Cancer screening among older women in a culturally insular community

Abstract

Background. “Culturally insular communities” are defined by a religious or ethnic orientation that effectively places them outside mainstream sources of information on health promotion. We investigated whether older women in one such community were less likely to be screened for breast, cervical, and colorectal cancer than other women in the same geographic area.

Methods. A random sample of older orthodox Jewish women in Borough Park, Brooklyn, was compared to white women of the same age in the New York metropolitan area who were surveyed in the Behavioral Risk Factors Surveillance System (BRFSS).

Results. Borough Park women aged 50–69 were less likely to report they had been screened for colorectal cancer, and women over age 70 were less likely to report screening for all three cancer prevention modalities. Among Borough Park women, functional and cognitive deficits, elicited by self-report, also reduced the likelihood of screening.

Conclusions. Cultural and religious prescriptions are important to consider in health promotion. These factors should be taken into account in designing strategies to promote cancer screening.

Introduction

“Culturally insular communities” offer an important challenge to public health efforts. These communities are defined by a religious or ethnic orientation that effectively places them outside mainstream sources of information on health promotion. A countervailing feature is their high level of community integration, reflected in a variety of community organizations, that may decrease some health risks (e.g., sexually transmitted diseases, drug abuse), and which may also allow effective mobilization for public health efforts. We are unaware of studies that have examined the significance of cultural insularity for health in mid- and late-life, though some studies have shown that racial and ethnic minorities are less likely to take advantage of cancer screening.

The distinction between cultural insularity as defined here and ethnicity or race is worth comment. The importance of ethnic and racial differences in cancer screening is well established, but cultural insularity within sociocultural groups also needs to be taken into account, especially in predicting health promotion and cancer screening behaviors. For example, in the 1998 National Health Interview Survey, 74% of white, non-Hispanic women aged 50–74 reported having a mammogram in the prior 2 years, compared to 70% of African-American women and 66% of Hispanic women [1]. The prevalence of mammographic screening across the sociocultural groups was not significantly different, however, in analyses that adjusted for factors correlated with race-ethnicity, such as age, education, income, self-reported health, number of medical conditions, and body mass index. Yet additional analyses examining place of birth showed that foreign-born Hispanic women were significantly less likely to report screening than white women, even with adjustment for these differences [1]. Indeed, recent immigrants differ from more acculturated members of the same ethnic group in use of screening and perceptions of risk factors and treatment [2].

In addition to differences in access to care, an extensive body of research has shown that cultural factors may also affect beliefs about the causes of cancer and efficacy of cancer treatment, appraisal of risk factors, knowledge of cancer, and estimates of personal risk or susceptibility [3], [4], [5], [6]. In addition, cultural groups have been shown to differ in affective processes relevant to cancer screening behavior, such as “cancer worry” and embarrassment regarding bodily function [7]. Variation in culture within race-ethnicity groups is also important. Features of culture, such as “racial pride” and collectivism, have also been shown to predict mammography use in urban African-American women [8].

Less investigated is the tendency for some sociocultural groups to choose to live in distinct communities apart from the mainstream. This choice may affect opportunities for screening and sources of information about health promotion. In this research, we examined the extent to which health-protective behaviors and utilization of available health promotion programs, including cancer screening, may differ between one such culturally insular community and neighboring, ethnically diverse communities. We compared self-reported health behaviors in a random sample of orthodox Jewish women aged 50+ (all resident in Borough Park, Brooklyn) to white women of the same age living in the New York City metropolitan area. We surveyed Borough Park women using items from the Behavioral Risk Factors Surveillance System (BRFSS) and compared their responses to NYC women who participated in the BRFSS in the same year.

We hypothesized that use of prevention services, such as mammography and colorectal cancer screening, would be lower among orthodox Jewish women in this community than among NYC women. This difference, if present, would likely reflect a variety of culturally specific factors. Prior research suggests that Jewish religiousness and cultural identify are relevant for screening behaviors [9], [10], [11], but these studies for the most part did not include orthodox Jews living in tightly integrated, distinct communities such as Borough Park and did not compare orthodox Jews to other sociocultural groups.

Borough Park (in New York City parlance, “Boro Park”) is a densely populated, low-income area, primarily populated by haredim, ultra-orthodox Jews, who have established a society quite apart from mainstream secular communities. (Haredim include but are not limited to the more visible hassidic Jews.) About 80% of the 100,000 people living in this 1.5 square mile area are Jewish, and the neighborhood includes more than 200 synagogues [12]. The area is defined by 8th to 20th Avenues, and from 37th to 62nd Streets, near the center of Brooklyn. A New York Times real estate report describes the community this way: “Despite its size, Borough Park still feels in some ways like the now-vanished Jewish villages of Eastern Europe. It largely lacks such contemporary trappings as video stores or even a national retail or food chain.” The Times quotes a community leader as saying, “We try not to rely too much on the outside world. We're a self-contained community that helps itself” [13].

In this community, cultural insularity can be seen in negative attitudes toward television and the secular press, a preference for Yiddish over English, and recourse to longstanding rabbinical traditions for governing behavior. Cultural factors relevant to health behaviors include adherence to dietary codes, stress on modesty in personal behavior, great value placed on fertility and arranged marriages, structuring of daily activities around prayer, separation of men and women in public domains, and separation from the secular world. These features define a form of cultural insularity evident in other urban communities as well, such as orthodox Muslims, some south Asian communities, and ethnic groups whose identity is defined by orthodox or fundamentalist religious behavior.

We hypothesized that the prevalence of self-reported cancer screening among orthodox Jewish women would be lower in this community compared to NYC, generally. Informal inquiries in Borough Park suggested that cancer is rarely referred to by name (it is “that disease”, which has been reported for Israeli orthodox communities as well [14]). Breast self-examination is unmentionable in mixed-sex public settings and sometimes within families. Codes of modesty, even within same-sex groups, impede frank discussions of organs of elimination or reproduction. In a community where marriages are often arranged and lineages are inspected for blemishes in behavior or biology, fears of stigmatization, we suspected, would lead to denial of symptoms, under-recognition of some medical disorders, and aversion to cancer screening. In addition, religious leaders in the community specifically proscribe television and other mainstream media, such as the internet, which are primary sources of information for cancer risk factors and health screening [15].

In this study, we compared a random sample of Borough Park women to NYC women matched for age, geographic residence, and race-ethnicity. Since the latter were interviewed as part of the statewide BRFSS effort, we were limited in this comparison to survey items included in the BRFSS. Because the BRFSS does not consistently assess many of the culturally specific factors relevant to cancer screening, we were unable to distinguish all of the sources of potential differences in screening between Borough Park and NYC women. That is, differences in screening prevalence could be due to specific cultural beliefs about the causes of cancer and efficacy of cancer treatment, for example, or to a more general community-wide proscription of access to mainstream media that provide information about screening. Our data are best for establishing broad differences in screening rather than specific factors responsible for these differences.