Barriers preventing Palestinian women from having a mammogram: a qualitative study

The mammogram is considered a life-saving breast cancer screening procedure for women aged 40 years and older, yet uptake of mammography services by Palestinian women is very low. Breast cancer is the most common cancer, comprising 17% of all reported cancer cases, and the second leading cause of death in women in the occupied Palestinian territory. The aim of this study was to understand the barriers to mammography uptake through an exploratory qualitative study in Ramallah and Salfeet. The qualitative approach of the study consisted of 24 semi-structured, in-person interviews and seven focus-group discussions with women from different settings and backgrounds through a purposive sampling approach. The interviews and discussions focused on women's knowledge of mammograms, reasons behind their decision to use the service or not, and whether they encouraged the service. Interviews were recorded after informed consent was received. Interviews and focus-group discussions were then transcribed and analysed thematically. Women mentioned a variety of barriers, including their psychological, social, and religious beliefs as well as disease-related, health system-related, political, and financial factors. Women expressed psychosocial issues such as shyness, fear from being diagnosed, losing femininity, losing financial and emotional support, losing independence and control of their lives, suffering pain besides low self-prioritising, being busy with children and house keeping, and having low knowledge of mammography. Only one woman expressed political concerns about access to screening services. Interviewees raised cultural factors, and lack of health insurance was a primary barrier to mammography for uninsured, widowed, and divorced women. More women had financial concerns with the treatment process and access if they were found to have cancer. Others had concerns about test efficacy, safety, and importance. Participants also raised issues related to social stigma: many women had concerns about family norms and values with respect to a possible second marriage of their husband if they were diagnosed with cancer as well as the potential negative effect of a cancer diagnosis on their daughters' marriage prospects. Health-seeking behaviours by women are controversial and affect their decision to participate in mammography for screening or diagnoses. Given the sensitivity of the topic and the importance of early detection, health policies need to take those behaviour