A Culturally Tailored Intervention for Promoting Breast Cancer Screening Among Women From Faith-Based Communities in Israel: A Randomized Controlled Study

Abstract

Lower rates of screening for early detection of cancer were reported among ethnic minorities and faith-based communities. The purpose of the article is to assess the effect of a culturally based intervention program intended to increase breast cancer screening adherence among two groups in Israel: ultra-Orthodox Jewish and Arab women. Using a randomized controlled study design, 598 participants completed the 3-month follow-up questionnaire regarding adherence to screening and perceived effect of intervention. Results show that having a lower level of religious beliefs and gaining a better understanding of the importance of screenings were significant predictors of performing breast awareness practice (BAP) and undergoing clinical breast examination (CBE) in both groups. We conclude that interventions should be specifically tailored to cultural groups to reduce barriers stemming from unique beliefs and perceptions, which prevent individuals in these groups from undergoing screening. Special efforts should be made to increase CBE among young women.

Keywords

culturally tailored intervention breast cancer screening faith-based communities faith-based barriers and promoters randomized controlled study

Scientific Background

Evidence suggests that surviving breast cancer greatly depends on its detection at an early stage. Although regular mammography screening has recently been questioned due to a high overdiagnosis rate (Gøtzsche & Jørgensen, 2013), empirical evidence indicates that regular screening for breast cancer increases women’s chances of survival. A lack of screening adherence can result in a later diagnosis, the potential implication being advanced-stage disease, large tumors, and ultimately higher mortality rates (Smith, Cokkinides, & Eyre, 2005). Israeli guidelines for early detection practices, which are similar to those in America and Europe, recommend that average-risk women, aged 50–74 years of age, undergo mammography once every 2 years and that high-risk women, aged 40 and above, undergo annual mammography and possibly additional examinations (Paci, Broeders, Hofvind, Puliti, & Duffy, 2014; Smith, 2014). Clinical breast examination (CBE) is now suggested as part of annual medical examinations. In the past, screening by breast self-examination was recommended to all women, and an extensive effort was invested in teaching women how to conduct a monthly systematic self-examination (Pennypacker et al., 1982). However, results of large trials found no beneficial effect of breast self-examination; in fact, the opposite was found—evidence supporting increased harm including increased numbers of identified benign lesions and performed biopsies (O’Mahony et al., 2017). Therefore, a paradigm shift occurred—from breast self-examination to general breast awareness practices (BAPs; MacBride, Pruthi, & Bevers, 2012), which is now recommended by various national and international cancer and health organizations (O’Mahony et al., 2017). BAP is defined as women’s becoming familiar with their breasts and learning to notice when changes occur in them by conducting monthly breast self-examinations (Israeli Cancer Association, 2016; O’Mahony et al., 2017). Although BAP and CBE have not proven efficient in terms of reducing breast cancer mortality (Ludman, Curry, Meyer, & Taplin, 1999), they may create increased awareness about the importance of screening. CBE has especially been proven to be a valuable way of educating patients about risk factors and healthy lifestyle, also providing them with information about the importance of mammography. It is especially important as a means to discuss and alleviate barriers to mammography exams (Azaiza, Cohen, Daoud, & Awad, 2010), thereby creating enhanced readiness for adherence to mammography at the age of 50.

Studies have shown a lower adherence to health behaviors among women in ethnic minorities and distinct groups (Allison, Jensky, Marshall, Bertoni, & Cushman, 2012) and an even lower screening attendance for the early detection of breast cancer (Cohen & Azaiza, 2005; Miranda, Tarraf, González, Johnson-Jennings, & González, 2012) and colorectal cancer (Azaiza & Cohen, 2008). For example, the Amish faith has a much lower rate of mammography than the general average rate among American women (Geiger & Grigsby-Toussaint, 2017).

Culture and Health Beliefs

Barriers to screening attendance have mostly been assessed using models originating from studies conducted in Western countries (Rosenstock, 1974) that assess the health belief model, followed by the Health Belief Scale created by Champion (1999). These assessment models propose that the likelihood of adherence to screening for cancer depends mainly on cognitive perceptions and rational decision-making processes; they do not take into account cultural and religious beliefs and social norms (Pasick et al., 2009). However, it has been shown that these beliefs do in fact have a substantial effect on health behaviors, especially regarding adherence to screening examinations (Cohen, 2014). Health beliefs such as “everything causes cancer” or “some cancers are slow growing” are also an important factor connected to avoiding cancer-related information and, subsequently, adherence to examinations (Emanuel et al., 2015). Cancer, as a life-threatening disease connected to humans’ deepest fears of suffering and death, is especially deeply entrenched in cultural beliefs (Ashing-Giwa & Kagawa-Singer, 2006).

Azaiza and Cohen (2008) presented a measure for assessing cultural barriers to screening, the Culture-Based Health Belief Questionnaire. This measure was validated among a group of 300 Muslim and Christian Arab women with no previous history of cancer and expanded to include the beliefs of ultra-Orthodox women (Azaiza & Cohen, 2006), showing good validity and reliability. Five dimensions were identified by factor analysis: social barriers (e.g., stigma and fear of being seen at a breast clinic), exposure barriers (e.g., embarrassment at exposing one’s body), environmental barriers (e.g., difficulties getting to appropriate facilities), uneasiness with one’s body (e.g., feeling uncomfortable looking at one’s own body), and fear of cancer-related losses (e.g., cancer as a form of punishment from God). In later studies, a Fatalism subscale was added (cancer perceived as a matter of fate and cancer as a noncurable disease).

While cultural perceptions of health and disease are changing worldwide, in parallel with the spreading and adoption of Western ideas and ways of life, the pace of change has varied across countries (Adams et al., 2015). Therefore, the effect of culture on screening behaviors is complex and dynamic (Pasick et al., 2009). Even largely similar ethnic groups may be at different points along the traditional/Westernized beliefs continuum and therefore reflect different rates of screening adherence (Cohen, 2014). In light of the tremendous demographic changes throughout the world including immigration, there are many more traditional groups in Western societies. Therefore, cultural effects are especially relevant for studying barriers among women from faith-based communities, who reside in Western societies.

Ultra-Orthodox Jewish Women in Israel and Health Perceptions

Ultra-Orthodox Jews comprise 8.8% (about 645,000 people) of the Jewish population in Israel (Israel Central Bureau of Statistics, 2013) and lead a deeply religious lifestyle. Lower health service utilization was found among this population as compared to the general population (Coleman-Brueckheimer, Spitzer, & Koffman, 2009; Schnitzer, Loots, Escudero, & Schechter, 2011). A previous study reported that ultra-Orthodox Jewish women are less knowledgeable about breast cancer screenings than non-ultra-Orthodox Jewish women and have a greater belief in the protective qualities provided by their religious lifestyle (Freund, Cohen, & Azaiza, 2014). In addition, ultra-Orthodox women have been shown to experience higher levels of embarrassment and fatalistic beliefs (Baron-Epel, 2010). Nevertheless, the only study to assess mammography rates among ultra-Orthodox Jewish women reported that 74.3% of the participants had undergone a mammography at some point during the 2 previous years, similar to the figure among non-ultra-Orthodox Jewish women. The subject of on-schedule mammography rates has received very little research attention, with the few existing studies showing low adherence according to ultra-Orthodox Jewish women (Azaiza & Cohen, 2006). Other studies reported low adherence with regard to other health behaviors among ultra-Orthodox Jews in and outside Israel (Baron-Epel, Friedman, & Lernau, 2009).

Arab Women in Israel and Health Perceptions

The Arab population in Israel constitutes 20.58% of the general population (almost 1,629,000 people) and is comprised of several religious groups (84.1% Muslims, 7.7% Christians, 8% Druze, and 0.2% others; CBS, 2013). Although this population is more conservative and religious than mainstream Jewish society in Israel, it is currently experiencing modernization on a major scale, one result of which is this population’s greater use of health services (Azaiza & Brodsky, 1997; Cohen, 2014). Age-adjusted incidence rates of breast cancer in Arab women have increased by 202% since 1979. Arab women are also more likely to be diagnosed at a more advanced stage of the disease. This likelihood may be attributed to the significantly lower incidence of mammography screening and CBE among this population (Baron-Epel, Friedman, & Lernau, 2008; Tarabeia et al., 2007). Researchers have attributed the above-mentioned gap to stricter personal, social, and cultural barriers in the Arab population (Azaiza & Cohen, 2008).

Faith-Based Communities

“Faith-based communities” are groups that, based on their religion, culture, and way of life, differ from the mainstream population around them. They are rigorous in their conservative or religious way of life and are segregated from the mainstream culture, despite their interactions and complex relationships with it (Baum, 2007). Compliance with social–cultural–collectivist codes in the community and family is a central psychocultural theme, which reflects the nature of the relationship between the individuals and their community (Hakak, 2011).

The Arab population and the ultra-Orthodox Jewish population in Israel consist of distinct religious, cultural, and social groups, but both populations hold conservative social norms and values, and both live in a country in which the dominant culture is Western, secular, and Jewish.

The Arab society, although comprised of several different groups, is still best described as a religious and conservative society on the whole. These groups share common cultural characteristics and values such as collectivist norms. Although trends for modernism are more evident in the Arab society than the ultra-Orthodox, studies show that even individuals who define themselves as “nonreligious” or “moderately religious” tend to uphold religious rituals and laws and adhere to traditional beliefs (Cohen, 2014). These two groups may therefore be defined as faith-based communities, although the pace of modernization is more rapid in the Arab community. Despite their differences, these two groups share common perceptions about health such as fatalism, disease as punishment, and prayers as a cure process (Freund et al., 2014).

Culturally Sensitive Interventions

Studies show that health-related intervention programs affect health behaviors (Steinmo, Fuller, Stone, & Michie, 2015). Yet, among minority groups, the reality is much more complex. The lower rate of screening utilization by women from certain ethnic groups could be due to the lower efficacy of educational and media programs, as they do not usually address the unique cultural beliefs and social norms of specific ethnic groups. Social scientists refer to the ability to respond to cultural barriers as cultural competence (Ka’opua, Park, Ward, & Braun, 2011), defined as the system’s ability to provide health care to patients of diverse backgrounds, tailoring the treatments to each patient’s social, cultural, and linguistic needs (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003; Shaya & Gbarayor, 2006). Nevertheless, while most culturally adapted interventions focus on providing information in a culturally sensitive way, very few directly addresses the cultural barriers of the specific groups themselves (Barrera, Castro, Strycker, & Toobert, 2013; Bhui et al., 2015). In addition, to be effective, interventions must be tailored to each cultural group, taking into account where it stands on the traditional-Western spectrum.

Based on the model of cultural barriers presented in 2008, Azaiza and Cohen went on to devise a model of tailored intervention programs intended to reduce these barriers (see a more detailed description in the Method section). This model was then used as a means of intervention to reduce barriers and promote screening attendance for breast cancer in a controlled study (Azaiza et al., 2010). Preliminary results showed an increased rate of CBE and mammography attendance or the scheduling of these screenings in the intervention group as compared to the nonintervention group. In addition, a Significant Group × Time Effect was found for the decrease in barriers of exposure, social barriers, and feelings of discomfort with one’s own body, with a larger decrease in barriers being seen in the intervention group. No other studies to date have assessed the use of this kind of culturally tailored intervention in other faith-based communities, and no comparison has been made between communities at different points of change on the traditional/Western continuum. Therefore, the aim of the present study was to assess the effect of a tailored intervention program for ultra-Orthodox Jewish women and Arab women living in Israel.

Specific hypotheses were as follows:
Hypothesis 1: Postintervention rates of adherence will be higher in the intervention group (Arab and ultra-Orthodox) than the comparison group.

Hypothesis 2: The perceived effect of intervention will be higher in the interventions group as compared to nonintervention group and among Arab participants as compared to the ultra-Orthodox participants. In addition, an Intervention × Group interaction will be found.

Hypothesis 3: Adherence to early detection procedures will be predicted by ethnic group, intervention type, perceived importance of screening (post intervention), and cultural beliefs (preintervention).

Method

Participants and Procedure

Participants consisted of 598 women, aged 40–60, randomly selected from two faith-based communities in Israel. A total of 331 of these participants were Arab women and a total of 267 were ultra-Orthodox Jewish women. Arab participants were recruited by means of a randomized sample within a cluster sample often cities and villages in northern, central, and southern Israel. The initial sample of Arab women was intentionally twice as large as the ultra-Orthodox Jewish sample, in order to include a sufficient number of participants from the different Arab groups in Israel (i.e., Muslims, Bedouins, and Christians). Ultra-Orthodox Jewish women were randomly recruited from three cities with large ultra-Orthodox populations in the north and center of Israel. Eligibility for the study included age (i.e., between 40 and 60 years of age), not being previously diagnosed with cancer and having either a Hebrew or Arabic literacy level sufficient to answer the questionnaires (see Figure 1). Meeting criteria means not completely adherent to screening (i.e., not having performed/undergone any of the following three screening modes: BAP, CBE, and mammography according to the guidelines). Despite the fact that in Israel, mammography is recommended from the age of 50, BAP and CBE as part of medical checkups are recommended to start at a younger age. Thus, the inclusion criteria specifies ages 40–60.

Figure 1.
Study participants flowchart. Eligibility for the study was age (i.e., between 40 and 60 years), not being previously diagnosed with cancer and having a literacy level either in Hebrew or in Arabic sufficient to answer the questionnaires. Meeting criteria means not having at least one of the following three screening modes: breast awareness practice, clinical breast examination, and mammography. UOJ = ultra-Orthodox Jewish.

The study consisted of four steps: (1) We approached 1,579 eligible participants, 1,203 of whom completed questionnaires in their homes or in another place of their choosing (376 refused). One woman from each household was eligible to participate; (2) Participants’ adherence to the recommendation for early detection of breast cancer screening was assessed. Participants who were not completely adherent were offered a chance to participate in the intervention study. The criteria for complete adherence are described in Figure 2 and in the Questionnaires section; (3) The 971 participants who did not meet the criteria for full adherence were randomly allocated either to the intervention group (570 participants from both groups) or to the nonintervention group (401 participants, a detailed description of the attrition rate, and final participation rates of each group are described in the Results section and Figure 1). The participants in the intervention group underwent intervention according to the protocol (see Appendix A), while the participants in the nonintervention group did not receive any intervention. Both groups continued receiving standard regular care from their health services; (4) Three months after the intervention was conducted (or after allocation to the nonintervention group), 598 participants in both the intervention and nonintervention group answered a telephone questionnaire (373 participants withdrew). Three months are a reasonable period of time for behavioral changes to occur following an intervention, and this time period is suggested in other intervention studies (Azaiza et al., 2010; Norcross, Krebs, & Prochaska, 2011; Prochaska et al., 1994, 2005). However, regarding BAP, there isn’t any recommendation for the period of time for performing it. Therefore, we see 3 months intervals as a reasonable period of time for self-check.

Figure 2.
Screening adherence criteria. BAP = breast awareness practice; CBE = clinical breast examination; Mamm. = mammography.

Intervention

The intervention was tailored to each participant based on her specific degree of adherence, knowledge, and beliefs. The intervention protocol has been previously described and tested for efficacy (Azaiza et al., 2010). In the current study, the intervention was tailored to each participant based on her specific degree of adherence, knowledge, and beliefs (Azaiza & Cohen, 2006). At the beginning of the intervention, information was provided regarding the examinations that each woman should undergo according to her age and familial risk level and her degree of adherence to the suggested guidelines. The interviewer stressed that these were general recommendations and that a specific examination plan should be drawn up by the woman’s personal physician, with whom she was encouraged to discuss the screening program. The interviewer and participant then discussed her previous experience with breast examinations, emphasizing misconceptions about breast cancer facts and early detection procedures, using scripted answers to address barriers and promoters. The interviewers were trained to give specific answers, according to the personal and cultural barriers of each woman, so that the intervention was personally and culturally tailored.

Two lists of scripted answers were prepared, one list of scripted responses to barriers and another list of religious and cultural promoters in order to address each of the five cultural barriers to women’s performance of breast cancer screenings (i.e., exposure of body, social barriers, religious beliefs about cancer and health, environmental barriers, and uneasiness with one’s own body). These were prepared based on the cultural competence approach (Azaiza & Cohen, 2008) and using information gleaned from five focus groups previously conducted with Arab women and two focus groups more recently conducted with ultra-Orthodox Jewish women (Freund et al., 2014). For example, in response to the fatalistic perception of cancer as an immutable fate, the interviewer stressed the statement (rooted in Jewish, Muslim, and Christian writings) that a woman bears responsibility for her own health and that by availing herself of early detection measures, she is taking a positive step to insure that she will remain healthy and continue to be able to take care of her family. In addition, the interviewer addressed the social barrier of fear of being seen at the clinic by stressing the higher levels of openness that now exist in ultra-Orthodox Jewish and Arab societies toward cancer and the growing understanding of the importance of prevention. Scripted responses were also created for general barriers such as fear of harm to the body or of pain.

Questionnaires

Time 1: Preintervention

Demographic details included age, family status, education, perceived economic status, and perceived level of religiosity. History of breast cancer in the family included whether the participant had a first-degree relative who had ever had breast cancer and if so, in what way the participant was related to this individual (i.e., mother, sister, aunt, etc.). Adherence to screening guidelines included questions on mammography, CBE and BAP frequency, and the last time the participant underwent mammography and CBE examinations. Adherence to guidelines was defined according to three criteria: (1) “On-schedule with mammography” was defined as having undergone a mammography examination every 2 years, with the last mammography having been conducted not later than 2 years ago for women aged 52+ and having undergone at least one mammography if the woman was aged 50–52; (2) “On-schedule with CBE” was defined as having undergone a CBE examination once a year, with the last examination having been conducted no more than 1 year ago;(3) “On-schedule with BAP” was defined as performing BAP at least once every 2 months, while BAP itself was defined as being acquainted with one’s breasts and inspecting them for any changes in structure, color, or texture.

A Culture-Based Health Belief Questionnaire was composed by Azaiza and Cohen (2008). Five focus groups dealing with the cultural and religious perceptions of Arab women toward breast cancer preceded the construct of the questionnaire (Azaiza & Cohen, 2008). It was then tested in a study prior to this one with 300 randomly selected Arab women in Israel. The final questionnaire includes 22 items and was tested for content validity by four professional experts. In addition, construct validity was confirmed by assessing correlations between the subscales of barriers based on Champion’s (1999) model and the cultural barriers of the present questionnaire.

Based on the two additional focus groups that were conducted with ultra-Orthodox Jewish women, 8 items were added. A factor analysis with varimax rotations was then conducted, revealing five factors explaining 63.13% of the scale’s variance as follows: focusing on religious-related beliefs about cancer and about being cured of cancer (e.g., prayer helps to cure cancer, cancer is a punishment or test by God; 15 items, eigenvalue = 5.44), fear of social losses due to cancer (e.g., fear of losing friends, social roles, children being neglected; 8 items, eigenvalue = 3.28), accessibility barriers (e.g., distance from treatment centers or language barriers; 4 items, eigenvalue = 1.95), and exposure barriers (e.g., uneasiness about being undressed, examining breasts; 2 items, eigenvalue = 1.85). An additional item addressed fatalistic beliefs about cancer being perceived as resulting in certain death. The internal consistency (Cronbach’s α) of the subscales was .86, .72, .71, and .61, respectively.

Time 2: Postintervention

Undergoing early detection examinations within the last 3 months, participants were asked whether they underwent, or had at least scheduled, either a mammography or CBE and whether they performed BAP during this period.

Perceived effect of the intervention or completion of the questionnaire. Due to the possibility that the completion of the questionnaire itself might have had an effect on the women’s motivation to undergo screening or perform BAP independent of the effect of the intervention itself, participants in both the intervention and nonintervention groups were asked to grade the perceived effect of completing the questionnaire or of the intervention on their actual attendance or scheduling of a mammography and/or CBE and on their understanding of the importance of adhering to screening guidelines on a scale from 1 to 5 (1 = not at all, 5 = very high effect).

Data Analysis

Multiple imputation was performed for the incomplete multivariate data (8.1% missing data), utilizing the regression method for monotone missing data (Yuan, 2010), using the SAS 9.3 program. Background, health beliefs, and cultural perception variables were imputed. Descriptive statistics were followed by t-tests for independent groups, and χ² tests were conducted to compare differences between and within groups (Intervention × Religion). Effect sizes are presented with Φ value for χ² tests and partial η² for repeated measures. Logistic regression analyses were conducted to identify the contribution of the intervention, background, and study variables for the variance of adherence to breast examinations at Time 2 (T2; SPSS 20.0). The bootstrap method using PROCESS (Hayes, 2012) was used to test the effect of the interaction of Intervention Group × Gaining more understanding of the importance of screening on attending screening at T2.

Results

The background characteristics of the participants and the differences between the Jewish and Arab participants, as well as the differences between the intervention and nonintervention groups, are described in Table 1. The participants’ mean age was similar across the two groups. The mean years of education and economic status were slightly higher among the ultra-Orthodox Jewish participants than among the Arab participants. The level of religiosity also differed between groups: While all of the Jewish participants were very religious (by definition of eligibility), the Arab women were mostly either very religious or moderately religious (in the sense that the religion was perceived as being important) with a few reporting being secular.

Table 1.
Background Characteristics of Arab and Ultra-Orthodox Jewish Participants by Intervention.

Demographic Variables Ultra-Orthodox Jewish Arabs F/χ² (p)

Intervention (n = 148) Nonintervention (n = 119) Intervention (n = 241) Nonintervention (n = 90) Religion Intervention

Age

M (SD) 50.9 (6.1) 49.6 (5.9) 51.4 (6.0) 49.9 (7.3) 0.23 5.1 (.016)

Range 40–60 40–60 40–60 40–60

Education, years

M (SD) 14.0 (2.1) 14.17 (1.9) 10.1 (3.0) 9.3 (3.7) 275.7 (.000) 2.3

Range 9–20 9–20 1–20 3–20

Family status (N, %) 33.9 (.000) 2.7

Single 0 0 25 (10.4) 8 (8.8)

Married 141 (95.3) 111 (93.4) 197 (81.7) 70 (77.8)

Divorced/separated 1 (0.68) 4 (3.3) 6 (2.5) 2 (2.2)

Widowed 6 (4.05) 4 (3.3) 13 (5.4) 10 (11.2)

Has children (N, %) 148 (100) 121 (98.4) 204 (88.3) 76 (87.4) 28.5 (.000) 0.1

Religiosity (N, %) 98.7 (.000) 0.8^a

Very religious 148 (100) 123 (100) 25 (10.4) 9 (10.0)

Religious 0 0 89 (37.0) 29 (32.2)

Moderate 0 0 110 (45.6) 44 (48.9)

Secular 0 0 17 (7.0) 8 (8.9)

Employed (N, %) 69 (46.9) 67 (54.5) 133 (55.2) 53 (58.8) 8.8 (.003) 0.4

Economic status (N, %)² 8.3 (.004) 5.9

Very good 11 (7.4) 7 (5.9) 10 (4.1) 5 (5.5)

Good 50 (33.8) 46 (38.7) 68 (28.3) 25 (27.8)

Fair 72 (48.6) 56 (47.0) 142 (58.9) 47 (52.2)

Poor 15 (8.2) 10 (8.4) 21 (8.7) 13 (15.5)

Note.* Fischer Z is provided for comparisons with less than five counts per cell.

^aχ² is reported for the Arab group only.

**p <* .05. ***p <* .001.

Regarding a comparison between the intervention and nonintervention groups, the participants in the intervention groups were, on average, a year older than participants in the nonintervention groups, but the mean years of education, family status, having children, employment status, and economic status were similar among both groups. The level of religiosity in both intervention and nonintervention groups was similar.

A comparison between participants who participated at follow-up and those who declined showed no differences in levels of education, employment status, family status, and having children. The mean age of the ultra-Orthodox Jewish participants who remained in the study was slightly lower as compared to those who dropped out (ΔM = 1.82 years, t = 2.5, p < .05) and slightly higher for Arab participants who remained in the study as compared to those who dropped out ΔM = 1.53 years, t = 2.5, p < .05).

Rates of Adherence Preintervention and Postintervention

Table 2 shows that, pre-intervention, rates of adherence in regard to all three examination types were similar in the intervention and nonintervention groups for the ultra-Orthodox and Arab participants. Several differences emerged between the intervention and nonintervention groups at the postintervention measurement. Within the ultra-Orthodox Jewish group, a significantly greater number of participants from the intervention group reported that they conducted BAP during the 3 months preceding the postintervention measurement compared to those from the nonintervention group (Φ = .17, indicative of a small effect size). In addition, a significantly higher percentage of participants (aged 50+) from the intervention group reported that they underwent or scheduled a mammography as compared to those from the nonintervention group (Φ = .17, indicative of a small effect size). However, no differences were found between the groups for CBE attendance. In the Arab group, a significantly higher number of participants from the intervention group reported that they conducted BAP postintervention as compared to those from the nonintervention group (Φ = .23, indicative of a small effect size). However, increases in adherence to CBE and mammography in the intervention group were not significantly different from increases in the nonintervention group. One should note that the very high rate of participants in the intervention group who reported that they had been on schedule with their mammography test, preintervention, rendered the number of participants from this group who were in need of a mammography in the subsequent 3 months very small. Thus, the first hypothesis was partially confirmed.

Table 2.
Examination Adherence Rate: Pre- and Postintervention Reported by Ultra-Orthodox Jewish and Arab Women.

Demographic Variables Ultra-Orthodox Arab

Intervention (n = 148) Nonintervention (n = 119) Intervention (n = 241) Nonintervention (n = 90)

Pre-N (%) Post-N (%) Pre-N (%) Post-N (%) χ² (p) Pre-N (%) Post-N (%) Pre-N (%) Post-N (%) χ² (p)

BAP 38 71 27 38 Pre: 0.5 115 151 28 34 Pre: 1.3

(25.7) (48.0) (22.6) (31.9) Post: 8.2 (.004) (47.7) (62.7) (31.1) (37.8) Post: 10.0 (.002)

CBE 17 19 19 13 Pre: 0.9 23 29 12 7 Pre: 1.0

(11.5) (12.8) (16.0) (10.6) Post: 0.3 (9.5) (12.0) (13.3) (7.8) Post: 1.2

Mammography (underwent or scheduled) 51 28 34 10 Pre: 0.1 108 42 29 5 Pre: 2.9

(59.3) (46.7) (39.5) (16.4) Post: 4.7 (.009) (76.1) (29.6) (63.0) (10.9) Post: 2.4

Note. For mammography distribution, women aged ≥ 50, ultra-Orthodox Jewish: N = 147 (86 intervention and 61 nonintervention) and Arab: N = 188 (142 intervention and 46 nonintervention). BAP = breast awareness practice; CBE = clinical breast examination.

Perceived Effect of the Intervention

According to Table 3, participants in both the intervention and nonintervention groups reported that either the completion of questionnaires, in and of itself, or the structured intervention had a substantial effect on their actual adherence behavior regarding the three screening types and their perceived greater understanding of the importance of adherence with regard to screening guidelines (possible range 1–5). However, a significant effect was found for the structured intervention on these perceptions, namely, participants in the intervention group reported a greater perceived effect of the intervention on their behaviors (high effect size [ $η_{p}^{2}$ ] for BAP, mammography attendance and understanding the importance of screening, and no effect for attending CBE). A significant effect was found for the group variable across the three types of screening behaviors and perceived understanding, namely, Arab participants, whether they were in the intervention or nonintervention group, reported a greater perceived effect of the interview or intervention than the ultra-Orthodox Jewish participants did. Effect sizes ( $η_{p}^{2}$ ) of the differences were moderate for mammography, CBE and BAP, and low for understanding the importance of screenings. No Intervention × Group Effect was found. Therefore, the second hypothesis was practically confirmed, but not in regard to the interaction effect.

Table 3.
Perceived Effect of Intervention or Interview as Reported by Participants: Means, SDs, and Differences Between Groups.

Perceived Effect on Ultra-Orthodox Jewish Arab

Intervention (n = 148) Nonintervention (n = 119) Intervention (n = 241) Nonintervention (n = 90) Group F Intervention F Intervention× Group (F)

(Effect Size) (Effect Size)

Mammography attendance 2.5 (1.4) 2.02 (1.2) 3.3 (1.4) 2.7 (1.4) 36.8 (.000) 13.9 (.000) 1.0

(0.6) (0.2)

CBE attendance 2.1 (1.4) 1.8 (1.3) 2.8 (1.5) 2.7 (1.3) 37.2 (.000) 1.4 0.3

(0.6) (0.0)

BAP performance 2.5 (1.5) 2.2 (1.4) 3.3 (1.4) 2.6 (1.3) 23.2 (.000) 11.8 (.01) 1.3

(0.4) (0.9)

Gaining understanding of importance of screening 3.2 (1.4) 2.9 (1.4) 3.4 (1.4) 3.1 (1.5) 8.6 (.03) 4.2 (.006) 0.4

(0.2) (0.1)

Note. For mammography distribution, women aged ≥ 50, ultra-Orthodox Jewish: N = 147 and Arab: N = 188. BAP = breast awareness practice; CBE = clinical breast examination.

Factors Predicting Adherence to Examinations at Follow-Up

Logistic regression was conducted to identify the effect of the group and the intervention variables together with perceived barriers on change in adherence to the three types of examination, while controlling for age, education, and having a first-degree relative currently or previously ill with breast or ovarian cancer (Table 3). According to Table 4, a higher chance of participants’ report of undergoing CBE at follow-up was found among Arab women, while receiving the intervention increased the chances of performing BAP or undergoing mammography. Religious beliefs predicted lower performance of BAP and attendance of CBE, while the other barriers were not related to undergoing the tests. Gaining a greater understanding of the importance of screening as a result of the completion of the questionnaire was associated with a higher adherence to BAP and CBE and, when entered in the second step, rendered the intervention variable insignificant for predicting BAP. This is indicative of its mediating effect on the association between the intervention/nonintervention factor and BAP and CBE interaction effect of Intervention Group × Gaining more understanding of the importance of screening on performance at T2 of BSE (p < .05), CBE (p < .05), and a trend for the same effect for mammography (p > .05; Table 3). The third hypothesis was confirmed for the predictive role of ethnic group and intervention as well as for the predictive role of learning the importance of screening and the interaction between learning the importance of Screening × Intervention, but only partially confirmed regarding the role of cultural beliefs.

Discussion and Applications to Practice

In accordance with Hypothesis 1, the results showed that, postintervention, both ultra-Orthodox Jewish and Arab participants in the intervention group reported that they performed significantly more BAP and underwent more CBE and mammography screening than the nonintervention participants did (in regard to mammography, this difference was only apparent among the ultra-Orthodox Jews). In addition, the present study supports previous findings indicating that tailored interventions that target specific cultural and social barriers are effective in increasing adherence to early detection procedures (Barrera et al., 2013). The effectiveness of interventions that address specific cultural barriers was demonstrated in the present study for two very distinct cultural groups. These findings contrast with the inconsistent outcomes following the provision of general nontargeted information and interventions that are not culturally based (Bhui et al., 2015). Mammography attendance rates were relatively high among both groups, possibly due to the current national campaign meant to motivate women aged 50 and older to undergo mammographies; the rates of performance at T2 were relatively low. However, among the ultra-Orthodox Jewish participants, in which adherence rates were low, a significantly greater number of women from the intervention group reported that they underwent mammography at T2 compared to those from the nonintervention group. There was also a difference between the Arab intervention and nonintervention groups, perhaps due to the small number of participants; however, the difference was not statistically significant.

Although medical professionals often claim that women should not be encouraged to perform BAP or undergo CBE (Azaiza et al., 2010; Azaiza, Cohen, Daoud, & Awad, 2011) because these examinations have not been proven to be effective for early diagnosis and survival, they do create awareness of the importance of examinations. BAP heightens the awareness of the need to undergo mammography at the right age; it may also comprise the first step in reducing the barriers that prevent a woman from undergoing mammography. In addition, CBE may create an opportunity to discuss screening issues with physicians. Indeed, previous studies have consistently shown that a physician’s recommendation is the strongest factor in predicting adherence with regard to mammography. For this reason, we decided to include BAP and CBE as outcome variables in the current study. Another rationale for including BAP and CBE as outcome variables in this study stems from the low rate of undergoing CBE. CBE could perhaps be used as a tool for physicians treating women from faith-based communities in reducing fears and barriers, since these women are less exposed to the media, the Internet, and even interpersonal conversations about cancer (Azaiza et al., 2010).

The issues discussed herein are particularly salient in Israel, where a high rate of breast cancer, which often takes an aggressive form, is diagnosed in young women. For Jewish women, this high rate may be attributed to the high numbers of carriers of the BRCA gene among Ashkenazi women (Belkic et al., 2010). In young Arab women, the high breast cancer rate may be attributable to the transition that the Arab population in Israel, in general, has undergone in recent years (Zidan et al., 2012). As CBE and BAP may allow the earlier detection of a breast lump, the higher performance seen in the current study of both examinations, postintervention, is of great importance. This finding could be related to the fact that the Israeli health system invests most of its efforts in mammography (e.g., advertising, inviting women in for free examinations, mobile mammography clinics, and educating family physicians to encourage mammography attendance; Barrera et al., 2013).

Participants in the nonintervention group reported that the completion of the questionnaire, in itself, created a higher motivation to undergo screening and increased their understanding of the importance of screening adherence (Azaiza et al., 2010, 2011). However, and in accordance with Hypothesis 2, the change in motivation and understanding was still much stronger among members of the intervention groups than among the nonintervention participants. Moreover, a strong effect on screening performance of BAP and CBE was found for the interaction of Intervention Group × Gaining more understanding of the importance of screening, namely, the higher adherence in the intervention group was possibly due to the gaining of a better understanding of the importance of screening, a result of the intervention itself. This effect was not significant for mammography, a finding that might be explained, as it was previously, by the high initial adherence rates in regard to mammography and the small number of participants in this study who were aged 50 and older.

In line with Hypothesis 3, participating in the intervention predicted a higher performance of BAP and undergoing mammography. Furthermore, gaining a better understanding of the importance of screenings and having a lower level of religious beliefs, which related to religion’s salience in one’s life, were significant predictors of performing BAP and undergoing CBE. This difference may be explained by the ultra-Orthodox Jewish women’s stronger religious beliefs, meaning a higher importance of religion in their lives, their being a segregated group and a more homogenous group as far as religiosity level, and their having very strong beliefs in the role of their religious lifestyle in protecting their health (Freund et al., 2014). The Arab participants represented more divergent levels of religiosity and higher levels of employment, both of which signify a more Westernized way of life. These factors are in line with those found previously in relation to adherence rates with regard to various screening examinations (Adams et al., 2015). In addition, the Arab participants, both those in the intervention and those in the nonintervention groups, perceived the intervention or the completion of the questionnaire as being more effective in changing perceptions and attitudes toward screening than their ultra-Orthodox Jewish counterparts did. However, religious beliefs in both groups were predictors of lower adherence to BAP and CBE.

The present results show that in two faith-based communities in Israel, similarities and differences exist regarding individuals’ beliefs and perceptions about breast cancer and examinations for its early detection. The similarities stem from the values, beliefs, and norms of religious and traditional societies, in general, while the differences may be related to their different levels of segregation from the general society around them.

The study has several practical implications in terms of adherence to regular breast cancer screening examinations but also in regard to other types of cancer and different health behaviors. We suggest that intervention programs will be based on cultural competence, tailored specifically to each cultural group, and directed to reduce barriers stemming from the unique beliefs and perceptions found therein. Moreover, it is worthwhile to design specific culturally sensitive interventions for different groups, even within Arab (i.e., Christian, Muslim, Druze, etc.) and ultra-Orthodox societies, so that the intervention can better address the needs of subgroups and not only the entire cultural group. Special efforts should be made to increase CBE attendance among young women, many of whom, in both groups, are underchecked. The present study, like previous ones, indicates the central role played by physician recommendations to mammography adherence. Educating physicians to impart information recommending CBE performance and to discuss barriers in a culturally competent way would also likely increase CBE adherence.

The strength of this study lies in its use of random and relatively large sample sizes from the notably difficult-to-approach faith-based communities. In particular, the recruitment of a large sample from the ultra-Orthodox Jewish community, which usually refuses to participate in studies, adds to the current study’s robustness.

The study also had several limitations, one of which was its use of self-reported data in regard to examination performance, which can be prone to inaccurate recall or social desirability bias. Future studies should be based on information obtained from claims records concerning mammography and CBE performance in a longitudinal study. Also, in one questionnaire, caution should be exercised regarding the α level of .61. Finally, caution should also be exercised with regard to causal inferences. Future studies should use prospective designs and assess the effects of interventions on beliefs and adherence.

Table 4.
Logistic Regression for Predicting Reported Adherence to Early Detection Procedures.

Demographic Variables BAP (N = 557) CBE (N = 521) Mammography (N = 335)

OR (CI 95%) OR (CI 95%) OR (CI 95%)

Group 1.9 [0.9, 4.3] 3.8* [1.2, 12.0] 2.5 [0.4, 1.7]

Intervention 1.2* [1.1, 1.6] 0.6 [0.9, 1.3] 1.1* [1.1, 1.8]

Religious beliefs 0.6* [0.4, 0.9] 0.5* [0.3, 0.9] 0.9 [0.4, 2.2]

Social barriers 0.9 [0.7, 1.2] 1.2 [0.7, 1.7] 1.2 [0.6, 2.2]

Fatalism 1.0 [0.9, 1.1] 1.1 [0.7, 1.3] 1.2 [0.8, 2.3]

Exposure barriers — 1.4 [1.1, 1.9] 0.8 [0.5, 1.5]

Accessibility barriers — 1.0 [0.7, 1.4] 1.3 [0.6, 3.0]

Learning importance of screening 1.6*** [1.3, 1.9] 1.3* [1.1, 1.7] 0.8 [0.5, 1.2]

Note. Relative with cancer: 0 = no, 1 = yes; group: 0 = ultra-Orthodox Jewish, 1 = Arab; intervention: 0 = nonintervention, 1 = intervention. BAP = breast awareness practice; CBE = clinical breast examination.

*p < .05.

Demographic Variables	Ultra-Orthodox Jewish	Arabs	F/χ² (p)
Age
M (SD)	50.9 (6.1)	49.6 (5.9)	51.4 (6.0)	49.9 (7.3)	0.23	5.1 (.016)
Range	40–60	40–60	40–60	40–60
Education, years
M (SD)	14.0 (2.1)	14.17 (1.9)	10.1 (3.0)	9.3 (3.7)	275.7 (.000)	2.3
Range	9–20	9–20	1–20	3–20
Family status (N, %)		33.9 (.000)	2.7
Single	0	0	25 (10.4)	8 (8.8)
Married	141 (95.3)	111 (93.4)	197 (81.7)	70 (77.8)
Divorced/separated	1 (0.68)	4 (3.3)	6 (2.5)	2 (2.2)
Widowed	6 (4.05)	4 (3.3)	13 (5.4)	10 (11.2)
Has children (N, %)	148 (100)	121 (98.4)	204 (88.3)	76 (87.4)	28.5 (.000)	0.1
Religiosity (N, %)					98.7 (.000)	0.8^a
Very religious	148 (100)	123 (100)	25 (10.4)	9 (10.0)
Religious	0	0	89 (37.0)	29 (32.2)
Moderate	0	0	110 (45.6)	44 (48.9)
Secular	0	0	17 (7.0)	8 (8.9)
Employed (N, %)	69 (46.9)	67 (54.5)	133 (55.2)	53 (58.8)	8.8 (.003)	0.4
Economic status (N, %)²					8.3 (.004)	5.9
Very good	11 (7.4)	7 (5.9)	10 (4.1)	5 (5.5)
Good	50 (33.8)	46 (38.7)	68 (28.3)	25 (27.8)
Fair	72 (48.6)	56 (47.0)	142 (58.9)	47 (52.2)
Poor	15 (8.2)	10 (8.4)	21 (8.7)	13 (15.5)

Demographic Variables	Ultra-Orthodox	Arab
BAP	38	71	27	38	Pre: 0.5	115	151	28	34	Pre: 1.3
(25.7)	(48.0)	(22.6)	(31.9)	Post: 8.2 (.004)	(47.7)	(62.7)	(31.1)	(37.8)	Post: 10.0 (.002)
CBE	17	19	19	13	Pre: 0.9	23	29	12	7	Pre: 1.0
(11.5)	(12.8)	(16.0)	(10.6)	Post: 0.3	(9.5)	(12.0)	(13.3)	(7.8)	Post: 1.2
Mammography (underwent or scheduled)	51	28	34	10	Pre: 0.1	108	42	29	5	Pre: 2.9
(59.3)	(46.7)	(39.5)	(16.4)	Post: 4.7 (.009)	(76.1)	(29.6)	(63.0)	(10.9)	Post: 2.4

Perceived Effect on	Ultra-Orthodox Jewish	Arab
Mammography attendance	2.5 (1.4)	2.02 (1.2)	3.3 (1.4)	2.7 (1.4)	36.8 (.000)	13.9 (.000)	1.0
				(0.6)	(0.2)
CBE attendance	2.1 (1.4)	1.8 (1.3)	2.8 (1.5)	2.7 (1.3)	37.2 (.000)	1.4	0.3
				(0.6)	(0.0)
BAP performance	2.5 (1.5)	2.2 (1.4)	3.3 (1.4)	2.6 (1.3)	23.2 (.000)	11.8 (.01)	1.3
				(0.4)	(0.9)
Gaining understanding of importance of screening	3.2 (1.4)	2.9 (1.4)	3.4 (1.4)	3.1 (1.5)	8.6 (.03)	4.2 (.006)	0.4
				(0.2)	(0.1)

Demographic Variables	BAP (N = 557)	CBE (N = 521)	Mammography (N = 335)
Group	1.9 [0.9, 4.3]	3.8* [1.2, 12.0]	2.5 [0.4, 1.7]
Intervention	1.2* [1.1, 1.6]	0.6 [0.9, 1.3]	1.1* [1.1, 1.8]
Religious beliefs	0.6* [0.4, 0.9]	0.5* [0.3, 0.9]	0.9 [0.4, 2.2]
Social barriers	0.9 [0.7, 1.2]	1.2 [0.7, 1.7]	1.2 [0.6, 2.2]
Fatalism	1.0 [0.9, 1.1]	1.1 [0.7, 1.3]	1.2 [0.8, 2.3]
Exposure barriers	—	1.4 [1.1, 1.9]	0.8 [0.5, 1.5]
Accessibility barriers	—	1.0 [0.7, 1.4]	1.3 [0.6, 3.0]
Learning importance of screening	1.6*** [1.3, 1.9]	1.3* [1.1, 1.7]	0.8 [0.5, 1.2]

Footnotes

Appendix A

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by The Israel National Institute for Health Policy Research.

References

Adams

S. A.

Choi

S. K.

Eberth

J. M.

Friedman

D. B.

Yip

M. P.

Tucker-Seeley

R. D.

… Hebert

J. R.

(2015). Is availability of mammography services at federally qualified health centers associated with breast cancer mortality-to-incidence ratios? An ecological analysis. Journal of Women’s Health, 24, 916–923.

Allison

M. A.

Jensky

N. E.

Marshall

S. J.

Bertoni

A. G.

Cushman

(2012). Sedentary behavior and adiposity-associated inflammation: The multi-ethnic study of atherosclerosis. American Journal of Preventive Medicine, 42, 8–13.

Ashing-Giwa

Kagawa-Singer

(2006). Infusing culture into oncology research on quality of life. Oncology Nursing Forum, 33, 31–36.

Azaiza

Brodsky

(1997). Changes in the Arab world and the development of services for Arab elderly in Israel during the last decade. Journal of Gerontological Social Work, 27, 37–53.

Azaiza

Cohen

(2006). Health beliefs and rates of breast cancer screening among Arab women. Journal of Women’s Health, 15, 520–530.

Azaiza

Cohen

(2008). Between traditional and modern perceptions of breast and cervical cancer screenings: A qualitative study of Arab women in Israel. Psycho-Oncology, 17, 34–41.

Azaiza

Cohen

Daoud

Awad

(2010). Factors associated with low screening for breast cancer in the Palestinian Authority: Relations of availability, environmental barriers, and cancer-related fatalism. Cancer, 116, 4646–4655.

Azaiza

Cohen

Daoud

Awad

(2011). Traditional-Westernizing continuum of change in screening behaviors: Comparison between Arab women in Israel and the West Bank. Breast Cancer Research & Treatment, 128, 219–227.

Baron-Epel

(2010). Attitudes and beliefs associated with mammography in a multiethnic population in Israel. Health Education & Behavior, 37, 227–242.

10.

Baron-Epel

Friedman

Lernau

(2008). Validity of self-reported mammography in a multicultural population in Israel. Preventive Medicine, 46, 489–491.

11.

Baron-Epel

Friedman

Lernau

(2009). Reducing disparities in mammography: Use in a multicultural population in Israel. International Journal for Equity in Health, 8, 19–30.

12.

Barrera

Castro

F. G.

Strycker

L. A.

Toobert

D. J.

(2013). Cultural adaptations of behavioral health interventions: A progress report. Journal of Consulting & Clinical Psychology, 81, 196–205.

13.

Baum

(2007). Social work practice in conflict-ridden areas: Cultural sensitivity is not enough. British Journal of Social Work, 37, 873–891.

14.

Belkic

K. L.

Cohen

Marquez

Mints

Wilczek

Berman

A. H.

… Castellanos

(2010). Screening of high-risk groups for breast and ovarian cancer in Europe: A focus on the Jewish population. Oncology Reviews, 4, 233–267.

15.

Betancourt

J. R.

Green

A. R.

Carrillo

J. E.

Ananeh-Firempong

(2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118, 293–312.

16.

Bhui

K. S.

Aslam

R. W.

Palinski

McCabe

Johnson

M. R. D.

Weich

… Szczepura

(2015). Interventions to improve therapeutic communications between Black and minority ethnic patients and professionals in psychiatric services: Systematic review. The British Journal of Psychiatry, 207, 95–103.

17.

Central Bureau of Statistics. (2013). Statistical abstracts of Israel—2013, No. 64. Jerusalem, IL: Author. (In Hebrew)

18.

Champion

V. L.

(1999). Revised susceptibility, benefits, and barriers scale for mammography screening. Research in Nursing & Health, 22, 341–348.

19.

Cohen

(2014). An integrated view of cultural perceptions of cancer among Arab people in Israel. Health Psychology Review, 8, 490–508.

20.

Cohen

Azaiza

(2005). Early breast cancer detection practices, health beliefs, and cancer worries in Jewish and Arab women. Preventive Medicine, 41, 852–858.

21.

Coleman-Brueckheimer

Spitzer

Koffman

(2009). Involvement of Rabbinic and communal authorities in decision-making by Haredi Jews in the UK with breast cancer: An interpretative phenomenological analysis. Social Science & Medicine, 68, 323–333.

22.

Emanuel

A. S.

Kiviniemi

M. T.

Howell

J. L.

Hay

J. L.

Waters

E. A.

Orom

Shepperd

J. A.

(2015). Avoiding cancer risk information. Social Science & Medicine, 147, 113–120.

23.

Freund

Cohen

Azaiza

(2014). The doctor is just a messenger: Beliefs of Ultraorthodox Jewish women in regard to breast cancer and screening. Journal of Religion & Health, 53, 1075–1090.

24.

Geiger

S. D.

Grigsby-Toussaint

(2017). Mammography-seeking practices of central Illinois Amish women. Journal of Community Health, 42, 369–376.

25.

Gøtzsche

P. C.

Jørgensen

K. J.

(2013). Screening for breast cancer with mammography. Copenhagen, Denmark: The Cochrane Collaboration.

26.

Hakak

(2011). Psychology and democracy in the name of God? The invocation of modern and secular discourses on parenting in the service of conservative religious aims. Mental Health, Religion & Culture, 14, 433–458.

27.

Hayes

A. F.

(2012). Introduction to mediation, moderation and conditional process analysis: A regression-based approach. Retrieved September 5, 2017, from http://www.afhayes.com/introduction-to-mediation-moderation-and-conditional-process-analysis.html

28.

Israeli Cancer Association. (2016). Guidelines for detection and prevention of cancer. Retrieved August 3, 2016, from the website: http://www.cancer.org.il/template/default.aspx?PageId=7655 (In Hebrew)

29.

Ka’opua

L. S. I.

Park

S. H.

Ward

M. E.

Braun

K. L.

(2011). Testing the feasibility of a culturally tailored breast cancer screening intervention with native Hawaiian women in rural churches. Health & Social Work, 36, 55–65.

30.

Ludman

E. J.

Curry

S. J.

Meyer

Taplin

S. H.

(1999). Implementation of outreach telephone counseling to promote mammography participation. Health Education Behavior, 26, 689–702.

31.

MacBride

M. B.

Pruthi

Bevers

(2012). The evolution of breast self-examination to breast awareness. The Breast Journal, 18, 641–643.

32.

Miranda

P. Y.

Tarraf

González

Johnson-Jennings

González

H. M.

(2012). Breast cancer screening trends in the United States and ethnicity. Cancer Epidemiology, Biomarkers & Prevention, 21, 351–357.

33.

Norcross

J. C.

Krebs

P. M.

Prochaska

J. O.

(2011). Stages of change. Journal of Clinical Psychology, 67, 143–154.

34.

O’Mahony

Comber

Fitzgerald

Corrigan

M. A.

Fitzgerald

Grunfeld

E. A.

… Hegarty

(2017). Interventions for raising breast cancer awareness in women. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD011396.pub2

35.

Paci

Broeders

Hofvind

Puliti

Duffy

S. W.

(2014). European breast cancer service screening outcomes: A first balance sheet of the benefits and harms. Cancer Epidemiology, Biomarkers & Prevention, 23, 1159–1163.

36.

Pasick

R. J.

Burke

N. J.

Barker

J. C.

Joseph

Bird

J. A.

Otero-Sabogal

… Guerra

(2009). Behavioral theory in a diverse society: Like a compass on Mars. Health, Education & Behavior, 36, 11–35.

37.

Pennypacker

H. S.

Bloom

H. S.

Criswell

E. L.

Neelakantan

Goldstein

M. K.

Stein

G. H.

(1982). Toward an effective technology of instruction in breast self-examination. International Journal of Mental Health, 11, 98–116.

38.

Prochaska

J. O.

Velicer

W. F.

Redding

Rossi

J. S.

Goldstein

DePue

… Laforge

(2005). Stage-based expert systems to guide a population of primary care patients to quit smoking, eat healthier, prevent skin cancer, and receive regular mammograms. Preventive Medicine, 41, 406–416.

39.

Prochaska

J. O.

Velicer

W. F.

Rossi

J. S.

Goldstein

M. G.

Marcus

B. H.

Rakowski

… Rossi

S. R.

(1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13, 39–46.

40.

Rosenstock

I. M

. (1974). Historical origins of the health belief model. Health Education Monographs, 2, 328–335.

41.

Schnitzer

Loots

Escudero

Schechter

(2011). Negotiating the pathways into care in a globalizing world: Help-seeking behavior of Ultra-Orthodox Jewish parents. International Journal of Social Psychiatry, 57, 153–165.

42.

Shaya

F. T.

Gbarayor

C. M.

(2006). The case for cultural competence in health professions education. American Journal of Pharmaceutical Education, 70, 124–131.

43.

Smith

P. A.

(2014). The value of modern mammography screening in the control of breast cancer: Understanding the underpinnings of the current debates. Cancer Epidemiology, Biomarkers & Prevention, 23, 1139–1146.

44.

Smith

R. A.

Cokkinides

Eyre

H. J.

(2005). American cancer society guidelines for the early detection of cancer. CA: Cancer Journal for Clinicians, 55, 31–44.

45.

Steinmo

Fuller

Stone

S. P.

Michie

(2015). Characterizing an implementation intervention in terms of behaviour change techniques and theory: The “Sepsis Six” clinical care bundle. Implementation Science, 10, 1–19.

46.

Tarabeia

Baron-Epel

Barchana

Lipshitz

Ifrah

Fisher

Green

M. S.

(2007). A comparison of trends in incidence and mortality rates of breast cancer, incidence to mortality ratio and stage at diagnosis between Arab and Jewish women in Israel, 1979–2002. European Journal of Cancer Prevention, 16, 36–42.

47.

Yuan

Y. C.

(2010). Multiple imputations for missing data: Concepts and new development (Version 9.0). Rockville, MD: SAS Institute.

48.

Zidan

Sikorsky

Basher

Sharabi

Friedman

Steiner

(2012). Differences in pathological and clinical features of breast cancer in Arab as compared to Jewish women in Northern Israel. International Journal of Cancer, 131, 924–929.

Demographic Variables	Ultra-Orthodox Jewish		Arabs		F/χ² (p)
Demographic Variables	Intervention (n = 148)	Nonintervention (n = 119)	Intervention (n = 241)	Nonintervention (n = 90)	Religion	Intervention
Age
M (SD)	50.9 (6.1)	49.6 (5.9)	51.4 (6.0)	49.9 (7.3)	0.23	5.1 (.016)
Range	40–60	40–60	40–60	40–60
Education, years
M (SD)	14.0 (2.1)	14.17 (1.9)	10.1 (3.0)	9.3 (3.7)	275.7 (.000)	2.3
Range	9–20	9–20	1–20	3–20
Family status (N, %)					33.9 (.000)	2.7
Single	0	0	25 (10.4)	8 (8.8)
Married	141 (95.3)	111 (93.4)	197 (81.7)	70 (77.8)
Divorced/separated	1 (0.68)	4 (3.3)	6 (2.5)	2 (2.2)
Widowed	6 (4.05)	4 (3.3)	13 (5.4)	10 (11.2)
Has children (N, %)	148 (100)	121 (98.4)	204 (88.3)	76 (87.4)	28.5 (.000)	0.1
Religiosity (N, %)					98.7 (.000)	0.8^a
Very religious	148 (100)	123 (100)	25 (10.4)	9 (10.0)
Religious	0	0	89 (37.0)	29 (32.2)
Moderate	0	0	110 (45.6)	44 (48.9)
Secular	0	0	17 (7.0)	8 (8.9)
Employed (N, %)	69 (46.9)	67 (54.5)	133 (55.2)	53 (58.8)	8.8 (.003)	0.4
Economic status (N, %)²					8.3 (.004)	5.9
Very good	11 (7.4)	7 (5.9)	10 (4.1)	5 (5.5)
Good	50 (33.8)	46 (38.7)	68 (28.3)	25 (27.8)
Fair	72 (48.6)	56 (47.0)	142 (58.9)	47 (52.2)
Poor	15 (8.2)	10 (8.4)	21 (8.7)	13 (15.5)

Demographic Variables	BAP (N = 557)	CBE (N = 521)	Mammography (N = 335)
Demographic Variables	OR (CI 95%)	OR (CI 95%)	OR (CI 95%)
Group	1.9 [0.9, 4.3]	3.8* [1.2, 12.0]	2.5 [0.4, 1.7]
Intervention	1.2* [1.1, 1.6]	0.6 [0.9, 1.3]	1.1* [1.1, 1.8]
Religious beliefs	0.6* [0.4, 0.9]	0.5* [0.3, 0.9]	0.9 [0.4, 2.2]
Social barriers	0.9 [0.7, 1.2]	1.2 [0.7, 1.7]	1.2 [0.6, 2.2]
Fatalism	1.0 [0.9, 1.1]	1.1 [0.7, 1.3]	1.2 [0.8, 2.3]
Exposure barriers	—	1.4 [1.1, 1.9]	0.8 [0.5, 1.5]
Accessibility barriers	—	1.0 [0.7, 1.4]	1.3 [0.6, 3.0]
Learning importance of screening	1.6*** [1.3, 1.9]	1.3* [1.1, 1.7]	0.8 [0.5, 1.2]