BEIRUT: Have you ever wondered why many Lebanese women still do not test themselves for Breast Cancer knowing that earlier detection leads to higher chances of responding to treatment and being subsequently cured? What encourages a woman to test herself for Breast Cancer routinely and regularly? What are the factors influencing women’s decision to undergo a mammography?
In fact, Breast cancer is the most common cancer among females in Lebanon. And worldwide, it became the second most commonly diagnosed cancer both among males and females, after lung cancer. Among women, it has become the most commonly diagnosed cancer and the leading cause of cancer deaths as per the 2018 cancer statistics, published by the International Agency for Research on Cancer (IARC).
Early detection of Breast cancer
“I felt a small lump in one of my breasts while showering, I was terrified, but I immediately called my gynecologist and booked an appointment to get it checked” explains Isabelle, a 56-year-old Breast Cancer survivor from Mount Lebanon.
Studies from around the world have shown that early detection through screening can reduce Breast Cancer mortality and increase treatment options. Early detection revolves around two strategies, early diagnosis, and screening. Screening tests and methods used to diagnose Breast Cancer include several tests such as screening mammography, breast ultrasound, breast MRI and clinical breast exams (CBE) and, to some degree breast self-examination (BSE).
Factors influencing Lebanese women’s decision to seek Breast cancer screening
"I know that I have to take care of my health and do the mammography, but I do not, there are many important things in life other than my own health," said Khouloud, a 40-year-old from Mina Tripoli in Northern Lebanon, who shared her thoughts on health and Breast Cancer Screening.
In fact, there are multiple intertwined factors influencing Lebanese women’s decision to seek Breast Cancer screening, which is not only limited to their knowledge of this disease as commonly described in Lebanon. The level of awareness is not an indicator or a contributing factor on its own to Breast Cancer screening, but rather is one of several factors.
It is therefore worth highlighting that Lebanese women’s experiences and attitudes toward Breast Cancer are directly linked to their knowledge, attitudes, and experience in regards to cancer in general and not only Breast Cancer itself. The majority of Lebanese women have lesser knowledge of various Breast Cancer-related aspects than what they think they know. They have limited knowledge of the real signs of Breast Cancer, recommended age to initiate a mammography and how to conduct BSE.
There are several identified barriers that simultaneously interfere in the decision-making process to seek screening. A woman would consciously and unconsciously weigh the different factors, fears and expected outcomes all together, rather than each element separately. Many women are afraid of the word “cancer”, mammography results, possibly being diagnosed with Breast Cancer, the treatment itself, losing their hair and their breasts after a mastectomy, becoming a burden on their families, pain, dying and leaving their families “alone”, and the fear of becoming frowned upon in society.
Consequently, Lebanese women pondering whether to undergo a mammography or not should factor in their knowledge and misconceptions of cancer, Breast Cancer and its signs, other friends or relatives’ experience with the disease, her own experience and level of trust in the healthcare system and institutions, extent of accessibility (including location of residence), religious values and beliefs, as well as her relationship with her family and husband. “Women who are married are more motivated to undergoing the mammography for fear of losing their husband," said a 57-year-old woman from Baalbek.
Economic and psychosocial factors
All of the factors influencing women’s participation in Breast Cancer screening are also linked to economic factors and affordability extending beyond the mere cost of the test itself, but also the associated expenses with transportation, additional tests incurred, medical visits, as well as treatment, drugs and medical interventions potentially required. That is why the availability of health care coverage is not a strong predictor for the test itself, yet it extremely facilitates a woman’s decision to seek screening services.
In addition, there are also psycho-social factors influencing her decision such as her self-efficacy and the extent to which she considers her own well-being and external looks a priority. "How will I see myself without a breast if it will happen to me? We always say that it is important to love life but if we think of it happening to us personally, it is so scary" said Fadia, a 41-year-old from Jdaide.
The culture of taboo and pity
Women’s participation in screening activities is also influenced by the culture of taboo and shame, which are widespread in the Lebanese community if someone is ever diagnosed, with Therese from Halat, Mount Lebanon explaining that “society is harsh on cancer patients, I would never see myself pitied by the people”.
Mammography is thus only the tip of the iceberg. Lebanese women get discouraged from the idea of having to do follow-up tests and operations, in addition to how society would look at them after being diagnosed.
Previous experience with the healthcare system
It is also worth mentioning that even when the levels of “ever conducting a mammography test” are relatively high in Lebanon, this behavior is not maintained but rather conducted intermittently or on one single occasion in a lifetime. This is where the importance of women’s actual experience with the health care system comes into play, as well as the different social and economic factors influencing their decision to integrate screening methods as part of their lifestyle.
Facilitating factors to Breast Cancer Screening
At the same time, there are facilitating factors that improve women’s decision to opt for screening tests. Higher levels of knowledge and awareness of the importance of early detection in addition to the availability of health care coverage and free tests provided by the Ministry of Public Health during certain months of the year (October till January) mark better results in terms of screening measures taken.
Having the physicians extend the recommendation to do a mammography and repeating it when necessary, rather than launching awareness-raising campaigns, increases the adherence to screening measures.
Overall, there is a significant difference in terms of access, affordability, and trust in health care institutions and services between urban and rural locations, given that women in urban areas have better chances of accessing such services than those living in rural areas.
There is no substantial correlation between a woman’s level of education and obtaining a mammography. However, age was found to be a factor as older women are more likely to seek health care.
Religion itself acts as a barrier and facilitator among women across Lebanon. It is worth highlighting that there is no substantial difference between women from different religious affiliations, except for barriers related to commuting and intersex interaction. Many Muslim and Druze women depend on the availability of a male chaperone to accompany them to the hospital to obtain any health-related service.
At the same time, women from Druze, Muslim Shiaa, Muslim Sunni and different Christian denominations greatly exhibited a fatalistic belief, which for some acted as a strong push to take care of themselves, while others laid everything in the hands of God without pursuing preventative actions. "I could have done the mammography for free but I did not because I leave my health in God's hands," said Noha, a 52-year-old from Bazouriye in South Lebanon.
What could be done?
In order to increase women’s participation in Breast Cancer screening, tackling the identified barriers and capitalizing on the facilitators, policies, campaigns and programs can work toward tailoring awareness-raising campaigns and adopting more personalized communication and messaging with women while increasing engagement of family members and community-based organizations. Paying more attention to women in rural areas, providing psycho-social support for patients and women seeking screening, working on prevention in addition to early detection, encouraging breast self-examination and improving the comfort of mammography experience can also go a long way in decreasing the stigma around Breast Cancer.
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