Disparity in Cervical Cancer Screening in Muslim American Women

Abstract

Cervical cancer, the second leading cause of cancer death in women aged 20 to 39 years, can be successfully prevented or mitigated through routine cervical cancer screening, which allows for early detection and treatment of precancerous cells. However, despite the effectiveness of these screening strategies, significant disparities in cervical cancer screening and detection still exist for certain populations, such as that of Muslim American women. These disparities are likely attributable to social factors that have deterred Muslim American women from seeking cervical screening. These include their religion’s emphasis on modesty and God’s decree over health and sickness, and their interactions with the healthcare system, which involves a lack of health insurance access and discrimination from healthcare providers. This disparity is a significant issue that needs to be addressed, as a disparity in cervical cancer screening may result in late or advanced-stage diagnosis which translates to increased morbidity (disease occurrence) and mortality (death from disease) rates in this population. Several programs focus on improving screening rates in underserved and under-screened communities. However, none of these programs identify Muslim American women as a disparate population and tailor interventions to serve them. An ideal program could use religious leaders and religiously tailored messages in support of screening that are grounded in Islamic values to educate Muslim American women on the benefits of screening, while also removing financial barriers through no-cost screening. It is crucial that awareness is brought to the inequity faced by Muslim American women in terms of cervical cancer screening and that steps are taken to protect this vulnerable population. 

Keywords: Muslim American women, health disparity, cervical cancer screening, interventions

Introduction

Cervical cancer, which affects the tissue that connects the vagina (or birth canal) to the uterus (or womb), is the second leading cause of cancer death in women aged 20 to 39 years [1]. Routine cervical screening, through Pap tests and HPV tests, has been shown to significantly reduce the high incidence and mortality rate of this cancer [2]. However, significant disparities in screening and detection still exist [3]. The considerable disparity in cervical cancer screening in the Muslim American women population, due to a combination of their unique religious beliefs and interactions with the healthcare system, is a serious issue that must be addressed to prevent an increase in cervical cancer morbidity and mortality within this vulnerable population. 

Background

Each year in the United States, about 13,000 new cases of cervical cancer are diagnosed, and about 4,000 women die [4]. Cervical cancer occurs most often in those over the age of 30 and more than 90% of cases are caused by persistent infection with high-risk types of human papillomavirus (HPV), a sexually transmitted virus [2, 4, 5]. Persistent HPV infections, and thus cervical cancer, are more likely in those with weakened immune systems, those who smoke or second-hand smoke, and those who are sexually active at an early age [2]. 

Despite its high incidence and wide-ranging risks, cervical cancer is one of the most successfully treatable and preventable forms of cancer [6]. It can be eliminated as a public health problem within a generation if a comprehensive prevention, screening, and treatment approach is adopted [6]. HPV vaccination, recommended for preteens (aged 11 to 12) and up until the age of 26, is a common prevention method as it defends against infection by the types of HPV that most often cause cervical cancer. In addition, routine cervical cancer screening methods significantly decrease cervical cancer rates as they allow for early detection of precancerous cells which can then be treated to prevent them from becoming cancerous [2]. The most commonly used screening methods are the Pap test and HPV test. During these tests, a plastic or metal speculum is used to look inside the vagina and collect mucus and cells, which are then examined for abnormalities or tested for HPV [4]. Screening strategies are so effective in the mitigation of cervical cancer that after the introduction of the Pap test in the 1950s, cervical cancer in the U.S. decreased by over 70% [7]. However, despite the effectiveness of these screening strategies, a growing number of studies suggest that significant disparities in cervical cancer screening and detection still exist due to multiple intersecting factors—such as race, ethnicity, socioeconomic and immigration status, and religion—that influence the ability to receive preventive care, including screening [8]. Identifying and addressing disparate populations is particularly important in effectively eliminating cervical cancer in general, as medically underserved and under-screened populations account for more than 60% of diagnoses [9]. The population of Muslim American women is one such under-screened population. 

Selected Population

The Muslim American population in the United States is one with significant racial and ethnic diversity that is overarchingly defined by their following the religion of Islam. As one of the fastest-growing religious groups in the U.S., the Muslim population continues to grow in size but was estimated to be about 3.45 million, or 1.1% of the total U.S. population, in 2017 [10]. Among these 3.45 million, 41% are white - which includes those who identify as Arab, Middle Eastern, Persian/Iranian; 28% are Asian, including those from South Asia; 20% are Black; 8% are Hispanic; and an additional 3% identify with another race or with multiple races, compared to the 64%, 6%, 12%, 16%, and 2% respectively of the general U.S. public [10]. Despite this diversity and large population size, Muslim Americans, and even more so Muslim American women, are an under-studied population in terms of health disparities. Although data is limited, studies have found low rates of timely cervical cancer screenings among Muslim American women compared to other racial/ethnic groups in the U.S. [3]. One study done in New York City (the state of New York has one of the highest Muslim American population densities in the U.S.) reported that only 16.9% of Muslim American women had received an up-to-date Pap test [3, 10]. This is significantly lower than the general American population (73.5% of women aged 21-65 years) [11]. This disparity in timely screening translates into increased late-stage diagnosis, as one study done in Virginia found, with the portion of advanced-stage diagnosis being 17% for Muslim women compared to 7% for non-Muslim women. This disparity is likely attributed to an intersection of the religious beliefs and healthcare experiences of Muslim American women.

Muslim American women often find their religious customs at odds with their healthcare needs, which leads to delayed care-seeking and lower cancer screening rates [12]. Some of the religious beliefs that act as barriers to seeking preventive care are the importance of modesty and monogamy, as well as God’s decree over health and sickness [3, 12, 13]. Due to the Islamic emphasis on modesty and monogamy, many Muslim American women avoid cervical screening as they believe that exposing the relevant body parts may be perceived as a violation of modesty and that cervical cancer diagnosis will associate them with sexual promiscuity [13]. In addition, there exists the belief that because only God, as the highest power, controls health outcomes, there is no reason to actively engage in preventive health behaviors like screening [3].

Healthcare experiences of Muslim American women, such as discrimination and insensitivity from physicians and lack of access to health insurance, also lead to lower screening rates. A 2021 study done in Virginia found significant differences in health insurance status between the Muslim and non-Muslim female cohorts: 41% of the Muslim women were uninsured while only 10% of the non-Muslim women were uninsured [12]. Lack of health insurance decreases motivation to get screened as there is no guaranteed coverage of screening costs, resulting in lower screening rates. In addition, studies have found that wearing a hijab (head covering and modest dress) may subject women to discrimination and harassment, which can affect the receipt of social and health services [13]. Perceived religion-based discrimination of Muslims in healthcare settings has also been shown to ultimately cause delays or avoidance of seeking medical treatment [3]. This perceived discrimination may be based on the insensitivity of providers to patients' needs, which has been indicated as a barrier to cervical cancer screening by research on Muslim women in NYC [3]. 

Implications

Cervical cancer screening disparity in Muslim American women has serious implications including increased morbidity and decreased quality of life for current, and future, generations. Increased morbidity rates mean that Muslim American women increasingly experience the decreased quality of life (QOL) associated with disease and treatment, which persists even after recovery [12, 14]. Persistent sequelae, or aftereffects, of cervical cancer include pain, bladder and bowel dysfunction, sexual dysfunction, lymphedema, reproductive concerns among women of childbearing age, depression and anxiety, sleep disturbance, and concentration difficulties to a greater magnitude than many other cancer patient populations [14]. Thus, this disparity not only increases the morbidity rate of Muslim American women but also decreases the QOL and ability to reproduce for those who survive.

Cancer Moonshot is a national program, first established by President Obama in January of 2016, that has been reignited by President Biden to reduce the death rate from cancer by at least 50% over the next 25 years [2, 15]. This program is supported by the Federal Cervical Cancer Collaborative (FCCC), a federal partnership between the Health Resources & Services Administration (HRSA) and other agencies [16]. Between the years 2020 and 2021, the FCCC conducted an analysis of previous research to identify supports and barriers to cancer screening, as well as gaps in screening services and research. Additionally, they identified underserved groups of people in low-resource settings and ways to improve screening for these groups. This information will be used to offer new practices, technical assistance, policies and programs, and outreach and education [17]. These measures will improve the disparity in cervical cancer screening as they specifically consider the barriers and inequities - avoidable and unjust differences due to corruption or cultural exclusion, notably different from inequality, which simply refers to the uneven distribution of health or health resources - faced by disparate populations [18] .  

Future Recommendations and Conclusions

Several programs have been developed to address cervical cancer screening inequity for under-screened populations. These programs aim to increase the proportion of females who get screened through one-on-one education on the benefits and importance of screening, assistance in navigating screening services, and reminders to get screened [19]. 

De Casa en Casa: Cervical Cancer Screening Program is one such program, designed to increase screening among under-screened women aged 21 to 65 and delivered at clinical, home, religious, school, and workplace locations in Texas [2, 19]. The program involves outreach and education on cervical cancer screening through promotoras (community health workers), navigation (e.g., assistance with scheduling appointments), and no-cost screening [2, 19]. Another program designed to reduce cancer screening inequity among medically underserved Appalachian women is Faith Moves Mountains [2, 19]. This program is delivered at home and religious locations by lay health advisors, who determine each participant’s barriers to screening, prepare a tailored newsletter, conduct home visits to provide education on cervical cancer and screening, develop an action plan, and assist with scheduling a Pap test [2, 19]. While both programs ensure that women are aware of the benefits of cervical cancer screening and remove potential barriers to getting screened by helping them navigate screening services, the first program removes an additional barrier by eliminating the cost of screening. Both studies showed an increase in the receipt of Pap tests in their respective service areas [2, 19].

However, a significant issue among these, and other existing evidence-based programs is that they are not tailored to address religious barriers for Muslim American women. In fact, while the programs were meant to address inequity by targeting under-screened and underserved communities, none of the programs were tailored to Muslim American women, despite their being a significantly under-screened population. Some aspects of these programs apply to the Muslim American women population, for whom barriers include lack of health insurance coverage for testing, such as no-cost screening. A majority of these programs focus on educating individuals about the benefits of screening. An effective way to tailor this intervention toward Muslim American women would be to use religiously tailored messages in support of screening grounded in Islamic values, as this would increase the acceptability of these messages [20]. Additionally, instead of involving promotoras, this intervention could use Islamic religious leaders (imams) and respected female community members in the promotion of these messages. In fact, a study that utilized these methods with Somali Muslim American women in Minnesota found that they had a positive impact on the intention to screen [20]. Given the central importance of religion-related factors in predicting the likelihood of obtaining cervical cancer screening, mosques, and other trusted community settings are promising settings for health interventions [3].

Cervical cancer is one of the few cancers that can be effectively and easily eliminated through timely prevention and treatment. Thus, disparities in preventive care and screening must be addressed, especially in populations such as Muslim American women which are largely overlooked in health disparities research and intervention programs despite their vulnerability.

About the Author: Tasneem Nasim

Tasneem Nasim is a class of 2024 Global Disease Biology student with a minor in the Public Health Sciences. As a future healthcare and public health professional who is passionate about reducing healthcare disparities and promoting disease control and prevention in minority communities, she chose the GDB major as it would allow her to combine and pursue her interests in both healthcare and public health research. She chose to focus her article on cervical cancer disparities in the minority community of Muslim American women because she hopes that readers will gain a better understanding of the many challenges that minority communities face, including disparate health outcomes and a lack of acknowledgment of such disparities. She hopes that readers will recognize that the solution to many of our serious health crises, such as cervical cancer disparities, can easily be remedied if we simply lead with cultural humility and awareness in public health research and healthcare. 

Author's Note

I wrote this piece for my Health Disparities in the U.S. class (SPH 113). As a Global Disease Biology major and Public Health Sciences minor with an interest in disease control and prevention in underserved communities, I specifically chose this topic because Muslim American women are a minority group in the U.S. whose health outcomes are often overlooked. Additionally, cervical cancer is one of the few cancers that can be effectively eliminated through timely screening and treatment. Thus, addressing the cultural and social barriers to screening in this group can effectively reduce cervical cancer disparities. I hope that this review will raise awareness of the health disparities of Muslim American women and the lack of research and recognition of these disparities, as the first step towards fixing any problem is acknowledging that a problem exists.

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