Psychosocial Aspects of Female Breast Cancer in the Middle East and North Africa

Breast cancer, the most common cancer among women in the Middle East and North Africa (MENA) region, is associated with social and psychological implications deriving from women’s socio-cultural contexts. Examining 74 articles published between 2007 and 2019, this literature/narrative review explores the psychosocial aspects of female breast cancer in the MENA region. It highlights socio-cultural barriers to seeking help and socio-political factors influencing women’s experience with the disease. In 17 of 22 Arab countries, common findings emerge which derive from shared cultural values. Findings indicate that women lack knowledge of breast cancer screening (BCS) and breast cancer self-examination (BSE) benefits/techniques due to a lack of physicians’ recommendations, fear, embarrassment, cultural beliefs, and a lack of formal and informal support systems. Women in rural areas or with low socioeconomic status further lack access to health services. Women with breast cancer, report low self-esteem due to gender dynamics and a tendency towards fatalism. Collaboration between mass media, health and education systems, and leading social-religious figures plays a major role in overcoming psychological and cultural barriers, including beliefs surrounding pain, fear, embarrassment, and modesty, particularly for women of lower socioeconomic status and women living in crises and conflict zones.


female teachers
Kingdom of Saudi Arabia (KSA) More than half of the women showed a limited knowledge level. Among participants, the most frequently reported risk factors were non-breast feeding and the use of female sex hormones. The printed media was the most common source of knowledge. Logistic regression analysis revealed that high income was the most significant predictor of better knowledge level. Knowing a non-relative case with breast cancer and having a high knowledge level were identified as the significant predictors for practicing BSE. Between traditional and modern perceptions of breast cancer and cervical cancer screenings: a qualitative study of Arab women in Israel.

Israel
All women knew about breast cancer and screening for early detection for breast cancer but not for cervical cancer. Sources of information were mainly: lectures, electronic media and personal acquaintance and conversations with friends. Knowledge of breast cancer was a mixture of traditional concepts and biomedical views. In the Bedouin group, traditional thoughts like the evil eye were also expressed together with the modern views. There was consensus amongst these women that breastfeeding, giving birth and lowfat rich vegetables nutrition were protective factors against breast cancer. General thought was that cancer is a matter of fate and test that is determined by God. Major barriers to screening were accessibility, language and unfriendly attitudes from the specialists and personal responsibility. Other major factors affecting screening are exposure of body parts when doing the tests, fear from and that women want their husbands to love and accept them and their bodies. Libya Only 30.0% of patients were diagnosed within 3 months after symptoms. 14% of patients were diagnosed within 3-6 months and 56% within a period longer than 6 months. A number of factors predicted diagnosis delay: Symptoms were not considered serious in 27% of patients. Alternative therapy (therapy not associated with cancer) was applied in 13.0% of the patients. Fear and shame prevented the visit to the doctor in 10% and 4.5% of patients, respectively. Inappropriate reassurance that the lump was benign was an important reason for prolongation of the diagnosis time. Diagnosis delay was associated with initial breast symptom(s) that did not include a lump (p < 0.0001), with women who did not report monthly self examination (p < 0.0001), with old age (p = 0.004), with illiteracy (p = 0.009), with history of benign fibrocystic disease (p = 0.029) and with women who had used oral contraceptive pills longer than 5 years (p = 0.043). (p < 0.0001), and with metastatic disease (p < 0.0001). With regard to the way their children treated them, in 84% of cases mothers indicated that there was a positive change (i.e., a change for the better). In only two cases did mothers say the change was negative, one indicating that the child became angry and the other that the child withdrew from her. With regard to changes in the child's personality, in 90% of cases the change was reported to be positive and in only 1% (1 of 99 children) was it negative, i.e., the child became more emotional. Although in the vast majority of cases there was improvement in the way the child treated the mother, in the personality of the child, and in the relationship between mother and child, school performance did appear to suffer. In over threequarters (77%), school performance worsened, whereas in only 8% did it improve. Oman, Muscat Four main themes emerged. These were: a) factors related to psychological distress of the disease and uncertainty (worry of death, interference with work and family responsibilities, searching for hope/cure, travelling overseas); b) reactions of family members (shocked, saddened, unity, pressure to seek traditional treatments); c) views of society (sympathy, isolation, reluctant to disclose information); and d) worries and threats about the future (side effects of chemotherapy, spread of the disease, effect on offspring).
The availability of such services in their home country could also help reduce anxiety from being away and they could get support from family members. Some of the participants felt that the relationships with their family members, including husbands, became stronger after diagnosis and that family members became more supportive 86.2 (SD=22.7)). The most distressing symptom on the symptom scale was financial difficulties (Mean 63.2 (SD=38.2)). Using the disease specific tool, it was found that future perspective scored the lowest (Mean 40.5 (SD=37.3)). On the symptom scale, arm symptoms scored the highest (Mean 23.6 (SD=21.6)). Significant mean differences were noted for many functional and symptom scales.
Knowledge and practice of university female students toward breast cancer. The highest negative impact was for Breast Cancer impact on happiness, followed by "ability to focus on daily tasks". Sleep was the third negatively affected domain of life and "carrying out house chores" was the fourth and last domain where more than half of participants showed a negative impact. There was a high percentage of observed agreement between the calculated breast cancer impact and the perceived overall negative impact of breast cancer assessed by direct questioning. This high observed agreement was significantly beyond chance. mean 23.21 (SD = 5.37), while the lowest was physical well-being with a mean 18.57 (SD = 6.93). A positive linear relationship was found between spirituality and QoL, r = 0.67, p = 0.000. The highest score of correlation was seen between spirituality and the functional domain, r = 0.63, p = 0.000. Spiritual intervention could contribute to increased functional, social, and physical well-being and enhance the total health and QoL of women diagnosed with breast cancer. Isolation and prayer as mean of solace for Arab women with breast cancer: An in-depth interview study Assaf, G.N.; Holroyd, E.; Lopez, V.

Psycho-Oncology
Face-to-face depth interviews 20 Arab women attending a public hospital in Abu Dhabi UAE Arab women's experiences following their breast cancer diagnoses and treatments included the themes of (1) protecting one's self from stigma, (2) facing uncertainties and prayers, and (3) getting on with life. Overall, the ways to find solace were through isolation and prayer, which are heavily influenced by religion and spiritual practices. They recommended that to help women with breast cancer, a campaign to raise awareness for early screening is needed as well the need to form a peer-led support group for women with breast cancer consisting of breast cancer survivors so that they can learn from each other's experiences. Egypt, Sohag One-third reported an advanced degree of depression, anxiety or both (33.34%; 33.33%, and 32.29%, respectively). As regards associations; patients with progressive/relapse disease have higher anxiety and depression with sustained statistically significant relationship in univariate and multiple regression analyses (p-value = 0.03 and 0.04, respectively); while hormonal treatment has a statistically significant positive impact on anxiety alone (p-value 0.02).

Summary of the Main Findings Bahrain
Emotional and sexual functioning scored the lowest and the main concern affecting quality of life was fatigability and hair loss. Evil eye, stress and God's punishment were believed to be fundamental causes of the disease. Factors associated with a major reduction in all domains of quality of life included the presence of metastases, having had a mastectomy as opposed to a lumpectomy

Egypt
Women tend not to visit the doctor unless they are severely ill which resulted in delayed diagnosis and low screening level. Women believed that they should directly visit a gynecologist in case of breast cancer and wanted doctors to be more encouraging. An interventional study for health education about BC was found to be effective. Female students had a poor knowledge related to BSE practices. 34.2% of women with BC had low hope and 32% reported having both depression and anxiety, therefore, emotional functioning, had the lowest scores.

Iraq
The majority of the subjects have heard about Breast self-examination and the main source of this information was the television and internet even though only 48.3% practiced BSE and 187 only had a mammogram in the past. Iraqi women who were diagnosed with BC, job, stage of cancer, size of tumor, and radiotherapy significantly influenced their QoL. The highest negative impact was for Breast Cancer impact on happiness, followed by "ability to focus on daily tasks". Sleep was the third negatively affected domain of life and "carrying out house chores" was the fourth and last domain where more than half of participants showed a negative impact.

Jordan
Women tend to prioritize their families, children and chores as mothers and wives over themselves. Women were also perceiving themselves as not being in the risk zone for breast cancer and in their accepting breast cancer as a test from God. Women with BC scored the lowest on emotional functioning due to the hair loss. Spiritual intervention could contribute to increased functional, social, and physical well-being and enhance the total health and QoL of women diagnosed with breast cancer.

KSA
Attendance of Saudi women to screening and CBE visits found to be low. This was associated with the low knowledge that women included in the studies had about the incidence of BC and its risk factors as well as lack of female doctors. Their main source of information was the media but they insisted on the need of recommendation from physicians. Level of knowledge regarding risk factors and appropriate screening was low and dependent upon educational and occupational status The most frequently reported risk factors were non-breast feeding and the use of female sex hormones. Barriers to not performing BSE were lack of confidence, anxiety, and not knowing how to. The most commonly used CAM therapy was spiritual therapy 70.5%.

Kuwait
Despite institutional supports, Kuwaiti women had clinically significant poorer global QOL and functional scale scores, more intense symptom experience, in comparison with the international data. Younger women had poorer HRQOL scores

Lebanon
The utilization of mammography found to be low and increased only slightly over 4 years (from 11% to 18%). Payments per month for medical expenses, presence of metastasis, time since diagnosis, and type of treatment received were significantly associated with QoL, the different functioning dimensions, and symptoms. The most commonly used CAM was 'special food' followed by 'herbal teas', 'diet supplements' and 'Spiritual healing'. Only 4 % of CAM users cited health professionals as influencing their choice of CAM Libya Only 30.0% of patients were diagnosed within 3 months after symptoms. Main causes of delayed diagnosis of BC among Libyan females were: fear and shame about this sensitive topic, inappropriate reassurance that the lump was benign, symptoms were not considered to be serious.

Morocco
Female doctors were the only professional group that had satisfactory knowledge of risk factors of BC and there was a common belief that herbal medicine can cure BC. 100% of participants have never spoken with their doctor about this subject. 84% of the participants continued sexual activity after treatment, but there was an increase in the incidence of sexual functioning problems which resulted in a slight reduction in the quality of their sexual lives.

Oman
Female students had good knowledge on symptoms of BC and about BSE, but were not trained on how to perform it. Educational status and family history were indicative factors for the higher knowledge about BC. Omani women felt more connected with their families after their diagnosis even though they feared the future.

Palestine
Women were more likely to perform SBE if they were more educated, resided in cities, were Christian, were less religious, had a first-degree relative with breast cancer, perceived higher effectiveness and benefits of SBE, and perceived lower barriers and fatalism. Disturbance in their ability to perform their chores affected the QoL of Palestinian women with BC. General thought was that cancer is a matter of fate and test that is determined by God. In addition, their faith in God "tawakkul" relieved some of the burden of the illness. In some cities in Palestine, the evil eye was the cause of BC. Major barriers to screening were accessibility, language and unfriendly attitudes from the specialists and personal responsibility. Other major factors affecting screening are exposure of body parts when doing the tests, fear from and that women want their husbands to love and accept them and their bodies.

Qatar
Generally, women living in Qatar had good knowledge about BC but did not regularly do BSE or CBE. Married women and women with higher education and income levels were significantly more likely to be aware of and to practice BCS than women who had lower education and income levels.

Syria
Women felt psychological discomfort (negative emotion, body image, and depressive symptoms), physical problems (acute consequences of chemotherapy and general aspects of chemotherapy), social dysfunction (social isolation and lack of marriage opportunities), and failure in the family role (mother role and sexual relationship).

Sudan
Female students had moderate level of knowledge on BC, but poor performance of BSE. Practicing BSE found significantly associated with higher level of education, receiving training or counseling and history of other breast disease

UAE
The majority of women were aware about the existence of BC screening techniques and how to perform them but did not view themselves at risk for BC and therefore, the knowledge they acquired did not seem to influence their practice of BSE, CBE or mammogram. UAE national women scored better than non-UAE national women younger women (40-49) had better scores regarding knowledge than older women (.49) The level of education was positively associated with better knowledge. Women who were diagnosed with BC focused on protecting themselves form the social stigma, facing their illness with prayers and moving on with their lives.

Yemen
Younger Yemeni females with BC diagnosis patients were experiencing worse QOL when compared to older patients. Women scored the highest on physical well being and lowest on functional well being.