Abstract
Arab Americans (AA) face increased risk for colorectal cancer (CRC), the third leading cause of cancer-related death in the US, due to low utilization of preventative care and socioeconomic disparities. This study explores associations with the receipt of CRC screening among AA in New York City. A cross-sectional survey was conducted among 100 individuals attending religious and community organizations with interviewer-administered surveys in Arabic and English. Results from 100 participants showed they were more likely to complete CRC screening with a doctor recommendation (74%) and were more likely to get a recommendation with a high school education or higher (86%). Uninsured participants and those with public insurance were the least likely to complete screening. Those with a higher mean score in Spiritual Life/Faith (13.34 vs. 11.67) were less likely to complete screening. Findings suggest the need for culturally sensitive interventions to increase CRC screening rates among AA.
Keywords: Immigrant health, Colorectal cancer screening, Colorectal cancer, Arab Americans, Minority health
Background
It is estimated that over one million, 2.5%, of the 41.3 million immigrants in the U.S., hail from the Middle East and North Africa [1]. Since 1980, the number of people who identify as Arab in New York state has more than doubled to the current 449,187, which puts New York Arabs as one of the fastest growing Arab populations in the country. The largest number of new Arab immigrants to New York come from Egypt, Yemen and Morocco [2].
Colorectal Cancer (CRC) rates are increasing in a number of Arab countries and patients are being diagnosed at younger ages [3], as Arabs adopt a more Westernized diet, and with increasing rates of obesity [4, 5]. In the United States, colorectal cancer (CRC) is the third most common cancer diagnosed and the third leading cause of cancer-related death in both men and women [6]. In 2017, there will be an estimated 135,430 new cases of CRC in the United States and an estimated 50,260 people will die from CRC [7]. Studies in Michigan, home to the second largest Arab community in the U.S. after California, reveal high CRC incidence and mortality among Arab Americans there [8, 9].
Screening for CRC for adults between 45 and 75 years of age can lead to early diagnosis and can also be preventive. Screening test use has contributed to the decrease in CRC mortality among US men and women [9–11]. Although screening for CRC has increased significantly nationwide, studies have shown that the rate of CRC screening remains low among Arab Americans [8, 10]. In a Michigan study, only 45.6% of the eligible Arab Americans underwent CRC screening, compared to 70.9% of Michigan’s total eligible population in the same year [8]. Access to screening may be hindered by lack of health awareness, non-recommendation by the primary care physician, language, cultural beliefs, and attitudes of health professionals [12]. Factors such as race, age, ethnicity, education, income, period of residence in the United States, health insurance, usual source of care, recent physician visit, use of other cancer screening tests, and recommendation from a physician for screening significantly impact access to and utilization of CRC tests [10]. Socioeconomic disparities also modulate CRC screening test use [13]. A health assessment conducted in Southwest Brooklyn, the largest Arab American area in New York City (NYC), showed that over 50% of Arab households lived below the poverty level and nearly 30% had no health insurance [13].
Spiritual beliefs may also impact cancer screening practices [14–16]. However, studies on the effects of spirituality and religion on cancer screening in Arabs in the United States are limited. In a focus group study with Muslim and Christian Arabs to examine factors that act as barriers to utilization of cancer prevention, treatment, and support services, most participants reported their belief that health is in God’s hands and that cancer is a punishment by God or that the prospect of a cure is up to God [16]. A qualitative study of mammography intention with proportional numbers of Arab, South Asian and African American Muslim women over 40 showed that some women perceived taking care of their bodies and health as part of their duties towards God, and that religious practices such as praying and fasting were important in maintaining good health [15].
Arabs, despite their growing numbers and at times greater risk, such as with CRC, receive little attention in health research [4, 5]. Despite higher CRC rates [8, 16, 17], there are limited data documenting associations with the CRC screening among Arab Americans. This study explores associations with the receipt of CRC screening, including socioeconomic factors and spiritual beliefs, among Arab Americans in New York City. Results can help guide interventions to increase CRC screening rates in this high-risk population.
Methods
The Arab Health Initiative (AHI), housed at Memorial Sloan Kettering Cancer Center, addresses cultural, linguistic and socioeconomic barriers to accessing health services and conducts research to improve health outcomes among Arab communities, locally in New York City, nationally, and internationally [16, 18, 19]. AHI collaborates with community and religious-based organizations servicing the Arab community, to link community members to health resources and services.
Design
This study, designed by AHI in partnership with the Population Studies and Disparities Research Program at Wayne State University School of Medicine, Department of Oncology, was a cross-sectional survey conducted among individuals attending religious and community-based organizations (CBOs) that are part of the AHI network. The project received Memorial Sloan Kettering Cancer Center Institutional Review Board exemption and a waiver of written consent was granted.
Settings
The research team visited large Arab community sites. Participants were recruited at mosques, churches, and at Arab American CBOs which provide social services to the Arab population in Manhattan, Brooklyn, the Bronx and Queens.
Participants
Eligibility for participation included: (1) Adult between the ages of 50–75 years (according to the CRC screening guidelines at the time of recruitment), (2) Identifies as Arab, (3) Moved to the US after the age of 12 years, (4) Lives in New York City, and (5) Has self-reported proficiency in either English, Arabic or both.
Data Collection
Each person was screened for eligibility. If eligible, the participant was informed of the purpose of the study, received a study brochure and oral consent was obtained to begin the questionnaire. AHI research staff administered a questionnaire in the patient’s preferred language, which was Arabic for all participants except for one who preferred to answer in English. Participants were given a $15 gift card as an incentive for their participation.
Measures
The questionnaire included sociodemographic data; health care access questions; and colorectal cancer screening and attitudes questions. Spiritual beliefs were measured using the Spiritual Health Locus of Control scale [20–22].
The sociodemographic characteristics queried included: sex, age, marital status, family size, household members, education, place of birth, income amount, employment status, and occupation. In addition, the survey asked questions related to immigration/acculturation (e.g. time in the US, preferred language, and spoken English proficiency) using the Acculturation Rating Scale of Arab Americans II (ARSAAII), a 30-item measure assessing acculturation among Arab Americans. The ARSAAII includes two subscales: 13 items measuring attraction to American culture and 15 items measuring attraction to Arab culture. This questionnaire has been validated in Arabic [23]. Participants were asked about their healthcare status, race or ethnicity of provider, language used by provider to communicate with patient, frequency of clinic and hospital visits, and overall satisfaction with healthcare [24].
The questionnaire and other study documents were translated into Arabic and then back translated into English. Two different translators conducted the translations independently. Once the back translation was completed, study personnel noted any items where content or style was in question. A final revision by the head Arabic translator was then executed to produce the final version in Arabic.
Participants were asked about their colorectal cancer screening history, and their providers recommendations regarding colorectal cancer screening, with a 17 question survey with questions taken from the Behavioral Risk Factor Surveillance Survey (BRFSS) [24]. This scale is currently validated in English. [25]. Colorectal cancer tests included colonoscopy and FOBT (fecal occult blood test) or FIT (fecal immunochemical test).
The Spiritual Health Locus of Control Scale [20] uses questions with a five-point Likert-type scale (1 = strongly disagree to 5 = strongly agree)to assess spiritual beliefs as they pertain to health. This scale is currently validated in English [20]. This 13-item multidimensional scale has 4 subscales: (1) Spiritual Life and Faith (α = .81), referring to belief that God will keep one healthy if one is faithful; (2) Active Spiritual (α = .66), referring to the idea of both God and the self each doing their part for health; (3) God’s Grace (α = .63), referring to the notion of a powerful but good God that has control over health; and (4) Passive Spiritual (α = .51), referring to belief that God has control over one’s health, and thus one need not do anything to impact their health. The questionnaire, which was administered by research staff, took approximately 45–60 minutes to administer.
Analysis
Statistical association between the recipient of self-reported CRC screening/recommendations and categorical covariates were analyzed using a series of univariate Chi square statistics. SHLC were scored into 4 subscales (Spiritual Life/Faith, Active Spiritual, God’s Grace and Passive Spiritual). Correlation between SHLC and self-reported CRC screening/recommendations were calculated using point-biserial test. Mean SHLC scores were compared between Christian and Muslim participants, using ANOVA test. Statistical significance was considered at p ≤ 0.05. All statistical analyses were conducted using SPSS version 24 [26].
Results
There were 251 participants screened for eligibility. Of the 251 participants, 40 were ineligible because they were less than 50 years old or not living in NYC. One-hundred eleven were eligible but declined participation because they were either not interested (n = 51) or did not have time (n = 60). Data from one-hundred eligible participants who agreed to participate were included in the analyses. (Table 1).
Table 1.
Demographic Characteristics, n = 100
| Characteristic | Overall n (%) |
Male, n = 50 n (%) |
Female, n = 50 n (%) |
|---|---|---|---|
| Age in years (mean [SD]) | 59.67 (SD = 7.026) | 61.28 (7.41) | 58.02 (6.26) |
| Education | |||
| High school and above | 54 (54.0) | 32 (64.0) | 22 (44.0) |
| Less than high school | 46 (46.0) | 18 (36.0) | 28 (56.0) |
| Marital status | |||
| Married | 79 (80.6) | 47 (95.9) | 32 (65.3) |
| Divorced | 7 (7.1) | 1 (2.0) | 6 (12.2) |
| Widowed | 7 (7.1) | 0 (0.0) | 7 (14.3) |
| Other | 5 (5.1) | 1 (2.0) | 4 (8.2) |
| Birth country | |||
| Egypt | 32 (32.0) | 21 (42.0) | 11 (22.0) |
| Yemen | 15 (15.0) | 6 (12.0) | 9 (18.0) |
| Morocco | 12 (12.0) | 6 (12.0) | 6 (12.0) |
| Lebanon | 10 (10.0) | 6 (12.0) | 4 (8.0) |
| Palestine | 11 (11.0) | 3 (6.0) | 8 (16.0) |
| Iraq | 5 (5.0) | 1 (2.0) | 4 (8.0) |
| Jordan | 5 (5.0) | 2 (4.0) | 3 (6.0) |
| Syria | 4 (4.0) | 1 (2.0) | 3 (6.0) |
| Sudan | 3 (3.0) | 2 (4.0) | 1 (2.0) |
| Algeria | 2 (2.0) | 1 (2.0) | 1 (2.0) |
| Saudi Arabia | 1 (1.0) | 1 (2.0) | 0 (0.0) |
| Are you proficient in | |||
| Arabic | 40 (40.0) | 9 (18.0) | 31 (62.0) |
| Both | 53 (53.0) | 37 (74.0) | 16 (32.0) |
| Religion | |||
| Christianity | 28 (28.0) | 10 (20.0) | 18 (36.0) |
| Muslim | 72 (72.0) | 40 (80.0) | 32 (64.0) |
| Household income last year | |||
| Less than $10,000 | 20 (28.2) | 4 (10.3) | 16 (50.0) |
| $10,000 to $20,000 | 21 (29.6) | 12 (30.8) | 9 (28.1) |
| $21,000 to $30,000 | 14 (19.7) | 12 (30.8) | 2 (6.3) |
| $31,000 to $40,000 | 5 (7.0) | 4 (10.3) | 1 (3.1) |
| $41,000 to $50,000 | 4 (5.6) | 3 (7.7) | 1 (3.1) |
| More than $50,000 | 7 (9.9) | 4 (10.3) | 3 (9.4) |
| Are you the main source of your family’s income? | |||
| Yes | 55 (57.3) | 41 (87.2) | 14 (28.6) |
| No | 41 (42.7) | 6 (12.8) | 35 (71.4) |
| Employment status | |||
| Full-time | 31 (32.3) | 27 (56.2) | 4 (8.3) |
| Part-time | 12 (12.5) | 7 (14.6) | 5 (10.4) |
| Retired | 12 (12.5) | 8 (16.7) | 4 (8.3) |
| Unemployed | 39 (40.6) | 6 (12.5) | 33 (68.8) |
| Other | 2 (2.1) | 0 (0.0) | 2 (4.2) |
| SHLC score [mean (SD)] | |||
| Spiritual life/faith | 12.44 (2.964) | 12.43 (3.358) | 12.45 (2.535) |
| Active spiritual | 13.45 (1.842) | 13.65 (1.853) | 13.24 (1.828) |
| God’s grace | 17.17 (3.020) | 17.04 (3.379) | 17.30 (2.653) |
| Passive spiritual | 6.42 (2.519) | 6.42 (2.519) | 6.32 (2.332) |
| Total score | 49.35 (7.262) | 49.44 (8.247) | 49.26 (6.294) |
All missing values were excluded from calculating percentages and p-values
The mean age of participants was 59.96 years (SD = 7.26). Most participants (80.6%) were married, and more than half (54%) had a high school degree or higher. Males and females differed in education levels, with 64% of men with a high school degree or higher compared to 44% of women. There were participants from 11 countries of origin, with the majority from Egypt (32.0%), Yemen (15.0%), and Morocco (12.0%). More than half (53%) of participants indicated that they were proficient in both English and Arabic. A larger percentage of males (74%) were proficient in both languages compared to 32% of women. Seventy two percent of participants were Muslim, and 28% Christian. The majority of respondents reported making less than $10,000 last year or between $10,000 and $20,000 (28.2% and 29.6%, respectively). Most of the male participants (87.2%) indicated that they were the main source of their family’s income, compared to 28.6% of female participants. The majority of males were employed full-time (56.2%), followed by retired (16.7%), and then by part-time (14.6%), and unemployed (12.5%). Most female participants were unemployed (68.8%), followed by employed part-time (10.4%), full-time (8.3%), and retired (8.3%).
Table 2 summarizes the association between CRC screening receipt and respondent characteristics (N = 100). Our result shows participants were more likely to complete a CRC screening test if their doctor recommended one (74%), compared to those who didn’t get a CRC recommendation (0%), at p < 0.001. Participants who were insured were more likely to have completed CRC screening. Among insured participants, those who had Medicaid or other public insurance (52% vs. 78% employer-based insurance, p < 0.01) were the least likely to have completed CRC screening. Similarly, insurance was also associated with getting recommendations for a CRC screening test from the doctor, as employee-based insurance holders (100%) were the most likely to get a CRC screening recommendation from their doctors, when compared to other participants (28.6% no insurance, 79.2% Medicaid or other public insurance, 80% Medicare), at p < 0.01. In addition, respondents who had a high school education or higher (86.0%) were more likely to get a recommendation for a CRC screening test than those who did not complete high school (66.7%), at p ≤ 0.05). In terms of spiritual beliefs, those who had a higher mean score in Spiritual Life/Faith (13.34 vs. 11.67, p ≤ 0.01) and God’s Grace (17.95 vs. 16.63, p ≤ 0.05) were less likely to have completed CRC screening.
Table 2.
Screening Rate and Recommendation in Association with Predictors, n = 100
| Has a doctor ever recommended that you have a CRC screening? |
Have you ever gotten a CRC screening? |
|||||
|---|---|---|---|---|---|---|
| Yes n = 71a |
No n = 21a |
p value | Yes n = 52b |
No n = 40b |
p-Value | |
| Gender | ||||||
| Male | 37 (80.4) | 9 (19.6) | 0.620 | 28 (60.9) | 18 (39.1) | 0.528 |
| Female | 34 (73.9) | 12 (26.1) | 24 (52.2) | 22 (47.8) | ||
| Religion | ||||||
| Christianity | 20 (80.0) | 5 (20.0) | 0.786 | 14 (53.8) | 12 (46.2) | 0.817 |
| Muslim | 51 (76.1) | 16 (23.9) | 38 (57.6) | 28 (42.4) | ||
| Preferred language for health communication | ||||||
| Arabic | 52 (74.3) | 18 (25.7) | 0.324 | 38 (53.5) | 33 (46.5) | 0.489 |
| English | 15 (93.8) | 1 (6.3) | 10 (66.7) | 5 (33.3) | ||
| French | 1 (100.0) | 0 (0.0) | 1 (100.0) | 0 (0.0) | ||
| German | 1 (100.0) | 0 (0.0) | 1 (100.0) | 0 (0.0) | ||
| Education | ||||||
| High school and below | 28(66.7) | 14(33.3) | 0.045 | 20(46.5) | 23(53.5) | 0.092 |
| More than high school | 43(86.0) | 7(14.0) | 32(65.3) | 17(34.7) | ||
| Household income last year | ||||||
| Less than $10,000 | 14 (73.7) | 7 (26.3) | 0.612 | 9 (45.0) | 11 (55.0) | 0.244 |
| $10,000 to $20,000 | 14 (73.7) | 5 (26.3) | 12 (60.0) | 8 (40.0) | ||
| $21,000 to $30,000 | 10 (90.9) | 1 (9.1) | 8 (80.0) | 2 (20.0) | ||
| $31,000 to $40,000 | 4 (80.0) | 1 (20.0) | 2 (40.0) | 3 (60.0) | ||
| $41,000 to $50,000 | 3 (75.0) | 1 (25.0) | 3 (75.0) | 1 (25.0) | ||
| More than $50,000 | 7 (100.0) | 0 (0.0) | 6 (85.7) | 1 (14.3) | ||
| Employment status | ||||||
| Full-time | 26 (83.9) | 5 (16.1) | 0.337 | 16 (53.3) | 14 (46.7) | 0.073 |
| Part-time | 8 (80.0) | 2 (20.0) | 7 (70.0) | 3 (30.0) | ||
| Retired | 10 (83.3) | 2 (16.7) | 10 (83.3) | 2 (16.7) | ||
| Unemployed | 22 (64.7) | 12 (35.3) | 15 (42.9) | 20 (57.1) | ||
| Other | 2 (100.0) | 0 (0.0) | 2(100.0) | 0 (0.0) | ||
| Type of health insurance | ||||||
| No insurance | 2(28.6) | 5(71.4) | 0.008 | 0(0.0) | 7(100.0) | 0.005 |
| Medicaid/other public | 38(79.2) | 10(20.8) | 25(53.2) | 22(46.8) | ||
| Medicare | 4(80.0) | 1(20.0) | 5(83.3) | 1(16.7) | ||
| Employer-based | 9(100.0) | 0(0.0) | 7(77.8) | 2(22.2) | ||
| More than one insurance | 14(87.5) | 2(12.5) | 12(75.0) | 4(25.0) | ||
| Provider’s gender | ||||||
| Male | 45 (78.9) | 12 (21.1) | 1 | 33 (57.9) | 24 (42.1) | 1 |
| Female | 23 (82.1) | 5 (17.9) | 17 (60.7) | 11 (39.3) | ||
| Language for health communication | ||||||
| Arabic | 43 (81.1) | 10 (18.9) | 0.765 | 28 (51.9) | 26 (48.1) | 0.183 |
| English | 26 (76.5) | 8 (23.5) | 23 (69.7) | 10 (30.3) | ||
| French | 1 (100.0) | 0 (0.0) | 1 (100.0) | 0 (0.0) | ||
| Overall, how much do you trust your doctor? | ||||||
| A lot | 42 (79.2) | 11 (20.8) | 0.670 | 30 (56.6) | 23 (43.4) | 0.927 |
| A fair amount | 23 (85.2) | 4 (14.8) | 16 (59.3) | 11 (40.7) | ||
| A little | 2 (66.7) | 1 (33.3) | 2 (66.7) | 1 (33.3) | ||
| Not at all | 0 (N/A) | 0 (N/A) | 0 (N/A) | 0 (N/A) | ||
| Provider’s race | ||||||
| Arab/Arab American | 43 (81.1) | 10 (18.9) | 1 | 30 (55.6) | 24 (44.4) | 1 |
| Caucasian or white | 5 (83.3) | 1 (16.7) | 3 (50.0) | 3 (50.0) | ||
| SHLC score | Mean (SD) | Sig | Mean (SD) | Sig | ||
| Spiritual life/faith | 11.67 (3.284) | 13.34 (2.269) | 0.160 | 11.67 (3.284) | 13.34 (2.269) | 0.008 |
| Active spiritual | 13.27 (2.031) | 13.70 (1.596) | 0.907 | 13.27 (2.031) | 13.70 (1.596) | 0.290 |
| God’s grace | 16.63 (3.520) | 17.95 (2.134) | 0.236 | 16.63 (3.520) | 17.95 (2.134) | 0.047 |
| Passive spiritual | 6.45 (2.459) | 6.05 (2.309) | 0.312 | 6.45 (2.459) | 6.05 (2.309) | 0.451 |
Numbers are n (%) unless otherwise indicated. All missing values were excluded from calculating percentages and p-values
8 with no response to this question
8 with no response to this question
The impact of religious affiliation on participants’ spiritual beliefs was examined (Table 3). There was no statistical significance between the responses of Christian and Muslim participants in Spiritual Life/Faith or God’s grace. Muslims [13.68 SD (1.720)] had a significantly higher mean score in Active Spiritual than Christians [12.85 SD (2.033)], meaning Muslims were more likely to have the idea that both God/Allah and the self each do their part for health than Christians, at the p ≤ 0.05. In addition, Christians [7.15 SD (2.092)] had a significantly higher mean score in Passive Spiritual than Muslims [6.05 SD (2.472)], meaning compared to Muslims, Christians were more likely to believe that God has control over one’s health, and thus one does not need to do anything to impact their health, at the p ≤ 0.05.
Table 3.
The Spiritual Health Locus of Control Scale (SHLC) by religious affiliations (N = 100)
| SHLC Score | Mean (SD) |
Sig | Items | |
|---|---|---|---|---|
| Christian (N = 28) | Muslim (N = 72) | |||
| Spiritual life/faith | 12.19 (2.669) | 12.54 (3.071) | 0.616 | Through my faith in God/Allah, I can stay healthy |
| If I lead a good spiritual life, I will stay healthy | ||||
| If I stay healthy, it’s because I am right with God/Allah | ||||
| Active spiritual | 12.85 (2.033) | 13.68 (1.720) | 0.050 | Living the way the Lord/Allah says I’m supposed to live means I have to take care of myself |
| Even though I trust God/Allah will take care of me, I still need to take care of myself | ||||
| God/Allah gives me the strength to take care of myself | ||||
| God’s grace | 16.69 (3.026) | 17.25 (3.037) | 0.678 | I rely on God/Allah to keep me in good health |
| God/Allah works through doctors to heal us | ||||
| Prayer is the most important thing I do to stay healthy | ||||
| If I stay well, it is because of the grace of the good Lord/Allah | ||||
| Passive spiritual | 7.15 (2.092) | 6.05 (2.472) | 0.048 | It’s ok not to seek medical attention because I feel that God/Allah will heal me |
| There is no point in taking care of myself when it’s all up to God/Allah anyway | ||||
| God/Allah and I share responsibility (reverse) | ||||
| Total score | 51.000 (8.546) | 51.84 (7.964) | 0.658 | |
Discussion
In this sample of 100 Arab Americans living in New York City, associations with the receipt of CRC screening uptake included socioeconomic factors (i.e. education level, health insurance coverage), doctor recommendations, period of residence in the United States, and spiritual and religious beliefs. Although studies have shown high CRC incidence and mortality rates among Arab Americans [17, 27], this is one of the few studies to document associations with the receipt of CRC screening among this population [28–30].
Higher level of education was significantly associated with higher rates of getting a recommendation to have CRC screening by the primary care physician but not significantly associated with completing screening for CRC. Previous studies have shown the effect of lower education on increasing the risk of non-participation in CRC screening [31, 32]. According to a systematic review of socioeconomic factors and doctor-patient communication, more educated patients tend to communicate more actively with their physicians than patients with a lower education level, eliciting more information [33]. A study of primary care visits in New York concluded that physicians spent less time on questions from patients with lower education, and less screening tests were introduced to them [33].
There was a significant association between the length of stay in the United States and the likelihood of receiving a CRC screening recommendation and completing the test. The longer the participants lived in the United States, the more likely they received the recommendation for CRC screening, and the more likely they would have done the test. These results are consistent with a study about predictors of CRC screening among Arab Americans in Michigan [28]. Other studies found a positive association between length of stay among different immigrant groups in the US and CRC screening [34] and positive perceptions about CRC screening [35].
Participants were more likely to complete a CRC screening test if their doctor recommended one. In recent studies, the role of primary care physicians in screening for CRC has been recognized as very important [36, 37] as they play a key role in increasing the participation rate in CRC screening programs [36, 37]. Data indicate higher participation rates in CRC screening programs with the involvement of a general practitioner and reduction of barriers that discourage participation including lack of time and scheduling issues [36]. Another study found that in addition to a recommendation from a physician, knowing someone who has/had cancer were the most common factors in patients decisions to complete CRC screening [36, 37].
Participants who lacked health insurance coverage had significantly lower CRC screening rates. Participants reported higher probability of one’s PCP not recommending CRC screening if they were uninsured or had public insurance. These findings are consistent with other studies that showed a higher association between having health insurance and completing colorectal screening among Arab Americans [28, 30, 38]. According to studies conducted with other immigrants groups including Latinos and Asian Americans, participants who had health insurance were more likely to receive screening for colorectal cancer [39].
The completion of CRC screening was negatively associated with the belief that God: (a) will keep one healthy if one is faithful, and (b) has control over health. Most of the participants, whether Muslim or Christian, believed that staying healthy is a grace from God, that God works through doctors to heal them and that prayer is the most important thing they do to stay healthy. These beliefs were consistent with a previous study, where both Arab Muslim and Christian focus group participants mentioned God when talking about their health [16]. Muslims, however, were more likely to believe in the idea that both God and the self each doing their part for health while Christians were more likely to believe that God has control over their health.
New Contributions to Literature
We believe this study to be the first of its kind to examine the factors associated with the receipt of CRC screening within a solely Arab American population. The findings provide valuable information to healthcare providers and health educators in designing culturally sensitive interventions and educational materials to increase CRC screening rates in this population with a focus on the uninsured. A successful intervention that utilizes a community based participatory approach and provides culturally appropriate Arabic language breast cancer education, screening coordination, and cultural competency training for healthcare professionals to increase breast cancer screening among Arab women could be replicated for CRC education and screening coordination in an Arab community [18]. Based on what we learned in this study, educating physicians in the community, who are trusted healthcare professionals, on the importance of focusing on more recent immigrants, available community resources to assist the uninsured and underinsured, and religious and spiritual issues that may directly affect screening uptake can improve CRC screening rates in an age-appropriate Arab American population. Furthermore, culturally tailored resources should be developed and partnerships with community based and religious institutions should be forged to facilitate trust with this potentially hard to reach population, to help improve access to available CRC services.
Study Limitations
Our study has several limitations. First, the sample size was small, which resulted from difficulties in recruiting Arab American participants due to the strict age criteria. Second, the income variable was hard to collect with this population due to their limited knowledge about their household income. The income variable was also collected in categorized groups which made it hard to calculate the income for participants based on household size, therefore, we could not infer a relationship between CRC screening and income level. Also, the majority of participants were from the following three Arab countries: Egypt, Yemen, and Morocco. Although immigrants from these countries represent the majority of new Arab immigrants in New York City, this demographic composition may affect the generalizability of the results for other Arab populations. Lastly, the BRFSS and the Spiritual Health Locus of Control scales used in this study have not been validated in Arabic. Future studies should include more representation from different Arab countries.
Acknowledgements
This publication was supported by the National Institutes of Health under Award Number P30 CA 008748. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
References
- 1.Zong JB J: Middle Eastern and North African Immigrants in the United States. 2015. https://www.migrationpolicy.org/article/middle-eastern-and-north-african-immigrants-united-states Accessed 13 Jul 2017.
- 2.Arab American Institute Foundation: New York Demographic Sheet. Washington, DC; 2011. https://d3n8a8pro7vhmx.cloudfront.net/aai/pages/7778/attachments/original/1431630650/NewYork.pdf?1431630650 Accessed 13 Jul 2017. [Google Scholar]
- 3.Ali Hussein Alhurry AM, Rezaianzadeh A, Rahimikazerooni S, Abdzaid Akool M, Bahrami F, Shahidinia SS, Pourahmad MI. A Review of the Incidence of Colorectal Cancer in the Middle East. Annals of Colorectal Research. 2017;5(3–4):e46292. [Google Scholar]
- 4.Salim EI, Moore MA, Al-Lawati JA, Al-Sayyad J, Bazawir A, Bener A, Corbex M, El-Saghir N, Habib OS, Maziak W, Mokhtar HC, Seif-Eldrin IA, Sobue T. Cancer epidemiology and control in the arab world—past, present and future. Asian Pac J Cancer Prev. 2009;10(1):3–16. [PubMed] [Google Scholar]
- 5.Salim EI, Moore MA, Bener A, Habib OS, Seif-Eldin IA, Sobue T. Cancer epidemiology in South-West Asia—past, present and future. Asian Pac J Cancer Prev. 2010;11(Suppl 2):33–48. [PubMed] [Google Scholar]
- 6.American Cancer Society: Key statistics for colorectal cancer. 2018. https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html Accessed 13 Jul 2017.
- 7.American Cancer Society: Colorectal Cancer Facts & Figures 2017–2019. 2017. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-and-figures-2017–2019.pdf Accessed 13 Mar 2018.
- 8.Schwartz KL, Kulwicki A, Weiss LK, Fakhouri H, Sakr W, Kau G, Severson RK. Cancer among Arab Americans in the metropolitan Detroit area. Ethn Dis. 2004;14(1):141–6. [PubMed] [Google Scholar]
- 9.U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149(9):627–37. [DOI] [PubMed] [Google Scholar]
- 10.Meissner HI, Breen N, Klabunde CN, Vernon SW. Patterns of colorectal cancer screening uptake among men and women in the United States. Cancer Epidemiol Biomark Prev. 2006;15(2):389–94. [DOI] [PubMed] [Google Scholar]
- 11.Brenner H, Stock C, Hoffmeister M. Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies. BMJ. 2014;348:g2467. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Thomas VN, Saleem T, Abraham R. Barriers to effective uptake of cancer screening among Black and minority ethnic groups. Int J Palliat Nurs. 2005;11(11):562. (564–571). [DOI] [PubMed] [Google Scholar]
- 13.Sarsour L, Tong VS, Jaber O, Talbi M, Julliard K. Health assessment of the Arab American community in southwest Brooklyn. J Community Health. 2010;35(6):653–9. [DOI] [PubMed] [Google Scholar]
- 14.Padela AI, Murrar S, Adviento B, Liao C, Hosseinian Z, Peek M, Curlin F. Associations between religion-related factors and breast cancer screening among American Muslims. J Immigr Minor Health. 2015;17(3):660–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Padela AI, Vu M, Muhammad H, Marfani F, Mallick S, Peek M, Quinn MT. Religious beliefs and mammography intention: findings from a qualitative study of a diverse group of American Muslim women. Psychooncology. 2016;25(10):1175–82. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Shah SM, Ayash C, Pharaon NA, Gany FM. Arab American immigrants in New York: health care and cancer knowledge, attitudes, and beliefs. J Immigr Minor Health. 2008;10(5):429–36. [DOI] [PubMed] [Google Scholar]
- 17.Darwish-Yassine M, Wing D. Cancer epidemiology in Arab Americans and Arabs outside the Middle East. Ethn Dis. 2005;15(1 Suppl 1):S1–5. [PubMed] [Google Scholar]
- 18.Ayash C, Axelrod D, Nejmeh-Khoury S, Aziz A, Yusr A, Gany FM. A community intervention: AMBER: Arab American breast cancer education and referral program. J Immigr Minor Health. 2011;13(6):1041–7. [DOI] [PubMed] [Google Scholar]
- 19.Ayash C, Costas-Muniz R, Badreddine D, Ramirez J, Gany F. An investigation of unmet socio-economic needs among Arab American breast cancer patients compared with other immigrant and migrant patients. J Community Health. 2018;43(1):89–95. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Holt CL, Clark EM, Klem PR. Expansion and validation of the spiritual health locus of control scale: factorial analysis and predictive validity. J Health Psychol. 2007;12(4):597–612. [DOI] [PubMed] [Google Scholar]
- 21.Holt CL, Clark EM, Kreuter MW, Rubio DM. Spiritual health locus of control and breast cancer beliefs among urban African American women. Health Psychol. 2003;22(3):294–9. [DOI] [PubMed] [Google Scholar]
- 22.Holt CL, Lukwago SN, Kreuter MW. Spirituality, breast cancer beliefs and mammography utilization among urban African American women. J Health Psychol. 2003;8(3):383–96. [DOI] [PubMed] [Google Scholar]
- 23.Jadalla A, Lee J. The relationship between acculturation and general health of Arab Americans. J Transcult Nurs. 2012;23(2):159–65. [DOI] [PubMed] [Google Scholar]
- 24.Centers for Disease Control and Prevention (CDC): 2013 Behavioral Risk Factor Surveillance System Survey Questionnaire. 2018. https://www.cdc.gov/brfss/questionnaires/pdf-ques/2013-BRFSSEnglish.pdf Accessed 2 Nov 2018.
- 25.Pierannunzi C, Hu SS, Balluz L. A systematic review of publications assessing reliability and validity of the behavioral risk factor surveillance system (BRFSS), 2004–2011. BMC Med Res Methodol. 2013;13:49. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.IBM Corp: IBM SPSS Statistics for Windows: (ed Version 24.0), Armonk, NY: 2016. [Google Scholar]
- 27.Bergmans R, Soliman AS, Ruterbusch J, Meza R, Hirko K, Graff J, Schwartz K. Cancer incidence among Arab Americans in California, Detroit, and New Jersey SEER registries. Am J Pub Health. 2014;104(6):e83–91. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Khawaldeh AI: Predictors of colorectal cancer screening among Arab Americans: the role of fatalism. UCLA 2008.
- 29.Talaat N, Harb W. Reluctance to screening colonoscopy in Arab Americans: a community based observational study. J Community Health. 2013;38(4):619–25. [DOI] [PubMed] [Google Scholar]
- 30.Alsayid M Barriers to and Facilitators of Colorectal Cancer Screening in Arab Americans: a qualitative study, in Department of Health Services. Washington State: University of Washington; 2017. [Google Scholar]
- 31.Domingo JB, Chen JJ, Braun KL. Colorectal Cancer Screening Compliance among Asian and Pacific Islander Americans. J Immigr Minor Health. 2017;20(3):584–93. [DOI] [PubMed] [Google Scholar]
- 32.Deding U, Henig AS, Salling A, Torp-Pedersen C, Boggild H. Sociodemographic predictors of participation in colorectal cancer screening. Int J Colorectal Dis. 2017;32(8):1117–24. [DOI] [PubMed] [Google Scholar]
- 33.Willems S, De Maesschalck S, Deveugele M, Derese A, De Maeseneer J. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns. 2005;56(2):139–46. [DOI] [PubMed] [Google Scholar]
- 34.Kim K, Chapman C, Vallina H. Colorectal cancer screening among Chinese American immigrants. J Immigr Minor Health. 2012;14(5):898–901. [DOI] [PubMed] [Google Scholar]
- 35.Manne S, Steinberg MB, Delnevo C, Ulpe R, Sorice K. Colorectal cancer screening among Foreign-born South Asians in the Metropolitan New York/New Jersey Region. J Community Health. 2015;40(6):1075–83. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Triantafillidis JK, Vagianos C, Gikas A, Korontzi M, Papalois A. Screening for colorectal cancer: the role of the primary care physician. Eur J Gastroenterol Hepatol. 2017;29(1):e1–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Feeley TH, Cooper J, Foels T, Mahoney MC. Efficacy expectations for colorectal cancer screening in primary care: identifying barriers and facilitators for patients and clinicians. Health Commun. 2009;24(4):304–15. [DOI] [PubMed] [Google Scholar]
- 38.Savas LS, Vernon SW, Atkinson JS, Fernandez ME. Effect of acculturation and access to care on colorectal cancer screening in low-income Latinos. J Immigr Minor Health. 2015;17(3):696–703. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Lee S, Chen L, Jung MY, Baezconde-Garbanati L, Juon HS. Acculturation and cancer screening among Asian Americans: role of health insurance and having a regular physician. J Community Health. 2014;39(2):201–12. [DOI] [PMC free article] [PubMed] [Google Scholar]