Breast-Health Screening Perceptions of Chinese Canadian Immigrant Women Aged 30 to 69

The Exchange Volume 3, Number 1 - July 2014 13 Breast-Health Screening Perceptions of Chinese Canadian Immigrant Women Aged 30 to 69 Fung Kuen Heidi Sin, Patricia Y. Talbert, Louise Underdahl, & Chris Enslin, University of Phoenix Abstract The global prevalence of breast cancer in the century continues to increase although mortality rates could be reduced by early detection and treatment. While the incidence of cancer, stages of diagnosis, and survival rates vary among different ethnic groups, early detection through breast-health screening and prompt treatment are effective in reducing mortality rates. The purpose of this case study was to explore and describe the perceptions of breast-health screening among Chinese Canadian immigrant women and barriers that prevented them from having breast-health screening. A purposeful sample of 27 women aged 30 to 69 who had migrated from China, resided in Canada for 5 years, and had no history of breast cancer was recruited. Semi-structured interviews and two focus groups provided information about participants breast-health screening experiences. Although participants were cognizant of the ramifications of breast cancer and benefits of screening, they were reluctant to utilize clinical opportunities for early detection. Findings suggested that Chinese cultural beliefs and practices contribute to low participation in breast-health screening can represent opportunities for health care professionals to proactively educate communities on the benefits of preventive health and recommend breast-health screening. Potential strategies to promote breast-health screening include culturally sensitive linguistic educational programs, physician recommendations or referrals to breast-health screening as a standard process for annual medical visits, expanded operating hours for screening clinics, and community-based outreach initiatives. Findings from this study may provide policymakers, health care leaders, public health officials, and health educators evidence-based information for developing policies, guidelines, and educational programs to help new immigrant women access preventive health services such as breast-health screening program. Future research on a broader demographic group may yield additional insights on strategies to optimize early detection of breast cancer. Keywords: breast cancer, breast-health screening, mortality rates, early detection, cultural beliefs, community-based outreach Introduction Breast cancer has a significant mortality rate with 458,000 female deaths reported globally by the (World Health Organization [WHO], 2013a). Early detection and prompt treatment could reduce fatalities (WHO, 2013b). In Canada, 22,700 women were diagnosed with breast cancer in 2012, with 5,100 cancer-related deaths in women predicted; 1 in 9 females was

The Exchange Volume 3, Number 1 - July 2014 14 anticipated to develop breast cancer and the mortality rate from this disease was assumed to be 1 in 29 (Canadian Cancer Society, 2012). McDonald and Neily (2011) conducted a statistical analysis of the National Health Interview Survey (NHIS) database from 1998 through 2007, including 128,966 women between ages of 21 and 65; findings on incidence of cancer, stages of diagnosis, and survival rate varied among different ethnic groups (McDonald & Neily, 2011). Among different ethnic groups, the incidence of breast cancer in Asian women increased rapidly at a rate of 2.1% yearly between 1992 and 2000 when compared to non-asian women in the United States (Wu & Ronis, 2009). Early detection through breast-health screening and prompt treatment could reduce mortality in Native, African, and Asian American women in the United States (Alexandraki & Morradian, 2010). According to Cancer Care Ontario (2010), participation in breast-health screenings and advanced treatment may have reduced breast cancer mortality rates by 35% in all women between 1990 and 2007. Despite the effectiveness of mammography screening and health education, participation rates among all women remain low and even lower within ethnocultural groups (Todd, Harvey, & Hoffman-Goetz, 2011). A better understanding of the perceptions of breast-health screening among Chinese Canadian immigrant women is required to develop more effective strategies for preventive care. Research Question This study was organized around one central question and five subquestions. The central research question was: What are the perceptions of breast-health screening among Chinese Canadian immigrant women aged 30 to 69? The related subquestions were: (1) What types of preventive health measures are used by Chinese Canadian immigrant women? (2) What are the perceived benefits of breast-health screening for Chinese Canadian immigrant women? (3) What are the obstacles to breast-health screening for Chinese Canadian immigrant women? (4) What are the females perceptions of condition, situations, or contexts that influence their lived experiences with breast-health screening? (5) What perceived role does breast-health screening play in Chinese Canadian immigrant women s health? Theoretical Framework The purpose of preventive health programs is to help people maintain and improve health. To achieve optimal outcomes, understanding individuals health behaviors and the environmental context is crucial. Salient theories include (1) Transtheoretical Model (TTM), (2) Theory of Planned Behavior and Theory of Reasoned Action (TPB and TRA), (3) Social Cognitive Theory (SCT), and (4) Health Belief Model (HBM). Glanz, Rimer, and Viswanath (2008) stated, The TTM posits change as a process through six stages, including precontemplation, contemplation, preparation, action, maintenance, and termination (p. 100). In the precontemplation stage, individuals do not intend to take action to change behavior in the next 6 months. Individuals demonstrate resistance, are unmotivated, and are not ready for program. In the contemplation stage, individuals intend to change their health behaviors in the next 6 months and they recognize the positive outcomes of the change. In the preparation stage, individuals acquire a plan for action and they have taken significant steps toward health behaviors in the last year. Individuals intend to take action in a very short time. In the action stage, individuals have made specific modifications in their lifestyles in the last year. A significant behavioral change is observed. In the maintenance stage, individuals have made

The Exchange Volume 3, Number 1 - July 2014 15 specific modification in behaviors and are working to prevent relapse. In the termination stage, individuals had no temptation to relapse and built confidence (Glanz et al., 2008). Both TPB and TRA were used to explore the relationship among beliefs, behaviors, attitudes, and intentions (National Cancer Institution, 2005). The TPB and TRA, behavioral intention is identified as the predictor of a behavior and attitude toward the behavior. The focuses of the TPB and TRA are on the constructs of attitude, subjective practices, perceived control, and explanation of different opinions in behavioral intention and prediction of various behaviors. Fishbein and Ajzen (1975) demonstrated attitude toward behavior such as mammography was a predictor of the behavior, participation in mammography, and the attitude toward cancer as the object at which the behavior was directed. SCT was based on function of developed principles of learning within a human social environment (Bandura, 1977). SCT explained behavior as a reciprocal interaction between individuals and their environments (McAlister, Perry, & Parcel, 2008). SCT assumed that an individual s behavior was a result of dynamic effect among individual, behavioral, and context influences (Glanz et al., 2008). SCT provides an inclusive and robust conceptual framework for knowing the factors that affect an individual s behavior and the processes provide insight into different health related issues. The health belief model (HBM) was established by a group of social psychologists who focused on public health in the early 1950s (Glanz et al., 2008; Tanner-Smith & Brown, 2010). The HBM continues to be the most commonly recognized model used to address health behaviors and it has been significant with altering heath behaviors and a valuable model to develop interventions. The HBM focused on primary prevention and early detection of diseases (Glanz et al., 2008). Psychologists sought to explain the rationale for low participation rates in disease prevention and detection program (Glanz et al., 2008). Later, Kirscht (1974) applied the HBM to study how individuals responded to symptoms of diseases. In addition, Glanz et al. (2008) explored individual behaviors in response to diagnosed diseases, particularly adherence to course of treatment. Bedgood (2010) reported that women were compliant to regular breasthealth screening if individuals perceived the severity of negative outcomes of late diagnosed of breast cancer. Within the health environment, if an individual is fearful of cancer, the person would participate in regular breast-health screening to allow for early detection. That would indicate recognition of the benefit of having cancer screenings and an individual was motivated by the perceived benefits. Furthermore, if a person feared cancer, the fear (a perceived threat) could serve as motivation to change an individual s behavior in proactively participating in cancer screenings. The studies of Champion (1994) applied the HBM to predict the use of mammography in terms of perceived barriers, benefits, and susceptibility. All of these models have been instrumental in explaining multiple health behaviors and they support the development of health programs, create interventions, and change behaviors. Methods, Techniques, or Modes of Inquiry Qualitative research is appropriate for the study of any issue in which researchers have little information and require exploration of the research problem by learning from the study participants (Merriam, 2009). The case study approach was optimal as it examined the life experiences and described activity or concept from the study participants. This case study used in-depth semi-structured interviews to explore and describe detailed information about Chinese Canadian women s perceptions of breast-health screening and barriers that prevented them from having breast-health screening. The goal was to understand these perceptions so health

The Exchange Volume 3, Number 1 - July 2014 16 educators and promoters could develop appropriate programs to increase the awareness of breasthealth screening and participation in mammography among Chinese Canadian immigrant females to reduce mortality rates. To increase triangulation of results, this study included the use of two focus groups to collect information. The focus groups consisted of six people with the same characteristics as the semi-structured interview participants and were facilitated by a moderator (Christensen, Johnson, & Turner, 2011; Leedy & Ormrod, 2010). Data Sources, Evidence, Objects, or Materials This study used a purposeful and intentional sample. A purposeful sample, with a total of 27 Chinese Canadian females aged 30 to 69 who had migrated from mainland China, were recruited. The recruited participants were female Chinese Canadian immigrants who have resided in Canada for 5 years or less and had no personal history of breast cancer. Women with history of breast cancer were excluded from this study because they were likely to engage in regular breast-health screening to detect any recurrences of the disease and solicit recommendations from physicians (Lee-Lin et al., 2007). All participants were recruited from the Welcome Centre Immigrant Services-Markham South (WCIS-Markham South; 2012) and The Cross-Cultural Community Services Association (TCCSA; 2012) in the Greater Toronto Area in Ontario, Canada. The rationale for choosing the two organizations for recruiting participants was that both organizations are located in the areas accessible by Chinese Canadian immigrants and the availability of staff who speak the participants language. The researcher used a short survey to collect demographic data, semi-structured interviews, and two focus groups to gather information from participants surrounding breasthealth screening. The researcher recruited participants and distributed the invitation letters in simplified Chinese to the women who met study participant criteria. The researcher followed the interview protocol and conducted 15 in-depth semi-structured interviews to explore the experiences and the meanings of Chinese Canadian immigrant women toward breast-health screening. The use of a semi-structured interview in a qualitative study could provide freedom for the interviewer in asking the central question and a few customized questions to probe an individual s reasoning and to clarify any ambiguities (Christensen et al., 2011; Leedy & Ormrod, 2010). In addition, in-depth interviewing could provide ongoing interaction between the researcher and participant, and it was essential for relationship building and encouraging participation (Leedy & Ormrod, 2010). By asking open-ended questions in such a manner, the researcher could encourage participants to share life experiences and thoughts about the research topic (Tong, Sainbury, & Craig, 2007). To create a nonthreatening environment, the researcher used conversational language to conduct the semi-structured interviews and focus groups. The interviews were audio tape-recorded, transcribed into Chinese text, and translated into English for analysis. Interview questions were pilot tested through face-to-face interviews of two Chinese Canadian immigrant women who fell in the age bracket of the study participants to evaluate the appropriateness of the interview protocol and clarity of the interview questions. The researcher employed a second data collection method to triangulate data. Two focus groups were used to collect information from the women who had not participated in the semistructured interviews. During the data collection process, no new information was collected from the and participants of semi-structured interview and the second focus group, so the assumption was made that data saturation had occurred. Since ethical issues could arise during the sharing of a person s life experiences, the participants were reassured of the anonymity and confidentiality of the collected information.

The Exchange Volume 3, Number 1 - July 2014 17 Results and Point of View Participants shared perceptions to add to understanding the phenomenon of low participation in breast-health screening among Chinese Canadian immigrant women. Analysis revealed several findings. First, Chinese Canadian immigrant women were influenced by the Chinese cultural beliefs and practices rather than practicing screening to maintain health. The Chinese cultural practices included healthy balanced diet, regular physical and daily activities, positive psychological attitude, and good mood. Following Chinese Canadian immigrant women s preventive health measures and a holistic approach to health, it is not surprising that many participants did not perceive breast-health screening to be one of the preventive health measures. Next, Chinese Canadian immigrant women believed that breast-health screening could identify problem early and screening was beneficial to individuals, their children, and family. An individual could receive prompt treatment and result in live saving. If no problem was identified by screening, stress could be relieved. The women could fulfill their caregiver role if they were healthy. Third, Chinese Canadian immigrant women experienced many challenges that affected the accessibility to and utilization of screening services. The top barrier was lack of knowledge about breast-health screening because the individuals were new to Canada and acquired poor English language proficiency. Others barriers included inconvenience, embarrassment, perceived illness, and fear of radiation. Next, there was a lack of preventive health concept in Chinese Canadian immigrant women. Fifth, experiences and perceptions of screening affected the participation in breast-health screening among Chinese Canadian immigrant women. The emotional responses, feelings, and perceptions about screening were strongly affected by the perceived benefits and barriers to access screening. Last, lack of information about breast-health screening program among Chinese Canadian immigrant women was identified. The majority of participants were aware of the benefits of breast-health screening to detect breast cancer early. Participants did not receive any information about screening because they were new to Canada. Only 20% of the participants were aware of breasthealth screening programs in Canada through physicians recommendations and reminders. Results provide information to help physicians, health care practitioners, and public health officials improve effectiveness of breast-health educational programs and increase participation rates in breast-health screening. Recommendations Development of culturally sensitive linguistic programs and educational materials is requisite to increase participation in breast-health screening. Health care professionals should reinforce and recommend breast-health screening. Lack of a physician s recommendation contributes to low participation in breast-health screening. Policymakers may include recommendations or referrals to breast-health screening as the standard process for annual medical visits done by the physicians and recommend in-depth discussion of the breast-health prevention and screening. To increase knowledge of breast-health information and promote breast-health screening, collaboration with the media is also crucial. Additionally, public services announcements (PSAs) through ethnic media are employed. Sun, Zhang, Tsoh, Wong- Kim, and Chow (2007) reported the effectiveness of using PSAs as a promotion strategy to promote breast-health messages among Chinese American immigrants. To maximize effectiveness, policymakers should consider extending hours of operation for breast-health screening clinics during weekdays and weekends to accommodate a variety of work schedules. Initiation of a mobile women s clinic would provide access to breast-health screening

The Exchange Volume 3, Number 1 - July 2014 18 information and mammography screening to women who have shift work, are unable to take time off from their work, or have no family doctor. To minimize communication problems due to poor English proficiency, instruction sheets or translation services in Chinese at the breasthealth screening clinics should be provided as a continued education measure. Limitations Potential limitations of this study included population size, geographic areas, and generalizability. The findings of this study were derived from the 15 individual Chinese Canadian immigrant females and two groups of six Chinese Canadian immigrant females who were recruited exclusively from the WCIS-Markham South and TCCSA in the GTA. Additionally, only the Chinese women who came from Mainland China were recruited. Therefore, the findings could not be generalized to the entire population of such women in Canada or represented Chinese immigrant women from other areas such as Hong Kong or Taiwan. This has implication for future studies to explore the needs of Chinese Canadian immigrant women who came from other countries and to expand the geographic areas for the recruitment of Chinese women. Conclusions To promote and increase participation in breast-health screening among Chinese Canadian immigrant women, it is crucial to develop culturally sensitive education programs in their language. It is important for health care professionals to reinforce and recommend breasthealth screening. To further reinforce the practice, policymakers can include recommendation to breast-health screening as the standard process for the annual medical visit done by the physicians. Future research on factors that encourage Chinese Canadian immigrant females to utilize breast-health screening may identify additional strategies to increase participation rate. Findings may provide policymakers, health care leaders, public health officials, and health educators with evidence-based information for developing policies, guidelines, and educational programs to help new immigrant women access preventive health services such as breast-health screening programs. References Alexanadraki, I., & Mooradian, A. D. (2010). Barriers related to mammography use for screening among minority women. Journal of the National Medical Association, 102, 206-218. Bandura, A. (1977). Self-efficacy. Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215. doi:10.1016/0146-6402(78090002-4 Bedgood, N. L. (2010). Using the health belief model to explore differences in breast cancer perceptions and self-reported mammography screening in African American women (Master thesis). Available from ProQuest Dissertation and Theses database. (UMI No. 1490115) Canadian Cancer Society. (2012). Breast cancer statistics at a glance. Retrieved from http://www.cancer.ca/canada-wide/about%20cancer/cancer%20statistics/ stats%20at%20a%20glance/breast%20cancer.aspx

The Exchange Volume 3, Number 1 - July 2014 19 Cancer Care Ontario. (2010). Ontario breast screening program 20th anniversary report 1990-2010. Toronto, ON: Author. Champion, V. (1994). Beliefs about breast cancer and mammography by behavioral stage. Oncology Nursing Forum, 21, 1009-1014. Christensen, L. B., Johnson, R. B., & Turner, L.A. (2011). Research methods, design, and analysis (11th ed.). Boston, MA: Allyn & Bacon. Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley. Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health behavior and health education. Theory, research and practice (4th ed.). Hoboken, NJ: Jossey-Bass. Kirscht, J. P. (1974). The health belief model and illness behavior. Health Education Monographs, 2, 2387-2408. Lee-Lin, F., Menon, U., Pett, M., Nail, L., Lee, S., & Mooney, K. (2007). Breast cancer beliefs and mammography screening practices among Chinese American immigrants. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 36, 212-221. doi:10.1111/j.1552-6909.2007.00141.x Leedy, P. D., & Ormrod, J. E. (2010). Practical research: Planning and design (9th ed.). Upper Saddle River, NJ: Pearson. McAlister, A.L., Perry, C. L., & Parcel, G. S. (2008). How individuals, environments. and health behaviors interact. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education (pp. 169-188). San Francisco, CA: Jossey-Bass. McDonald, J. T., & Neily, J. (2011). Race, immigrant status and cancer among women in the United States. Journal of Immigrant Minority Health, 13, 27-35. doi:10.1007/ s10903-009-9268-1 Merriam, S. B. (2009). Qualitative research: A guide to design and implementation. San Francisco, CA: John Wiley. National Cancer Institute. (2005). Theory at a glance: A guide for health promotion practice (2nd ed.). Retrieved from http://www.cancer.gov/cancertopics/ cancerlibrary/theory.pdf Sun, A., Zhang, J., Tsoh, J., Wong-Kim, E., & Chow, E. (2007). The effectiveness in utilizing Chinese media to promote breast health among Chinese women. Journal of Health Communication, 12, 157-171. doi:10.1080/10810730601150106 Tanner-Smith, E. E., & Brown, T. N. (2010). Evaluating the health belief model: A critical review of studies predicting mammographic and pap screening. Social Theory & Health, 8(1), 95-125. doi:10.1057/sth.2009.23 The Cross-Cultural Community Services Association (TCCSA). (2012). Settlement workshops and services in China 2011. Retrieved from http://www.tccsa. on.ca/en_main.php Todd, L., Harvey, E., & Hoffman-Goetz, L. (2011). Predicting breast and colon screening among English-as-a-second-language older Chinese immigrant women to Canada. Journal of Cancer Education, 26, 161-169. doi:10.1007/s13187-010-0141-7

The Exchange Volume 3, Number 1 - July 2014 20 Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19, 349-357. Welcome Centre Immigrant Services. (2012). Welcome Centre Markham South. Retrieved from http://www.welcomecentre.ca/markham_south.html World Health Organization. (2013a). Breast cancer: Prevention and control. Retrieved from http://www. who.int/cancer/detection/breastcancer/en/ World Health Organization. (2013b). Cancer. Retrieved from http://www.who.int/ mediacentre/factsheets/fs297/en/ Wu, T. Y., & Ronis, D. (2009). Correlates of recent and regular mammography screening among Asian-American women. Journal of Advanced Nursing, 65, 2434-2446. doi:10.1111/j.1365-2648.2009.05112.x Author Information Fung Kuen Heidi Sin University of Phoenix School of Advanced Studies - Online Campus 625 W. Fountainhead Pkwy Mail Stop: CF-S909 Tempe, AZ 85282 Heidi Sin has been in the health care field for over 35 years. She earned a BScN at the Hong Kong Polytechnic University, BEd in Adult Education at the Brock University in Canada, MA in Education at the Central Michigan University, and Doctor of Health Administration at the University of Phoenix. Email: sunnyy123@email.phoenix.edu Patricia Y. Talbert University of Phoenix School of Advanced Studies - Online Campus 625 W. Fountainhead Pkwy Mail Stop: CF-S909 Tempe, AZ 85282 Patricia Y. Talbert, PhD, MPH, earned a BA (Ethics Studies) at Metropolitan State University, St. Paul, Minnesota followed by a MS, at St. Cloud State University, MPH, and PhD from Walden University. She has served as a public health consultant for Kevin Kennedy Associates, Inc. since 2000 and she is a director of public health for Ustawi Research Institute. Email: pytalbert@email.phoenix.edu Louise Underdahl University of Phoenix School of Advanced Studies - Online Campus 625 W. Fountainhead Pkwy Mail Stop: CF-S909 Tempe, AZ 85282 Louise Underdahl earned a BA (English Literature) at the University of California, Los Angeles (UCLA) followed by a MSLS, MPA, and PhD at the University of Southern California (USC). She has served UCLA since 1978, UCLA Health System Risk Management since 1992, and University of Phoenix Online since 2004. Email: lunderdahl@email.phoenix.edu

The Exchange Volume 3, Number 1 - July 2014 21 Chris Enslin University of Phoenix School of Advanced Studies - Online Campus 625 W. Fountainhead Pkwy Mail Stop: CF-S909 Tempe, AZ 85282 Chris Enslin earned a BS at the University of Wisconsin Parkside, Kenosha, Wisconsin followed by MBA and Ed.D. at Cardinal Stritch University, Milwaukee, Wisconsin. She has served in Manufacturing, Distribution, Healthcare since 1984, and the University of Phoenix since 2007. Email: censlin@email.phoenix.edu