Knowledge, Attitudes and Behaviors Relating to Breast Cancer Detection in Asian Indian Immigrant...

8/18/2019 Knowledge, Attitudes and Behaviors Relating to Breast Cancer Detection in Asian Indian Immigrant Women

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KNOWLEDGE, ATTITUDES AND BEHAVIORS RELATING TO BREAST CANCER DETECTION IN ASIAN INDIAN IMMIGRANT WOMEN

BY

NIRUPA MA NEN E

A Thesis Submitted to the School of Graduate Studies

in Partial Fulfillment for the Requirement for the Degree of

Master of Public Health

Southern Connecticut State University

New Haven, Connecticut

May 2006

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KNOWLEDGE, ATTITUDES AND BEHAVIORS RELATING TO BREAST CANCER DETECTION IN ASIAN INDIAN IMMIGRANT WOMEN

BY

NIRUPAMA NENE

This thesis was prepared under the direction o f candidate’s thesis advisor, Dr. John Nwangwu,

Department of Public Health, and it has been approved by the members o f the candidate’s thesis

committee. It was submitted to the School of Graduate Studies and was accepted in partial

fulfillment o f the requirements for the degree o f Master o f Public Health.

John T. Nwangwu, Dr.P.H., M.B.

Thesis Advisor

June 27, 2006

Date

ancbp SelsH&Uwn’h.D., M.S.

Second Reader

idra C. Holley, Ph.f).)ean, School of Graduate Studies

William G. Faraclas, Dr.P.H., M.P.H.

Department Chairperson

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ABSTRACT

Author: Nirupa ma Nene

Title: KNOWLEDGE, ATTITUDES AND BEHAV IORS RELATING TO

BREAST CANCER DETECTION IN ASIAN INDIAN IMMIGRANT

WOMEN

Thesis Advisor: Dr. John Nwangwu, Department of Public Health

Institution: Southern Connecticut State University

Degree: M aster of Public Health

Year: 2006

Breast cancer is the second leading cause of cancer-related death in women in the United

States (American Cancer Society, 2006). Breast cancer screening has been shown to reduce

breast cancer mortality . Women of certain race and eth nic subgroups and those who immigrated

to the United States within last 10 years are less likely to have had a recent mammogram. The

purpose of this study was to assess the knowledge of breast cancer risks and screening practices,

related attitudes and screening behavior among Asian Indian immigrant women in Connecticut.

The data was collected from a convenience sample of 91 Asian Indian Imm igrant women who

were 35 years or over via a self-administered survey. The study finding revealed that a large

majority of women were knowledgeable about the common risk factors for breast cancer. Results

indicated that perceived benefits outweighed perceived barriers to mammogram screening.

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Although many participants did not consider themselves at risk for breast cancer, recent

utilization of mamm ography screening by eligible wom en was very high.

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TABLE OF CONTENTS

CHAPTER ONE - INTROD UCTION ........................................... 1

Background......................................................................... 1

Statement of the Problem ................................................................................................. 4

Research Ques tions ............................................................................................. 5

Definition of Terms..........................................................................................

5

Limitations of the S tudy .................................................................................................. 6

Delimita tions of the S tu dy ................................................ 6

Assumptions........................ 7

Significance of the Study ..................................................... 7

Summary.................................................................................. 8

CHAPTER TWO - REVIEW O F LITERATURE ...................... 9

Introduction .................. 9

Breast Cancer Risk F actors ............................................. 9

Breast Cancer and Screen ing .......................................... 12

Asian Am erican Women and Breast Ca nc er ................................................................. 15

Asian Indian Women and Breast Cancer .............................

17

Health Belief Model..... .................................................. 19

Summary ......................... 20

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CHAPTER THREE - METHODOLOGY AND PRO CED URE S ....................................... 21

Study Des ign....................................................................................................................... 21

Study Population ................................................................................................................. 21

Sampling Procedures.............................................................

22

Instrumentation.................................................................................................................. 23

Institutional Review Board ................................................................................................ 24

Pilot Te st ................................................................................................................................. 24

Data Collection Proced ures.................................................................................................. 24

Data Analysis Pr oced ures ................................................................................................. ....25

Schedule of Activities.......................................................................................................................25

Summary............................................................................................................................... 26

CHAPTER FOUR - DATA ANALYSIS AND R ES U LT S .................................................. 27

Introduction ........................................................................................................................ 27

Age of Respondents .......................................................................................................... 28

Knowledge of Breast Canc er ........................................................................................

29

Knowledge of Breast Cancer Detection and Screenin g Prac tices ................................ .32

Susceptibility, Benefits and Barriers to Mam mograph y Screen ing ................................ 33

Susceptibility.................................................................................................................... . 33

Benefits of Mammography Screening.................... 34

Barriers to Mammography Screening ................. 35

Mammography Screening Behaviors................................... 37

Summary .................................................................................... 38

CHAPTER FIVE - DISCUSSION ................................................... 39

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Introduction.......................................................................................................................... 39

Discussion .......................................................................................................................... 39

Knowledge of Breast Cancer Risk Factors ................................................... 39

Perception of Susceptibility to Breast Can cer ................................................ 40

Knowledge about Breast Cancer Screening ..................................................... 41

Benefits of Mammography Screening ................................................................... 41

Barriers to Mammography Screening ............................................................ 42

Mamm ography Screening Behaviors.............................................................. 42

Strengths and Weaknesses of the Stud y .......................................................... 43

Recommendations for Future Res earch ................. 44

Conclusion......................................................................................................................... 45

APPENDICES ...................................................................... 47

Appendix A- IRB A pproval Le tter .............................. 48

Appendix B- Permission to Adapt the Instrument ............................................................ 50

Appendix C- Cover Letter ..............................

54

Appendix D- Informed Consent........................... 55

Appendix E- Questionnaire............................................................................................ 56

REFERENCES .............................................................................. 60

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LIST OF TABLES

Table 1. Schedule o f Ac tivities ....... .............................................................. ....25

Table 2. Age o f Respondents ................. ...... ..................................................... ............. ................ 28

Table 3. Level o f Pa rt ic ip ants ’ BreastCancer General Kn ow ledge .................... 31

Table 4. Mean Scores o f Participan ts ’ Atti tude s Re ga rd ing Ba rriers to Mam mog raphy

Screening ....................................... ...................... .............................. .................................. 36

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LIST OF FIGURES

Figure 1. Age distribution of participants according to screening guide lines ............ 29

Figure 2. Participants’ Scores on Breast Cancer Kno wledge T es t...................................... 30

Figure 3. Participants’ Responses to How the Most Breast Lum ps are Fo un d ....... 32

Figure 4. Participants’ Responses to "Susceptibility" Sc ales ..................................... 34

Figure 5. Participants' Responses to "Benefits" Sca les .................................................. 35

Figure 6. Participants’ Last M amm ogram ......................................................................................... 37

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CHAPTER ONE

INTRODUCTION

Background

Cancer is the second leading cause of death in Am erica according to the National Center

for Health Statistics (NCHS) mortality data for 2002 (Anderson & Smith, 2005). Deaths caused

by heart disease, the nu mber one killer in America and cerebrovascu lar diseases decreased from

1975 to 2002, but cancer deaths increased to some extent (National Cancer Institute [NCI],

2005a). It is estimated that in the U.S. 1,339,790 new cases of cancer would be diagnosed in

2006. Out of this the new cancer cases estimated in w omen are 679,510 (Am erican Cancer

Society, 2006). All women are at risk for breast cancer. One in every eight women in the U.S.

has a lifetime probability of developing breast cancer (NCI, 2005a). It is the most commonly

diagnosed cancer in American women, except for skin cancer. In 2006, estimated 212,920 new

cases of breast cancer will be diagnosed among women. An estimated 40,970 w omen will die of

this disease (American Cancer Society, 2006).

Although breast cancer is more common in US and other industrialized western nations,

it occurs globally. Breast cancer is the third most commonly occurring tumor in the world and

represents 10% of the global cancer burden. According to the International Agency for Research

on Cancer (IARC) Globocan 2002 data, 1,151,298 new cases of breast cancer occur yearly in the

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world (Ferlay, Bray, Pisani, & Parkin, 2004). A total of 410,712 deaths are attributed to breast

cancer in the world annually. Breast cancer makes up 20.1% of all the female cancers. The

leading cause of cancer deaths among females is breast cancer, which causes 14.9% of all the

female cancer deaths (Shibuya, Mathers, B oschi-Pinto, Lopez, & M urray, 2002).

Breast cancer affects women o f all races and ethnicities. D uring 1992-2000, breast cancer

incidence rate increased more among Asian and Pacific islanders than any other race/ ethnicity

(American Cancer Society, 2005). Established and probable risk factors for breast cancer include

age, gender, family history, geographical variation, age at menarche and menopause, age at first

full pregnancy, previous benign disease, cancer in other breast, socioeconomic group, diet, body

weight, alcohol consumption, exposure to ionizing radiations, taking exogenous hormones (oral

contraceptives, hormone replacement therapy, DES), and physical activity (Fentiman, 2001;

Sasco, 2003; McPherson, Steel & Dixon, 2000). It is important to note that several risk factors

and genetic markers for breast cancer incidence are identified but more than 50% of cases occur

in women w ithout known major predictors. It is not possible to prevent b reast cancer with

current knowledge and available technology. It is possible that a woman of average risk for

breast cancer might r educe he r r isk somewhat by changing those modifiable risk facto rs, such as

giving birth to several children and breast feeding them for several months, avoiding alcohol,

exercising regularly, and maintaining optimum body mass index (Fentiman).

The most important action a woman can take is to follow early detection guidelines.

Breast cancer cannot be prevented but if detected early, the 5-year survival rate for localized

breast cancer is 97% (American Cancer Society, 2005). All lum ps are no t de tec tab le by touch.

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Mam mography is a low-dose X-ray exam ination that can detect breast cancer up to two years

before it is large enough to be felt. American Cance r Socie ty guidelines (2005) for early

detection of breast cancer recommend clinical breast exam ination every three years for women

ages 20 to 39 and yearly for women 40 years and older. The guidelines also recommend yearly

mam mogram and optional monthly breast self-examination for w omen after 40 years of age.

According to these new guidelines, breast self-examination is optional. These guidelines ask

women to be self-aware about their breasts and any changes.

Women, who have less than a high school education, are older, live below the poverty

level or are members of certain racial and ethnic minority groups have shown to under use

mamm ography tests (Centers for Disease Control and Prevention [CDC], 2002). A ccording to

the Surveillance, Epidemiology, and End Results (SEER) 2001 data, the breast cancer survival in

Whites is 89.5% whereas in African Americans it is 75.9% (NCI, 2005a). According to the Fred

Hutchinson Cancer Research Center study, Blacks, Hispanics and Native Americans are 1.7-2.5

times more at risk to be diagnosed at the later stage of cancer (Li, Malone, & Daling, 2003).

Harold Freeman , director of the National Cancer Institute Center to reduce cancer health

disparities confirmed the existence of a breast cancer racial gap related to cancer prevention,

early detection and treatment (Vastag, 2003).

According to a report by Chopra (2001), breast cancer is the second most common cancer

after cervical cancer in women in India. Current estimates suggest 75,000 new cases occur every

year. This is not the complete picture as national cancer registry and hospital-based tumor

registries in India sample only three percent of the total population. According to a news report

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in India, it is said that one in every nine women in India between the ages 30 to 50 would

develop breast cancer in their lifetime. In India around 50% of women come in at the last stage

of cancer, when nothing much can be done. The research shows that relative risk of breast cancer

changes in migrant populations, evolving rapidly to those of the US populations (Ziegler et al.,

1993). In the light of these facts, it is important to understand the risk of breast cancer associated

with Indian immigrant women and their perceptions regarding screening practices. Information is

limited for Asians and P acific Islanders (API), p articularly for disagg regated subgroups,

regarding early detection of breast cancer even as these populations are increasing in the US. The

purpose of this study is to explore know ledge, attitudes, and beliefs abou t breast cancer risk

factors and screening beh avior among Asian Indian imm igrant women in Connecticut.

Statement o f the Problem

One of the Healthy People 2010 objectives is to increase the proportion of women aged

40 years and older who have received a mam mogram within the preceding 2 years (Department

of Health and Human Services [DHHS], 2000). According to the National Health Interview

Survey (cited in American Cancer Society, 2005), 58.8% of Asian women obtained

mamm ography screening within the past two years and only 48.0% o f Asian women had

mammography screening within the past year. This is below the Healthy People 2010 target of

70% of women aged 40 and above getting screened. Research suggests that race/ ethnicity along

with other socioeconomic factors are associated with the difference in screening rates (Qureshi,

Thaker, Litaker, & Kippes, 2000; Campbell, 2002; Rawl, Champion, Menon, & Foster, 2000).

According to Swan, Breen, Coates, Rimer, and Lee (2003) women who immigrated to the United

States within the last 10 years are more likely to have low utilization o f mammography. There is

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not sufficient research regarding breast cancer risks and screening behavior in the subsets of

Asian imm igrant population. If the attempts are not mad e to unde rstand this minority

populat ion, disparities associa ted with breast cancer ou tcom e may increase in the future .

Research Questions

The research questions are based on the constructs of the health belief model. The

following research questions pertain to Asian Indian immigrant women in Connecticut:

1. Wh at is the knowledge of Asian Indian imm igrant wom en regarding breast cancer risk

factors?

2. What is the perception o f Asian Indian wom en regarding their susceptibility to the

disease?

3. What is their knowledge about breast cancer screening?

4. Do they participate in mammography screening if they are of eligible age?

5. What are the perceived benefits and barriers to mamm ography practice?

Definition o f Terms

The following definitions pertain to terms used in this study:

Invasive cancer. Cancer that has spread beyond the layer of tissue in which it developed

and is growing into surrounding, healthy tissues. Also called infiltrating cancer (National Cancer

Institute Dictionary, n.d.).

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Asian. The term “Asian ” refers to people having origins in any of the original peoples of

the Far East, Southeast Asia, or the Indian subcontinent (for example, Cambodia, China, India,

Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam). Asian groups

are not limited to nationalities, but include ethnic terms, as well (Census Bureau, 2000).

Health Bel ie f Model. The Health Belief Model (HB M) is a psychological model that

attempts to explain and predict health behaviors by focusing on the attitudes and beliefs of

individuals (Glanz, Rimer, & Lewis, 2002).

Mammogram. A m ammogram is an X-ray picture of the breasts (National Cancer

Institute Dictionary, n.d.).

Limita tions o f the Study

The following limitations are present in this study. This study used survey questionnaires

for data collection. The knowledge and behaviors are self-reported. Self-reporting jeopardizes

accuracy of the data because of respon den ts’ selective mem ories in recalling past events,

experiences and behavior (recall bias). There could also be respondents’ failure to reveal the

information requested (reporting bias). The respondents might have altered the responses and

tried to present socially desirable qualities (social desirability bias).

Delim ita tio ns o f the Study

This study used a small convenience sample in Connecticut. The women who

volunteered to participate in the survey were selected from the mailing lists available from

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different informal groups. This might not be the accurate representation of all the Asian Indian

women in the United States. Asian Indians are a very diverse group who speak different

languages, have different food habits and cultural practices. Due to financial and time

constraints, a survey instrument in English was used. This questionnaire was not linguistically

customized for all the participants. This may limit the accuracy of responses.

Assum ptions

The major assumption for this study was that each participant would respond honestly. It

is assumed that respondents understood English and could interpret the questions correctly. It is

also assumed that the person com pleting the questionnaire was the person to w hom the

questionnaire was ad dressed and not another mem ber of the household.

Significance o f the Study

The Census B ureau projects that the Asian-American population w ill grow to 37.6

million individuals by the year 2050, comprising 9.3% of the population. The Asian population

grew faster than the total population between 1990 and 2000 according to the 2000 Census.

Asian Indians are the second largest subset of the Asian population. Asian Indians are a

comparatively new set of immigrants to the United States. They represent a wide variety of

languages, dialects, and cultures as different from one another as from other Asian and non-

Asian groups. The problems and needs of this immigrant population have been overlooked due

to its’ small numb er and newness. Due to the “myth of Model M inority” associated with Asian

popu lation health needs of th is population are not addressed sufficiently. Th is study attempts to

fill the research gap pertaining to Asian Indians by using the Health Belief Model to gain insight

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into the knowledge, attitudes and behaviors of Asian Indian women regarding breast cancer. This

would help in planning breast cancer prevention and health promotion strategies in the future for

this minority group.

Summary

Wom en of all ethnicities and races are at risk for breast cancer. T o reduce the im pact of

the disease and improve health related quality o f life, early detection of breast cancer is

important. Identifying knowledge and attitudinal factors associated with breast cancer and

mammography will allow planning health promotion and education strategies that are

appropriate and culturally sensitive for Asian Indian im migrant w omen.

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CHAPTER TWO

REVIEW OF LITERATURE

Introduction

The focus of this study was to identify the level of knowledge, attitudes regarding breast

cancer and early detection screening behaviors am ong Asian Indian imm igrant women in

Connecticut. The Health B elief Model (HBM ) was used to identify perceived susceptibility and

severity of breast cancer in the study population. The study helped in understanding the

pe rceived benefits and barriers regarding breast canc er screening procedures . The rev iew of

literature for this study begins with the risk factors associated with breast cancer and importance

of screening for breast cancer. The following review consists of different breast cancer studies

perta ining to Asian American popu lat ions. Th e lite rature review furth er concentrates on Asian

Indian women and breast cancer. The review also documents HBM as the main health education

theory in guiding this research. Finally in essence, this literature review provided the in-depth

backgrou nd fo r the objec tive of this study.

Breas t Cancer R isk Factors

Risk factors are the factors or conditions that affect the likelihood of developing breast

cancer. Meister and Morgan (2000) describe all the risk factors for breast cancer under three

categories.

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The first category of “established” risk factors for breast cancer are gender, age, previous

history, family or genetic factors, reproductive history, obesity, physical inactivity, and exposure

to high doses of radiation. The U.S. Preventive Services Task Force report (2002b) states that the

risk of developing breast cancer increases from the age of 40. For w omen of ages 50 and older,

the risk increases further. W omen with reproductive history of early onset of menarche and late

menopause have a slightly h igher chance of developing breast cancer (Meister & Morgan, 2000).

The other aspect of reproductive history that affects breast cancer risk is woman’s age at first full

term pregnancy. Chie et al. (2000) found that the risk related to a first birth is especially elevated

among older women. With every five-year increase in the age at which a woman has her first

full-term pregnancy, her odds of developing breast cancer rise by 7%. Th e study results were

based on analysis of po oled da ta from two large, popu latio n-based case-con trol studies

conducted in the states of Maine, Massachusetts, New Flampshire and W isconsin. Com plete

information on a comprehensive set of risk factors for breast cancer was available for 9,891 cases

and 12,271 controls. Women with a first-degree family history, meaning those women whose

sisters or mothers have had breast cancer, are at increased risk of developing the disease. The

risk ratio for premenopausal breast cancer in first-degree female relatives of women with breast

cancer is 3.1 (Meister & Morgan). The results of several studies (van den Brandt et al., 2000;

Brinton & Swanson, 1992; Swanson et al., 1996) have also established obesity as a risk factor for

breast cancer. The American Cancer Socie ty 's Cancer P revention Study II (CPS-II) results

showed an increasing risk of breast cancer with increasing body fat (determined by body mass

index measurements) in postmenopausal women. The study analyzed data from 424,168

po stmenopausal women who participa ted in CPS-II, start ing in 1982. All women were cancer-

free upon enrollment. Upon follow-up 14 years later, 2852 of the subjects had died of breast

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cancer. After controlling for potential confound ing factors, analysis revealed women who had a

body mass index of 40 or higher were three times more lik ely to die from breast canc er than were

women with a BMI from 18.5-20.5. Height was also positively asso ciated with breast cancer

mortality. The women who were 66 inches and higher w ere 1.6 times more likely to die of breast

cancer than those wom en wh o were less than 60 inches (Petrelli, Calle, Rodriguez, & Thun,

2002). Understanding obesity as a breast cancer risk factor is important, as this is the modifiable

factor. It also suggests that maintaining normal body mass index can reduce the postmenopausal

risk of breast cancer.

The second category of risk factors for breast c ancer includes “speculated” factors. These

factors are supported by some scientific research but the research is not really conclusive. Some

of the speculated factors are never having been pregn ant, no t breast feeding after pregnancy,

po stmenopausal estrogen or hormone replacem ent therapy, use of oral contraceptives, certa in

dietary practices such as high fat diet, and low consumption of fruits and vegetables (Meister &

Morgan, 2000). Alcohol consumption has also gained some scientific support as a risk factor. To

assess the risk of invasive breast cancer associated with total and beverage-specific alcohol

consumption, the study conducted by Sm ith-Wamer et al. (1998) found that risk increased

linearly with increasing intake of alcohol. The specific type of alcoholic beverage did not

strongly influence risk estimates. The association between oral contraceptives and breast cancer

is not very clear. Recently the results of a population based case-control study showed that

current and previous pill users had essentially the same risk of cancer as never-users when a wide

range of risk-related factors was taken into account (Marchbanks et al., 2002). The study results

were based on the interviews of 4575 women with breast cancer and 4682 controls. The results

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were similar among white and black women. Use of oral contraceptives by women with a family

history of breast cancer was not associated with an increased risk of breast cancer. The initiation

of oral-contraceptive use at a young age didn’t affect the risk. Grabrick et al. (2000) found

women with family history of breast cancer are at increased risk of developing the disease, and

their risk is further elevated if they use oral contraceptives. The historical cohort study which

took place between 1991 and 1996, collected data by telephone interview from 426 families of

breas t cancer cases diag no sed between 1944 and 1952 at the Tum or Clin ic of the University of

Minnesota Hospital. An elevated risk associated with pill use appeared only among women who

had taken oral contraceptives during or before 1975. The oral contraceptive pills introduced after

1975 contain less than 50 meg of estrogen. The scientific research regarding oral contraceptives

until now has presented conflicting results. There is not sufficient body of research in relation to

new low dose formulations of oral contraceptive pills.

In addition to these established and speculated factors, a wide variety of other factors that

may affect breast cancer risk are suggested. These include breast size, xenoestrogenes, breast

trauma, and use of antiperspirants. These factors lack the scientific evidence.

Breast Cancer and Screening

Breast cancer cannot be prevented. According to the American Cancer Society (2005),

the key to surviving breast cancer is early detection. The earlier a tumor is found, the less time it

has to spread. Once breast cancer metastases, prognosis worsens. If detected early, the 5-year

survival for women with localized breast cancer is 97%. Currently, the best way to find cancer in

its early stage is through screening. American Cancer Society’s screening guidelines include

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mammography, breast self-exammations and clinical breast examinations. In 2002, the U.S.

Preventive Services Task Force (USPSTF, 2002a) evaluated pub lished research about the risks

and benefits of breast self-examination, clinical breast examination and screening

mammography. The USPST F found no evidence that b reast-self examination or clinical breast

examination reduced breast cancer death rates. Thomas et al. (1996) found that breast self-

examination (BSE) did not reduce breast cancer mo rtality. The study results were based on a

large randomized controlled trial. The trial involved 267,040 women ag ed 3 1-6 4 recruited from

520 factories in Shanghai, China. The 133,375 women in the intervention group received

extensive BSE training. W omen were followed up for the development of breast cancer and

death, confirmed by registry data. After the first 5 years of follow-up, the cumulative breast

cancer mortality rate was not significantly lower among women who receiv ed BSE instruction

than among the control subjects. The breast cancers detected in the instruction group were not

diagnosed at an appreciably earlier stage or smaller size than those in the control group.

How ever USPS TF (2002a) found fair evidence that mamm ography screening every 12 to

33 months significantly reduces mortality from breast cancer. Evidence is strongest for women

aged 50 to 69, the age group generally included in screening trials. For women aged 40 to 49, the

evidence that screening mammography reduces mortality from breast cancer is weaker, and the

absolute benefit of mammog raphy is smaller, than it is for older women. U SPS TF gathered

evidence largely from the review of eight random ized controlled trials (RC Ts) of mamm ography

that have reported results with 11 to 20 years of follow up. Stockholm, Gothenburg, Malmo and

Swedish two-county trial were the four trials of mamm ography alone. C NBS S-1, CNBSS-2,

HIP, and Edinburg w ere the four RCTs of mamm ography plus clinical breast examination. RCTs

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have demonstrated a 30% reduction in breast cancer mortality in women 50-69 years who are

screened annually or biennially with mamm ograms. T he benefits increase as women become

older. Inviting 838 women 50 to 69 years of age to have mammography will prevent one breast

cancer death. Inviting 1792 women 40 to 49 years of age to have mammography will prevent one

breast cancer dea th. (Hum phrey, Helfand, Chan & Woo lf, 2002).

The scientific research has proved the efficacy o f screening m amm ography in improving

breast canc er outcomes. Mam mography is the best availab le me thod to de tect breast cancer in its

earliest, most treatable stage, an average of 1.7 years before the woman can feel the lump (CDC,

2001). Breast cancer screening programs do not reach all women at the same rate. Screening

mammography use varies according to sociodemographic characteristics, race and ethnicity.

Swan et al. (2003) analyzed the data from the 2000 National Health Interview Survey (NHIS)

and earlier surveys to discern patterns and trends in cancer screening practices. The data are

reported for population subgroups that were defined by a number of demo graphic and

socioeconomic characteristics. Their study results showed that women who were least likely to

have had a mammogram within the last 2 years were those with no usual source of health care,

women with no health insurance, and women who immigrated to the United States within the last

10 years. Their data indicated that for immigrant women who were in the United States for less

than 10 years mammography prevalence was only 17% within past one year. For those

immigrant women living in the United States for more than 10 years, the prevalence was 32%.

The study suggested that screening use for most groups has increased since 1987, but major

disparities remain.

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As ian Am erica n Women and Breast Cancer

To address the issue of disparities, it is important to focus on the current research that

puts light on the relat ionship between breas t canc er and Asian American wom en. Breast cancer

risk varies considerably around the world. Traditionally, breast cancer incidence rates are four to

seven times higher in North America than in Asian countries. It has been observed that when

Chinese, Japanese, or Filipino women migrate to the United States, their risk rises over the time

and after some generations approaches that of non-Hispanic Whites. Ziegler et al. (1993)

conducted a population-based, case-control study of breast cancer among A sian women o f

Chinese, Japanese and Filipino ethnicities. A total of 597 eligible patients were diagnosed with

breast cancer during 1983 through 1987 and 966 eligible controls par tic ipated in this study.

Trained interviewers using standardized questionnaires collected the data. The study results

showed a six-fold rise in breast cancer risk by migration patterns. Asian American women who

were bom in the United States had 60% more risk of cancer than those w ho were bom in the

East. Amongst those born in the Un ited States, women who had three to four generations of

grandparents bom in the United States were at more risk. Am ongst women who were bom in the

East and migrated to the United S tates, the risk was higher for those wom en who m igrated from

urban areas in Asia. The study also made it evident that the migrating generation of Asian

American women have a higher incidence rate than those back in their homeland.

A recently conducted epidemiological study by Deapen, Liu, Perkins, Bernstein, and

Ross (2002) does not only support the previous findings, but found that in recent years the

incidence rates are rapidly rising amongst Asian American women. The study analyzed trends in

invasive female breast cancer incidence using data from the Los Angeles Cancer Surveillance

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Program, the population-based cancer registry covering the County. Los Angeles County has

ethnically diverse populations. The results suggest that after stabilized incidence rates during

1980 and early 1990s, incidence has been escalating for A sian-Am erican and non-Hispanic white

women over age 50 with an estimated annual percent change of 6.3% (p < 0.05) and 1.5% (p


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Asian Indian and Southeast Asians and data was also stratified on the basis of place of birth. The

study results showed that Asian American women as a group were more likely than white

women to have tumors larger than 1 cm. The study finding docum ented that the chance of having

a tumo r size larger than 1 cm is significantly highe r in Asian American im migrant wom en of first

generation.

From the review of the research regarding breast cancer and migration am ong Asian

Americans, it is evident that the incidence rate is increasing, detection is occurring with larger

tumor size at a later stage and many Asian American women are not getting screened early. The

research also suggests need of intervention to improve the utilization of mamm ography amongst

first generation Asian American im migrant women.

Asian Indian Women an d Breast Cancer

Asian Americans represent a wide variety of languages, dialects, and cultures as different

from one another as from non-Asian groups. Asian Indians are those who have their origins in

the people of Indian subcontinent. Recently the num ber of people imm igrating to United States

from Indian subcontinent increased significantly making them the second largest group amongst

Asian Americans. Modern India with her one billion population is a legacy of British India.

Chopra (2001) described the epidemiology of breast cancer in India. The data is collected mainly

through hospital-based cancer registries. There are registries in cities of Mumbai, New Delhi,

Chennai, Bangalore, Bhopal and Barshi that are managed by the Indian Council of Medical

Research. There are additional registries in other cities, which are the part of private

organizations. These registries represent only 3% of the total populations. In India, breast cancer

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is the second most commo n cancer in w omen after cancer of the cervix. According to Globocan

2002 data (Ferlay et ah, 2004), 82951 cases occur every year in India. A total of 44795 deaths

are attributed to breast cancer in India annually. The incidence rate is higher in urban cities than

rural areas. The maximum numbers of cases occur in women in the age range of 45 to 49.

Approximately 80% o f Indian women with breast cancer are younger than 65. Fifty to seventy

percent of Indian women are diagnosed at la ter II and III stages when breas t cancer is locally

advanced. Chopra noted that breast cancer in Indian women was biologically aggressive in

nature.

There is limited data regarding Asian Indian women and their breast cancer risk after

immigrating to United States. This could be because of smaller size of this ethnic group and it is

categorized with other Asian ethnic groups. Sadler, Dhanjal, et al. (2001) described the

knowledge, attitudes and behaviors of Asian Indian women regarding breast cancer early

detection. This study used a small convenience sample of 194 Asian Indian women in San

Diego, California. The Asian Indian college students, who were trained by the senior researcher,

collected the data. The study found that 45.5% of the study population thought that they had

adequate knowledge of breast cancer. Approximately 61% o f the women reported having a

mammogram in the past year. Those Asian Indian women who were more acculturated and

be tter educated consented to take part in the study. These study results cannot be generalized, as

there are many methodological limitations.

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Health Belief Model

The Health Belief Model (HBM) and its constructs could be impleme nted for potential

intervention strategies to increase mamm ography s creening amongst Asian A merican Women

particularly Asian Indian im migrant wom en . The HBM originated in 1950 from seminal research

conducted by the United States Public Health Service. Social psychologists tried to explain the

lack of participation of people in free health screening programs such as tuberculosis screening

program s. According to this theory health behav ior is a function of kn ow ledg e, attitudes and

perceptions (Glanz et al., 2002). This theory sta tes tha t there are two im po rtan t fac tors tha t

determine the likelihood of a person adopting the recomm ended health behavior. An individu al’s

belie f in his/ her suscep tib ili ty and severity of the disease leads to health po si tiv e behavior. The

other factor that controls possibility of behavior change is the person’s belief that benefits of

positive health behavior , in this study, getting mam mogram outweigh the barriers. To address the

issue of increasing mammography utilization: a health positive behavior, it is important to

understand the perceived susceptibility and seriousness regarding breast cance r among Asian

American women. Understanding Asian American women’s views regarding benefits of

mammography and barriers to getting screened will help in planning necessary interventions.

Several studies (Maxwell, Bastani, & Warda, 1998; Sadler, Dong, Ko, Luu, & Nguyen, 2001;

Wong-Kim, Sun, & DeMattos, 2003; Pham & McPhee, 1992) documented the knowledge,

beliefs, and att itudes of A sian American wom en rega rding breast can ce r and screening for early

detection. The findings suggested that lack of time, knowledge, transport, embarrassment, and

inability to understand English language were some of the barriers. Higher socioeconomic level,

a physician's recomm endation to obtain a mam mogram, longer duration of residency in the U.S.

and greater acculturation were associated positively with screening. In a recent study of health

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beliefs and practices related to breast canc er sc reening in Filip ino , Chine se and Asian Ind ian

women (Wu, West, Chen, & Hergert, 2006), results showed strong influence of ethnicity on

pe rceived susceptibility and seriousness. The study also found that each ethn ic group repo rted

distinct barriers for getting mammograms. Chinese participants identified “I do not need

mam mogram if I feel ok.” as a barrier. For Filipino wom en “w aiting time is too long” was an

important barrier, whereas for Asian Indian wom en “do not know where to get a mam mog ram”

was a major barrier. This study involved 125 Asian American women out of whom 47 were

Filipinos, 40 were Chinese, and 38 were Asian-Indians. A self-administered questionnaire was

used to evaluate participan ts’ knowledge, beliefs, and screening practices.

Summary

This literature review reveals that there are multiple risk factors associated with breast

cancer. Women of all races and ethnicities including Asian Indian women are susceptible to

breast cancer. Migration increases the risk of breast cancer in Asian wom en. Mam mography

screening is an important health positive behavior that leads to early detection. The available

data and studies document that the rate of utilization is less in Asian American women. Most of

the studies do not reflect the breast cancer risks, know ledge and screening behaviors among

Asian Indian subset in particular. It is clear from the existing research that there is a need to

focus on knowledge, attitudes and behaviors of Asian Indians about breast cancer early

detection.

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CHAPTER THREE

METHODOLOGY AND PROCEDURES

Study Design

This study aimed to measure knowledge, attitudes, and breast cancer-screening behaviors

amongst Asian Indian immigrant wo men in Connecticut. The study was d esigned as a descriptive

cross-sectional survey. Personal or phone interviews, focus groups, or other methods were not

feasible because of money and time restraints. C onsidering this, the survey method o f self

completion of mailed questionnaire was used for data collection. The questions included in mail

surveys were formatted to assess k nowledge o f breast cancer risk factors and screening methods.

The questionnaire also evaluated attitudes such as perceived susceptibility of breast cancer,

perceived benefits and barriers rega rd ing breast cancer screening, mam mograph y in par ticular.

Study Population

The study population was comp osed of Asian Indian imm igrant women in Connecticut.

According to the American Cancer S ociety (2005) guidelines, an annual m ammog raphy is

recommended for women 40 years and older. Women are sometimes advised to have a baseline

mammogram at the age 35. Considering this, women 35 years of age and older made up the

study population. Keeping in mind the research objective, the study included only Asian Indian

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women who were bom in India and migrated to the U.S. and not those wom en who were bom in

United States.

Sampling Procedures

It is not feasible to include every member of the study population hence sample is drawn.

Non-probability convenience and snowball or network sampling procedures were used fo r this

purpose. India is a m elting po t of d ifferent relig ions. Hindu ism is the oldest of all the major

world religions and originated in Indian subcontinent. The majority of Asian Indians are Hindus.

Jainism, Buddhism, and Sikhism are other major faiths that evolved from Hinduism. The

researcher visited representative religious centers such as the Hindu temple in Middletown,

Connecticut, and Sikh Gurudw ara in Norwalk, Co nnecticut. W ith the help of researcher’s

acquaintances who visited these religious places regularly, the researcher obtained names and

addresses of women who could be recruited for the study. The Indian population is diverse with

multiple major languages. In Connecticut, there are many formal and informal groups

representing people with different languages such as Marathi, Gujarati, Telagu, Tamil and many

more. Through the principal investigator’s contacts, names and addresses of women from such

groups who could be eligible as study participants were acquired. The sample also included

Asian Indian women congregated for cultural events. The names and addresses were obtained

from key informal leaders and networking within the Asian Indian community. Eligible women

who agreed to participate were requested to provide the names and addresses of others who met

the study criteria.

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Instrumentation

A self-administered questionnaire, used for collecting data was put toge ther by using

previously published instruments with proven va lid ity and reliability. Th e instrumen ts were

adapted with the permission of authors to fulfill the study objectives. The letters of permission to

use the published instruments can be found in Appendix B. To measure the know ledge of breast

cancer risk factors, the subscale of the Com prehensive B reast Cancer Kn owledge T est (Stager,

1993) was used. To assess the participant’s knowledge about breast cancer screening practices,

Breast Cancer Knowledge Test (McCance, M ooney, Smith, & Field, 1990) was used. B enefits,

and Barriers scale for mamm ography utilization and R evised Susceptibility, Benefits, and

Barriers scale for mamm ography screening were used to assess participan ts’ perceived

susceptibility related to breast cancer, perceived b enefits and barriers for mam mography

screening (Champion, 1995, 1999). The prevalence of mammograph y screening is measured

using two questions from 2003 Behavioral Risk Factor Surveillance System (BRFSS)

questionnaire (CDC, 2003). The data and materials produ ced by federal agencies come under

pu blic domain. The Centers for D isease Control and Prevention (CDC) allow use of BRFSS

survey questions without permission, but with proper citation. Only one additional question

about participant’s age was included to get relevant information for the data analysis. The

questionnaire had closed questions with dichotomous, rating, and ranking type of response

format. The adapted questionnaire that was used for this study is presented in Appendices as

Appendix E.

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Institu tiona l Review Bo ard

As the study involved interaction with human participants, the National Institute of

Health (NIH) online comp uter based training pro gram on protecting human research participants

was completed and the on-line Certificate of Com pletion was obtained before de veloping the

IRB proposal. According to federal guidelines concerning the use of human participants in

research and Southern Con necticut State University (SCSU) policies, the researcher su bmitted an

IRB application for the pilot study. After IRB approval (see Appendix A), the pilot study was

conducted and results were evaluated. Later on another application for the large scale survey was

submitted for review. This protocol was exem pted from further IRB review on the condition of

making suggested modification. Data collection was conducted after the IRB approval.

Pilo t Test

Although the validated and reliable pu blished instruments were used, the pilot testing was

done to check the appropriateness, readability, cultural sensitivity and practicality of the

questions for Asian Indian immigrant population. The pilot testing included a small convenience

sample of 10 Asian Indian immigrant women.

Data Co llection Procedures

The list of all the names and addresses of eligible Asian Indian immigrant women

participants was prepared. A survey packet was put toge ther with a cov er letter, an Informed

Consent form, a questionnaire, and a self-addressed stamped envelope. The packet was mailed

using regular mail of the United States Postal Services. The cover letter included information

about the principal investigator; research objective, directions for completing and returning

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completed questionnaire. The cover letter and informed consent letter also assured the

participants about anonymity and confidentiality . Cover letter and Informed Consent form appear

in the Appendices as Appendix C and Appendix D respectively.

Data Analysis Procedures

The collected data was organized and analyzed using SPSS 12.0 for Windows software

so that the data could be interpreted. Descriptive statistical analysis such as frequency

distribution, measures of central tendency was conducted. Range and standard deviation

(measure of variability) was calculated. Cross tabulation was done w herever necessary.

Schedule o f Activities

Table below represents the sequential steps followed in the completion of thesis.

Table 1.

Schedule o f Activities

Activity Sept-Dee. Jan. Feb. Mar. Apr. May.

2003 2006 2006 2006 2006 2006

Compose Thesis Proposal

Submit IRB application for pilot study

Conduct pilot study

Submit IRB application for large scale

study

Collect Data

Analyze data

Compose thesis document

Complete revisions and submit final

thesis

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Summary

The research is only as good as the methods chosen; sample selected, instrument used

and analyzing procedures applied. To accomplish the research objective, a self-administered mail

survey was used. To get the sample representative of the Asian Indian immigrant population in

Connecticut, multiple avenues were used. Already published, validated and reliable instruments

after checking for face and content validity by the pilot study were utilized. Data was analyzed

using SPSS software.

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CHAPTER FOUR

DATA ANALYSIS AND RESULTS

Introduction

The purpose of this study was to highlight and assess the knowledge, beliefs, and

attitudes of Asian Indian immigrant women in Connecticut regarding breast cancer and its

screening. Through networking, Asian Indian immigrant women of age 35 and above were

asked, on a voluntary basis to fill out a questionnaire. A total of 150 questionnaires were

distributed. There was a response rate of 60.67% (N = 91 out of 150) of potential participants.

The questionnaire measured variables such as knowledge of breast cancer risk factors and early

detection screening, perception of risk, benefits, and barriers to screening. The instrument

consisted of multiple choice questions. Data analysis was performed on the different sections of

the survey using the Statistical Package for the Social Science (SPSS) 12.0 for Windows. Basic

descriptive statistics and frequency calculations were performed on all variables considered in

this study. This chapter contains a presentation of the data collected and analyzed in an attempt

to answer the following research questions:

What is the knowledge of Asian Indian immigrant women regarding breast cancer risk

factors?

What is the perception of Asian Indian women regarding their susceptibility to the disease?

What is their knowledge about breast cancer screening?

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Do they participate in mamm ography screening if they are of eligible age?

Wh at are the perceived benefits and barriers to ma mm ograph y practice?

Data presentation is in tabular, graphic or narrative form, depending on the nature of the

information, and is structured around the research questions.

Age o f Respondents

Table 2 displays the age distribution of the participants. Out of 91 Asian Indian

immigrant women who returned the completed questionnaires, 14 participants did not write the

age. The mean age was 43.86. Of the total participants, 36.4% (n = 28) women were between the

ages 35 to 39. The remaining were ages 40 and above, thus eligible for American Cancer

Society’s recom mendation of annual mamm ograms. Figure 1 is graphic representation of these

statistics.

Table 2.

Age o f Respondents

Years of Age Frequency Percent

35-39 28 36.4

40-44 17 22.1

45-49 14 18.2

50-54 9 11.7

55-59 7 9.1

60-64 0 0

65-69 1 1.3

>=70 1 1.3

Total 77 100

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63.6%

Annual

mammogram

recommended

36.4%

Baseline

mammogram

recommended

18.2%

22.1%11.7%

9.1%1.3%

0 .0%

H 35-39 Years

■ 40-44 Years

□ 45-49 Years

□ 50-54 Years

■ 55-59 Years

■ 6 0-64 Years

■ 65-69 Years

□ >=70 Years

Figure 1. Age distribution of participants according to screening guidelines

Knowledge o f Breast Cancer

This study examined the participan ts’ general knowledge of breast cancer. The

participants were asked 11 questions regarding risk facto rs and ep idem iology of breast cancer.

The mean score was 6.52 with standard deviation of 1.97. In general, the participan ts’ general

knowledge about breast cancer was good. Approximately one fourth of the respondents (25.2%)

received the score of five or less than five out of 11. Figure 2 displays the distribution of score

achieved by the participants.

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1 2 3 4 5 6 7 8 9 10 11

Score

Figure 2. Partic ipants ’ Scores on Breast Can cer Kno wledge Test

Women show ed reasonable understanding and know ledge of risk factors: 75.8% women

acknowledged that a hard blow to the breast is not the established risk factor for breast cancer;

61.3% women knew that “the constant irritation of a tight bra over time can cause breast cancer”

is false; 62.6% women knew that “in some women, being overweight increases the risk of

developing breast cancer.” The participants (79.1%) recognized that “women who bear their first

child before the age of 30 are less likely to develop breast cancer compared to those who bear

their first child after the age of 30.” The statement “Women with no known risk factors for breast

cancer rarely get breast cancer,” 70.3% wom en recogn ized it as false. Ap proximately half of the

total participants (53.8%) were aware of the fact that some types of fibrocystic breast disease

(non cancerous breast lumps) increase a wo ma n’s risk of breast cancer. Surprisingly 60% of the

women did not know that wom en in the United States have higher risk of breast cancer than

those in Asia or Africa. In response to the question regarding the age as a risk factor for breast

cancer, a large number of participants (83.5%) failed to identify that breast cancer is more

common in 65 year old women than in 40 year old women. An interesting finding was that the

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. majority of the participants (60.4%) correctly disagreed w ith the statement that “women over age

70 rarely get breast cancer.” This suggested that women realized that the disease could occur at

any age but they needed to be more aware of the fact that risk increased with age. Out of 91

responses 75 were correct in acknowledging that most breast lumps are not cancerous. Table 3.

illustrates the particip ants ’ level of knowledge on each Breast Cancer Gen eral Knowledge test

item.

Table 3.

Level o f Partic ipants’ Brea st Cancer General Knowled ge

Question

Percentage

answered

correctly

A hard blow to the breast may cause a woman to ge t breast cancer la te r in life. 75.8

The constant irritation of a tight bra can, over time, cause breast cancer. 61.5

One out of every eight women in the United States will get breast cancer

sometime during her life.

54.9

In some women, being overweight increases the risk of developing breast cancer. 62.6

A woman who bears her first child before the age of 30 is more likely to develop

breast cancer than a w om an who bears he r f irs t child after the age of 30.

79.1

Women with no known risk factors for breast cancer rarely get breast cancer. 70.3

Some types of fibrocystic breast disease (non-cancerous breast lumps) increase a

wom an’s risk o f breast cancer.

53.8

Women in the United States have a higher risk of breast cancer than do wo men

in Asia or Africa.

39.6

Breast cancer is more common in 65-year-old women than in 40-year-old

women.

16.5

Women over age 70 rarely get breast cancer. 60.4

Most breast lumps are cancerous. 82.4

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Kn owledge o f Breast Cancer Detection and Screening Practices

This study tested breast cancer screening awareness among participants using some of the

items obtained from the 1990 Breast Cancer Knowledge Test (BCK test). BCK test is a valid and

reliable instrument developed to measure knowledge about screening and detection practices.

The participants were asked how the most breast lumps are found. As depicted in Figure 3., out

of 91 valid responses, 43 women (47.3%) thought most breast lumps are found by women

through breast self examination, whereas 40 participants (44%) believed that most breast lumps

are found by mammograms. Only eight participants (8.8%) thought that mo st breast lumps are

found by physicians during clinical examination.

\ Mammogram

•\ 44 %

Figure 3. Participants’ Responses to How the Most Breast Lumps are Found

The majority of the participants (90.1%, n = 82) believed that regular breast cancer

screening makes great difference in the chance of curing breast cancer. Only 1% thought that

regular breast cancer screening would make no difference in the chance of curing breast cancer.

When participants were asked about mammography screening guidelines, 94.5% participants

correctly identified that mammography is recommended yearly for women over 40 years old. A

32

Women

47 %

Physician

9%



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total of 87.9% of the participants also agreed to the fact that mammography can detect lumps that

cannot be felt. Out of 91 participants, 85 women disagreed with the statement, “If a woman gets

a regular mammography, she does not need to do breast self-examination o r have physical

examination.”

Susceptibility, Benefits and Barriers to Mam mography Screening

Susceptibility. The “Susceptibility” grouping included variables that deal with the

perceived risk of breast cancer. Th e suscep tib ili ty scale consisted of three items: 1. It is likely

that I will get breast cancer. 2. My chances of getting breast cancer in the next few years are

great. 3 .1 feel I will get breast cancer som etime during my life. The re sults o f these questions are

summarized in Figure 4. As displayed in Figure 4., the majority of respondents were unsure

about the risk of Breast cancer to them, more than one-third disagreed that they were at risk. It is

evident from the figure that the responses were similar to all “susceptibility” items.

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Agree

Undecided

Disagree

Strongly

Disagree

~113.2

" □ 15.4

■ I feel that I will get breast

cancer sometime during my

life.

■ My chan ces of getting breast

cancer in the n ext few years are

great.

□ It is likely that I will get brest

cancer.

□ 3.3

10 20 30

Percent

40 50

Figure 4. Particip ants’ Respon ses to "Suscep tibility" Scales

Bene fits o f Mam mog raphy Screening. Participants were asked a series of questions to

assess perceived benefits of obtaining a mammogram . T he “benefits” scale had five items based

on Likert format with five response options. F igure 5 depicts the participants ’ responses to all the

“benefits” items.

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Strongly

Agree

Agree

Undecided

Disagree

StronglyDisagree

11.0

11.0

I 15 .4

14.3

11.0

29.7

I

2.2

1.1

1.1

□ 3.3

53.8

□ 57.1

64.8

20 40 60

Percents

80

■ Having a mammogram will

decrease my chances of dying

from breast cancer.

□ Having a mammogram is the best way for me to find a very

small lump.

□ I f 1find a lump through a

mammogram my treatment for

breast cancer may not be as

bad.

■ Having a mammogram will

help me find breast lumps

easily.

□ If I get mammogram and nothing is found, I do not worry

as much about breast cancer.

Figure 5. Participants' Resp onses to "Benefits" Scales

As seen in Figure 5., more than 50% o f participants agreed to the benefits of having a

mamm ogram. Although half the participants thought that if they found a lump through a

mamm ogram their treatment for breast cancer would not be as bad, around 31.5% respondents

did not agree to it. Only 6-15% of the women w ere undecided regarding the perceived benefits of

mammography screening.

Barriers to M am mograph y Screening. “Barriers” scales included 10 items to measure

resp ond ents’ perceived emotional, physical, or structural concerns respon sible for nega tive

outcome related to mam mography behaviors. Similar to susceptibility and benefits scales,

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3


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barriers scales had items based on Likert scale with response op tions from “strongly agree” to

“strongly disagree.” The scores are on a scale of one to five in which one is “strongly disag ree,”

two is “disagree,” three is “undec ided,” four is “ag ree,” and five is “strongly ag ree.”

Table 4.

Mean Scores o f Pa rt ic ipants ’ Attitudes Reg ard ing Barrier s to Mammography Screening

Barriers Mean SD

I am afraid to have a mammogram because I might find out

something is wrong.

1.92 1.02

I am afraid to have a mammogram because I don’t understand what

will be done.

1.65 .73

I don’t know how to go about getting a mammogram. 1.64 .77

Having a mammogram is too embarrassing. 1.57 .66

Having a mammogram takes too much time. 1.62 .76

Having a mammogram is too painful. 2.03 .98

Having a mammogram exposes me to unnecessary radiation. 2.11 .91

I cannot remember to schedule a mammogram. 1.97 .96

I have other problems more important. 1.99 .87

Having a routine mamm ogram o f the breast would cost too much

money.

1.88 .77

It is evident from Table 4., most o f the items had the mean scores less than two, which indicated

that majority o f the participants either strongly disagreed or disagreed to barriers to having

mammograms. Pain and exposure to unnecessary radiation were only two barriers that got mean

score slightly over two, 2.03 and 2.11 respectively, still indicating feelings o f disagreement.

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Mammography Screening Beha viors

The prevalence of mammography screening was measured using two questions from the

2003 Behavioral Risk Factor Surveillance System (BRFSS) qu estionnaire. T he participants were

asked if they ever had a mam mogram and how long it had been since they had their last

mammogram. Out of 91 participants, 64 (70.3%) women had a mam mog ram. It is very

interesting to note that of the total participants, roughly 64% women were 40 years and above,

thus eligible for an annual mammogram. This suggests that most of the eligible women had a

mammogram. W hen asked how long it had been since they had their last mamm ogram, the

majority (72.3%) had a mamm ogram within the last one year. Figure 6. shows participants’

responses to this question.

80

70

60

50

40

30

20

10

0

72.3

13.8

7.7

3.11.5

| ] i ,,1.5

Less than 1 1 Year but less 2 Year but less 3 Years but 5 or more

Ye ar than 2 Years than 3 Years less than 5 Years ago

Years

Refused

Figure 6. Participants’ Last Mam mogram

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Summary

The data presented in this chapter are the results of a survey of Asian Indian immigrant

women 35 years old or above that addressed this study’s research questions. The results showed

that participants had a decent level of knowledge regarding breas t cancer risk factors and

screening practices. Approximately half of the responden ts were u ndecided about their risk of

breast cancer, whereas a third of the participan ts did no t perceive breast cancer as a risk.

Participants’ attitude toward benefits of mam mograp hy screening was favorable, m ore than 50%

agreed to benefits of having mammograms. At the same time, the majority of the participants did

not agree with reasons that discourage women form obtaining a recom mended mammogram.

Compliance with American Cancer Soc iety’s mam mog raphy guidelines was very high. Further

discussion of the meaning of data, in the context of this study is presented in Chapter Five.

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CHAPTER FIVE

DISCUSSION

Introduction

The final chapter of this study contains a discussion and conclusions based on the

research that has been presented. The body of this chapter will include interpretation of data

analysis results organized around the research questions addressed in this study. As stated earlier,

this study explored Asian Indian imm igrant wom en’s knowledge regarding breast cancer risk

factors and screening practices. The research investigated about partic ipan ts’ perception of breast

cancer risk, benefits of mammography screening, and barriers to it. The study also attempted to

find out mammography utilization among Asian Indian immigrant women. To comprehend

soundness of study results, this chapter will also discuss strengths and weaknesses of this study.

The chapter ends with recommendations for future research and concluding remarks.

Discussio n

The results of data analysis provided some interesting findings. These findings are

discussed in detail in the context of the study’s research questions.

Knowledge o f Breast Cancer Risk Factors. In general participants’ knowledge regarding

breast cancer risk fac tors was positive, with 74.7% correctly identifying six or more risk factors

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out of 11. Participants’ know ledge o f established risk factors such as gender, age, previous

history, family or genetic factors, reproductive history, and obesity was tested. One in every

eight women in the U.S. has a lifetime probability of developing breast cancer (NCI, 2005a).

Only half the respondents acknowledged this. Although p articipan ts’ knowledge of most of the

risk factors was encouraging, many (60.4%) failed to recognize that women in the United States

have a higher risk of breast cancer than do women in Asia or Africa. It is an important factor that

Asian Indian immigrant women should be aware of as the research shows that relative risk of

breast cancer changes in migrant populat ions, evolving rapidly to those of US populations

(Ziegler et al., 1993). The only other risk factor for which partic ipan ts’ knowledge seemed to be

lacking was age. The majority (83.5%) were not aware that breast cancer is most common in 65-

year-old women than 40-year-old women. The U.S. P reventive Services Task Force (USPSTF)

report (2002b) states that the risk of developing breast cancer increases from the age of 40. For

women of ages 50 and older, the risk increases further.

Perception o f Susceptib ili ty to Breast Cancer. Although participants exhibited

satisfactory level of knowledge regarding breast cancer risk factors, surprisingly a large number

of respondents were not sure about their own risk for breast cancer. Tw o possible reasons for this

lack of perception of risk can be suggested. One reason could be that most of the data available

for Asian immigrants living in the U.S. has been aggregated under the Asian-American/Pacific

Islanders (AAPI) ethnic category. Due to insufficient availability of information, many Asian

Indian imm igrant women were not aware of the breast canc er prevalence for their ethnic group.

The other possible reason could be that women migrating to A merica did not know o f the breast

cancer statistics in India as the data is collected mainly through hospital-based cancer registries,

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registries managed by the Indian Council of Medical Research and some additional registries,

which are the part of private organizations. These registries represent only 3% of the total

popu lat ions (Chopra, 2001).

Knowledge about Brea st Cancer Screening. Participan ts’ knowledge o f breast cancer

screening was excellent. When participants were asked about mammography screening

guidelines, 94.5% participants correctly identified that mamm ography is recomm ended yearly

for women over 40 years old. This is in accordance with American Cancer Society’s Breast

Cancer early detection guidelines. According to the C enters of Disease Control and Prevention ’s

(CDC) National Breast and Cervical Cancer Early Detection Program (NBCC EDP),

mammography is the best way to detect breast cancer in its earliest, most treatable stage, an

average of 1-3 years before a woman can feel the lump (CDC, 2001). The majority (87.9%) of

the participants agreed to the fact that mammography can detect lumps that cannot be felt.

Benefits o f Mam mog raph y Screening. USP STF (2002a) found fair evidence that

mamm ography screening every 12 to 33 months significantly reduces mortality from breast

cancer. Breast cancers found during screening tend to be smaller and confined to the breast. The

size and spread of cancer are important factors in determining the prognosis. Early detection also

improves the chances of less invasive and successful treatment options. The participants of this

study were aware of the benefits of mam mography screening. M ore than half of the participants

agreed to all the items on “benefits” scales. Over 84.2% of the respondents either strongly agreed

or agreed to benefit of mamm ograms in finding small lumps. Approximately 71.6% respondents

either strongly agreed or agreed that mam mograms are beneficial in decreasing chances of dying

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8/18/2019 Knowledge, Attitudes and Behaviors Relating to Breast Cancer Detection in Asian Indian Immigran

Knowledge, Attitudes and Behaviors Relating to Breast Cancer Detection in Asian Indian Immigrant...

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