16
sahtak - June 2011
Arab American community-based outreach cancer preven on
model within a cultural and spiritual framework
Targeting Arab-American women in southeastern Michigan
By Adnan Hammad, Ph.D.
Senior Director, ACCESS Community Health &Research Center
Chairman, National & International Health Research Initiative
Professor,WayneStateUniversitySchoolof Medicine,Departmentof Fam-
ily Medicine and Public Health Sciences
By HiamHamade RN. MAOM. MPH
Cancer Control ProgramCoordinator
ACCESS Community Health &Research Center
By Kendra Schwartz, MD, MSPH
Professor, Department of Family Medicine and Public Health Sciences
WayneStateUniversitySchoolof MedicineandKarmanos CancerInstitute
By Karen PatriciaWilliams, Ph.D.
Associate Professor, Obstetrics, Gynecology &Reproductive Biology
Michigan State University
Background and Significance
Arab and Chaldeans in the State of Michigan are the third largest
minority group and the fastest growing population in the State. Cur-
rent figures indicate that there are an estimated 500,000Arabs living
in theDetroitMetropolitan area, the second largest concentration of
Arabs outside of theMiddle East after Paris, France. Sickness is, in
essence, an unwanted condition, and conceptions, theories, and ex-
periences of sickness are elements of socially transmitted cultural
systems. Despite this fact, knowledge of the Arab andMuslim cul-
tures and spirituality has not increased accordingly among the gen-
eral population, let alone the medical professions. With respect to
health care, many providers have difficulty understanding the cul-
tural patterns of their diverse patient populations as well as the
health-related behavioral motivations of their patients.
Cancer Worldwide Dilemma
Despite national and international comprehensive prevention ef-
forts, cancer is still the second leading cause of death in the world
after heart disease, claimingmore than 7.4million lives in 2004, 30%
of which could have been prevented through risk factors modifica-
tion or avoidance (ACS Global Cancer Facts). It is projected that
the deaths from cancer will continue to escalate to reach 12 million
deaths in 2030 (Ibid.). Globally speaking, breast cancer is the most
common cancer type among women worldwide; it represents 22%
of all cancer cases and is responsible for 519,000 overall deaths an-
nually. In the U.S., according to the National Institutes of Health
(NIH), cancers cost the United States more than $170 billion in
2002. This includedmore than $110 billion in lost productivity and
over $60 billion in direct medical costs (CDC, 2003). Healthier
lifestyles (e.g., avoiding tobacco use, increasing physical activity, im-
proving nutrition, and avoiding sun exposure) can significantly re-
duce the risk for cancer. Making cancer prevention and cancer
screening information available, understandable, and accessible is
essential for quantity and quality of life. Breast, cervical, and col-
orectal screening tests reduce morbidity and mortality by finding
cancers early when they are most likely to be curable. . Screening
for cervical and colorectal cancers can actually prevent these can-
cers fromdeveloping by detecting treatable pre-cancerous conditions
(CDC, 2003).
SIGNIFICANCE
The Arab Community Center for Economic and Social Services
(ACCESS) has developed and evaluated a culturally sensitive and
culturally competent model of cancer awareness, prevention, and
cancer screening activities to encourage appropriate health seeking
behavior. Cancer does not affect all races and ethnic groups equally.
Arab Americans may be more likely to die of some cancers than
their counterparts of other racial/ ethnic groups due to cultural in-
hibition around health and health seeking behavior, lack of insur-
ance coverage, and change of diet after immigrating to the host
country. Cancer incidence data are not available as ArabAmericans
are not considered a minority by the federal government. The AC-
CESS model took all of these socio-economic and cultural condi-
tions into consideration and developed a culturally sensitive cancer
awareness program specifically tailored for Arab Americans. The
ACCESS Community Health Clinic has effectively implemented
campaigns to increase cancer screening rates and to improve health
awareness for cancer screening for these compelling reasons: (1) The
number of Arab Americans refugees and immigrants settling in
Southeastern Michigan is increasing, (2) their access to health care
and health insurance is limited, due to immigration status and
poverty (3) cancer is one of the top five leading mortalities affecting
the Arab American community in Michigan, (4) Cancer screening
rates for this population are lower than the general population, (5)
The need for outreach and health education far exceeds local com-
munity resources, (6) Cultural values and language barriers can im-
pede health seeking behaviors, and (7) The lead agency and its
partners have effectively implemented other campaigns to increase
cancer screening rates and improve health awareness.
The outcome of this model illustrates the relationship between
culture, spirituality and health across the life course of Arab Amer-
icans. Cultural concepts, values, and beliefs shape the way health
symptoms are expressed and how individuals and their families re-
spond to such distresses. Cultural norms dictate when a cluster of
symptoms and behaviors are labeled ‘normal” or ‘abnormal.” Cul-
ture also determines the accessibility and acceptability of health serv-
ices. Immigration and acculturation are additional variables in the
mechanics of illness in Arab Americans. Effective health care sys-
tems started to consider how cultural and spiritual beliefs are im-
portant in the formation and expression of the “ill distress”, the
coping strategies of the patients and their families and communi-
ties, and the diagnostic and therapeutic activities of the “healer.”
The concept of “Fatalism” (“it is meant to be”) and cultural inhibi-
tion around discussion of disease are understood at ACCESS. Ad-
ditionally, we recognize ways in which religious and faith
communities can affect the health of individuals and broader com-
munities. In a communitywhere cultural and spiritual values play an
important role in health seeking behaviors, especially amongwomen
who have modesty concerns and the stigma of chronic diseases
(such as cancer) associatedwith discussingmany health concerns is
somewhat taboo, the likelihood of initiating or maintaining health
care is decreased.
Health Disparities
Recent studies have shown that racial and ethnic minorities receive
a lower quality of health services, are less likely to receive routine
medical procedures, and have higher rates of morbidity and mor-
tality than non-minorities. Disparities in health care by race and eth-
nicity still exist even after factoring in gender, condition, age, and
socio-economic status. Additionally, racial and ethnicminorities ex-
perience a lower quality of health services and are less likely to re-
ceive access to routine medical procedures and have higher rates of
morbidity and mortality than non-minorities. Cancer among Arab
Americans in theDetroit/Metropolitan area indicates that: themost
common cancers diagnosed amongArabmen andwomen are lung,
colorectal and urinary bladder cancers; the most common cancers
diagnosed among Arab men are prostate, lung, and colorectal can-
cers; themost common cancers diagnosed amongArabwomen are
breast, cervical, and colorectal cancers. Appropriately timed screen-
ing promotes early diagnosis and is, therefore, key to reducing these
evident disparities bymovingmoreminoritywomen into the group
whose cancers have been diagnosed early. Breast andCervical Can-
cer Screening Arab American Community-based Cancer Preven-
tionModel
Arab American Community – Based Cancer Prevention and
ScreeningModel
The overall objective of ACCESSCancer ControlModel is to elim-
inate the linguistic, cultural, and financial barriers for Arab Ameri-
canwomen by recruitingwomenwho have never been screened for
breast cancer; thus, increasing awareness of breast cancer in this un-
derserved population. The knowledge gained from the project and
the increase in breast cancer screening will definitely help in bridg-
ing the disparity gap between this minority and the general popula-
tion. The Arab American community supports ACCESS as their
“neighborhood center” and has trust in the agency's ability to pro-
vide quality services. ACCESS’ success is due in part to its belief
that to move the community forward, individuals within our com-
munity must be empowered with knowledge, resources, and sup-
ported through their change process.
It is well-known that breast cancer mortality can be reduced by
increased adherence tomammography screening and clinical breast
examination on an annual basis for women in their 40s (American
Cancer Society, 2010). Underserved populations, in general, are
more likely than the U.S. general population to be diagnosed with
and die from preventable cancers, receive diagnosis at late-stage for
cancers detectable at an early stage through screening, receive no
treatment or inappropriate treatment, die from cancer that are gen-
erally curable, and/or suffer from terminal cancers. Therefore, as
with most minority groups it is assumed that Arab American
women are less likely to seek cancer screening activities as compared
to the general population. Moreover, Arab American women con-
front significant barriers to healthcare access in general, and to breast
cancer screening services specifically, mainly due to culture-bound
values and religious beliefs, language barrier, lack of transportation,
and lack of financial means and/or health insurance. On the other
hand, health provider’s lack of awareness on the socio-religious be-
haviors of this subpopulation as related to health makes the issue
more complicated.
The ACCESS model focuses on health promotion and preven-
tion programs by successfully identifying and addressing the indi-
vidual, family, and community factors, and the relationships among
such factors, that influence the cultural and lifestyle practices of Arab
Americanwomen, in order to reduce cancer disparities and improve
health behaviors. Approximately 100Health care providers are con-
sidered an institutional component of the community environment.
In their ideal form, they encourage women to engage in health pro-
moting practices and use of health services. Currently, they represent
the strongest influence on a woman getting screened.
Thus, cultural influences are incorporated into the framework
for the current proposal.
Tell-a-Friend and Kin Keeper Cancer Prevention Intervention
Using an ecological approach (community and family influences)
and determinates of health behavior framework - predisposing , en-
abling, reinforcing factors), Kin Keeper was based on the premise
that the natural ways that Black women communicate health mes-
sages to women in their families (mother, grandmother, sister,
daughter and aunt) can be used to influence their engagement in
cancer prevention and screening behaviors.
Building on generational and cultural behavior, theKinKeeper was
developed as a women’s health advocacy intervention model that
naturally integrates health literacy, by teaching them about screen-
ing guidelines, what to expect when they are screened, how to com-
municatewith health care providers regarding their screening results,
various community-based resources as well as demonstrations with
breast models. It uses various indigenous lay health models in con-
cert with community development principles of capacity building.
Themodel has the following rationale: 1) women serve as point
persons for their own and their families’ health and well-being by
makingmost of the decisions for health care ; 2) female familymem-
bers have the ability to influence one another to conduct or arrange
for regular breast self examinations (BSE), clinical breast examina-
tions (CBE) and mammograms at the appropriate times; and 3)
when cancer prevention options—such as a chemoprevention trial—
are presented in a non-intimidating environment such as the home,
by a trusted person such as a community healthworker (CHW) who
serves as a liaison between the woman and the health care system,
womenwill bemore likely to be actively engaged in promoting their
health.
The Kin Keeper model makes two assertions: 1) understanding
individual and familial cancer risk factors will influence early
detection behaviors and 2) the model helps women make the
connection between cancer risk factors, family cancer history,
and cancer screening behavior. The model helps to explain var-
ious dynamic factors—the community, the provider, and the
family—that influence Black, Latina, and Arab women to par-
ticipate in cancer prevention and screening practices.
The Kin Keeper model was designed 1) to build positive re-
inforcing factors (e.g. Female family members,) for health be-
havior change; 2) to strengthen enabling factors (engagement
with community-based programs, health care provider); and 3)
to address predisposing factors (culture beliefs, mistrust) that
may influence positive health behavior and reduce disparities.
Because the concepts of trust, health literacy and cultural influ-
ences are central to the model, they are described in more detail.
The outcome of the Arab American Community-Based
Cancer Prevention Model is less morbidity and mortality in can-
cer disease. This model provides strong evidence that a woman’s
risk of developing cancer can be substantially reduced through
education and intervention. The model also presents that edu-
cating woman at risk about healthier behavior reduces the like-
liness of forming other diseases such as cardiovascular and
diabetes, as well. By using the best science model, we can de-
velop the most effective ways to encourage healthy behaviors
and to reach out to the community to educate themmore about
cancer prevention and early detection. Advocacy and educa-
tional research provides the science that can guide the devel-
opment of programs and policies that promote changes in
behaviors and lifestyles – changes that prevent or reduce suf-
fering and morbidity from cancer and other related diseases.
This model is an important part of the work and mission of
the ACCESS.
