thanked her friend because she advised her not to
gram, and the local doctors and nurses providing the program
neglect herself.
must capitalize on the encouraging factors and eliminate the
I tell my friends everything.
discouraging factors as much as possible. The analysis of the
group discussions produced the concepts and theoretical frame-
No, the husband will not refuse anything to do with
work outlined in Figure 1.
health.
Perceptions of Cancer
Most women had a positive attitude toward doctors and the
healthcare system.
Any breast health promotion or public awareness program
must reinforce the perceptions that lead to good screening
The knowledge is usually with the doctor.
practices and alter those that discourage such practices. For
I would come to the doctor, and she will show me how.
example, the realistic fears and concerns about cancer, as ex-
pressed by these women, should be used in a nonthreatening
If they are not concerned about our health, they will not
and supportive manner to encourage women to seek screen-
ask us to do this test or that.
ing. Dismissing such feelings may lead to avoidance and de-
We thank them for taking care of us.
nial that would be counterproductive for a screening program.
BENER VOL 29, NO 9, 2002
E95
Health Services and Social Support for Cancer Screening
Perceptions of Breast Cancer and Screening
Encouraging factors
Encouraging factors
Support from husband, family, and friends
Feeling of susceptibility
Establishment of screening programs by government
Fear leading to action
Deterring factors
Deterring factors
Lack of availability of services, especially female doctors
Faith reduces fear.
Lack of confidence in the healthcare system
Enigma and source of anxiety
Lack of educational services
Fear leading to denial
Breast cancer screening
practice among women
Beliefs Related to Breast Cancer and Screening
Knowledge of Breast Cancer and Screening
Encouraging factors
Encouraging factor
Belief in informed decision
Appropriate knowledge about etiology,
Belief in personal responsibility
symptoms, and screening methods
Belief in prevention
Deterring factors
Belief that God's will acts through screening
Lack of knowledge and misconceptions
Deterring factors
about etiology, symptoms, and screening
Belief in folk medicine
methods
Faith (predestination) leads to passivity
Awareness of limitation of medical practice
Attitudes Toward Breast Cancer and Screening
Encouraging factors
Eagerness to learn
Readiness and willingness to practice
Openness to discussion
Trust in the healthcare system
Deterring factor
Fear and embarrassment caused by the healthcare system
Figure 1. Determinants of Screening Practice Among Women in the United Arab Emirates
Breast cancer should be put into the context of all of the
prevention practices in the healthcare setting. An effective
other diseases that women commonly encounter. This is con-
health promotion program that is disseminated widely in the
gruent with the findings of Tessaro et al. (1994) in their study
Al Ain community would meet the needs of the study partici-
of breast cancer screening in older African American women.
pants. The program should involve healthcare professionals
They found that women under 60 years of age were con-
and the media because the women in the current study re-
cerned about breast cancer, and the major barriers to screen-
ported that their information had been derived from both
ing were the fear of finding the disease and the social conse-
sources.
quences of losing a breast.
Attitudes Toward Cancer and Screening
Knowledge About Breast Cancer
The very positive attitudes already present in the commu-
a n d Screening
nity, such as the women's eagerness to learn, willingness to
A public health promotion program supporting breast can-
participate in screening, and their generally positive atti-
cer screening should build on existing community knowl-
tudes toward the healthcare system, should be capitalized on
by any health promotion program. For example, an authority
edge. Women who were informed participated in screening.
The main knowledge barrier for participants in the current
figure in a healthcare system, such as a doctor or nurse, could
study was lack of information about screening. Both Caplan
be featured in a media campaign. Any attitudes that discour-
et al. (1992) and Weinberger et al. (1992), in their studies of
age women from seeking screening, such as fear and embar-
breast cancer screening among several groups in the United
rassment, should be dealt with by the healthcare system. The
States, noted that their subjects faced the same barrier, which
provision of comfortable, supportive settings for screening
that positively alter women's fears and concerns would be
resulted, in part, from a lack of health promotion and disease
ONF VOL 29, NO 9, 2002
E96
grown tremendously. The high-quality and accessibility of
helpful (Benedict, Williams, & Baron, 1994). As major
sources of referral for screening, PHC centers must be able to
healthcare services are reflected by a sharp decline in infant
mortality from 14.7 per 1,000 live births in 1983 to 6.57 per
dedicate time and educate women about breast screening.
1,000 live births in 1999. Also, the life expectancy approaches
Beliefs About Cancer and Screening
levels found in western and developed countries (i.e., 74 years
for males and 76 years for females) (Al-Hosani, 2000).
The very positive beliefs in informed decisions and per-
The PHC clinics are part of a comprehensive care package
sonal choice must be incorporated into the attitudes and prac-
offered to UAE citizens, expatriate workers, families, and the
tices of healthcare professionals through continuing profes-
community. The Ministry of Health has made a great effort to
sional development. The culture of the healthcare system
develop PHC services to make them more equitable and ac-
should be developed to support these beliefs. The study par-
cessible to all residents in UAE. The number of PHC centers
ticipants' strong personal faith in God and His actions
increased from 45 clinics in 1977 to 105 by the end of 1999
through the provision of health care should be encouraged
(Al-Hosani, 2000). Although curative medical services re-
actively and supported by the healthcare system and health
ceived more careful attention by the UAE government than
promotion programs, whereas any tendency by the subjects
public health services, early screening programs for children
to accept their fate passively must be confronted through
and adults, promotion of occupational health and safety, and
education. Health promotion messages must be tailored to
promotion of a healthy lifestyle are gaining ground (Alwash
the strong Muslim faith of these women and should support
& Abbas, 1999).
the Muslim concept that God wishes people to take responsi-
bility for themselves.
Focus Group Approach
Healthcare Services and the Social Milieu
The current study's researchers found focus groups to be a
The community and family support felt by the study par-
productive and effective approach for gathering information
ticipants is a very positive aspect of their coping system and
about the social, environmental, and personal aspects associ-
should be supported by the screening program and health-
ated with breast cancer and breast cancer screening practices
care system. Other researchers have found similar support in
in this population of women. Despite the deficiencies in
other communities. Benedict et al. (1994), when studying
their knowledge and practices, most women were capable of
American women living in the South and undergoing diag-
expressing their views and needs. Encouraged by the group
nosis for a breast lesion, found that those who could talk
synergy, they had no difficulty communicating freely. By
with others found comfort and caring in the conversations.
starting with simple concepts (e.g., BSE) and proceeding to
Women who already are knowledgeable about breast cancer
more complex issues (e.g., the adequacy of the healthcare sys-
could be recruited to participate in peer teaching and sup-
tem), the women described their behavior and the factors that
port, which would strengthen the peer support network al-
influence their behavior. Through these discussions, partici-
ready present in the community.
pants were able to provide information that will help to im-
To successfully implement a breast cancer screening pro-
prove the breast cancer screening program and stimulate fur-
gram among the study women, their concerns about the
ther research. This supports the view of Hoffman-Goetz and
healthcare system must be addressed by the Ministry of
Mills (1997) that the contribution of qualitative approaches
Health and local healthcare providers through policy devel-
to the development of cancer prevention and control pro-
opment and continuing professional development.
grams and policies is threefold: to collect a greater depth of
information, identify processes and relationships among be-
Health Services
haviors, and develop variables and hypotheses for quantita-
in the United Arab Emirates
tive research.
The inequitable geographic distribution of healthcare re-
Health planners and healthcare providers must capitalize on
sources in UAE has long been recognized as a problem that has
encouraging factors and minimize deterring factors to optimize
continued despite immense progress. Healthcare personnel,
breast cancer screening practices among this group of women.
like those in many other professions, tend to locate in large
towns and cities. Specialization in medicine, nursing, and
The authors very gratefully acknowledge Tariq Gaber, MD, director
many other healthcare professions has made it necessary for
of Primary Health Care Clinics, for providing support and assistance
throughout the research survey.
practitioners to be located in areas with larger populations to
ensure an adequate patient base. Health services in UAE have
undergone a remarkable development since the establishment
Author Contact: Anne O. Carter, MD, MHSc, can be reached at
of the Federation in 1971, when the country was created by
anne.carter@uaeu.ac.ae, with copy to editor at rose_mary@earthlink
joining seven emirates. The healthcare infrastructure has
.net.
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