Participants’ characteristics
Thirty-six women from the Moroccan community and 37 women from the Pakistani community participated in either FGD or SSI. Participants ages ranged from 24 to 65 years, with a median age of 40 years. Marital status varied among the participants, with 82.2% (N = 60) reported being married. Nearly all the Pakistani women (97.3%, N = 36) had children whilst among Moroccan participants, 77.8% (N = 28) had kids. Half of the participants had been living in Spain for at least 10 years (N = 36), while approximately 10% (N = 7) had arrived within the 2 years preceding the initiation of the study. The primary reason for migration to Spain among almost 85% (N = 62) was family reunification. Pakistani women had a higher level of studies than Moroccan women: 16 Pakistani participants had university studies, while only four Moroccan women had. Nine participants had no education (7 from Morocco and 2 from Pakistan). Regarding employment, a significant majority of the women, 80,8% (N = 59) were housewives and only 14 (12 from Morocco) were employed in either formal or informal jobs. In terms of Spanish language skills, approximately 37% of women (47.2% Moroccan and 27% Pakistani) reported not needing a translator during medical visits. Regarding religion, 90.4% of women considered themselves very or somehow religious and 97.3% identified themselves as Muslim. Up to 72.6% of the participants reported having been screened for CC at least once in their lifetime. Detailed information regarding participants’ characteristics can be found in Table 3.
Beliefs about health and illness
We explored participants’ perspectives on health and illness, including their beliefs regarding life and death, as well as their views on the causes, diagnosis, treatment and cure of a disease, considering both spiritual and biomedical perspectives.
God’s will and destiny
Both Moroccan and Pakistani women share the Islamic view that life and death are granted by God and that individuals’ fate is predetermined by God. For instance, women had the belief that being blessed with children is solely by God’s will regardless of the use of modern family planning methods, such as contraceptive pills or intrauterine devices, among others, as well as getting treated for fertility issues. The following excerpts illustrate this belief:
“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).
Similarly, both Moroccan and Pakistani respondents perceive God as the one who ultimately controls health and illness, but also who provides the means to prevent, treat and cure the disease: “Every disease can be cured if God wants” (FGD 3, younger Pakistani woman). Referring to illness, women stated that “you cannot escape from what God brings you” (SSI MC10, older Moroccan woman). However, in both groups, women agreed that their faith does not hinder individuals from taking responsibility of their own health and from seeking appropriate care when necessary. Some respondents emphasized that God provides the medical options for healing and, therefore, it is the responsibility of individuals to utilise them:
“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).
Two Pakistani respondents mentioned that in certain cultural contexts some people view disease as a direct punishment from God for sins committed. They stated that in Pakistan there are still individuals who believe that cancer and other illnesses are God’s punishment, implying that disease prevention can be achieved by avoiding sinful behaviours. Women of Moroccan origin did not provide any comment regarding this perspective. In fact, two of the Moroccan respondents did not make any mention to God throughout the individual interviews.
Spiritual prayers for healing and protection
Spiritual prayers for healing and protection continue to be practiced in Morocco and Pakistan. In both groups, some Moroccan and Pakistani women believed that engaging in ritual prayers and readings of the Qur’an may have health benefits. Several of the respondents reported to make use of these spiritual rituals as complementary sources of healing to conventional medicine, as this Pakistani woman with an educational background in Economics explained:
“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).
Two respondents from Morocco also reported using spiritual treatments, such as Ruqyah, which consists of recitation of certain Quranic verses for healing, pain relief or protection against ‘evil eye’. Our findings also show the use of ‘transnational’ healers among Pakistani women. One participant explained that women not only consult (via phone) their families in Pakistan for advice on home remedies, but also to seek spiritual services from traditional healers in their home country.
While the mention of spiritual prayers was limited to a small number of participants, overall women believed in God’s power to protect from and cure diseases. However, they emphasized the importance of complementing faith with appropriate medical options or vice versa: “My mum tells me to pray; she says that you can cure yourself (by praying), but she also tells me to go to the doctor and take care of myself” (SSI MC11, younger Moroccan woman).
Self-care attitudes and practices
Throughout the FGDs and SSIs, women shared and discussed their self-care attitudes and practices, highlighting the significance they place in their own health. This included their understanding and awareness of self-care along with the actions they take to maintain their health and well-being independently of the health system.
Self-care and women’s caregiver role
The prevailing sentiment among the respondents was that Moroccan and Pakistani women tend to neglect their own self-care. Instead, their priority and responsibility, or even “mission” according to one Pakistani woman, relies on taking care of their children, husbands and families. Their own well-being often takes a backseat with little importance given to their personal needs and self-care:
“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).
Similarly, when the women discussed motivations and benefits of self-care, they primarily focused on the notion of taking care of themselves to ensure their ability to fulfil their responsibilities towards their families and homes, rather than focusing on their personal benefit:
“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
The concept of self-care is often associated with adopting healthy lifestyles, including engaging in physical activity and maintaining a healthy diet. The study participants showed little or no engagement with formal physical activities (e.g., jogging, fitness or swimming classes). Women described a discrepancy between their understanding of physical activity which was closely associated with daily living tasks and the concept of formal physical activity to maintain health, as advocated by health providers:
“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).
On the other hand, healthy eating was important for all participants. Both Moroccan and Pakistani women associated healthy eating with the consumption of homemade rather than processed food. However, it should be noted that this preference was partially influenced by the high prices of food:
“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
In addition to the discussion around healthy lifestyles, when discussing the potential causes of Fatima’s CC, some participants in both groups emphasized that Muslim women do not smoke or consume alcohol. Consequently, they believed these could not be risk factors for developing cancer disease within their communities: “We (Muslim women) don’t smoke or drink alcohol, so it can’t be because of that” (FGD 3, younger Moroccan woman).
Some women mentioned that religious practices can serve as a form of protection against disease, “religion cares for your health” (SSI PC06, younger Pakistani woman). For example, most women in both groups emphasized the value of virginity and marriage not only from a religious standpoint, but also as a self-care practice. However, this belief led to a lower risk perception of acquiring sexually transmitted infections (STIs), such as Human Papillomavirus (HPV) and reduced their awareness, as this Moroccan woman expressed: “We (Moroccan women) don’t do as many check-ups as Europeans, because in general Europeans have many sexual relationships and they get this disease (HPV infection) more than us. We only have one relationship with our husband, so this doesn’t encourage us to go for check-ups” (FGD 0, younger Moroccan woman).
Self-medication
Once Pakistani women perceived themselves to be ill, they tended to self-medicate: “We avoid going to the doctor and if we have any infection we take antibiotics and, if we feel pain, we take painkillers at home. We don’t visit them on time” (FGD 0, younger Pakistani woman). In contrast, a Moroccan woman referred to self-medication as an unhealthy habit: “I avoid taking medicines as it is said they damage our kidneys and liver, so I only take what the doctor prescribes me” (SSI MC07, older Moroccan woman).
While many women from both countries had knowledge of herbal remedies, their use was not widespread. Participants combined traditional and Western medicine, and some even expressed scepticism regarding the effectiveness of herbal remedies to treat and cure disease:
“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
We also explored Moroccan and Pakistani participants’ understanding and awareness of disease prevention. We asked them about their health-seeking behaviours and practices within the health system to prevent disease, including regular check-ups, as well as their views regarding the relevance and usefulness of early detection tests.
Low awareness of disease prevention
Participants perceived health as the absence of symptoms, leading them to delay seeking medical care until the appearance of discomfort or symptoms such as severe pain, as this Pakistani woman illustrated: “My mum always said ‘we have to take care of ourselves when there is a reason; before, you don’t have to worry’” (SSI PC03, older Pakistani woman). For example, when asked why Fatima, the fictional immigrant woman diagnosed with CC, did not see a gynaecologist for 8 years, many women in both groups answered that it was due to the lack of symptoms:
“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).
Both Moroccan and Pakistani women reiterated that they tend to overlook their bodily concerns, leading to delays in seeking care and potentially receive a more severe diagnosis:
“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).
Both groups of women agreed that there was a lack of interest in regular check-ups, possibly explained by the fact that regular check-ups are not commonly practiced in their countries of origin as they are in Europe:
“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).
One possible explanation for the absence of this self-care habit may be the lack of a public health system in their countries of origin, as one Pakistani woman noted: “because there is not a public health system (in Pakistan) and people don’t have much money and the check-ups and tests are very expensive” (SSI PC07, younger Pakistani woman). However, in the context of the Spanish health system where preventive care services are free of charge, another Pakistani participant suggested that some women may be unaware that these services exist and are free of charge:
“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).
Another potential reason that emerged during the FGD with Moroccan women was the fear of being diagnosed with a disease. In some cases, these women had personal experiences of cancer within their families and had witnessed the traumatic impact of cancer, which deterred them from attending regular check-ups:
“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).
In contrast, Pakistani women did not mention this fear, although some associated regular check-ups with children’s and elderly’s health:
“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
Although women showed limited awareness regarding the existence of asymptomatic diseases, the majority were familiar with the concept of early detection. There were differences between the two groups of respondents in their perception of the benefits of regular check-ups, particularly in relation to CC screening. Pakistani women felt more positive about the utility of preventive care services while in all FGD with Moroccan women scepticism was expressed. In this sense, some participants expressed their concern about the time interval between screening tests, particularly in the case of HPV test, which is set at 5 years:
“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).
This sceptic view regarding the screening tests generated a rich discussion surrounding the importance of detecting diseases, particularly cancer, at an early stage, rather than in advanced stages. For instance, when participants were asked about what Fatima (the fictional patient diagnosed with cervical cancer) could have done to prevent the disease, many women from both Moroccan and Pakistani origin agreed that she should have undergone regular check-ups: “If she would have done regular check-ups, then she could have known about it (cancer) at an initial stage, and her treatment could have been easier and earlier” (FGD 2, older Pakistani woman). Participants also referred to the benefits of early detection even when only the risk factor is identified. This fact was highlighted by one participant who tested positive for HPV: “This is like fighting against the disease, even before it comes out. If you detect the disease in the beginning is not the same as when it is developed” (SSI MC05, older Moroccan woman).
Changing perceptions
Finally, we identified different motivators to encourage the engagement of Moroccan and Pakistani women with preventive care services, and by the end of both group and individual interviews, we confirmed an enhanced self-awareness among participants.
Increasing self-awareness
Some participants questioned that Moroccan and Pakistani women do not prioritize self-care and their own well-being. Participants in the FGD advocated for being more responsible with their own health and emphasized the importance of effectively managing their time as means of promoting self-care:
“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).
Throughout FGD and SSI, certain women felt guilty for not taking responsibility for their own health: “I am also getting sad that I’ve not gone to the gynaecologist for the last 22 years. We should go and get the tests done” (FGD 3, older Pakistani woman). Although most women believed that seeking care in the healthcare system was only necessary when symptoms were present and a disease needed to be treated, a growing awareness was observed at the end of the interviews in both groups regarding the possibility of feeling healthy while having undetected conditions:
“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
Women seemed to be more amenable to adopt lifestyle changes when they either had a chronic condition or had a personal experience of cancer or another severe disease within their families or close friend circles.
“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).
Finally, both Moroccan and Pakistani women mentioned that receiving a direct invitation or request from a doctor or from the health system, such as call reminders or letters, would serve as a strong motivator for them to attend regular check-ups. One Pakistani woman even suggested the implementation of compulsory check-ups:
“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).
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