Breast cancer is a major public health issue and the most commonly diagnosed cancer for women worldwide [
A recent study conducted by Ziegler and colleagues (2008) projects that based on a representative sample of Chinese women from both urban and rural areas, the age-standardized breast cancer incidence rate in China will be 87.8 per 100,000 women by the year 2021 [
Not only is the overall incidence rate for breast cancer rising in China, but also, another intriguing fact is that women in China are diagnosed with breast cancer at an earlier age than Caucasians. In Hong Kong, the incidence of breast cancer occurs at the highest rate at the age of 40 years [
Early detection of breast cancer through regular screening modalities and enhanced treatment has been found to decrease mortality rates by 25–30% [
The purpose of this descriptive study was to explore the relationships of sociodemographic characteristics, knowledge, and beliefs about breast cancer (BC) and their practices to the self-reported practice of BC screening (BCS) among women in China. The specific aims were to (a) describe the sociodemographic characteristics, knowledge, beliefs, and mammography screening practices of women in China ages 40 and older and (b) identify correlates of BCS practices.
In this cross-sectional study, the data was collected from the Wuhan, the capital city of Hubei Province, an important central city as the political, economic, scientific and technological, cultural, and financial center in inland China. The study sample consisted of 400 Chinese women aged 40 years and older. This study protocol was reviewed and approved by the Institutional Review Board for conducting this research.
The study participants were recruited at the gatherings of community centers, parks, and temples. The study aim was explained to eligible women, who were assured that their participation would be voluntary and confidential. After consents were obtained, the participants completed the survey, which took approximately 20–30 minutes.
The study measurement survey included two parts: (a) Chinese Mammogram Screening Beliefs Questionnaire (CMSBQ) and three subscales were used in current study: (1) perceived self-efficacy (2 items; sample item: I am confident in my ability to obtain breast cancer screening regularly), (2) perceived benefits subscale (7 items; sample item: having breast cancer screening will help to find breast lumps early), and (3) perceived barriers subscale (21 items; sample item: I feel uncomfortable taking off clothes in front of health professionals during the screening). Possible responses to the items ranged from 1 (strongly agree) to 4 (strongly disagree). Each subscale was scored by calculating the means of all item scores. The findings of benefits and barriers subscales among Asian women demonstrated excellent supportive psychometric properties with promising Cronbach’s alphas above 0.70, and the results from the confirmatory factor analysis supported construct validity with good model fit indices [
Data analyses were performed using the SPSS statistical software package (Version 18.0). Descriptive statistics, including percentages, means, and standard deviation (SDs), were calculated. Next, multivariate logistic regression analysis was performed to examine the associations of demographics, knowledge, beliefs, and behavioral factors with the probability of having received mammograms/ultrasounds after accounting for all other factors in the model. These associations were expressed in the form of adjusted odds ratios with 95% confidence intervals (CI).
Qualitative analytic techniques were employed for the analysis of the open-ended questions. The primary researcher and two research associates reviewed and coded participants’ responses separately to uncover emerging themes and categories of the responses. The coding of the responses was then discussed and verified by two senior investigators with expertise in cancer control and qualitative research. Once consensus on coding was reached by the research team, the set of themes/categories were finalized. To complete each content area, quotes from the responses have been highlighted to illustrate the category. Discrepancies between the two researchers were resolved through iterative discussions until consensus was reached. Both the content and frequency of the responses were then analyzed.
The sociodemographic characteristics of the study participants are presented in Table
Demographic characteristics of study participants.
Characteristic | Frequency | % |
---|---|---|
Age, years | ||
40–49 | 155 | 39 |
50–59 | 179 | 45 |
60+ | 65 | 16 |
Marital Status | ||
Married | 385 | 96 |
Widowed/divorced/separated | 14 | 4 |
Never married | 1 | — |
Income (monthly) | ||
<$2600 RMT (equals to U.S. $410) | 77 | 20 |
2601–4600 RMT (U.S. $411–$725) | 189 | 47 |
4601–11500 RMT (U.S. $726–$1,812) | 107 | 27 |
11501–16500 RMT (U.S. $1,813–$2,600) | 19 | 4 |
16501–23000 RMT (U.S. $2,601–$3,625) | 4 | 1 |
>23001 RMT (>U.S. $3,626) | 4 | 1 |
Occupation type | ||
Unemployed | 43 | 11 |
Blue collar | 90 | 23 |
White collar | 113 | 28 |
Retired | 148 | 37 |
Other | 4 | 1 |
Level of education | ||
None | 16 | 4 |
Elementary school | 23 | 6 |
Middle school | 97 | 24 |
High school | 179 | 45 |
Vocational school | 32 | 8 |
Bachelor’s degree | 45 | 11 |
Master’s degree | 7 | 2 |
Diagnosis of breast cancer | ||
Yes | 8 | 2 |
No | 391 | 98 |
Do not know | 1 | 0 |
Family history of breast cancer | ||
Yes | 8 | 2 |
No | 391 | 98 |
Health insurance | ||
Yes | 189 | 47 |
No | 211 | 53 |
Health insurance covering mammograms ( |
||
Yes | 74 | 35 |
No | 35 | 17 |
Do not know | 102 | 48 |
RMT: Renminbi, Chinese currency.
Note:
(1) due to missing data, the frequency did not add up to the total sample size.
(2) marital status and education level distribution is similar to China 2000 census; however, the education level in this sample is higher. The comparisons in other variables were not available.
As shown in Table
Knowledge beliefs and practice of breast cancer screening.
Characteristic | Frequency | % |
---|---|---|
|
||
Heard of breast self-exam ( |
||
No | 79 | 19.8 |
Yes | 321 | 80.2 |
Practice of breast self-exam ( |
||
Never | 166 | 47.7 |
Once every year | 1 | — |
2–6 times a year | 93 | 26.7 |
7–11 times a year | 20 | 5.8 |
Once every month | 68 | 19.5 |
|
||
Heard of CBE ( |
||
Yes | 132 | 33.2 |
Obtaining most recent CBE ( |
||
Never | 141 | 35.2 |
Do not remember | 44 | 11.0 |
More than 2 years ago | 80 | 20.0 |
Less than 2 years | 135 | 33.8 |
|
||
Heard of mammograms ( |
||
Yes | 165 | 41.2 |
*Obtaining mammogram(s) in past 5 years ( |
||
Yes | 83 | 24.5 |
Obtaining mammogram(s) in the past year ( |
||
Yes | 52 | 13.0 |
|
||
Heard of ultrasounds ( |
||
Yes | 191 | 47.9 |
*Obtaining ultrasound(s) in past 5 years ( |
||
Yes | 77 | 23.6 |
Obtaining ultrasound(s) in the past year ( |
||
Yes | 48 | 12.1 |
| ||
Beliefs: CMSBQ Subscales | Mean | S.D. |
| ||
Self-efficacy (range: 1–4) | 2.4 | 0.6 |
Barriers (range: 1–4) | 2.5 | 0.4 |
Benefits (range: 1–4) | 3.2 | 0.5 |
Note: due to missing data, the frequency did not add up to the total sample size.
*The calculation of this item was based on a selective sample of 326 women ages between 45 and 75.
The study tool asked the respondents to name up to three of the most important reasons that prevented women from having regular breast cancer screening. In this sample, 346 women (86.5%) gave 807 responses related to their perceptions on barriers toward BC screening.
Ten themes emerged from the participants’ responses to the question of barriers to breast cancer screening (Table
Self-reported barriers toward breast cancer screening.
Characteristic | Frequency | % |
---|---|---|
Low priority | 217 | 63 |
Feeling OK | 202 | 58 |
Lack of info/knowledge | 145 | 42 |
Cost | 114 | 33 |
Logistics | 34 | 10 |
Had other exam(s) earlier | 26 | 8 |
Fear of finding cancer | 19 | 6 |
Discomfort | 16 | 5 |
Doctors not recommending it | 9 | 3 |
Radiation | 4 | 1 |
As shown in Table
Logistic regression analyses were conducted modeling the odds of ever having screening done within the previous five years. The
Factors associated with breast cancer screening.
Variables | Coefficient | Standard error | Significance |
Odds ratio | 95% CI |
---|---|---|---|---|---|
Age | 0.00 | 0.02 | 0.81 | 1.00 | (0.97, 1.04) |
Education | 0.14 | 0.13 | 0.29 | 1.15 | (0.89, 1.49) |
Insurance | 0.25 | 0.28 | 0.37 | 1.28 | (0.75, 2.21) |
Perform BSE | 1.51 | 0.43 | 0.00** | 4.53 | (1.94, 10.57) |
Perform CBE | 1.11 | 0.34 | 0.00** | 3.04 | (1.56, 5.92) |
Self-efficacy | 0.67 | 0.31 | 0.03* | 1.95 | (1.07, 3.55) |
Barriers | 0.16 | 0.41 | 0.67 | 1.18 | (0.52, 2.64) |
Benefits | −0.05 | 0.30 | 0.88 | 0.95 | (0.53, 1.71) |
Knowledge | −0.07 | 0.09 | 0.45 | 0.93 | (0.78, 1.12) |
Interaction between CBE and BSE | −1.26 | 0.63 | 0.04* | 0.28 | (0.08, 0.97) |
Note: BSE: breast self-exams, CBE: clinical breast exams; **
While breast cancer incidence has been historically less prevalent in Asian countries compared to the West, recent statistic data reveal breast cancer incidence rates have had a 20–30% increase in China in the past decade according to China’s urban cancer registries [
The results provided evidence that few Chinese women in the study sample participated in any BCS modalities (mammography, ultrasound, CBE, and/or breast self-exams); specifically, only 30% of women reported they had CBE done in the past two years and 70% of women never had a mammogram. The rates reported in the current study were even lower than the rates of (43–64%) in previous studies conducted in other regions of China (i.e., Beijing, Shanghai, Guangzhou, and Xi’an) [
Nevertheless, the mediating effects of psychosocial and cultural variables on the impact of breast cancer intervention in low-to-middle income countries (LMC) are still understudied [
In terms of knowledge and attitudes related to breast cancer screening, Chinese women participants in the current study had much lower knowledge levels about breast cancer and risk factors, perceived less susceptibility, and reported greater barriers to screening and lower self-efficacy compared to study findings on immigrant Chinese women in the U.S. [
The study participants were also cognizant about their lacking awareness in breast cancer. The data lent support for the recent release of the Consensus Statement from the Breast Health Global Initiative that indicated a lack of public awareness in the importance of early detection of breast cancer in LMCs [
The study found positive associations between ever having had a mammogram, having CBE within the past two years, and performing monthly breast-exams, that is, adoption of one screening practice was positively correlated with other breast screening modalities in the current study. This finding was consistent with a previous study conducted in the U.S. among immigrant Asian women [
Financial cost emerged as one of the top five barriers for Chinese women in this study to access mammography screening. This finding is consistent with other studies done in Hong Kong and immigrant Chinese women in the U.S. Women’s lack of resources, combined with cultural and attitudinal barriers, along with limited access to affordable mammography services directly affect the likelihood of BCS since women with low incomes may have many other competing priorities related to survival that make breast cancer screening a low priority. The responses of study participants suggest that they might be amenable to engage in more BCS if they were more aware of what was available to them and if they still have access to preventive services such as mammograms after they retire. In 2008, the Chinese Ministry of Health started a program on early detection and treatment of cancer sponsored by central financial assistance that provide CBE, mammography, and ultrasound for women in 30 provinces in China. Efforts to develop programs and/or policies to improve breast cancer screening will be more successful if the implementation includes strategies to increase cancer knowledge, awareness, and information and complementary efforts to help women address emotional, socioeconomic, and other barriers to clinical breast exam and mammography use.
The current study had several limitations. First, due to the nature of self-report data, there may have been over- or under-reporting of screening practices. Future studies with a combination of self-report and verification from objective chart reviews are warranted to ensure the accuracy in reporting socially desired behaviors, such as cancer screening. Second, because the use of convenience sample and small sample size, this approach can lead to sampling error; therefore, the results cannot be generalized to other regions/provinces in China, a country with more than 1.3 billion citizens with diverse socioeconomic and cultural backgrounds. Nevertheless, based on the demographics in the current study sample, the study recruited relatively diverse groups of women with a wide range of income and educational levels.
Changes in breast cancer incidence and distribution of breast cancer patterns in Chinese women present opportunities for developing and implementing effective public health programs to promote BCS for women in China. It is essential that public health campaigns focus on the importance of early detection and prevention that target both general public and health care professionals working directly with their clients. The findings of this descriptive correlational study provide a foundation to better understand beliefs and attitudes of Chinese women toward BCS. The concept of screening while asymptomatic is lacking and a low priority toward BCS was observed in the current study. As a result, this study highlights a critical need among general public, health professionals, and the health care system to work collaboratively toward narrowing the gap in BCS and to improve the quality of breast cancer care in this population.
The project was supported by a Sabbatical Leave Award from Eastern Michigan University and Susan G. Komen for the Cure. The authors are extremely grateful to the Chinese women who participated in the study and appreciated the assistance from the Healthy Asian Americans Project (HAAP) team members, Yanxia Cao and Soo Ji Ha during the project period and paper preparation, HAAP’s collaborators in China (Chunxiao Wu and Jianguo Shi), and Alethea Helbig who provided editorial assistance with earlier drafts of the paper.