European Journal of Oncology Nursing xxx (2015) 1e6
Contents lists available at ScienceDirect
European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
Breast cancer knowledge, attitudes and screening behaviors among IndianeAustralian women C. Kwok a, *, R. Tranberg a, F.C. Lee b a b
School of Nursing and Midwifery, University of Western Sydney, Sydney, New South Wales, Australia Department of Biostatistics, Singapore Clinical Research Institute, 31 Biopolis Way, Nanos #02-01, 138669, Singapore
a b s t r a c t Keywords: Breast cancer Screening behaviors Indian women Knowledge Attitudes
Purpose of research: The aims of the study were to report breast cancer screening practices among Indian eAustralian women and to examine the relationship between demographic characteristics, cultural beliefs and women's breast cancer screening (BCS) behaviors. Method: A descriptive and cross-sectional method was used. Two hundred and forty two Indian eAustralian women were recruited from several Indian organizations. English versions of the Breast Cancer Screening Beliefs Questionnaire (BCSBQ) were administered. The main research variables are BCS practices, demographic characteristics and total scores on each of the BCSBQ subscales. Result: The majority of participants (72.7%e81.4%) had heard of breast awareness, clinical breast examination (CBE) and mammograms. Only 28.9% performed a BSE monthly and although 60% had practiced CBE, only 27.3% of women within the targeted age group had annual CBE. Only 23.6% of women within the targeted age group reported they had a mammogram biennial. Marital status and length of stay in Australia were positively associated with women's screening behaviors. In terms of BCSBQ score, women who had the three screening practices regularly as recommended obtained significantly higher scores on the “attitude towards general health check-ups” and “barriers to mammographic screening” subscales. There was a significant difference in the mean score of the “knowledge and perceptions about breast cancer” between women who did and who did not engage in breast awareness. Conclusions: Our study reveals that attitudes toward health check-ups and perceived barriers to mammographic screening were influential in determining compliance with breast cancer screening practices among IndianeAustralian women. © 2015 Elsevier Ltd. All rights reserved.
Introduction Over the last two decades, significant numbers of South Asian people (i.e. people from India, Pakistan, Bangladesh and Sri Lanka) have moved to economically developed countries. In Australia for example, the number of Indian-born immigrants trebled from 95,720 to 365,550 between 1992 and 2012 and as a result they have become the third largest immigrant group in the country. Compared to other ethnic immigrant groups, Indians are relative newcomers, their median length of residence being five years (Australian Bureau of Statistics, 2012). Given the increasing
* Corresponding author. School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith, 2751, New South Wales, 61 2 9685, Australia. E-mail addresses: [email protected] (C. Kwok), [email protected] (R. Tranberg), [email protected] (F.C. Lee).
numbers and that preventive health behaviors, such as cancer screening are little known in India (Patel et al., 2012), raises serious public health concerns for this group. Despite having a lower incidence of breast cancer than Caucasian women, this still remains the most common cause of cancer morbidity among Indian women, accounting for 25%e31% of all cancers among women in living in India (Khokhar, 2012). Studies suggest that some immigrant Asian women, for example those from China, have a 40%e60% increased risk of developing breast cancer after immigration to Western countries (Grulich et al., 1995; Ziegler et al., 1993). While information about whether this increase also applies among women of Indian background is limited, it is significant that Indian women with breast cancer are more likely to be diagnosed at younger ages, at later stages and to have disproportionately high mortality rates (Khokhar, 2012). Similarly, while five-year breast cancer survival rates of Caucasian women in economically developed countries such as the USA, the UK and
http://dx.doi.org/10.1016/j.ejon.2015.05.004 1462-3889/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kwok, C., et al., Breast cancer knowledge, attitudes and screening behaviors among IndianeAustralian women, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.004
2
C. Kwok et al. / European Journal of Oncology Nursing xxx (2015) 1e6
Australia are between 85% and 89% (Allemani et al., 2014), survival rates among Indian women are as low as 51% (Khokhar, 2012). Early detection involving breast cancer screening practices plays a vital role in breast cancer survival. Such screening includes breast awareness (women of all ages are encouraged to become familiar with the normal look and feel of their breasts), an annual clinical breast-examination (CBE) by a health professional for women aged over 40, and having mammography every two years between the ages of 50 and 69 (Cancer Australia, 2014). Australia has a national screening program, which offers women in this age range a free mammographic examination biannually (BreastScreen NSW, 2014). The rate of uptake among IndianeAustralian women of this program is unknown, although if the results from international studies into this issue are accurate, it is likely to be low. Women of Indian background have been consistently reported as having markedly lower mammographic screening rates than Caucasian women. For example, Mehrotra et al. (2012) report that only between 37.1% and 40.1% of the foreign born IndianeAmerican women included in their study practiced breast self-examination and underwent regular mammographic screening. Studies by Tripathi et al. (2014), Sadler et al. (2001) and Wu et al. (2006) reported similar results. One important factor contributing to the low participation rate of women from minority cultures in breast cancer detection measures, even in Australia, is the strong influence of traditional and cultural health beliefs (Kwok and Sullivan, 2006; Poonawalla et al. (2014); Conway-Phillips and Janusek, 2014). For instance, the idea of having a check-up in the absence of signs and symptoms is foreign to Asian cultures (Daley et al., 2012; Lee et al., 2012). Preventive medicine or early detection measures are not a priority in India. As a result, attending preventive health services is uncommon among Indian immigrants in Western countries (Mehrotra et al., 2012). Moreover, study by Tolma et al., (2014) reveal that a fatalistic attitude toward breast cancer is a predictor of low mammography use among IndianeAmerican women. This is similar to the findings that some Indian women hold negative beliefs about breast cancer and believe that there is no cure for it breast cancer (Grunfeld & Kohli (2010)). As demonstrated by Kwok and Sullivan (2006), modesty is another key cultural factor inhibiting the use of mammographic screening by ChineseeAustralian women. The same considerations of modesty and embarrassment appear to be a key barrier preventing IndianeAmerican women from presenting themselves for mammographic screening (Daley et al., 2012). This could also help explain the low utilization of cancer screening among IndianeAmerican women reported by Mehrotra et al., (2012), although another key factor they highlight is the lack of understanding of cancer screening as a preventive measure. In India itself, studies indicate the mediocre survival rates are due to the limited knowledge of breast cancer among the general public and also that cancer screening is not commonly promoted (Kumar et al., 2011; Tripathi et al., 2014). However, the number of studies relating to Indian women's knowledge and beliefs about breast cancer and screening is limited, due to the fact that most research to date has been concentrated on Caucasian women (Engelman et al., 2012; Watson-Johnson et al., 2011) and those of other Asian ethnic groups in Western countries (Chen, 2009; Lee et al., 2012). Our study attempts to fill this gap in the literature and as such, forms part of a larger investigation of IndianeAustralian women's beliefs, knowledge, and attitudes toward breast cancer and screening practices. The aims of this present study are to report breast cancer screening practices (breast awareness, CBE and mammographic screening) among Indian women in Australia, and to examine the relationship between demographic characteristics, cultural beliefs and women's screening behaviors. Importantly, this study, the first of its kind in Australia,
was designed to assess the knowledge and beliefs about breast cancer and barriers to participation in breast cancer screening among women of Indian background living in this country. Methods This descriptive and cross-sectional study used a selfadministered survey. Participants A convenience sample of 242 IndianeAustralian women was recruited through a number of Indian organizations such as churches, community centers, festival groups and also through personal networking. Selection criteria included 1) being aged 18 years and over, 2) being born overseas either in India itself or in Indian communities in other countries and 3) having no history of breast cancer. Data collection Prior to data collection, the study was granted approval by the Human Ethics Committee of University of Western Sydney. Participants were given an information statement, were made aware that participation was voluntary and also that no personally identifiable information would be collected. Because the questionnaire was distributed en masse, its return by an individual was taken as an indication of voluntary consent. With the assistance of the leaders of various Indian community organizations, female members were invited to participate in the study. The second author, who is of Indian background, attended women's meetings to explain the details of the study. Women were invited to ask questions and if they chose, to fill out the questionnaire and return it either immediately or through the post. The questionnaire took approximately 20 minutes to complete. Organisation leaders assisted those with limited English proficiency to complete the questionnaire. Instrument The Breast Cancer Screening Beliefs Questionnaire (BCSBQ) was originally developed in English as a culturally-sensitive and validated instrument to assess women's knowledge and attitudes regarding breast cancer and screening practices (Kwok et al., 2010). Validation of the BCSBQ in the Indian population evidenced good overall reliability. Cronbach's alpha for the three subscales ranged from 0.81 to 0.91 (validation study will be published elsewhere). BCSBQ contains a 13-item scale requiring respondents to make ratings for each subscale along a five point Likert scale ranging from ‘Strongly agree’ (score of 1) to ‘Strongly disagree (score of 5). A ‘Don't know’ option was included for each item. The mean response to the items within a subscale was then calculated and converted to range between 0 and 100. If a participant scored all items within a subscale as 5, the final score was 100 and if a participant scaled all items as 1, the final score was 0. Subscale scores of 65 or higher were taken as indicative of more positive attitudes towards health check-ups, more accurate knowledge and less fatalistic perceptions about breast cancer and therefore of fewer perceived barriers to mammography than among those women with scores of less than 65. In addition to the three subscales, the BCSBQ also collected information on demographic variables such as age, length of time in Australia, English language proficiency and highest level of education. Information was also collected on participants' breast cancer screening practices. This involved asking participants if they had ever heard of mammography and if so, how regularly they had a mammogram.
Please cite this article in press as: Kwok, C., et al., Breast cancer knowledge, attitudes and screening behaviors among IndianeAustralian women, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.004
C. Kwok et al. / European Journal of Oncology Nursing xxx (2015) 1e6
Statistical analysis Participants' demographic characteristics were summarized using descriptive statistics. The numbers of participants who had ever heard of breast cancer screening practices, who had ever performed them or who had performed them as recommended, were counted. The associations between demographic characteristics and the screening practices were assessed by multivariable logistic regression analyses. Adjusted odds ratio (OR) was reported together with the 95% confidence interval (CI). The three subscale scores of the BCSBQ were computed and then using t-tests, compared those women who did and those who did not engage in the screening practices. This study is a secondary analysis of a validation study on the BCSBQ in IndianeAustralian women. The sample size was determined for examining the factor analysis of the instrument and this is secondary analysis of the validation study (validation study will be published elsewhere). Results The demographic characteristics of the 242 participants are presented in Table 1. The ages ranged from 20 to 78, with a mean (standard deviation) of 41.1 (11.7) years. They had lived in Australia for a mean of 12.3 (8.6) years. A majority were married or were Table 1 Demographic characteristics of the 242 participants. Characteristic Age (year) (mean:41.1; SD:11.7) 20e29 30e39 40e49 50e59 60e69 70 or above Country of birth (missing: N ¼ 1) India South Africa Fiji Others Language spoken at home (missing: N ¼ 1) Tamil English Others Length of stay in Australia (year) (mean:12.3; SD:8.6) 0e5 6e10 11e15 16e20 21e25 26 or above Marital status Single Married/living together Divorced/separated Widowed Education level Never attended school/primary school Secondary school TAFE/college Tertiary or above Current employment status Employed, full time Employed, part time Unemployed Retired English proficiency Not at all Little Average Good Very good
N (%) 42 76 59 50 12 3
(17.4) (31.4) (24.4) (20.7) (5.0) (1.2)
154 6 64 17
(63.9) (2.5) (26.6) (7.1)
46 (19.1) 88 (36.5) 107 (44.4) 63 62 48 28 21 20
(26.0) (25.6) (19.8) (11.6) (8.7) (8.3)
29 189 11 13
(12.0) (78.1) (4.5) (5.4)
5 26 81 130
(2.1) (10.7) (33.5) (53.7)
113 78 50 1
(46.7) (32.2) (20.6) (0.4)
1 6 19 87 129
(0.4) (2.5) (7.9) (36.0) (53.3)
3
living together with their partner (78.1%), had been born in India (63.9%), had tertiary education or above (53.7%) and rated their English proficiency as good or very good (89.3%). Table 2 shows the prevalence of breast cancer screening practices among the participants. Most participants had heard of breast awareness (81.4%), CBE (72.7%) and mammographic screening (75.6%). While three-quarters of those who had heard of breast awareness, only 28.9% had paid attention to their own breasts monthly as recommended. Although more than 60% had practiced CBE, only 27.3% had done it annually as recommended. This proportion was slightly higher (35.7%) within the target age group, i.e. those aged 40 years or above. Among those who had heard of mammographic screening, only 33.5% had ever had a mammogram, while 23.6% had it at least once every two years as recommended. Within the group aged between 50 and 69 years, more than half (58.0%) had followed the recommendation that they have a mammogram biennial. The impact of demographic characteristics on the likelihood of regularly performing breast cancer screening practices as recommended within the target age group, was investigated using multivariable logistic regression analyses. Results summarized in Table 3, indicate that it was the women who had lived in Australia for a longer time who were more likely to have practiced regular CBE (OR ¼ 1.11, 95% CI ¼ 1.03 to 1.20, p-value ¼ 0.008) and undergone mammographic screening (OR ¼ 1.18, 95% CI ¼ 1.03 to 1.36, p-value ¼ 0.019). Divorced, separated or widowed women were less likely to have had a mammogram biannually than their married counterparts (OR ¼ 0.03, 95% CI ¼ 0.002e0.50, pvalue ¼ 0.009). That there was only woman who was single within the target age group of mammographic screening resulted in a wide confidence interval in that category. These associations were not found to be of significance in women who did or did not perform monthly breast awareness routines. The mean and standard deviation of the subscale scores of the BCSBQ classified by breast cancer screening practices are shown in Table 4. Participants who had regularly practiced breast awareness, CBE and mammographic screening, obtained significantly higher scores on the “attitude towards general health checkups” and “barriers to mammographic screening” subscales. There was also a significant difference in the mean score of the “knowledge and perceptions about breast cancer” subscale between women who did and those who did not self-examine their breasts every month. Discussion Our study offers insights into the current screening status and factors associated with breast cancer screening behaviors among Table 2 Breast cancer screening practices (N ¼ 242). Screening practice
All participants Target age groupa N
Breast awareness Ever heard of it Ever preformed Performed as recommended (monthly) Clinical breast examination Ever heard of it Ever preformed Performed as recommended (annually) Mammogram Ever heard of it Ever preformed Performed as recommended (biannually)
(%)
N
(%)
197/242 (81.4) 148/197 (75.1) 57/197 (28.9) 176/242 (72.7) 84/124 109/176 (61.9) 62/84 48/176 (27.3) 30/84
(67.7) (73.8) (35.7)
183/242 (75.6) 50/62 61/182 (33.5) 34/50 43/182 (23.6) 29/50
(80.6) (68.0) (58.0)
a Clinical breast examination: 40 years or older; Mammogram: between 50 and 69 years.
Please cite this article in press as: Kwok, C., et al., Breast cancer knowledge, attitudes and screening behaviors among IndianeAustralian women, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.004
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C. Kwok et al. / European Journal of Oncology Nursing xxx (2015) 1e6
Table 3 Demographic characteristics and breast cancer screening practices among those who have heard of the practice and within the target age group. Have mammogram as recommended (biannually) (Target age groupa N ¼ 50)
Variable
Breast awareness as recommended (monthly) (N ¼ 197)
Clinical breast examination as recommended (annually) (Target age groupa N ¼ 84)
OR
95% CI
P-value
OR
95% CI
P-value
OR
95% CI
P-value
Age (year) Length of stay in Australia (year) Country of birth India Others Marital status Married/living together Single Divorced/separated/ widowed Education level Tertiary or above TAFE/college Secondary school or below Current employment status Employed, full time Employed, part time Unemployed/retired
1.02 1.04
(0.98, 1.06) (0.99, 1.09)
0.370 0.145
0.97 1.11
(0.88, 1.07) (1.03, 1.20)
0.604 0.008
1.26 1.18
(0.96, 1.65) (1.03, 1.36)
0.091 0.019
1 1.45
(0.71, 2.94)
0.305 0.543
1 1.24
(0.39, 3.95)
0.716 0.165
1 3.02
(0.47, 19.45)
0.245 0.028
1 1.79 1.24
(0.62, 5.16) (0.35, 4.39)
0.431 0.908
1 2.47 1.46
(0.38, 16.09) (0.17, 12.55)
0.502 0.949
1 5.38 0.03
(0.18, 160.35) (0.002, 0.50)
0.069 0.009
0.371 1 0.81 0.40
(0.39, 1.68) (0.11, 1.46)
0.358 1 0.57 2.30
0.554 0.204
(0.17, 1.94) (0.30, 17.74)
0.469 1 0.93 0.51
(0.44, 1.99) (0.17 1.51)
0.153 0.263
0.239 1 0.21 2.03
(0.03, 1.75) (0.10, 40.30)
0.942 1 0.88 1.20
0.515 0.231
(0.25, 3.03) (0.25, 5.71)
0.742 0.758
0.094 0.315 0.749
1 0.81 0.44
(0.07, 9.36) (0.05, 3.65)
0.871 0.512
Abbreviations: OR, adjusted odds ratio; CI, confidence interval. a Clinical breast examination: 40 years or older; Mammogram: between 50 and 69 years.
IndianeAustralian women. The findings demonstrate that while the majority of participants (72.7%e81.4%) had heard of the three breast cancer screening practices, only a relatively low proportion (28.9%e58%) had actually engaged in them as recommended. This was particularly the case with breast awareness (28.9%) and CBE (35.7%). As preventive care is not common in India and there is no national breast cancer screening program (Tripathi et al., 2014), this finding is hardly surprising. Given the fact that the peak incidence of breast cancer is among younger Indian women (Khokhar, 2012), our findings suggest an urgent need for the role of breast awareness and CBE to be strongly emphasised in health education efforts, as these are important measures for detecting early breast cancer among women aged under 50 years who are not eligible for mammography. In terms of mammographic screening practice, the study findings that 58% of IndianeAustralian women reported having a mammogram at least every two years is promising when compared to the rate of 55.3% among the general population and 37.7% among NESB women recorded in the national data (Australian Institute of Health and Welfare, 2012). Nevertheless, some caution is necessary
when interpreting this result for two reasons. Firstly, the relatively high figure may be due to recruitment being centered on more health-oriented community organizations in which the rates of screening are likely to be higher than among those for women not connected to such organizations. Secondly, women with poor English proficiency and geographically isolated women were not well represented in our study. Further research is warranted to validate the screening rates. Similar to other studies among women from minority cultures in Western countries (Chen, 2009; Glenn et al., 2009; Ryu et al., 2013; Vahabi, 2011), our findings demonstrate that length of residence is a predictor for breast cancer screening behaviors among IndianeAustralian women. This may be simply explained by the fact that the longer they are in Australia, the more awareness they are likely to have about the availability of free services and related campaigns. This is supported by the studies of Tripathi et al. (2014) and Wu et al. (2006), which indicate that lack of awareness of the availability of screening was an important factor inhibiting breast cancer screening practices among Indian women. Therefore, for a breast health education program to be effective in the local Indian community,
Table 4 Mean and standard deviation of subscale scores of the Indian Breast Cancer Screening Beliefs Questionnaire by breast cancer screening practices. Screening practice
Attitudes towards general health check-ups
Knowledge and perceptions about breast cancer
Barriers to mammographic screening
Yes
P-value
Yes
No
P-value
Yes
No
Contents lists available at ScienceDirect
European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon
Breast cancer knowledge, attitudes and screening behaviors among IndianeAustralian women C. Kwok a, *, R. Tranberg a, F.C. Lee b a b
School of Nursing and Midwifery, University of Western Sydney, Sydney, New South Wales, Australia Department of Biostatistics, Singapore Clinical Research Institute, 31 Biopolis Way, Nanos #02-01, 138669, Singapore
a b s t r a c t Keywords: Breast cancer Screening behaviors Indian women Knowledge Attitudes
Purpose of research: The aims of the study were to report breast cancer screening practices among Indian eAustralian women and to examine the relationship between demographic characteristics, cultural beliefs and women's breast cancer screening (BCS) behaviors. Method: A descriptive and cross-sectional method was used. Two hundred and forty two Indian eAustralian women were recruited from several Indian organizations. English versions of the Breast Cancer Screening Beliefs Questionnaire (BCSBQ) were administered. The main research variables are BCS practices, demographic characteristics and total scores on each of the BCSBQ subscales. Result: The majority of participants (72.7%e81.4%) had heard of breast awareness, clinical breast examination (CBE) and mammograms. Only 28.9% performed a BSE monthly and although 60% had practiced CBE, only 27.3% of women within the targeted age group had annual CBE. Only 23.6% of women within the targeted age group reported they had a mammogram biennial. Marital status and length of stay in Australia were positively associated with women's screening behaviors. In terms of BCSBQ score, women who had the three screening practices regularly as recommended obtained significantly higher scores on the “attitude towards general health check-ups” and “barriers to mammographic screening” subscales. There was a significant difference in the mean score of the “knowledge and perceptions about breast cancer” between women who did and who did not engage in breast awareness. Conclusions: Our study reveals that attitudes toward health check-ups and perceived barriers to mammographic screening were influential in determining compliance with breast cancer screening practices among IndianeAustralian women. © 2015 Elsevier Ltd. All rights reserved.
Introduction Over the last two decades, significant numbers of South Asian people (i.e. people from India, Pakistan, Bangladesh and Sri Lanka) have moved to economically developed countries. In Australia for example, the number of Indian-born immigrants trebled from 95,720 to 365,550 between 1992 and 2012 and as a result they have become the third largest immigrant group in the country. Compared to other ethnic immigrant groups, Indians are relative newcomers, their median length of residence being five years (Australian Bureau of Statistics, 2012). Given the increasing
* Corresponding author. School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith, 2751, New South Wales, 61 2 9685, Australia. E-mail addresses: [email protected] (C. Kwok), [email protected] (R. Tranberg), [email protected] (F.C. Lee).
numbers and that preventive health behaviors, such as cancer screening are little known in India (Patel et al., 2012), raises serious public health concerns for this group. Despite having a lower incidence of breast cancer than Caucasian women, this still remains the most common cause of cancer morbidity among Indian women, accounting for 25%e31% of all cancers among women in living in India (Khokhar, 2012). Studies suggest that some immigrant Asian women, for example those from China, have a 40%e60% increased risk of developing breast cancer after immigration to Western countries (Grulich et al., 1995; Ziegler et al., 1993). While information about whether this increase also applies among women of Indian background is limited, it is significant that Indian women with breast cancer are more likely to be diagnosed at younger ages, at later stages and to have disproportionately high mortality rates (Khokhar, 2012). Similarly, while five-year breast cancer survival rates of Caucasian women in economically developed countries such as the USA, the UK and
http://dx.doi.org/10.1016/j.ejon.2015.05.004 1462-3889/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kwok, C., et al., Breast cancer knowledge, attitudes and screening behaviors among IndianeAustralian women, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.004
2
C. Kwok et al. / European Journal of Oncology Nursing xxx (2015) 1e6
Australia are between 85% and 89% (Allemani et al., 2014), survival rates among Indian women are as low as 51% (Khokhar, 2012). Early detection involving breast cancer screening practices plays a vital role in breast cancer survival. Such screening includes breast awareness (women of all ages are encouraged to become familiar with the normal look and feel of their breasts), an annual clinical breast-examination (CBE) by a health professional for women aged over 40, and having mammography every two years between the ages of 50 and 69 (Cancer Australia, 2014). Australia has a national screening program, which offers women in this age range a free mammographic examination biannually (BreastScreen NSW, 2014). The rate of uptake among IndianeAustralian women of this program is unknown, although if the results from international studies into this issue are accurate, it is likely to be low. Women of Indian background have been consistently reported as having markedly lower mammographic screening rates than Caucasian women. For example, Mehrotra et al. (2012) report that only between 37.1% and 40.1% of the foreign born IndianeAmerican women included in their study practiced breast self-examination and underwent regular mammographic screening. Studies by Tripathi et al. (2014), Sadler et al. (2001) and Wu et al. (2006) reported similar results. One important factor contributing to the low participation rate of women from minority cultures in breast cancer detection measures, even in Australia, is the strong influence of traditional and cultural health beliefs (Kwok and Sullivan, 2006; Poonawalla et al. (2014); Conway-Phillips and Janusek, 2014). For instance, the idea of having a check-up in the absence of signs and symptoms is foreign to Asian cultures (Daley et al., 2012; Lee et al., 2012). Preventive medicine or early detection measures are not a priority in India. As a result, attending preventive health services is uncommon among Indian immigrants in Western countries (Mehrotra et al., 2012). Moreover, study by Tolma et al., (2014) reveal that a fatalistic attitude toward breast cancer is a predictor of low mammography use among IndianeAmerican women. This is similar to the findings that some Indian women hold negative beliefs about breast cancer and believe that there is no cure for it breast cancer (Grunfeld & Kohli (2010)). As demonstrated by Kwok and Sullivan (2006), modesty is another key cultural factor inhibiting the use of mammographic screening by ChineseeAustralian women. The same considerations of modesty and embarrassment appear to be a key barrier preventing IndianeAmerican women from presenting themselves for mammographic screening (Daley et al., 2012). This could also help explain the low utilization of cancer screening among IndianeAmerican women reported by Mehrotra et al., (2012), although another key factor they highlight is the lack of understanding of cancer screening as a preventive measure. In India itself, studies indicate the mediocre survival rates are due to the limited knowledge of breast cancer among the general public and also that cancer screening is not commonly promoted (Kumar et al., 2011; Tripathi et al., 2014). However, the number of studies relating to Indian women's knowledge and beliefs about breast cancer and screening is limited, due to the fact that most research to date has been concentrated on Caucasian women (Engelman et al., 2012; Watson-Johnson et al., 2011) and those of other Asian ethnic groups in Western countries (Chen, 2009; Lee et al., 2012). Our study attempts to fill this gap in the literature and as such, forms part of a larger investigation of IndianeAustralian women's beliefs, knowledge, and attitudes toward breast cancer and screening practices. The aims of this present study are to report breast cancer screening practices (breast awareness, CBE and mammographic screening) among Indian women in Australia, and to examine the relationship between demographic characteristics, cultural beliefs and women's screening behaviors. Importantly, this study, the first of its kind in Australia,
was designed to assess the knowledge and beliefs about breast cancer and barriers to participation in breast cancer screening among women of Indian background living in this country. Methods This descriptive and cross-sectional study used a selfadministered survey. Participants A convenience sample of 242 IndianeAustralian women was recruited through a number of Indian organizations such as churches, community centers, festival groups and also through personal networking. Selection criteria included 1) being aged 18 years and over, 2) being born overseas either in India itself or in Indian communities in other countries and 3) having no history of breast cancer. Data collection Prior to data collection, the study was granted approval by the Human Ethics Committee of University of Western Sydney. Participants were given an information statement, were made aware that participation was voluntary and also that no personally identifiable information would be collected. Because the questionnaire was distributed en masse, its return by an individual was taken as an indication of voluntary consent. With the assistance of the leaders of various Indian community organizations, female members were invited to participate in the study. The second author, who is of Indian background, attended women's meetings to explain the details of the study. Women were invited to ask questions and if they chose, to fill out the questionnaire and return it either immediately or through the post. The questionnaire took approximately 20 minutes to complete. Organisation leaders assisted those with limited English proficiency to complete the questionnaire. Instrument The Breast Cancer Screening Beliefs Questionnaire (BCSBQ) was originally developed in English as a culturally-sensitive and validated instrument to assess women's knowledge and attitudes regarding breast cancer and screening practices (Kwok et al., 2010). Validation of the BCSBQ in the Indian population evidenced good overall reliability. Cronbach's alpha for the three subscales ranged from 0.81 to 0.91 (validation study will be published elsewhere). BCSBQ contains a 13-item scale requiring respondents to make ratings for each subscale along a five point Likert scale ranging from ‘Strongly agree’ (score of 1) to ‘Strongly disagree (score of 5). A ‘Don't know’ option was included for each item. The mean response to the items within a subscale was then calculated and converted to range between 0 and 100. If a participant scored all items within a subscale as 5, the final score was 100 and if a participant scaled all items as 1, the final score was 0. Subscale scores of 65 or higher were taken as indicative of more positive attitudes towards health check-ups, more accurate knowledge and less fatalistic perceptions about breast cancer and therefore of fewer perceived barriers to mammography than among those women with scores of less than 65. In addition to the three subscales, the BCSBQ also collected information on demographic variables such as age, length of time in Australia, English language proficiency and highest level of education. Information was also collected on participants' breast cancer screening practices. This involved asking participants if they had ever heard of mammography and if so, how regularly they had a mammogram.
Please cite this article in press as: Kwok, C., et al., Breast cancer knowledge, attitudes and screening behaviors among IndianeAustralian women, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.004
C. Kwok et al. / European Journal of Oncology Nursing xxx (2015) 1e6
Statistical analysis Participants' demographic characteristics were summarized using descriptive statistics. The numbers of participants who had ever heard of breast cancer screening practices, who had ever performed them or who had performed them as recommended, were counted. The associations between demographic characteristics and the screening practices were assessed by multivariable logistic regression analyses. Adjusted odds ratio (OR) was reported together with the 95% confidence interval (CI). The three subscale scores of the BCSBQ were computed and then using t-tests, compared those women who did and those who did not engage in the screening practices. This study is a secondary analysis of a validation study on the BCSBQ in IndianeAustralian women. The sample size was determined for examining the factor analysis of the instrument and this is secondary analysis of the validation study (validation study will be published elsewhere). Results The demographic characteristics of the 242 participants are presented in Table 1. The ages ranged from 20 to 78, with a mean (standard deviation) of 41.1 (11.7) years. They had lived in Australia for a mean of 12.3 (8.6) years. A majority were married or were Table 1 Demographic characteristics of the 242 participants. Characteristic Age (year) (mean:41.1; SD:11.7) 20e29 30e39 40e49 50e59 60e69 70 or above Country of birth (missing: N ¼ 1) India South Africa Fiji Others Language spoken at home (missing: N ¼ 1) Tamil English Others Length of stay in Australia (year) (mean:12.3; SD:8.6) 0e5 6e10 11e15 16e20 21e25 26 or above Marital status Single Married/living together Divorced/separated Widowed Education level Never attended school/primary school Secondary school TAFE/college Tertiary or above Current employment status Employed, full time Employed, part time Unemployed Retired English proficiency Not at all Little Average Good Very good
N (%) 42 76 59 50 12 3
(17.4) (31.4) (24.4) (20.7) (5.0) (1.2)
154 6 64 17
(63.9) (2.5) (26.6) (7.1)
46 (19.1) 88 (36.5) 107 (44.4) 63 62 48 28 21 20
(26.0) (25.6) (19.8) (11.6) (8.7) (8.3)
29 189 11 13
(12.0) (78.1) (4.5) (5.4)
5 26 81 130
(2.1) (10.7) (33.5) (53.7)
113 78 50 1
(46.7) (32.2) (20.6) (0.4)
1 6 19 87 129
(0.4) (2.5) (7.9) (36.0) (53.3)
3
living together with their partner (78.1%), had been born in India (63.9%), had tertiary education or above (53.7%) and rated their English proficiency as good or very good (89.3%). Table 2 shows the prevalence of breast cancer screening practices among the participants. Most participants had heard of breast awareness (81.4%), CBE (72.7%) and mammographic screening (75.6%). While three-quarters of those who had heard of breast awareness, only 28.9% had paid attention to their own breasts monthly as recommended. Although more than 60% had practiced CBE, only 27.3% had done it annually as recommended. This proportion was slightly higher (35.7%) within the target age group, i.e. those aged 40 years or above. Among those who had heard of mammographic screening, only 33.5% had ever had a mammogram, while 23.6% had it at least once every two years as recommended. Within the group aged between 50 and 69 years, more than half (58.0%) had followed the recommendation that they have a mammogram biennial. The impact of demographic characteristics on the likelihood of regularly performing breast cancer screening practices as recommended within the target age group, was investigated using multivariable logistic regression analyses. Results summarized in Table 3, indicate that it was the women who had lived in Australia for a longer time who were more likely to have practiced regular CBE (OR ¼ 1.11, 95% CI ¼ 1.03 to 1.20, p-value ¼ 0.008) and undergone mammographic screening (OR ¼ 1.18, 95% CI ¼ 1.03 to 1.36, p-value ¼ 0.019). Divorced, separated or widowed women were less likely to have had a mammogram biannually than their married counterparts (OR ¼ 0.03, 95% CI ¼ 0.002e0.50, pvalue ¼ 0.009). That there was only woman who was single within the target age group of mammographic screening resulted in a wide confidence interval in that category. These associations were not found to be of significance in women who did or did not perform monthly breast awareness routines. The mean and standard deviation of the subscale scores of the BCSBQ classified by breast cancer screening practices are shown in Table 4. Participants who had regularly practiced breast awareness, CBE and mammographic screening, obtained significantly higher scores on the “attitude towards general health checkups” and “barriers to mammographic screening” subscales. There was also a significant difference in the mean score of the “knowledge and perceptions about breast cancer” subscale between women who did and those who did not self-examine their breasts every month. Discussion Our study offers insights into the current screening status and factors associated with breast cancer screening behaviors among Table 2 Breast cancer screening practices (N ¼ 242). Screening practice
All participants Target age groupa N
Breast awareness Ever heard of it Ever preformed Performed as recommended (monthly) Clinical breast examination Ever heard of it Ever preformed Performed as recommended (annually) Mammogram Ever heard of it Ever preformed Performed as recommended (biannually)
(%)
N
(%)
197/242 (81.4) 148/197 (75.1) 57/197 (28.9) 176/242 (72.7) 84/124 109/176 (61.9) 62/84 48/176 (27.3) 30/84
(67.7) (73.8) (35.7)
183/242 (75.6) 50/62 61/182 (33.5) 34/50 43/182 (23.6) 29/50
(80.6) (68.0) (58.0)
a Clinical breast examination: 40 years or older; Mammogram: between 50 and 69 years.
Please cite this article in press as: Kwok, C., et al., Breast cancer knowledge, attitudes and screening behaviors among IndianeAustralian women, European Journal of Oncology Nursing (2015), http://dx.doi.org/10.1016/j.ejon.2015.05.004
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C. Kwok et al. / European Journal of Oncology Nursing xxx (2015) 1e6
Table 3 Demographic characteristics and breast cancer screening practices among those who have heard of the practice and within the target age group. Have mammogram as recommended (biannually) (Target age groupa N ¼ 50)
Variable
Breast awareness as recommended (monthly) (N ¼ 197)
Clinical breast examination as recommended (annually) (Target age groupa N ¼ 84)
OR
95% CI
P-value
OR
95% CI
P-value
OR
95% CI
P-value
Age (year) Length of stay in Australia (year) Country of birth India Others Marital status Married/living together Single Divorced/separated/ widowed Education level Tertiary or above TAFE/college Secondary school or below Current employment status Employed, full time Employed, part time Unemployed/retired
1.02 1.04
(0.98, 1.06) (0.99, 1.09)
0.370 0.145
0.97 1.11
(0.88, 1.07) (1.03, 1.20)
0.604 0.008
1.26 1.18
(0.96, 1.65) (1.03, 1.36)
0.091 0.019
1 1.45
(0.71, 2.94)
0.305 0.543
1 1.24
(0.39, 3.95)
0.716 0.165
1 3.02
(0.47, 19.45)
0.245 0.028
1 1.79 1.24
(0.62, 5.16) (0.35, 4.39)
0.431 0.908
1 2.47 1.46
(0.38, 16.09) (0.17, 12.55)
0.502 0.949
1 5.38 0.03
(0.18, 160.35) (0.002, 0.50)
0.069 0.009
0.371 1 0.81 0.40
(0.39, 1.68) (0.11, 1.46)
0.358 1 0.57 2.30
0.554 0.204
(0.17, 1.94) (0.30, 17.74)
0.469 1 0.93 0.51
(0.44, 1.99) (0.17 1.51)
0.153 0.263
0.239 1 0.21 2.03
(0.03, 1.75) (0.10, 40.30)
0.942 1 0.88 1.20
0.515 0.231
(0.25, 3.03) (0.25, 5.71)
0.742 0.758
0.094 0.315 0.749
1 0.81 0.44
(0.07, 9.36) (0.05, 3.65)
0.871 0.512
Abbreviations: OR, adjusted odds ratio; CI, confidence interval. a Clinical breast examination: 40 years or older; Mammogram: between 50 and 69 years.
IndianeAustralian women. The findings demonstrate that while the majority of participants (72.7%e81.4%) had heard of the three breast cancer screening practices, only a relatively low proportion (28.9%e58%) had actually engaged in them as recommended. This was particularly the case with breast awareness (28.9%) and CBE (35.7%). As preventive care is not common in India and there is no national breast cancer screening program (Tripathi et al., 2014), this finding is hardly surprising. Given the fact that the peak incidence of breast cancer is among younger Indian women (Khokhar, 2012), our findings suggest an urgent need for the role of breast awareness and CBE to be strongly emphasised in health education efforts, as these are important measures for detecting early breast cancer among women aged under 50 years who are not eligible for mammography. In terms of mammographic screening practice, the study findings that 58% of IndianeAustralian women reported having a mammogram at least every two years is promising when compared to the rate of 55.3% among the general population and 37.7% among NESB women recorded in the national data (Australian Institute of Health and Welfare, 2012). Nevertheless, some caution is necessary
when interpreting this result for two reasons. Firstly, the relatively high figure may be due to recruitment being centered on more health-oriented community organizations in which the rates of screening are likely to be higher than among those for women not connected to such organizations. Secondly, women with poor English proficiency and geographically isolated women were not well represented in our study. Further research is warranted to validate the screening rates. Similar to other studies among women from minority cultures in Western countries (Chen, 2009; Glenn et al., 2009; Ryu et al., 2013; Vahabi, 2011), our findings demonstrate that length of residence is a predictor for breast cancer screening behaviors among IndianeAustralian women. This may be simply explained by the fact that the longer they are in Australia, the more awareness they are likely to have about the availability of free services and related campaigns. This is supported by the studies of Tripathi et al. (2014) and Wu et al. (2006), which indicate that lack of awareness of the availability of screening was an important factor inhibiting breast cancer screening practices among Indian women. Therefore, for a breast health education program to be effective in the local Indian community,
Table 4 Mean and standard deviation of subscale scores of the Indian Breast Cancer Screening Beliefs Questionnaire by breast cancer screening practices. Screening practice
Attitudes towards general health check-ups
Knowledge and perceptions about breast cancer
Barriers to mammographic screening
Yes
P-value
Yes
No
P-value
Yes
No
