Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
Paula Alexander Delpech, PhD Glenenna Haynes-Smith, DNP, RN
Breast Self-examination and Health Beliefs in Grenadian Women K E Y W O R D S
Background: Breast cancer incidence and mortality are rising in Grenada, and
Breast cancer
there is a lack of knowledge about women’s beliefs about breast self-examination
Breast self-examination
(BSE). Objective: The objective of this study was to quantify and identify patterns of
Champion revised Health Belief Model Scale
beliefs about health and BSE in Grenadian women to help plan targeted community
Grenada
community parish in Grenada, sociodemographic data and health beliefs were
Health Belief Model
collected using a self-administered questionnaire. The Champion revised Health Belief
interventions. Methods: In this descriptive cross-sectional study of 110 women in a
Model Scale was used to measure general health motivation (5 items), perceived susceptibility to breast cancer (4 items), seriousness of breast cancer (7 items), confidence in performing BSE (7 items), benefits of BSE (2 items), and barriers to BSE (6 items). Results: Younger women were motivated to perform BSE (P = .018), and divorced/separated/widowed women felt more susceptible to breast cancer (P = .014) but perceived fewer benefits in performing BSE (P = .032). Women who did not attend church were more motivated (P = .015) and saw greater benefit (P = .033) in BSE. Frequent church attendees perceived that they were more susceptible (P = .01), were less confident (P G .001), and saw less benefit in BSE (P = .024). Conclusions: There are groups of women in Grenada with belief patterns and sociodemographic characteristics that may benefit from targeted community intervention, perhaps in partnership with other stakeholders such as the church. Implications for Practice: Beliefs about health and BSE affect BSE uptake and are culture dependent. These data help identify the at-risk population to guide the development of targeted community-based and culturally appropriate breast screening programs. Author Affiliations: Division of Nursing, Barry University College of Health Sciences, Miami Shores, Florida (Dr Delpech); and Department of Nursing & Allied Health Sciences, St Georges University, Grenada, West Indies (Dr Haynes-Smith). The authors have no funding or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.cancernursingonline.com).
Correspondence: Paula Alexander Delpech, PhD, Division of Nursing, Barry University College of Health Sciences, 11300 NE 2nd Ave, Miami Shores, FL 33161 ([email protected]). Accepted for publication October 20, 2014. DOI: 10.1097/NCC.0000000000000218
E54 n Cancer NursingTM, Vol. 38, No. 5, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Delpech and Haynes-Smith
C
ancer is the second leading cause of death in the Americas after heart disease.1 There were 2.8 million new cases and 1.3 million deaths from cancer in 2012, with 47% of the cancer deaths occurring in Latin America and the Caribbean.2 Globally, breast cancer is the most common female cancer, and approximately 1.1 million new cases are diagnosed annually.3 However, despite stabilization of breast cancer incidence, morbidity, and mortality in high-income countries, incidence and mortality continue to increase in low- and middle-income countries (LMICs),4Y6 with more than half of global breast cancer deaths occurring in LMICs.7 Breast cancer mortality rates are expected to increase by 50% by 2020 in LMICs,8 where public health priorities and resourcing continue to face challenges.9 Numerous breast cancer initiatives have been developed to reduce breast cancer morbidity and mortality, increase breast cancer awareness, improve breast cancer screening, and ensure access to breast care for women in LMICs.10 However, the well-developed breast cancer guidelines developed in resource-rich countries tend to be inappropriate or inapplicable to LMICs because of low numbers of trained healthcare providers, inadequate healthcare infrastructure for diagnosis and treatment, and unique cultural, religious, or social barriers.11 For instance, in our experience, women in LMICs frequently lack awareness and have misconceptions about the process of breast cancer diagnosis and treatment, suffer loss of a husband or partner (and, consequently, income) after mastectomy, and cannot afford out-of-pocket expenses for diagnostic testing. Grenada is a tri-island state in the Eastern Caribbean with a population of 104 000 and comprises the islands of Grenada, Carriacou, and Petit Martinique. Grenada is classified as a middleincome country according to World Bank,12 and it has a mixed population of African, East Indian, and European descent; those of African descent comprise greater than 80% of the population. In Grenada, the primary health network consists of 6 district health centers and 30 medical stations that provide quality community health services to all citizens within a 3-mile radius. The majority of patients are treated in the public health system, and it is estimated that only 7% of the population has private health insurance.13 Doctors, nurses, and their assistants staff these facilities, which, when accessed, are able to deliver both education and treatment. However, fear of breast cancer and lack of awareness pose a significant challenge to women accessing these facilities. The rising incidence of, and increasing mortality from, breast cancer in Grenada is of major concern, and Grenada ranks 23rd in the world for breast cancer deaths.2 Breast cancer is the leading cause of cancer deaths among Grenadian women and accounts for 49% of female cancers in total and 16% of cancer deaths and has an age-standardized incidence of 170.2 per 100 000.14 Grenada has a poorly developed cancer strategy, with no formal cancer policy, strategy, or action plan and a lack of screening facilities in the public sector; mammography is only generally only available for private patients. Given the high incidence of breast cancer in Grenada and the limited resources in the country, breast cancer awareness programs are at best inadequate and at worst nonexistent. As a result, breast cancer commonly remains undiagnosed until late stage or metastatic, when treatment options have less benefit or are simply unavailable.15 The purpose of this study was to quantify beliefs about breast self-examination (BSE) in a sam-
Health Beliefs in Grenadian Women
ple of women living in Grenada in order to identify vulnerable groups that might require prioritizing when planning public health interventions.
n
Background
Women who are informed about the importance of breast health and BSE are known to be more confident in performing BSE and more likely to practice BSE.16 Cohen and Azaiza17 used a culturebased tailored telephone intervention to increase BSE practice in 300 Israeli women and showed that women who engaged in the intervention were more likely to practice BSE. In a study to identify and describe barriers to early detection of breast cancer, as well as current breast cancer screening behaviors and attitudes among women on the island of Tobago, low levels of BSE, infrequent clinical breast examination (CBE) as part of regular care, unavailability of mammography services, and cost were shown to be barriers to early detection of breast cancer.18 In Nigeria, a descriptive cross-sectional design was used to study women’s health beliefs and breast cancer screening practices in Nigeria.19 The study concluded that the intention to seek preventive health behaviors was found to have a strong influence on BSE. Another study utilized a community-based health project to increase breast health awareness in rural Nicaraguan women20 and found that women who participated in the program were receptive to learning about breast health and agreed to perform a BSE monthly; the community-based program was also effective for BSE training and breast health promotion in the LMIC setting. In another community-based interventional study in Pakistan, health education on BSE and testicular self-examination was successful,21 with post-intervention assessments showing a significant improvement (of 83% and 72%, respectively; P G .001) in self-examination knowledge among study participants. There is therefore a need to provide culturally appropriate and sustainable breast health awareness initiatives in LMICs, and those programs that are community based and focused on early detection appear to have favorable outcomes. However, the optimal population for prioritizing and targeting interventions remains uncertain.
n
Conceptual Framework
In this study, health beliefs about BSE were studied using the Champion22 revised Health Belief Model (HBM). The HBM proposes that changes in health-related behavior are based on several factors: (1) perceived susceptibility (the perceived personal risk of developing breast cancer), (2) perceived seriousness (the perceived degree of personal threat from breast cancer), (3) perceived benefits (the perceived benefits of BSE for the individual), (4) perceived barriers (the perceived negative components of BSE for the individual), (5) perceived confidence (the perceived competence to perform BSE with the perceived ability to detect abnormal lumps), and (6) health motivation (the beliefs and behaviors related to health concerns).23 The HBM offers an approach to understanding health behaviors related to breast cancer. The model hypothesizes that women Cancer NursingTM, Vol. 38, No. 5, 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
n
E55
who believe that they are susceptible to breast cancer are more likely to perform BSE, and women who perceive more benefit from, and fewer barriers toward, BSE are more likely to perform BSE. Conversely, women who are confident in their own ability to perform BSE, and the more motivated they are to engage in health promotion behaviors, are more likely to perform BSE.22 n
Purpose
The purpose of this study was to establish what relationships exist between sociodemographic characteristics (age, marital status, level of education, church attendance, frequency of church attendance, and healthcare-seeking behavior), breast health beliefs, and beliefs about BSE in a sample of women living in a parish in Grenada. These parameters were selected as the most common and easily obtainable sociodemographic variables likely to be related to overall attitudes to health. n
Methods
Design and Sampling Procedure A descriptive cross-sectional study was conducted in a parish in Grenada. A convenience sample of 110 women attending 2 health fairs held in June 2012 and September 2012 were recruited to participate in the study. The inclusion criteria were that women were at least 20 years old, were able to read English, and had not previously had (or did not currently have) breast cancer.
Instruments Demographic information (age, marital status, level of education, church attendance, frequency of church attendance, and healthcareseeking behavior) was collected using a self-administered questionnaire. The Champion revised Health Belief Model Scale (CHBMS), a commonly used and publicly available instrument for measuring the HBM,22 was used to measure health beliefs. The full CHBMS consists of 53 items designed to measure HBM variables related to breast cancer screening including perceived barriers, susceptibility, seriousness, health motivation, perceived benefits, and confidence (or self-efficacy). Although the original and revised versions also question HBM variables related to mammography, only the subscales related to BSE were used in the current study; the ‘‘motivation’’ subscale questions general health-related beliefs, whereas the other subscales are specific to breast cancer and BSE. The CHBMS questionnaire is shown in Document, Supplemental Digital Content 1, http://links.lww.com/CN/A3. All questions in the study were in a Likert format (1Y5, strongly disagree to
strongly agree). Motivation was scored using 5 items, susceptibility using 4 items, seriousness using 7 items, confidence using 7 items, benefits using 2 items, and barriers using 6 items. Responses to subscale items were averaged for each subscale to give a score out of 5 (TSD), with higher scores denoting a ‘‘greater’’ perception of barriers, susceptibility, seriousness, motivation, benefit, or confidence (see also Document, Supplemental Digital Content 1, http://links.lww.com/CN/A3). Cronbach’s ! coefficients, a measure of internal consistency of each subscale, ranged from .61 (benefits) to .93 (confidence) (Table 1); these values were consistent with the original CHBMS for BSE, which ranged from .69 (benefits) to .90 (confidence).24 This was the first time that this instrument had been used in this population.
Data Collection Internal review board approval was obtained prior to data collection from Barry University, Miami, and St Georges University, Grenada. Participants were recruited by the investigators (nurses from the nursing faculty at St Georges University College of Nursing) at health fairs. The 2 health fairs, which are common in Grenada and must be approved by the Minister of Health, were held at a church and a school. During recruitment, prospective participants were provided with an information letter that described the study purpose and procedures and were informed that all information provided would be anonymized and used only within the study by the investigators; they then gave oral consent. Participants were informed that the findings would be used to contribute to the design of breast health awareness programs for women in Grenada and its sister islands. The time for data collection was 20 to 50 minutes.
Data Analysis The Statistical Package for Social Sciences (IBM SPSS Statistics 19; SPSS Inc, Chicago, Illinois) was used for data analysis. Demographic data and data related to the study variables were analyzed in full using descriptive statistics. The Shapiro-Wilk test was used to assess the distribution of the data, which were not normally distributed. Correlations between variables were therefore determined using Spearman rank correlation coefficients, and the Kruskal-Wallis test was used to examine differences in beliefs between demographic groups. P G .05 was considered statistically significant.
n
Results
In total, 110 women participated in the study. The demographics of the study population are shown in Table 2. Participants ranged
Table 1 & Means, SDs, and Cronbach’s ! Coefficients of the Belief Subscales Used in This Study (n = 110) Variables Mean SD Cronbach’s !
Barriers
Susceptibility
Confidence
Seriousness
Motivation
Benefits
1.9 0.49
2.5 0.83 .89
2.9 1.0 .93
3.0 0.84 .91
3.5 0.62 .62
3.8 0.55 .61
E56 n Cancer NursingTM, Vol. 38, No. 5, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Delpech and Haynes-Smith
Table 2 & Demographics of the Study Participants (n = 110)
Characteristics Age, y 20Y29 30Y39 40Y49 50Y59 60Y69 Marital status Married Single Separate Divorced Widowed Education level Less than high school Completed high school More than high school Employment status Employed full time Employed part time Unemployed Retired No response Who takes care of health Government hospital Private doctor Other No response Church attendance Yes No No response Frequency of church attendance Once or more than once per week Once per month
n
%
28 22 20 29 10
25.5 20.0 19.1 26.4 9.1
38 60 1 5 6
34.5 54.5 0.9 4.5 5.5
55 35 20
50.0 31.8 18.2
39 16 47 6 2
35.5 14.5 42.7 5.5 1.8
57 47 4 5
52 43 3.6 4.5
99 9 2
92 8 1.8
65 33
59 30
The average responses for the 6 belief subscales are summarized in Table 1. Overall, study participants perceived a high level of benefit in performing BSE and were generally highly motivated. They perceived medium levels of seriousness about breast cancer and in their ability to perform BSE to detect abnormal lumps. They perceived low levels of personal risk of developing breast cancer but did not perceive many barriers to performing BSE. Health belief factors were investigated with respect to sociodemographic variables (Table 3). Younger women were more motivated to perform BSE than older women (P = .018), whereas divorced, separated, or widowed women were more likely to believe that they were susceptible to breast cancer (P = .014) but perceived fewer benefits in performing BSE (P = .032). Those women who did not attend church were more motivated (P = .015) and saw greater benefit (P = .033) in BSE and, of those who did attend church, frequent attendees perceived that they were more susceptible (P = .01), were less confident (P G .001), and saw less benefit in BSE (P = .024). Education level, employment, and healthcare provider were not associated with beliefs toward BSE or health-related motivation. Finally, the strength of the relationships between health beliefs was investigated (Table 4). Health-motivated women tended to be more confident (> = 0.383, P G .001) and perceived more benefit in BSE (> = 0.289, P = .002). Women who perceived themselves to be more susceptible to breast cancer lacked confidence (> = j0.480, P G .001) and perceived less benefit in BSE (r = j0.245, P = .01), whereas those who perceived breast cancer to be a serious disease also lacked confidence in BSE (> = j0.309, P = .001) and perceived barriers to performing it (> = 0.295, P = .002).
n
in age from 20 to 68 years, with a mean of 41.89 (SD, 13.099) years, and were evenly distributed across age groups. Most of the women were single (54.5%), had less than a high school education (50%), were unemployed (42.7%), attended church at least once per week (59%), and received their healthcare from the government hospital (53%).
Discussion
Here we present, for the first time, the health- and BSE-related beliefs of a group of Grenadian women. Although the respondents were, in general, highly motivated and perceived benefits in performing BSE, distinct subgroups of women could be identified who might benefit more from targeted breast awareness programs. In particular, older women (lacking general motivation); divorced, widowed, or separated women (felt susceptible to breast cancer but did not perceive benefits from BSE); and churchgoers all possessed belief systems that might reduce their chances of
Table 3 & Associations Between Sociodemographic Variables and Beliefsa Motivation
Susceptibility
Seriousness
Confidence
Benefits
Barriers
.018b .223 .555 .564 .602 .015b .241
.139 .014b .908 .421 .362 .213 .010b
.503 .439 .361 .704 .262 .942 .785
.079 .091 .615 .223 .695 .269 G.001b
.327 .032b .522 .969 .874 .033b .024b
.559 .099 .262 .821 .812 .675 .503
Age Marital status Education level Employment Status Healthcare provider Church attendance Attendance frequency a
Values are Kruskal-Wallis P values. Significant at the.05 level (2-tailed).
b
Health Beliefs in Grenadian Women
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Table 4 & Relationships Between Health Beliefs and Beliefs About Breast Self-examination Motivation Susceptibility Seriousness Confidence Benefits Barriers
a
Correlation P Correlation P Correlation P Correlation P Correlation P Correlation P
Motivation
Susceptibility
Seriousness
Confidence
Benefits
Barriers
1.000 V j0.240b .012 j0.213b .025 0.383c .000 0.289c .002 j.0125 .193
1.000 V 0.136 .157 j0.480c .000 j0.245c .010 0.132 .169
1.000 V j0.309c .001 j0.172 .073 0.295c .002
1.000 V 0.394c .000 j0.205b .032
1.000 V j0.252c .008
1.000 V
a
Spearman rank correlation. Correlation is significant at the .05 level (2-tailed). Correlation is significant at the .01 level (2-tailed).
b c
performing BSE and consequently increase breast cancer risk. In a resource-poor country such as Grenada, which also lacks coherent health awareness initiatives, these data might help to identify susceptible groups who might benefit from targeted community intervention. There are almost no specific data relating to breast cancer (either screening, risk, or treatment) in Grenadian women (or indeed the wider Caribbean community), making it challenging to design culturally appropriate and cost-effective breast screening programs. Screening uptake for cervical cancer in the Caribbean is, however, known to be poor; in 1 study, 25% of a group of women from Jamaica, Trinidad and Tobago, and the Virgin Islands had had no previous cervical smear, compared with 10% of US-born black women.25 Ethnicity is known to influence BSE practices, with observable differences in perception of worry and BSE practices even within major racial categories, such as within black women of different racial groups or the use of screening programs by subpopulations of Hispanic women.26,27 However, the majority of these studies relate to first- or second-generation US immigrants rather than native populations and their particular context, making the results difficult to extrapolate to the Grenadian setting. Although mammography has been shown to play a vital part in early detection and improved survival from breast cancer in highincome countries, it is the most costly of the 3 recommended methods for early detection (BSE, clinical examination, and mammography). There is controversy surrounding the efficacy of BSE as a screening tool, and a meta-analysis of 20 studies failed to show a clear benefit from BSE for early breast cancer detection.28 However, BSE can certainly help to discover malignant lesions and, according to some commentators, may reduce breast cancerrelated deaths by as much as 18%.29 It therefore remains a costeffective tool for LMICs, where sophisticated diagnostic screening methods are frequently unaffordable and unavailable.19 Breast self-examination, when used as part of health awareness and CBE, is associated with early detection and improved outcomes for women in LMICs30 and therefore remains of value. According to a report published by the Breast Health Global Initiative (BHGI),15 cancer awareness educational campaigns are critical for the effective treatment and diagnosis of breast cancer,
are relatively inexpensive, and are therefore suited to low-resource countries. In 2005, the BHGI recommended that all women have the right to access affordable healthcare and to receive breast health education that is culturally appropriate and tailored to the specific population.15 In terms of early detection, the BHGI recommended that breast health awareness should be promoted using CBE in both symptomatic and asymptomatic women and organized screening using CBE or BSE, and feasibility studies of mammographic screening should be undertaken in regions of the world that are not economically strained. Although the American Cancer Society no longer recommends BSE, it should be noted that BSE remains an important screening mechanism for economically and culturally poor regions where access to mammography is limited or nonexistent.31Y33 Psychosocial factors are known to be associated with BSE uptake, and therefore targeting specific subgroups of women with particular beliefs and attitudes is likely to translate into change on BSE behavior. In general, our results were consistent with the HBM hypothesis; health-motivated women were more confident and perceived more benefit in BSE, women who perceived themselves to be more susceptible to breast cancer lacked confidence and perceived less benefit in BSE, and those who perceived breast cancer to be a serious disease also lacked confidence in BSE and perceived barriers to performing it. Confidence, perceived benefits from BSE, and perceived susceptibility to breast cancer are all associated with more frequent BSE.34Y36 Because women who were widowed, divorced, and separated and those who attended church most regularly were more likely to have poor confidence and high perception of susceptibility, the church might provide a platform by which community breast cancer awareness programs are implemented or information disseminated in a culturally sensitive manner. This study has a number of limitations. The population was a convenience sample of health fair attendees; this population was therefore likely to be predisposed to seeking health-related information and this is a likely source of bias. It is unknown whether this population was completely representative of the population as a whole and therefore whether the data are fully generalizable. In addition, the study size was relatively small.
E58 n Cancer NursingTM, Vol. 38, No. 5, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Conclusions and Implications for Practice
n
Women in LMICs continue to be at particular risk of developing and dying of breast cancer. Here we identify groups of individuals with particular belief patterns and sociodemographic characteristics that may benefit from targeted community intervention, perhaps in partnership with other stakeholders such as the church. These data help guide the development of community-based and culturally appropriate programs that can integrate into the current health services in Grenada and help break negative cycles of belief that contribute to poor breast cancer outcomes. Given the success of global health initiatives (such as by the US Government Global Health Programs), support from these initiatives could also be considered as part of the intervention. In terms of practice, Grenada has a well-developed primary healthcare system that is well integrated with the community. Practitioners are similarly well integrated and have access to the individuals most at need of intervention; they are best placed to convey the specific message that breast cancer is treatable and curable if diagnosed early. Health education is not limited to patients, and providers can also benefit; they too require specific training about early detection, screening, and the barriers affecting women trying to access services, and training will require specific resourcing. There is an urgent need for a well-organized screening program in Grenada that includes BSE, clinical examination by a healthcare provider, and screening mammography, and practitioners have a role to play in driving and championing policy change. ACKNOWLEDGMENTS
The authors thank Dr Clarice Modeste, Minister of Health; Ms Ann Hopkin, MPH, RN, from the South St Georges Association; and the many women from St Mark who participated in the project.
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Health Beliefs in Grenadian Women
11. Anderson BO, Cazap E. Breast health global initiative (BHGI) outline for program development in Latin America. Salud Publ Mex. 2009;51(suppl 2): s309Y315. 12. World Bank. World Development Indicators 2012. 2012. Washington, DC: World Bank. https://openknowledge.worldbank.org/handle/10986/6014. 13. National Assessment Team of Grenada, Caribbean Development Bank. Country Poverty Assessment: Grenada, Carriacou, and Petit Martinique, 2007Y2008 (Vol. 1) [Internet]. 2008. http://www.gov.gd/egov/docs/reports/Grenada_ CPA_Vol_1_Main_Report_Submitted.pdf. Accessed September 17, 2014. 14. Asulin Y, McCann TJ, McCarty CW, Hage RW, Rooney PJ, Macpherson CN. Cancer incidence and mortality in Grenada 1990-2000. West Ind Med J. 2004;53(6):368Y373. 15. Anderson BO, Jakesz R. Breast cancer issues in developing countries: an overview of the Breast Health Global Initiative. World J Surg. 2008;32(12):2578Y2585. 16. Nahcivan NO, Secginli S. Health beliefs related to breast self-examination in a sample of Turkish women. Oncol Nurs Forum. 2007;34(2):425Y432. 17. Cohen M, Azaiza F. Early breast cancer detection practices, health beliefs, and cancer worries in Jewish and Arab women. Prev Med. 2005;41(5Y6):852Y858. 18. Modeste NN, Caleb-Drayton VL, Montgomery S. Barriers to early detection of breast cancer among women in a Caribbean population. Pan Am J Public Health. 1999;5(3):152Y156. 19. Olowokere A, Onibokun A, Irinoye O. Women’s health beliefs and breast cancer screening practices in Nigeria. Afr J Midwifery Womens Health. 2012; 6(2):91Y97. 20. Duda RB, Bhushan D. Teaching rural women in Nicaragua the principles of breast health. J Cancer Educ. 2011;26(3):560Y565. 21. Shallwani K, Ramji R, Ali TS, Khuwaja AK. Self-examination for breast and testicular cancers: a community-based intervention study. Asian Pac J Cancer Prev. 2010;11(1):145Y148. 22. Champion VL. Revised susceptibility, benefits, and barriers scale for mammography screening. Res Nurs Health. 1999;22(4):341Y348. 23. Champion VL. Instrument refinement for breast cancer screening behaviors. Nurs Res. 1993;42(3):139Y143. 24. Hacihasanoglu R, Gozum S. The effect of training on the knowledge levels and beliefs regarding breast self-examination on women attending a public education centre. Eur J Oncol Nurs. 2008;12(1):58Y64. 25. Fruchter RG, Wright C, Habenstreit B, Remy JC, Boyce JG, Imperato PJ. Screening for cervical and breast cancer among Caribbean immigrants. J Community Health. 1985;10(3):121Y135. 26. Kudadjie-Gyamfi E, Consedine N, Magai C, Gillespie M, Pierre-Louis J. Breast self-examination practices among women from six ethnic groups and the influence of cancer worry. Breast Cancer Res Treat. 2005;92(1):35Y45 27. Zambrana RE, Breen N, Fox SA, Gutierrez-Mohamed ML. Use of cancer screening practices by Hispanic women: analyses by subgroup. Prev Med. 1999; 29(6 pt 1):466Y477. 28. Ku YL. The value of breast self-examination: meta-analysis of the research literature. Oncol Nurs Forum. 2001;28(5):815Y822. 29. Salazar MK. Breast self-examination beliefs: a descriptive study. Public Health Nurs. 1994;11(1):49Y56. 30. Anderson BO, Cazap E, El Saghir NS, et al. Optimisation of breast cancer management in low-resource and middle-resource countries: executive summary of the Breast Health Global Initiative consensus, 2010. Lancet Oncol. 2011; 12(4):387Y398. 31. Bullock K, McGraw SA. A community capacity-enhancement approach to breast and cervical cancer screening among older women of color. Health Soc Work. 2006;31(1):16Y25. 32. Nelson HD, Tyne K, Naik A, et al. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;151(10): 727Y737, W237Y742. 33. Noroozi A, Jomand T, Tahmasebi R. Determinants of breast self-examination performance among Iranian women: an application of the Health Belief Model. J Cancer Educ. 2011;26(2):365Y374. 34. Erblich J, Bovbjerg DH, Valdimarsdottir HB. Psychological distress, health beliefs, and frequency of breast self-examination. J Behav Med. 2000;23(3): 277Y292. 35. Foxall MJ, Barron CR, Houfek J. Ethnic differences in breast self-examination practice and health beliefs. J Adv Nurs. 1998;27(2):419Y428. 36. Murray M, McMillan C. Health beliefs, locus of control, emotional control and women’s cancer screening behaviour. Br J Clin Psychol. 1993;32(1):87Y100.
Cancer NursingTM, Vol. 38, No. 5, 2015
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Paula Alexander Delpech, PhD Glenenna Haynes-Smith, DNP, RN
Breast Self-examination and Health Beliefs in Grenadian Women K E Y W O R D S
Background: Breast cancer incidence and mortality are rising in Grenada, and
Breast cancer
there is a lack of knowledge about women’s beliefs about breast self-examination
Breast self-examination
(BSE). Objective: The objective of this study was to quantify and identify patterns of
Champion revised Health Belief Model Scale
beliefs about health and BSE in Grenadian women to help plan targeted community
Grenada
community parish in Grenada, sociodemographic data and health beliefs were
Health Belief Model
collected using a self-administered questionnaire. The Champion revised Health Belief
interventions. Methods: In this descriptive cross-sectional study of 110 women in a
Model Scale was used to measure general health motivation (5 items), perceived susceptibility to breast cancer (4 items), seriousness of breast cancer (7 items), confidence in performing BSE (7 items), benefits of BSE (2 items), and barriers to BSE (6 items). Results: Younger women were motivated to perform BSE (P = .018), and divorced/separated/widowed women felt more susceptible to breast cancer (P = .014) but perceived fewer benefits in performing BSE (P = .032). Women who did not attend church were more motivated (P = .015) and saw greater benefit (P = .033) in BSE. Frequent church attendees perceived that they were more susceptible (P = .01), were less confident (P G .001), and saw less benefit in BSE (P = .024). Conclusions: There are groups of women in Grenada with belief patterns and sociodemographic characteristics that may benefit from targeted community intervention, perhaps in partnership with other stakeholders such as the church. Implications for Practice: Beliefs about health and BSE affect BSE uptake and are culture dependent. These data help identify the at-risk population to guide the development of targeted community-based and culturally appropriate breast screening programs. Author Affiliations: Division of Nursing, Barry University College of Health Sciences, Miami Shores, Florida (Dr Delpech); and Department of Nursing & Allied Health Sciences, St Georges University, Grenada, West Indies (Dr Haynes-Smith). The authors have no funding or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.cancernursingonline.com).
Correspondence: Paula Alexander Delpech, PhD, Division of Nursing, Barry University College of Health Sciences, 11300 NE 2nd Ave, Miami Shores, FL 33161 ([email protected]). Accepted for publication October 20, 2014. DOI: 10.1097/NCC.0000000000000218
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C
ancer is the second leading cause of death in the Americas after heart disease.1 There were 2.8 million new cases and 1.3 million deaths from cancer in 2012, with 47% of the cancer deaths occurring in Latin America and the Caribbean.2 Globally, breast cancer is the most common female cancer, and approximately 1.1 million new cases are diagnosed annually.3 However, despite stabilization of breast cancer incidence, morbidity, and mortality in high-income countries, incidence and mortality continue to increase in low- and middle-income countries (LMICs),4Y6 with more than half of global breast cancer deaths occurring in LMICs.7 Breast cancer mortality rates are expected to increase by 50% by 2020 in LMICs,8 where public health priorities and resourcing continue to face challenges.9 Numerous breast cancer initiatives have been developed to reduce breast cancer morbidity and mortality, increase breast cancer awareness, improve breast cancer screening, and ensure access to breast care for women in LMICs.10 However, the well-developed breast cancer guidelines developed in resource-rich countries tend to be inappropriate or inapplicable to LMICs because of low numbers of trained healthcare providers, inadequate healthcare infrastructure for diagnosis and treatment, and unique cultural, religious, or social barriers.11 For instance, in our experience, women in LMICs frequently lack awareness and have misconceptions about the process of breast cancer diagnosis and treatment, suffer loss of a husband or partner (and, consequently, income) after mastectomy, and cannot afford out-of-pocket expenses for diagnostic testing. Grenada is a tri-island state in the Eastern Caribbean with a population of 104 000 and comprises the islands of Grenada, Carriacou, and Petit Martinique. Grenada is classified as a middleincome country according to World Bank,12 and it has a mixed population of African, East Indian, and European descent; those of African descent comprise greater than 80% of the population. In Grenada, the primary health network consists of 6 district health centers and 30 medical stations that provide quality community health services to all citizens within a 3-mile radius. The majority of patients are treated in the public health system, and it is estimated that only 7% of the population has private health insurance.13 Doctors, nurses, and their assistants staff these facilities, which, when accessed, are able to deliver both education and treatment. However, fear of breast cancer and lack of awareness pose a significant challenge to women accessing these facilities. The rising incidence of, and increasing mortality from, breast cancer in Grenada is of major concern, and Grenada ranks 23rd in the world for breast cancer deaths.2 Breast cancer is the leading cause of cancer deaths among Grenadian women and accounts for 49% of female cancers in total and 16% of cancer deaths and has an age-standardized incidence of 170.2 per 100 000.14 Grenada has a poorly developed cancer strategy, with no formal cancer policy, strategy, or action plan and a lack of screening facilities in the public sector; mammography is only generally only available for private patients. Given the high incidence of breast cancer in Grenada and the limited resources in the country, breast cancer awareness programs are at best inadequate and at worst nonexistent. As a result, breast cancer commonly remains undiagnosed until late stage or metastatic, when treatment options have less benefit or are simply unavailable.15 The purpose of this study was to quantify beliefs about breast self-examination (BSE) in a sam-
Health Beliefs in Grenadian Women
ple of women living in Grenada in order to identify vulnerable groups that might require prioritizing when planning public health interventions.
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Background
Women who are informed about the importance of breast health and BSE are known to be more confident in performing BSE and more likely to practice BSE.16 Cohen and Azaiza17 used a culturebased tailored telephone intervention to increase BSE practice in 300 Israeli women and showed that women who engaged in the intervention were more likely to practice BSE. In a study to identify and describe barriers to early detection of breast cancer, as well as current breast cancer screening behaviors and attitudes among women on the island of Tobago, low levels of BSE, infrequent clinical breast examination (CBE) as part of regular care, unavailability of mammography services, and cost were shown to be barriers to early detection of breast cancer.18 In Nigeria, a descriptive cross-sectional design was used to study women’s health beliefs and breast cancer screening practices in Nigeria.19 The study concluded that the intention to seek preventive health behaviors was found to have a strong influence on BSE. Another study utilized a community-based health project to increase breast health awareness in rural Nicaraguan women20 and found that women who participated in the program were receptive to learning about breast health and agreed to perform a BSE monthly; the community-based program was also effective for BSE training and breast health promotion in the LMIC setting. In another community-based interventional study in Pakistan, health education on BSE and testicular self-examination was successful,21 with post-intervention assessments showing a significant improvement (of 83% and 72%, respectively; P G .001) in self-examination knowledge among study participants. There is therefore a need to provide culturally appropriate and sustainable breast health awareness initiatives in LMICs, and those programs that are community based and focused on early detection appear to have favorable outcomes. However, the optimal population for prioritizing and targeting interventions remains uncertain.
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Conceptual Framework
In this study, health beliefs about BSE were studied using the Champion22 revised Health Belief Model (HBM). The HBM proposes that changes in health-related behavior are based on several factors: (1) perceived susceptibility (the perceived personal risk of developing breast cancer), (2) perceived seriousness (the perceived degree of personal threat from breast cancer), (3) perceived benefits (the perceived benefits of BSE for the individual), (4) perceived barriers (the perceived negative components of BSE for the individual), (5) perceived confidence (the perceived competence to perform BSE with the perceived ability to detect abnormal lumps), and (6) health motivation (the beliefs and behaviors related to health concerns).23 The HBM offers an approach to understanding health behaviors related to breast cancer. The model hypothesizes that women Cancer NursingTM, Vol. 38, No. 5, 2015
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who believe that they are susceptible to breast cancer are more likely to perform BSE, and women who perceive more benefit from, and fewer barriers toward, BSE are more likely to perform BSE. Conversely, women who are confident in their own ability to perform BSE, and the more motivated they are to engage in health promotion behaviors, are more likely to perform BSE.22 n
Purpose
The purpose of this study was to establish what relationships exist between sociodemographic characteristics (age, marital status, level of education, church attendance, frequency of church attendance, and healthcare-seeking behavior), breast health beliefs, and beliefs about BSE in a sample of women living in a parish in Grenada. These parameters were selected as the most common and easily obtainable sociodemographic variables likely to be related to overall attitudes to health. n
Methods
Design and Sampling Procedure A descriptive cross-sectional study was conducted in a parish in Grenada. A convenience sample of 110 women attending 2 health fairs held in June 2012 and September 2012 were recruited to participate in the study. The inclusion criteria were that women were at least 20 years old, were able to read English, and had not previously had (or did not currently have) breast cancer.
Instruments Demographic information (age, marital status, level of education, church attendance, frequency of church attendance, and healthcareseeking behavior) was collected using a self-administered questionnaire. The Champion revised Health Belief Model Scale (CHBMS), a commonly used and publicly available instrument for measuring the HBM,22 was used to measure health beliefs. The full CHBMS consists of 53 items designed to measure HBM variables related to breast cancer screening including perceived barriers, susceptibility, seriousness, health motivation, perceived benefits, and confidence (or self-efficacy). Although the original and revised versions also question HBM variables related to mammography, only the subscales related to BSE were used in the current study; the ‘‘motivation’’ subscale questions general health-related beliefs, whereas the other subscales are specific to breast cancer and BSE. The CHBMS questionnaire is shown in Document, Supplemental Digital Content 1, http://links.lww.com/CN/A3. All questions in the study were in a Likert format (1Y5, strongly disagree to
strongly agree). Motivation was scored using 5 items, susceptibility using 4 items, seriousness using 7 items, confidence using 7 items, benefits using 2 items, and barriers using 6 items. Responses to subscale items were averaged for each subscale to give a score out of 5 (TSD), with higher scores denoting a ‘‘greater’’ perception of barriers, susceptibility, seriousness, motivation, benefit, or confidence (see also Document, Supplemental Digital Content 1, http://links.lww.com/CN/A3). Cronbach’s ! coefficients, a measure of internal consistency of each subscale, ranged from .61 (benefits) to .93 (confidence) (Table 1); these values were consistent with the original CHBMS for BSE, which ranged from .69 (benefits) to .90 (confidence).24 This was the first time that this instrument had been used in this population.
Data Collection Internal review board approval was obtained prior to data collection from Barry University, Miami, and St Georges University, Grenada. Participants were recruited by the investigators (nurses from the nursing faculty at St Georges University College of Nursing) at health fairs. The 2 health fairs, which are common in Grenada and must be approved by the Minister of Health, were held at a church and a school. During recruitment, prospective participants were provided with an information letter that described the study purpose and procedures and were informed that all information provided would be anonymized and used only within the study by the investigators; they then gave oral consent. Participants were informed that the findings would be used to contribute to the design of breast health awareness programs for women in Grenada and its sister islands. The time for data collection was 20 to 50 minutes.
Data Analysis The Statistical Package for Social Sciences (IBM SPSS Statistics 19; SPSS Inc, Chicago, Illinois) was used for data analysis. Demographic data and data related to the study variables were analyzed in full using descriptive statistics. The Shapiro-Wilk test was used to assess the distribution of the data, which were not normally distributed. Correlations between variables were therefore determined using Spearman rank correlation coefficients, and the Kruskal-Wallis test was used to examine differences in beliefs between demographic groups. P G .05 was considered statistically significant.
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Results
In total, 110 women participated in the study. The demographics of the study population are shown in Table 2. Participants ranged
Table 1 & Means, SDs, and Cronbach’s ! Coefficients of the Belief Subscales Used in This Study (n = 110) Variables Mean SD Cronbach’s !
Barriers
Susceptibility
Confidence
Seriousness
Motivation
Benefits
1.9 0.49
2.5 0.83 .89
2.9 1.0 .93
3.0 0.84 .91
3.5 0.62 .62
3.8 0.55 .61
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Table 2 & Demographics of the Study Participants (n = 110)
Characteristics Age, y 20Y29 30Y39 40Y49 50Y59 60Y69 Marital status Married Single Separate Divorced Widowed Education level Less than high school Completed high school More than high school Employment status Employed full time Employed part time Unemployed Retired No response Who takes care of health Government hospital Private doctor Other No response Church attendance Yes No No response Frequency of church attendance Once or more than once per week Once per month
n
%
28 22 20 29 10
25.5 20.0 19.1 26.4 9.1
38 60 1 5 6
34.5 54.5 0.9 4.5 5.5
55 35 20
50.0 31.8 18.2
39 16 47 6 2
35.5 14.5 42.7 5.5 1.8
57 47 4 5
52 43 3.6 4.5
99 9 2
92 8 1.8
65 33
59 30
The average responses for the 6 belief subscales are summarized in Table 1. Overall, study participants perceived a high level of benefit in performing BSE and were generally highly motivated. They perceived medium levels of seriousness about breast cancer and in their ability to perform BSE to detect abnormal lumps. They perceived low levels of personal risk of developing breast cancer but did not perceive many barriers to performing BSE. Health belief factors were investigated with respect to sociodemographic variables (Table 3). Younger women were more motivated to perform BSE than older women (P = .018), whereas divorced, separated, or widowed women were more likely to believe that they were susceptible to breast cancer (P = .014) but perceived fewer benefits in performing BSE (P = .032). Those women who did not attend church were more motivated (P = .015) and saw greater benefit (P = .033) in BSE and, of those who did attend church, frequent attendees perceived that they were more susceptible (P = .01), were less confident (P G .001), and saw less benefit in BSE (P = .024). Education level, employment, and healthcare provider were not associated with beliefs toward BSE or health-related motivation. Finally, the strength of the relationships between health beliefs was investigated (Table 4). Health-motivated women tended to be more confident (> = 0.383, P G .001) and perceived more benefit in BSE (> = 0.289, P = .002). Women who perceived themselves to be more susceptible to breast cancer lacked confidence (> = j0.480, P G .001) and perceived less benefit in BSE (r = j0.245, P = .01), whereas those who perceived breast cancer to be a serious disease also lacked confidence in BSE (> = j0.309, P = .001) and perceived barriers to performing it (> = 0.295, P = .002).
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in age from 20 to 68 years, with a mean of 41.89 (SD, 13.099) years, and were evenly distributed across age groups. Most of the women were single (54.5%), had less than a high school education (50%), were unemployed (42.7%), attended church at least once per week (59%), and received their healthcare from the government hospital (53%).
Discussion
Here we present, for the first time, the health- and BSE-related beliefs of a group of Grenadian women. Although the respondents were, in general, highly motivated and perceived benefits in performing BSE, distinct subgroups of women could be identified who might benefit more from targeted breast awareness programs. In particular, older women (lacking general motivation); divorced, widowed, or separated women (felt susceptible to breast cancer but did not perceive benefits from BSE); and churchgoers all possessed belief systems that might reduce their chances of
Table 3 & Associations Between Sociodemographic Variables and Beliefsa Motivation
Susceptibility
Seriousness
Confidence
Benefits
Barriers
.018b .223 .555 .564 .602 .015b .241
.139 .014b .908 .421 .362 .213 .010b
.503 .439 .361 .704 .262 .942 .785
.079 .091 .615 .223 .695 .269 G.001b
.327 .032b .522 .969 .874 .033b .024b
.559 .099 .262 .821 .812 .675 .503
Age Marital status Education level Employment Status Healthcare provider Church attendance Attendance frequency a
Values are Kruskal-Wallis P values. Significant at the.05 level (2-tailed).
b
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Table 4 & Relationships Between Health Beliefs and Beliefs About Breast Self-examination Motivation Susceptibility Seriousness Confidence Benefits Barriers
a
Correlation P Correlation P Correlation P Correlation P Correlation P Correlation P
Motivation
Susceptibility
Seriousness
Confidence
Benefits
Barriers
1.000 V j0.240b .012 j0.213b .025 0.383c .000 0.289c .002 j.0125 .193
1.000 V 0.136 .157 j0.480c .000 j0.245c .010 0.132 .169
1.000 V j0.309c .001 j0.172 .073 0.295c .002
1.000 V 0.394c .000 j0.205b .032
1.000 V j0.252c .008
1.000 V
a
Spearman rank correlation. Correlation is significant at the .05 level (2-tailed). Correlation is significant at the .01 level (2-tailed).
b c
performing BSE and consequently increase breast cancer risk. In a resource-poor country such as Grenada, which also lacks coherent health awareness initiatives, these data might help to identify susceptible groups who might benefit from targeted community intervention. There are almost no specific data relating to breast cancer (either screening, risk, or treatment) in Grenadian women (or indeed the wider Caribbean community), making it challenging to design culturally appropriate and cost-effective breast screening programs. Screening uptake for cervical cancer in the Caribbean is, however, known to be poor; in 1 study, 25% of a group of women from Jamaica, Trinidad and Tobago, and the Virgin Islands had had no previous cervical smear, compared with 10% of US-born black women.25 Ethnicity is known to influence BSE practices, with observable differences in perception of worry and BSE practices even within major racial categories, such as within black women of different racial groups or the use of screening programs by subpopulations of Hispanic women.26,27 However, the majority of these studies relate to first- or second-generation US immigrants rather than native populations and their particular context, making the results difficult to extrapolate to the Grenadian setting. Although mammography has been shown to play a vital part in early detection and improved survival from breast cancer in highincome countries, it is the most costly of the 3 recommended methods for early detection (BSE, clinical examination, and mammography). There is controversy surrounding the efficacy of BSE as a screening tool, and a meta-analysis of 20 studies failed to show a clear benefit from BSE for early breast cancer detection.28 However, BSE can certainly help to discover malignant lesions and, according to some commentators, may reduce breast cancerrelated deaths by as much as 18%.29 It therefore remains a costeffective tool for LMICs, where sophisticated diagnostic screening methods are frequently unaffordable and unavailable.19 Breast self-examination, when used as part of health awareness and CBE, is associated with early detection and improved outcomes for women in LMICs30 and therefore remains of value. According to a report published by the Breast Health Global Initiative (BHGI),15 cancer awareness educational campaigns are critical for the effective treatment and diagnosis of breast cancer,
are relatively inexpensive, and are therefore suited to low-resource countries. In 2005, the BHGI recommended that all women have the right to access affordable healthcare and to receive breast health education that is culturally appropriate and tailored to the specific population.15 In terms of early detection, the BHGI recommended that breast health awareness should be promoted using CBE in both symptomatic and asymptomatic women and organized screening using CBE or BSE, and feasibility studies of mammographic screening should be undertaken in regions of the world that are not economically strained. Although the American Cancer Society no longer recommends BSE, it should be noted that BSE remains an important screening mechanism for economically and culturally poor regions where access to mammography is limited or nonexistent.31Y33 Psychosocial factors are known to be associated with BSE uptake, and therefore targeting specific subgroups of women with particular beliefs and attitudes is likely to translate into change on BSE behavior. In general, our results were consistent with the HBM hypothesis; health-motivated women were more confident and perceived more benefit in BSE, women who perceived themselves to be more susceptible to breast cancer lacked confidence and perceived less benefit in BSE, and those who perceived breast cancer to be a serious disease also lacked confidence in BSE and perceived barriers to performing it. Confidence, perceived benefits from BSE, and perceived susceptibility to breast cancer are all associated with more frequent BSE.34Y36 Because women who were widowed, divorced, and separated and those who attended church most regularly were more likely to have poor confidence and high perception of susceptibility, the church might provide a platform by which community breast cancer awareness programs are implemented or information disseminated in a culturally sensitive manner. This study has a number of limitations. The population was a convenience sample of health fair attendees; this population was therefore likely to be predisposed to seeking health-related information and this is a likely source of bias. It is unknown whether this population was completely representative of the population as a whole and therefore whether the data are fully generalizable. In addition, the study size was relatively small.
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Conclusions and Implications for Practice
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Women in LMICs continue to be at particular risk of developing and dying of breast cancer. Here we identify groups of individuals with particular belief patterns and sociodemographic characteristics that may benefit from targeted community intervention, perhaps in partnership with other stakeholders such as the church. These data help guide the development of community-based and culturally appropriate programs that can integrate into the current health services in Grenada and help break negative cycles of belief that contribute to poor breast cancer outcomes. Given the success of global health initiatives (such as by the US Government Global Health Programs), support from these initiatives could also be considered as part of the intervention. In terms of practice, Grenada has a well-developed primary healthcare system that is well integrated with the community. Practitioners are similarly well integrated and have access to the individuals most at need of intervention; they are best placed to convey the specific message that breast cancer is treatable and curable if diagnosed early. Health education is not limited to patients, and providers can also benefit; they too require specific training about early detection, screening, and the barriers affecting women trying to access services, and training will require specific resourcing. There is an urgent need for a well-organized screening program in Grenada that includes BSE, clinical examination by a healthcare provider, and screening mammography, and practitioners have a role to play in driving and championing policy change. ACKNOWLEDGMENTS
The authors thank Dr Clarice Modeste, Minister of Health; Ms Ann Hopkin, MPH, RN, from the South St Georges Association; and the many women from St Mark who participated in the project.
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