CHAPTER EIGHT

ENABLING SYSTEMS RAISING AWARENESS OF BREAST CANCER AMONG MUSLIM OMANI WOMEN: A CASE STUDY EXEMPLAR

Esra Al Khasawneh and Michael C. Leocadio

THE NEED FOR A CASE STUDY

Breast cancer is the most common cancer among women and a major contributor to high rates of cancer-related morbidity and mortality in both developed and developing countries (WHO, 2015). Developing countries now bear a greater burden of the disease, as 62% of all breast-cancer–related deaths occur in these countries (International Agency for Research on Cancer [IARC], 2012) and cases are also diagnosed at later stages (Kumar, Burney, Al-Ajmi, & Al-Moundhri, 2011; WHO, 2015). Similarly, the burden of breast cancer is now growing and affecting women’s health care in the Sultanate of Oman, as the disease presents itself among younger age groups and at more advanced stages than those in developed countries (Al-Moundhri, et al., 2004; Kumar et al., 2011). The age-adjusted annual incidences of breast cancer in Omani women from 1998 to 2008 had risen steadily from 13.4 per 100,000 in 1998 to 1999 to 22 per 100,000 in 2008 (Mehdi et al., 2014).

The Sultanate of Oman has developed and initiated different initiatives and programs to combat breast cancer. The Omani Ministry of Health (MoH) functions under the principle of universal health care, and to date has been successful in its commitment to the global Health For All (HFA) strategy (Alshishtawy, 2010; WHO, 2008). In 30 years, this program has managed to achieve enviable goals in improving Oman’s health indicators: the under-five mortality has dropped 94%, and life expectancy at birth has improved from 60 years to 74 years (WHO, 2008). In addition, the MoH policies have significantly reduced the incidence of endemic communicable diseases such as malaria and tuberculosis.

Health planning is conducted by the MoH using a result-based approach to deliver evidence-based policies and practices (WHO, 2010). Policies are monitored and evaluated through performance indicators and updated on a 5-year basis (WHO, 2010). The ministry also supports research and development pursuant to its commitment to evidence-based practice in order to research and formulate policies. However, the WHO believes that the Omani health care system has room for improvement in the utilization of research results in the formulation of policies (WHO, 2010).

The health care system is based around a strong primary health care system, which serves the public on a wilayat, or district basis. As of 2013, the MoH was in charge of 49 hospitals, of which four are national referral hospitals in a certain governorate, and 10 are regional hospitals providing tertiary and secondary care (Alshishtawy, 2010). However, the frontline of national health care comprises 195 health centers divided among 61 wilayat (MoH, Oman, 2014). These include 23 “extended” health centers (with basic specialties), which provide a few secondary services and 69 health centers with beds. Overall, Oman is served by almost 20 physicians per 10,000 individuals and nearly 46 nurses per 10,000 individuals (WHO, 2014).

Each health center is essentially tasked with primary care, including family health, nutrition, and antenatal and neonatal care. Screening for infections, diabetes, and cardiovascular diseases is also conducted by primary health care facilities. Although minor infection management and long-term primary management of chronic illnesses, such as diabetes and cardiovascular diseases, is also conducted by the health centers, any secondary concerns are either referred to “extended” health centers or polyclinics, or specialized clinics in tertiary hospitals where inpatient treatment is managed.

GOVERNMENTAL BREAST HEALTH POLICY

Currently, Oman’s national screening policy for breast cancer needs further development (WHO, 2014a, 2014b). Although the MoH provides mammography units in all regional and two specialist hospitals, these units are more utilized as diagnostic more than for their screening capacity. The MoH has developed operational guidelines for breast cancer early detection and screening program as of 2010 (MoH, Oman, 2010), the program is yet to be fully implemented. Furthermore, these guidelines are still focusing on the teaching of breast self-examination (BSE) to patients and instructing primary health centers to focus on clinical breast examinations (CBE; MoH, Oman, 2010). Current evidence on effective screening programs suggests that mammography as the primary modality of breast cancer screening (Nelson et al., 2009; NHSBSP, 2009). Further evidence gained from asset mapping shows that training for breast cancer screening programs is ongoing in one governorate and scheduled by the MoH for the last quarter of 2015.

As per current guidelines, potential breast cancer cases are referred by physicians at health centers to regional hospitals for mammography. In a certain governorate, the health centers refer to one of two tertiary hospitals, depending on the catchment area. This referral can take from 2 to 3 weeks for a mammography appointment, and mammography results can take several days. If mammography either confirms a cancer case or requires further investigation, all cases are referred to a government hospital with a specialized breast oncology clinic and manned by surgical oncologists. Alternatively, patients may choose to utilize a “one-stop” clinic run by a breast oncologist at a teaching hospital, where women can request a biopsy appointment if referred by their health center, and receive a diagnosis within the day.

NONGOVERNMENTAL BREAST HEALTH EFFORTS

A breast cancer education program was created in 2002 by a group of cancer survivors and their family members and friends; it was officially registered in April 2004 as the Oman National Association for Cancer Awareness (OCA). This program is dedicated to the promotion of cancer awareness in general (Nakhweh, 2014). So far, the OCA has played a significant role in the distribution of awareness materials and conducting accessible breast cancer awareness events in Oman. It also utilizes a mobile mammography unit, which visits every health center in wilayat in the capital area once annually and serves to educate catchment populations on the importance of screening and early detection for successful treatment of breast cancer.

Despite these efforts and initiatives, breast cancer remains to be poorly understood in terms of prevention and early detection and is missing from the population’s health promotion practices. This is generally understood to be because of fear of cancer, shyness, poor health education, and difficult access to health care facilities (Kumar et al., 2011).

The situation in Oman prompted a group of researchers from different fields of medicine, nursing, and other allied health teams to conduct a study that determined the level of awareness of Omani women related to breast cancer and the intensity of the efforts of the different sectors of society to increase the public’s awareness of the disease. The proposal was approved and funded under His Majesty Sultan Qaboos Strategic Budget, a government-initiated project. The team from nursing decided to pursue a case study that could be considered a baseline for further investigation and plan. The case study scanned the specific wilayat’s health centers on the services they offer to Muslim Omani women and how women respond to these services. It is worth mentioning that the case study is only a part of the bigger project intended to raise the awareness of Omani women to breast cancer and early detection practices.

THE PROCESS

Determining What We Know

An examination of existing literature related to breast cancer awareness and early detection led to the development of research questions that guided our inquiry. The necessity to conduct a study was founded on the increasing breast cancer cases in Oman and the limited literature on awareness and interventions to promote breast health in the country.

The literature search was conducted through different search engines (e.g., PubMed, Medline, CINAHL, Google Scholar). Relevant, peer-reviewed literature was identified, analyzed, appraised, and synthesized. The synthesis was then used to provide the researchers the best grounding to defend the project during the proposal. Using the keywords “breast cancer,” “awareness,” “early detection,” “Arab,” “Muslim,” “incidence,” and “beliefs,” the literature search provided us significant themes, which were, and not limited to, the incidence of breast cancer in Arab countries, recent evidence on breast cancer, risk factors, awareness, early detection practices, and regional idiosyncrasies.

Although there is a substantial amount of literature and empirical evidence in the international arena, we encountered limitations for the Sultanate of Oman. Thus, the team decided to expand the study using terminologies that encompass not just Omanis, but Muslim women in general. Most of the literature specific to Muslim women was from studies conducted among Israeli, American, Iranian, Jordanian, and nonspecific Arab populations (e.g., Al Dasoqi, Zeilani, Abdalrahim, & Evans, 2013; Azaiza & Cohen, 2006; Azaiza, Cohen, Awad, & Daoud, 2010; Donnelly et al., 2013a; Donnelly et al., 2013b; El Saghir et al., 2007; Hatefnia et al., 2010; Kawar, 2013). The dearth of literature for Omani breast cancer early detection and awareness provided us the most valid and acceptable reasons to pursue the study.

The study objectives were focused primarily on the enabling systems of Omani Muslim women in increasing their awareness related to breast health and cancer. To place limits on the scope of the study and increase the feasibility of completing the project, case study propositions were made (Baxter & Jack, 2008). Based on the compiled literature, personal and/or professional experience, theories, and/or generalizations, this case study comprises the following propositions:

Although not a requirement, the case study propositions were instrumental in providing focus and feasible results that informed further strategies in the study design and evolution. This focus was especially helpful in dismissing the many irrelevant propositions made during the early stages of our research, and guided us in developing our conceptual structure, framework, and scope. It is important to mention that this framework was modified with the themes and elements that were discovered during the course of the study. The propositions were also helpful in review during the synthesis and reporting of the results of the study. The initial framework utilized and shaped by the study is presented in Figure 8.1.

Figure 8.1  Comprehensive and holistic systems affecting awareness on breast cancer.

The review of the framework in Figure 8.1, grounded on the propositions mentioned, provided the organization of themes at the end of the study. Although the use of such a framework is apparently geared toward the quantitative paradigm and may delimit the inductive reasoning and nature of qualitative philosophy, we avoided this by employing strategies such as journaling in research diaries, consulting external experts, inclining to direct views on the personal stories of the informants, and supplementing with concurrent literature.

Selecting the Design

To achieve the objectives of the study, we utilized the case study design because: (a) we focused on individuals representing our phenomenon of interest; (b) it is studied in its natural context, bound by space and time; and (c) it facilitates a research description of the phenomenon because it is grounded in deep and varied sources of information (Hancock & Algozzine, 2006). In order to satisfy the criteria for case study research, we intended to focus on developing an in-depth understanding on how Omani women might be enabled to raise their awareness related to breast cancer.

Our study mostly employed the case study design proposed by Yin (2003). Our inquiry was relevant to such a design because: (a) we focus our study on determining how

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