Health Education Research Advance Access originally published online on May 11, 2005
Health Education Research 2005 20(6):739-747; doi:10.1093/her/cyh034
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Factors associated with mammographic decisions of Chinese-Australian women
1 Faculty of Education and Social Work, University of Sydney, Sydney, NSW 2006 and 2 Faculty of Health Science, University of Sydney, Sydney, NSW 1825, Australia
3 Correspondence to: C. Kwok, E-mail: cannas{at}student.usyd.edu.au
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Abstract |
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BreastScreen (a free breast cancer screening service) has been implemented in Australia since 1991. Surveys conducted overseas consistently report that women of Chinese ancestry have low participation rates in breast cancer screening. Although Chinese women's use of breast cancer screening services has been investigated abroad, to date there are few studies of mammographic screening behavior among Chinese-Australian women. The purpose of this study is to explore and investigate the factors associated with mammographic decisions of Chinese-Australian women. Using a qualitative approach, in-depth interviews were conducted with 20 Chinese-Australian women. These were augmented by additional data from ethnographic observations. The findings show two facilitators: organizational factors (an invitation letter from BreastScreen and seniors' clubs arrangements) and the influence of ‘significant others’. Barriers identified were fear perceptions of mammography, modesty and fear of stigmatization. This study provides a useful framework for designing and implementing mammographic screening services for Chinese-Australian women that may improve their participation rates.
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Introduction |
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In Australia, a National Screening Program (BreastScreen) has been in place since 1991 providing free mammograms for all women over the age of 50 (NHMRC National Breast Cancer Centre, 1998
). Given that Australia is a multicultural nation, breast screening promotional efforts have also been targeted at women whose first language is not English. Relevant printed material is available in 19 languages including Chinese. Nevertheless, non-English-speaking background women have had markedly lower screening rates (48.9%) than English-speaking women (58.5%) (Australian Institute of Health and Welfare, 2003). Data from 1989–90 show that in New South Wales (the largest state of Australia in terms of population, of which Sydney is the capital) Chinese women are 50% less likely to have breast examinations compared to Australian-born women, which puts their screening participation rate among the lowest of all ethnic groups (Dollis et al., 1993). Such findings suggest that there are factors which discourage ethnic women, particularly Chinese women, from participating in screening programs.
Many overseas studies report that women from minority ethnic backgrounds are less likely to participate in screening programs than their Anglo-Caucasian counterparts (McAllister and Bowling, 1993; Roberson, 1994; Dibble et al., 1997; Bird et al., 1998; Bottorff et al., 1998; Buelow et al., 1998; Han et al., 2000; Anonymous, 2001). Acculturation factors such as language, length of residency in the host country and also financial barriers are commonly reported as significant causes of the low utilization of mammographic screening services among ethnic women, including Chinese (Hoare et al., 1994; Kung et al., 1997; McPhee et al., 1997; Yu et al., 1998; Han et al., 2000; Juon et al., 2000; Yu et al., 2003).
Although the evidence is that women of Chinese ancestry have a lower breast cancer incidence rate than other Australian women (Australian Institute of Health and Welfare, 1996), breast cancer still remains the most common cause of cancer morbidity among Chinese-Australian women (McCredie et al., 1993). It is also significant that the risk to women of Chinese ancestry in Australia developing breast cancer is 40% greater than their counterparts in China following their immigration to Australia (Grulich et al., 1995). This is consistent with overseas studies which report that Asian-American women born in the USA have a 60% greater risk of breast cancer than Asian women born in Asia, while the rate has continued to rise among subsequent generations of immigrant Chinese women (Deapen et al., 2002; Ziegler et al., 1993). If this pattern of morbidity is applicable, future generations of Chinese-Australian women may be expected to be at greater risk of breast cancer.
Although this evidence points to a significant problem, little or no investigation has been undertaken into the factors associated with mammography decisions among Chinese-Australian women whose culture is obviously different from women of Anglo-Celtic background. In the light of the former's remarkably low screening participation rate and the increased risk of breast cancer incidence, the study reported here forms a basis for ongoing research, and offers a useful framework which can be applied in the planning and implementation of breast cancer screening programs for Chinese-Australian women.
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Methodology |
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This study was part of a larger study that focused on the role of culture in breast cancer prevention among Chinese-Australian women, approved by the Human Ethics Committee of the University of Sydney. The criteria for selecting the sample were the same as those used to target women for breast cancer screening programs, i.e. women aged 50–69 who have never been diagnosed with breast cancer. A purposive sample of 20 Chinese-Australian women was recruited from different Chinese organizations including a church, community centers and seniors' clubs. Four potential informants declined to participate in this study after learning that the research topic was about breast cancer—a subject they did not feel comfortable talking about.
The mean age of the women was 59.9 years. With the exception of two, all were married or had been married. Twelve of the informants had not had more than a primary level of education, five had some secondary education and three had completed a university degree. While those with secondary or university education spoke some English, the others spoke very little, if any. The informants' length of stay in Australia varied from 3.5 to 14 years. The majority of the informants were Buddhist; some indicated that they were not religious, while two were Christians. Because of language barriers and age, many informants had no employment history in Australia, and were homemakers helping their children's families with domestic work and child care. Only two of the women were employed full-time, while four were part-time workers. Almost all informants were living with their family, regardless of marital status, apart from one whose family was in Hong Kong.
Data collection involved in-depth interviews which consisted of two parts. The first part was structured and focused on gathering informants' demographic data. The second part was largely unstructured, guided by only a few open-ended questions. For example, ‘Have you ever had a mammogram before?’. If so, ‘What was your experience?’. Interview questions were first designed with reference to the existing literature on the topic, and were revised and modified as the research evolved. Data were also obtained by ethnographic observations and casual conversations while the first named author worked in an ethnic community center as a volunteer for a breast health project, and in a Chinese seniors' club accompanying a group of Chinese women to mammography. Field notes were collected as supplementary data for analysis. These observations were conducted over a period of 2 months and involved interaction with approximately 15 women.
A consent form was obtained from all informants prior to interview. All interviews were tape-recorded and took place in the informants' homes. Even though some informants were fluent in English, all interviews were conducted in Cantonese, as the informants' preference.
The data were translated and transcribed into English. The translated interviews and field notes were coded, and thematically analyzed according to the principles outlined in Minichiello et al. (Minichiello et al., 1999). The second and the third author reviewed translated transcripts of interviews, and participated in the analysis to assist in minimizing any interpretation bias. Patterns and contrasts in the responses given by the informants were identified. Cases were contrasted according to age, length of stay in Australia and experience with screening services, among other factors. We also sorted the data into matrix tables (Miles and Huberman, 1994). Throughout the analysis, all three authors vigorously debated interpretation of data until close agreement was reached. Case summaries and matrix tables assisted in the identification of themes, and made clearer contrasts and comparisons between participants in screening (PSs) and non-participants in screening (NPSs).
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Results |
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Eight out of the 20 informants had undergone at least one mammogram. Of these, only three had more than one mammogram, while the other five decided not to have any more. Among the remaining 12 informants, eight rejected mammography, while four had never heard of it despite the major promotional efforts used to publicize it.
One of the main focuses of data analysis was to identify the factors associated with mammographic decisions. Two sets of facilitators and three sets of barriers were identified. Figure 1 illustrates the framework based on the results of the in-depth interviews.
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Facilitators of mammographic screening
Organizational factors
1. Written invitations from BreastScreen NSW. The initial facilitator for more than half PSs was the invitation letter to attend screening sent out by BreastScreen NSW, which introduced them to the services offered to women over 50 years of age. Almost all PSs showed appreciation of this.
I receive invitation letters regularly which keep reminding me to go for check-up. I appreciate Australia's health care system much more than Hong Kong's. Australia looks after people's health.Even though the invitation letters were written in English, which many of the informants were not able to understand, the findings indicate that this method is effective in introducing screening services to women's family members who could arrange an appointment and provide encouragement to attend.
An attractive point in the invitation letters is that the screening service is made available free of charge. It was this factor which persuaded most of PSs to participate in the screening. The PSs' response to the question ‘Why do you attend mammography?’ was summed up in the words of one:
Why not? It's free of charge and it does some kind of check-up to our bodies.
2. Seniors' club activities. One organizational factor, unique to this study, emerged from the field notes taken while the researcher was working as a volunteer in a Chinese seniors' club accompanying a group of six Chinese-Australian women who were undergoing mammographic testing. This was one of the annual activities of the club, for which their team leaders arranged transportation and an interpreter. One informant said that the visit to the screening center was not her idea and that she was doing it because:
It's been organized by the Seniors' Club. It's good because they have interpreters and transportation. Otherwise, I wouldn't go on my own. I don't know the way, and I don't know English at all. How could I go?That identifies two factors—transportation and language skills—which act as facilitators to persuade some Chinese-Australian women to accept screening.
Influence of ‘significant others’
Even though the invitation letter and free service motivated some PSs to attend screening, other factors, in particular the influence of their ‘significant others’, including family members, played a larger role. Family members, particularly daughters or husbands, have a very substantial influence on the informants' screening behavior.
The role of family members. It is notable that all the interviewed PSs went for mammography together with family members. The comments of the informants included:
When I first received the invitation letter, I showed it to my husband. At his suggestion I attended the screening. Otherwise I wouldn't have gone.
I went because my daughter arranged it for me and she knows everything.However, while this facilitator of screening is important, its disadvantage is that both PSs and NPSs, particularly those who had been widowed, indicated that they would not try to use medical services if they saw them as non-essential and a burden to their children. This is captured in the words of a widowed woman living with her daughter's family who had participated in mammography screening once:
I went once last time because my daughter took me. She can speak English and drove me to the center. But if my daughter is busy, I don't bother to ask her because it's not that important anyway.
Barriers to breast cancer screening
Fear perceptions of mammography
1. Fear about the physical damage of mammography. A prominent factor that emerged was that some women in this study had fears that the procedure would cause them physical harm and actually result in them developing cancer. Some of them who rejected participating in mammography screening had the impression that the screening procedure could damage the breasts. In their words:
I heard that they have to press your breasts until they can fit into the machine. I think that must really hurt the breasts. What if I was all right before and then it hurts my breasts and I develop cancer later. Who knows?
2. Concerns about radiation. It is not surprising that radiation concern is one of the barriers which prevents some Chinese-Australian from mammographic screening. A few of the NPSs expressed similar comments.
I heard that X-rays can cause cancer. What if I go for it [mammogram] today and the X-ray causes cancer to develop in my body.
Everybody knows that X-rays are harmful to our bodies. I won't go for it [X-ray] if it is not necessary.
3. Doubts about the efficacy of mammography. The NPSs' attitudes rejecting of screening were based in part on misgivings about the accuracy of the examination and also concerns about whether mammograms are as effective for Chinese women as they are for Western women. This is based on their belief that breast cancer is a ‘Western disease’ and that Caucasian women are prone to breast cancer as a result of having larger breasts. This leads them to believe that the mammogram machine does not operate as well on Chinese women with smaller breasts. One informant commented:
I think it [mammogram] may not be as good to us as to white women because our breasts are too small for it.This perception was even supported by two nurse informants, who strongly expressed their views against mammography:
I believe it [mammography] works well on women with big breasts such as those of white women. I won't go for it as our [breasts] are too small. It can't work properly.
I heard from one friend of mine that she palpated a lump around her breast. Then she went for mammogram. The result was negative. But she didn't believe in the result. Eventually, she was diagnosed with breast cancer but only by the eighth mammogram. You see how inaccurate a mammogram can be. I don't think mammography is effective for us [Chinese] as our breasts are not big enough for the machine to operate.
Modesty
For the 12 NPSs and the five PSs who had undergone mammogram, but refused to go again, modesty was one of the main barriers. Shame and embarrassment was mentioned repeatedly. The informants stated:
I think it's too inappropriate to have those [breast and vaginal] examinations. Nobody else (apart from husband) has seen my private parts.
To me [breast and vaginal examinations] are too embarrassing.Of the group of six Chinese-Australian women who were attending a mammography session as part of an annual group activity of a Chinese seniors' club, two of them refused the screening after they discovered that they were required to remove their tops and bras during the procedure. They did not think that this would be necessary, and were shocked and very embarrassed when asked to undress. They also felt humiliated, one saying:
I have never been for any body check-ups which required me to be naked.
Fear of stigmatization
A prominent barrier among the NPSs interviewed is fear of stigmatization. The findings revealed that personal health issues including cancer are viewed as very private issues which should only be shared within families. Discussion of cancer outside the family is generally seen as not being socially acceptable. This practice is based on two beliefs. First, some informants considered that their self-image would be negatively affected if others knew of their cancer. Second, they believed that family honor would be affected, and friends and relatives would isolate the whole family. This is an indication of cancer being a stigmatized disease and prevented many of the informants from using cancer screening services when they were asymptomatic. In their words:
Of course, I would not tell my friends if I had cancer. It [cancer] is not something good for sharing with friends. I don't know how they would feel about my cancer. I also don't know whether they would tell someone else. Family members are different. I am not afraid of telling my family about it.
Potential facilitator/barrier
The role of medical practitioners
The effect of doctors' recommendations on the women interviewed in this study was not consistent. Only three of the informants had had clinical breast examination and they were not for routine screening, but for diagnostic purposes. Although two of the informants had heard about mammograms from their family doctors, none of the PSs' decisions to undergo mammography was a result of their doctor's recommendations. In fact, the influence of doctors could actually be a barrier in this regard. Some women reasoned that they did not need to go for a mammogram because their doctors had never recommended it. When these women were asked if they had ever had a mammogram or practiced breast self-examination, the answer was:
No, because my doctor never suggested it to me.Some informants trusted their doctor implicitly to send them for a test if it was needed. This attitude is reflected in their comments:
If the doctor tells you to have [a mammogram], you have no choice to say ‘no’ even though you don't like the idea.
Doctors are all knowledgeable. They will make the right decision about when or what I should do.On the other hand, these women also implied that they assumed that if their doctors did not tell them to have a mammogram or perform breast self-examination, neither was necessary. This finding implies that medical practitioners are potentially good facilitators for women's screening decision.
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Discussion |
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The results of this study confirm that using mammographic screening is not a common health practice among the Chinese-Australian women who participated in this study; similar results have been reported for Vietnamese, Korean, Chinese and African women in the USA (McPhee et al., 1997
; Crump et al., 2000; Tu et al., 2003; Yu et al., 2003), and Thai, Macedonian and Italian women in Australia (Gifford, 1991; Jirojwong and Manderson, 2001). Understanding factors associated with mammographic decisions is the first step to improve screening participation rate in Chinese community.
Obviously, making screening services free of charge appears as a facilitator encouraging women's participation. This is consistent with overseas studies which reported cost as a barrier for women's mammography decisions in countries where there is a cost for service unless women are covered by private insurance (Straughan and Seow, 1995; Lee et al., 1996; McPhee et al., 1997; Yu et al., 1998). Nevertheless, actions and attitudes of family members seem to be important influential factors in determining mammographic decisions among this group of women. The company of especially younger, more acculturated family members serves three main functions: the provision of transport, facilitating communication with medical staff, but perhaps most important of all, providing psychological support in a strange environment. Even though some of PSs had no communication and transportation problems, they emphasized the importance of being accompanied by a member or members of their family when they went for screening. For this reason, involving family members in the promotion of screening programs is recommended as an effective strategy for improving Chinese-Australian women's screening rate.
Although seniors' clubs' arrangements appear to be a significant facilitator of women's willingness to undergo screening, this strategy could even be seen as unethical because participants were not fully informed of the nature of the test. Thus, although group visits facilitate some acceptance of mammography, it can be argued that their usefulness is limited unless they promote a full understanding of the procedure. Moreover, such visits, of course, exclude people who do not belong to seniors' clubs or other social groups.
The barriers reported in this study are similar to those reported elsewhere in studies of American women (Chavez, et al., 1997; Hoeman et al., 1996; Salazar, 1996; Facione et al., 2000). Fear perceptions of mammography are not unique to Chinese women (Wardlow and Curry, 1996; Chavez et al., 1997). This finding suggests that the current content in mammography promotion materials does not address this issue adequately. Educational programs that take into account the issues discussed here need to be developed. While adequate information is important, the effectiveness of its transmission is a key issue, and methods to address emotional and sensitive issues need to be developed. Given that about half of the informants were either illiterate or poorly educated, the availability of Chinese printed material may not be effective in reaching this community. There is a need for some innovative methods such as playing audio-tapes in waiting room of clinics and using role models to address particular concerns in community-based teaching programs.
Our observations on the modesty issue are consistent with other studies not only of Chinese women (Hoeman et al., 1996; Mo, 1992), but also women from other minority cultures (McAllister and Bowling, 1993; Salazar, 1996; Sent et al., 1998; Tang et al., 1999; Jirojwong and Manderson, 2001) and even including Caucasian women (Rimer et al., 1989; Rutledge et al., 1988). In general, Asian women may be more conservative with regard to modesty and privacy, and are less willing to reveal their breasts, even to health care providers. Thus, having it known that female technicians perform the procedure should be helpful for women to overcome some of their embarrassment.
This study indicates that culturally influenced beliefs about cancer are a key barrier to the use of screening services. The findings reveal that the degree of stigma associated with cancer is considerable and acts as a barrier for mammography participation among Chinese-Australian women. Taking cultural beliefs about cancer into account when designing screening promotional materials is profoundly important if Chinese-Australian women are to be convinced to accept mammography. Recognizing and respecting cultural differences is perhaps the most important issue to be considered in designing and implementing cancer screening programs.
The literature suggests that doctors' recommendations strongly motivate women to go for cancer screening tests, regardless of ethnicity (Beaulieu et al., 1996; Fox et al., 1991; Fox and Stein, 1991). While doctors' recommendations regarding cancer screening tests may be significant in this community, there are no reports on the prevalence of and barriers to prescribing cancer screening tests among doctors serving this ethnic population. However, our findings also reveal that recommending clinical breast examinations and cancer screening to patients is not common among doctors serving the Chinese-Australian women interviewed. Involving medical practitioners in the promotion of health screening appears to be essential in the success of such programs in reaching many potential participants.
A strength of this study is the common culture shared by the principal researcher and the informants. Levy (Levy, 1985) suggests that people are more willing and comfortable to share their views and stories when they are with someone who they perceive has similar interests; who displays a sympathetic understanding; who is familiar with their culture; and who is able to speak the language they were most comfortable using. Being able to understand the language of informants was important because it eliminated concerns about losing any meanings in the course of translation. There are implications here too for the establishment and staffing of health centers catering for specific cultural groups.
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Conclusion |
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While it is recognized that the sample in this study may not be representative in terms of the attitudes and behavior of the Chinese community in general, this is the first time a qualitative study of this type has been undertaken in Australia which explores the factors influencing Chinese-Australian women's breast cancer screening decisions from their perspective. To encourage greater screening participation among this community, each facilitator should be considered. Seniors' clubs' arrangements, for example, are very useful for getting elderly Chinese women involved in screening, but the information relayed must be considered carefully and ethical considerations addressed. In addition, this study also yields several health education and policy implications for designing and providing culturally sensitive screening services by specifically addressing the identified barriers. Health education programs need to go above and beyond the knowledge of screening recommendations, and address the attitudes that prevent Chinese-Australian women from participating in mammography.
A number of overseas studies consistently report that using mammographic screening service is a health issue among Chinese women in the USA (Tu et al., 2003), Canada (Jackson et al., 2003), the UK (McAllister and Bowling, 1993) and Singapore (Straughan and Seow, 2000), Australia is not an exception. This study provides valuable information from the women's perspective about why this is so. For screening to be effective, we must continue our efforts to understand the specific concerns of Chinese and women from other cultural backgrounds in regarding acceptance of mammography.
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Acknowledgments |
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The final stage of this study was supported by a Completion Scholarship from the NSW Nurses Registration Board.
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Received on January 25, 2005; accepted on April 11, 2005
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