Principal Investigator: Marta Meana, Ph.D.
Co-Investigators: Terry Bunston, Ph.D.
Lillian M. Wells, MSW, DipAdvSW, CSW
Usha George, Ph.D.
Walter Rosser, M.D., FCFP

Synopsis

This study sought to investigate the barriers and incentives to breast cancer screening (breast self-examination, clinical breast examination, mammography) in Tamil immigrant and refugee women in metropolitan Toronto by comparing health beliefs and level of acculturation of Tamil women who had had a mammogram to Tamil women who had not had a mammogram. One hundred and twenty women (52 never had mammogram, 68 had at least one mammogram) completed a series of questionnaire to assess health beliefs and acculturation and 3 focus groups were conducted with 20 other women. Women who had had mammograms had more confidence in breast self-examination, were more motivated to engage in general health behaviors, were more convinced about the benefits of mammograms, perceived less barriers to mammogram screening, were more knowledgeable about breast cancer and screening practices, and reported higher levels of acculturation than women who had never had a mammogram. Themes arising from the focus groups include religious beliefs about the meaning of breast cancer, fear of radiation exposure and low risk reduction expectancies. These results suggest specific areas of intervention to enhance the breast cancer screening behavior of this group of minority women.

OVERVIEW OF RESEARCH UNDERTAKEN

There were three components to this study.

The first consisted in the quantitative measurement of psychosocial barriers and incentives that mediate beast cancer screening behavior by comparing Tamil women who had had a mammogram and those who have not. One hundred and twenty women completed a questionnaire assessing perceptions of risk and risk reduction expectancies in respect specifically to the development of breast cancer (Risk Adaptation Scale), a questionnaire assessing breast health attitudes and beliefs regarding susceptibility, seriousness, benefits of mammography and breast self-examination, barriers to mammography and breast self-examination, confidence, health motivation, social influence and knowledge (Breast Health Attitudes/Behavior Inventory), and a questionnaire assessing degree of acculturation (adapted from the Suinn-Lew Self-Identity Acculturation Scale). We were able to administer our protocol to 52 women who had never had a mammogram and to 68 women who had had at least one mammogram. Measures were back-translated so that women who could only read Tamil were able to participate in our study.

The second component of the study consisted of focus groups in which facilitators attempted to elicit responses regarding benefits and barriers to mammography. Three focus groups were conducted. Two with exclusively Tamil-speaking women, one group having had mammograms and one group not. The English speaking group had had mammograms.

The third component of the study consisted of the mailing of a breast screening practices questionaire to physicians who have a significant number of Tamil women in their paractice. We collected a total of 63 completed questionnaires for a 63% response rate.

RESEARCH RESULTS

Research results below will be presented as a list of significant differences found between the two groups (mammography/no mammography) and the probability level of the difference. More sophisticated analyses are currently being conducted, including discriminant function analyses, correlational analysis, multivariate analyses of variance, and analyses of covariates. These will be duly reported in conference presentations and publications. The following is a preliminary analysis for the purposes of this report. Please note that M refers to the group of women that had had mammograms and NM refers to the group of women that had not ever had a mammogram.

M had lived in Canada longer than NM (p<.0001).

M had higher levels of formal education (p<.005).

M reported stronger belief that risk of breast cancer can be reduced by health behaviour than NM (p<.003).

M reported stronger belief that risk of breast cancer can be reduced by following the doctor’s recommendations (p<.0001).

NM reported a higher perception of personal risk of breast cancer than M (p<.001).

M reported feeling more confident about their skill in performing breast self-examination than NM (p<.03).

M reported being more motivated to engage in general health related behaviours than NM (p<.0001).

M reported being more convinced about the benefits of mammography than NM (p<.0001).

NM reported perceiving more barriers to mammography than M (p<.0001). These barriers include embarrassment, anxiety, time, fear of pain).

M were more knowledgeable about breast cancer and screening practices than NM (p<.005).

M were more acculturated than NM (p<.001).

NM had higher belief in South Asian values (p<.001)

Anxiety about breast cancer, fear of radiation exposure, language barriers, fear of pain during mammogram, social stigma of cancer, embarrassment especially with male doctors, religious belief that one is protected, religious belief that breast cancer is retribution for ill-doing, shame about illness.

Physician survey

When physicians were asked what they perceived to be the biggest barriers in their recommendation of breast cancer screening practices for their Tamil patients, the top three reasons given were:

patient seen for episodic care rather than regular care

patient seen for other reasons

patient refuses

language difficulties

NATURE OF RESEARCH COLLABORATION

This project was a collaboration of the Women’s Health Program and Department of Psychiatry, The Toronto Hospital and the University of Toronto, the Department of Psychosocial Oncology, Princess Margaret Hospital, the Department of Social Work, University of Toronto, Sunnybrook Hospital, the Department of Family Medicine, University of Toronto, and the South Asian Women’s Center. A large part of the data collection was conducted by two University of Toronto undergraduate students who were trained in the coordination of research and the recruitment of subjects. These students experienced the complexities of conducting community research and the various cultural issues that arise when research is conducted with minority groups.Data entry was conducted by four undergraduate students from the University of Nevada, Las Vegas.

PUBLICATIONS AND DISSEMINATION

A manuscript is currently being prepared for submission to either women’s health journals (e.g. Journal of Women’s Health) or multicultural health journals (e.g. Society and Medicine). The results will first be presented at the National Multicultural Conference and Summit of the American Psychological Association this Fall. Additional conference presentations are currently being planned for the Spring.

CONTRIBUTION TO POLICY DEVELOPMENT

The results of this study underline the need to reach recently arrived immigrant women with breast cancer screening recommendations that are culturally and religiously sensitive. The barriers to screening in this population are issues that can be addressed in community out-reach efforts to increase these health behaviors. Educational materials aimed at this and other minority groups must reflect their cultural reality and special education needs. Information is necessary but not sufficient to encourage the participation of groups whose barriers do not consist merely of informational deficits.

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