Mammography uptake among Malay-Muslim women low, blamed on multilevel factors

Breast cancer screening behaviour among Malay-Muslim women in Singapore appears to hinge on multilevel factors that involve not only personal relationships but also their religious beliefs and screening facilities’ availability and access.

In a study, a group of researchers from the National University of Singapore surveyed 271 Malay-Muslim women aged 50–69 years and interviewed another group of women (n=23) of the same ethnicity and within the same age range. They found that healthcare professionals facilitated both uptakes of a first mammography (adjusted odds ratio [aOR], 4.12; p<0.01) and regular screening (aOR, 3.45; p<0.01) among Malay-Muslim women. For both first and regular screening, the thinking that one had to have symptoms before going for a mammography was a key barrier. [BMC Womens Health 2022;22:383]

“Beyond this, having ever gone for mammography and regular mammography uptake were facilitated and hindered differently,” the researchers noted.

The likelihood of having ever gone for mammography was higher among women with older age, who believed that screening could save lives from early detection, and who had perceived importance of mammography; but lower among those who appraised their difficulties in life as a punishment from Allah (PMIR-PAR), and those with modesty concerns.

Meanwhile, women with a household income of SGD ≥4,000 per month and those neutral about their susceptibility towards breast cancer were more likely to submit themselves for regular breast cancer screening. The likelihood was lower among women who held a stronger perception of structural barriers to screening, such as cost and ease of access.

“One possible explanation for the differences in associations is that positive perceptions on mammography benefits and importance may encourage first uptake, but [it] is insufficient to sustain regular uptake possibly due to a null result which may in turn reinforce belief of low susceptibility,” the researchers explained.

“On the other hand, deep-seated values may impede first uptake; however, having overcome these initial barriers, affordability and ease of access matter more in decision for subsequent uptakes,” they added.

Push for breast cancer screening

In Singapore, mammography uptake is lowest among women of Malay ethnicity, with only 28.9 percent reporting having undergone mammography within the last 2 years in 2019 relative to their Chinese and Indian counterparts at 40.1 percent and 41.0 percent, respectively. This ethnic disparity, according to the researchers, is worrying, as it has persisted through the years and subsequently extends to age-standardized mortality rate of breast cancer. [https://www.hpb.gov.sg/docs/default-source/default-document-library/national-population-health-survey-2019.pdf]

Between 2013 and 2017, the age-standardized mortality rate of breast cancer was 19.1 deaths per 100,000 population among women of Malay ethnicity as compared with <15.0 deaths in other ethnic groups. [CA Cancer J Clin 2021;71:209-249]

“Our finding … highlights the crucial role healthcare professionals play in encouraging screening in this community, [as well as] indicates the need for health education to specifically clarify that mammography can detect breast cancer prior to development of physical symptoms,” according to the researchers.

“Given the strong association observed between PMIR-PAR and mammography uptake and the high prevalence of such beliefs (29.4 percent), clearly, breast cancer screening interventions and its accompanying health messages should be jointly developed with religious leaders and the Islamic Religious Council of Singapore,” they added.

It is high time that perceptions on punishing appraisals are reduced and religious teachings on health preventive measures cleared up in order to ease mental conflicts—particularly for those who highly value modesty in appearance (74.4 percent)—and facilitate decision-making on cancer screening, according to the researchers.

Moreover, conversations among Malay women and among their loved ones should be encouraged, with an aim to emphasize prioritization of one’s own health and foster a shift in norms with regard to women’s role in the community, the researchers added.

“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 neighbouring 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,” they said.