Background
Methods
Study design
Setting and study population
Sample and participant recruitment
Data collection
1 Fatima was diagnosed with cervical cancer. What do you think she could have done to prevent cervical cancer?
2 Since her last son was born 8 years ago, Fatima did not visit the gynaecologist to do a check-up. Why do you think she did not go back to the gynaecologist and she did not undertake a Pap smear?
Data analysis
Themes | Sub-themes |
---|---|
Theme 1: | |
Understanding of health and illness | • Health as the ‘absence of symptoms’ • Health and illness is controlled by God’s will • Faith healing practices (e.g., spiritual treatments or religious rituals) |
Theme 2: | |
Self-care attitudes and practices | • Prioritisation of family responsibilities • Lifestyle practices (e.g., physical activity, healthy eating) • Religion as a self-care practice • Self-medication |
Theme 3: | |
Knowledge and interest in disease prevention | • Low awareness of disease prevention (e.g., lack of interest/habit in performing regular check-ups) • Acceptance of early detection |
Theme 4: | |
Motivators to engage with preventive care | • Increasing awareness due to exposure to chronic diseases • Healthcare providers’ recommendation • Efficient call and recall system as facilitator |
Ethical considerations and consent to participate
Results
Participants’ characteristics
Total participants | Morocco | Pakistan | ||||
---|---|---|---|---|---|---|
N | (%)a | N | (%)a | N | (%)a | |
Participantsb | 73 | (100%) | 36 | (49.3%) | 37 | (50.7%) |
Age. median (IQR)c | 42 | (35-48) | 39 | (33-46) | 40 | (34.5-47.5) |
Age groups | ||||||
24-34 years | 18 | (24.7%) | 7 | (19.4%) | 11 | (29.7%) |
35-44 years | 28 | (38.4%) | 13 | (36.1%) | 15 | (40.5%) |
45-54 years | 19 | (26.0%) | 10 | (27.8%) | 9 | (24.3%) |
55-65 years | 8 | (11.0%) | 6 | (16.7%) | 2 | (5.4%) |
Level of studies | ||||||
No studies | 9 | (12.3%) | 7 | (19.4%) | 2 | (5.4%) |
Primary school | 15 | (20.5%) | 9 | (25.0%) | 6 | (16.2%) |
Secondary school | 25 | (34.2%) | 14 | (38.9%) | 11 | (29.7%) |
Vocational training | 3 | (4.1%) | 2 | (5.6%) | 1 | (2.7%) |
University | 21 | (28.8%) | 4 | (11.1%) | 17 | (45.9%) |
Employment | ||||||
Formal employmentd | 10 | (13.7%) | 8 | (22.2%) | 2 | (5.4%) |
Informal employment/not regulatede | 4 | (5.5%) | 4 | (11.1%) | 0 | (0.0%) |
Unemployed or housewives | 58 | (79.5%) | 23 | (63.9%) | 35 | (94.6%) |
Retired | 1 | (1.4%) | 1 | (2.8%) | 0 | (0.0%) |
Marital status | ||||||
Single | 4 | (5.5%) | 4 | (11.1%) | 0 | (0.0%) |
Married | 60 | (82.2%) | 26 | (72.2%) | 34 | (91.9%) |
Separated or divorced | 7 | (9.6%) | 5 | (13.9%) | 2 | (5.4%) |
Widowed | 2 | (2.7%) | 1 | (2.8%) | 1 | (2.7%) |
Children | ||||||
Yes | 64 | (87.7%) | 28 | (77.8%) | 36 | (97.3%) |
Number of childrenf | ||||||
1 | 6 | (9.4%) | 5 | (17.9%) | 1 | (2.8%) |
2 | 13 | (20.3%) | 6 | (21.4%) | 7 | (19.4%) |
3 | 20 | (31.3%) | 10 | (35.7%) | 10 | (27.8%) |
4 or more | 25 | (39.1%) | 7 | (25.0%) | 18 | (50.0%) |
Time since migration to Spain | ||||||
< 2 years | 7 | (9.6%) | 2 | (5.6%) | 5 | (13.5%) |
2-5 years | 11 | (15.1%) | 8 | (22.2%) | 3 | (8.1%) |
6-10 years | 19 | (26.0%) | 4 | (11.1%) | 15 | (40.5%) |
> 10 years | 36 | (49.3%) | 22 | (61.1%) | 14 | (37.8%) |
Reason of migration | ||||||
Economic | 1 | (1.4%) | 1 | (2.8%) | 0 | (0.0%) |
Family reunification | 62 | (84.9%) | 27 | (75.0%) | 35 | (94.6%) |
Tourist/student visa | 7 | (8.2%) | 6 | (16.7%) | 1 | (2.7%) |
Not reported | 3 | (2.7%) | 2 | (5.6%) | 1 | (2.7%) |
Languages most spoken at homeg | ||||||
Spanish or Catalanh | 14 | (19.2%) | 12 | (33.3%) | 2 | (5.4%) |
Arabic (Darija) | 31 | (42.5%) | 31 | (86.1%) | 0 | (0.0%) |
Urdu | 33 | (45.2%) | 0 | (0.0%) | 33 | (89.2%) |
English | 5 | (6.8%) | 1 | (2.8%) | 4 | (10.8%) |
French | 3 | (4.1%) | 3 | (8.3%) | 0 | (0.0%) |
Otheri | 8 | (11.0%) | 3 | (8.3%) | 5 | (13.5%) |
Spanish language skills | ||||||
I always need a translator | 20 | (27.4%) | 8 | (22.2%) | 12 | (32.4%) |
Most of the times I need a translator | 8 | (11.0%) | 3 | (8.3%) | 5 | (13.5%) |
Sometimes I need a translator | 11 | (15.1%) | 6 | (16.7%) | 5 | (13.5%) |
I do not need translator at all | 27 | (37.0%) | 17 | (47.2%) | 10 | (27.0%) |
Annual household income | ||||||
< € 12,000 | 11 | (15.1%) | 6 | (16.7%) | 5 | (13.5%) |
€ 12,001 - € 20,000 | 8 | (11.0%) | 4 | (11.1%) | 4 | (10.8%) |
> € 20,001 | 0 | (0.0%) | 0 | (0.0%) | 0 | (0.0%) |
I don’t know | 35 | (48.0%) | 16 | (44.4%) | 19 | (51.4%) |
Prefer not to answer | 14 | (19.2%) | 7 | (19.4%) | 7 | (18.9%) |
Self-perception of religiosity | ||||||
Very religious | 23 | (31.5%) | 13 | (36.1%) | 10 | (27.0%) |
Somehow religious | 43 | (58.9%) | 17 | (47.2%) | 26 | (70.3%) |
Very little religious | 2 | (2.7%) | 2 | (5.6%) | 0 | (0.0%) |
Prefer not to answer | 3 | (4.1%) | 2 | (5.6%) | 1 | (2.7%) |
Muslim self-identification | ||||||
Yes | 71 | (97.3%) | 35 | (97.2%) | 36 | (97.3%) |
Prefer not to answer | 1 | (1.4%) | 0 | (0.0%) | 1 | (2.7%) |
Public health insurance | ||||||
Yes | 68 | (93.2%) | 34 | (94.4%) | 34 | (91.9%) |
No | 2 | (2.7%) | 0 | (0.0%) | 2 | (5.4%) |
Cervical cancer screening status | ||||||
I don’t know what CC screening is | 4 | (19.2%) | 0 | (0.0%) | 4 | (10.8%) |
Never screened | 14 | (19.2%) | 7 | (19.4%) | 7 | (18.9%) |
Ever screened | 53 | (72.6%) | 27 | (75.0%) | 26 | (70.3%) |
Time since last cervical cancer screening | ||||||
< 1 year | 14 | (19.2%) | 8 | (22.2%) | 6 | (16.2%) |
1-3 years | 21 | (28.8%) | 12 | (33.3%) | 9 | (24.3%) |
3-5 years | 9 | (12.3%) | 2 | (5.6%) | 7 | (18.9%) |
> 5 years | 7 | (9.6%) | 3 | (8.3%) | 4 | (10.8%) |
Unknown | 2 | (2.7%) | 2 | (5.6%) | 0 | (0.0%) |
Beliefs about health and illness
God’s will and destiny
“God has blessed me with a child after ten years (…) I had thyroid problems, my uterus was closed and it was down side and my eggs were not creating. They slowly started my treatment for two years and now by the grace of God I’ve a baby girl who is 4 years old and a baby boy” (FGD 1, younger Pakistani woman).
“(…) because pregnancy is God’s will; even though I was taking the pill, I was pregnant for five months and I didn’t know” (FGD 2, older Moroccan woman).
“If God gives you a disease, you must accept it and fight it” (SSI MC07, older Moroccan woman).
“Allah himself has said that you should go for treatments” (FGD 2, younger and older Pakistani women).
“The fact that cancer is something that God brings you, it does not mean that you don’t have to take care of yourself, because prevention is better than cure” (FGD 0, older Moroccan woman).
“I believe in Him (God) and ask for His help, but I also take medicines and take care of myself, but I don’t get afraid of death” (FGD 3, older Pakistani woman).
Spiritual prayers for healing and protection
“People are now less scared (of cancer) because there is chemotherapy, but there is also a verse (in the Qur’an) to listen; it is called Surah Al Rahman; it is said that if we listen this verse three times a day, it helps to cure cancer (…) I heard that in England they put it for all Muslim and non-Muslim patients and they are recovering with these verses” (SSI PC03, older Pakistani woman).
Self-care attitudes and practices
Self-care and women’s caregiver role
“We Pakistanis don’t take care ourselves seriously, we take time out for the kids, but not for ourselves. We prepare meals for our husbands as well, but for ourselves, we don’t. We sacrifice ourselves” (FGD 3, younger Pakistani woman).
“A woman forgets about herself… she gets married and keeps busy with childcare, she forgets about herself, she is always the last thing” (FGD 1, older Moroccan women).
“I think (Pakistani) women should think about their health, as you are the main person (in the household) and things function through yourself. If you are healthy, then you can take care of them (husband and children) properly” (FGD 2, younger Pakistani woman).
“He (husband) always tells me that I need to take care of myself for them, that my children need me and that’s why I should take care of myself” (SSI PC03, older Pakistani woman).
Healthy lifestyle practices
“Doctors ask us ‘to drink water, eat salad and walk’. But what I do all day is walk as I’ve two grandchildren at home, so I’ve to go for the grocery, take them out. I don’t sit at home. I don’t walk like jogging but…” (FGD 3, younger Pakistani woman).
“Doctor said that I have to do exercise, you need to do sport for everything… I needed a solution for my health problem, not doing sport. I do ‘exercise’ at home (referring to house chores), I don’t need sport” (FGD 2, younger Moroccan woman).
“I do try to eat healthy. I try not to buy packed food, those high sugar foods and, instead, I try to buy natural food, such as vegetables, fruit and fish… I try not to bring home ‘bad food’ so they don’t get used to it” (SSI MC03, younger Moroccan woman).
“(…) nowadays we don’t know what we eat (…) and if you are going to buy good food it is very expensive, so it is difficult…” (SSI MC01, older Moroccan woman).
Religion as a self-care practice
Self-medication
“I don’t believe much in traditional medicine (…) It’s said that lavender with salt cures infections, I don’t know… In Morocco, people are used to healing with natural medicine, home remedies and this kind of things, and that’s because health care is expensive, medicines are expensive, so when they come to Spain they are already used to using natural remedies” (SSI MC09, younger Moroccan woman).
Knowledge and interest in disease prevention
Low awareness of disease prevention
“We Moroccan women don’t go to the doctor until we feel pain; we don’t know that cancer disease can be silent” (SSI MC11, younger Moroccan woman).
“We don’t show much concern about what’s happening with our bodies and, as a result, germs in our bodies keep growing and it’s late by the time we come to know about that (cancer)” (FGD 0, younger Pakistani woman).
“We don’t have the habit of doing check-ups (…) we don’t give importance to our health… until we get ill” (FGD 2, younger Moroccan woman).
“We don’t have enough information, many people don’t know that these tests exist. Even living here (Spain) we don’t know” (FGD 3, younger Pakistani woman).
“You don’t want to hear that you have cancer, it’s scary. So you tell yourself ‘better to leave it in God’s hands’” (FGD 0, older Moroccan woman).
“Yes, they are useful to detect something, but at my age, I’m 39… when we are older we have more health problems, that’s when we visit the doctor and we do more check-ups” (SSI PC07, younger Pakistani woman).
Acceptance of screening for early detection
“I have a Spanish colleague in the office, she did the test (Pap smear) and it was ok, and six months later the cancer came out, so I think these tests are useless, because my colleague had to do the test once a year, but she did it and, between tests, in six months the cancer came out (…) so I don’t think early detection can protect from cancer” (FGD 0, younger Moroccan woman).
Changing perceptions
Increasing self-awareness
“This is not good, we should get time for ourselves as well” (FGD, Pakistani woman PG303, 36 years), because “if we are not healthy, how will we do other things?” (FGD 2, older Pakistani woman).
“Do you work? You can get an appointment and get time to go. Children? You can get an appointment when they are at school. We must organise our own time” (FGD 2, older Moroccan woman).
“People don’t have to wait until they are in pain to go to the doctor, they need to do check-ups from time to time, because there are diseases that have not symptoms” (SSI MC12, older Moroccan woman).
“… our mother-in-law was well, she was 80-something years old and she was ok, very active… but sometimes we don’t know what we have inside our bodies” (SSI PC01, younger Pakistani woman).
Motivators for screening
“The first time that we gave importance to cancer was when my sister was diagnosed with breast cancer (…) then we were more aware and we started to get screened” (SSI MC01, older Moroccan woman).
“Before I didn’t take care of myself at all, but now because I have problems, I have a prothesis so I cannot hold much weight (…) so I follow a diet, I eat healthy food, I drink a lot of water and I also do some exercise” (SSI PC01, younger Pakistani woman).
“They need to call me or send me a letter to my home and remind me that I need to take an appointment. Then, I would go (for check-ups), but if it has to be from my own initiative, I just stayed telling myself ‘I’ll go, I’ll go;” (SSI MC03, younger Moroccan woman).
“I think rather than an invitation, it should be an obligation if it is a really important test (…) We (Pakistani) are like this, until we are not obligated, we don’t go (…) But if they obligate us, like with the COVID, then…” (SSI PC03, older Pakistani woman).