Knowledge, beliefs

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Knowledge, beliefs information needs of Iranian
Immigrant Women in Toronto regarding Breast
Cancer and Screening

• Dr. Mandana Vahabi
• Associate Professor, Daphne Cockwell School of
  Nursing, Faculty of Community Services
• Ryerson University
• Nov 2011

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Background Breast Cancer

• Breast cancer (BC) is a common threat to womens
  health worldwide
• 23 of global cancer incidence
• 14 of global cancer deaths
• More than half of these deaths occurred in
  lowmiddle income (developing) countries despite
  the higher incidence of breast cancer in high
  income (developed) countries.
• According to the Canadian Cancer Society
• BC is one of the leading causes of mortality and
  morbidity
• 1 in 9 Canadian women will be diagnosed with BC
  in their life-time
• 1 in 28 will die of BC
• This makes BC the most common cause of cancer and
  the 2nd leading cause of premature cancer deaths.

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Age-standardized Incidence and Mortality Rates
for Female Breast Cancer in Canada, 1979-2009
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Background BC Screening

• Secondary prevention early detection and
  treatment of BC
• BSE- Breast cancer awareness
• CBE
• Screening Mammography
• Screening mammography CBE can
• breast cancer mortality in women age 50 and
  over by 3040.

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Background BC Screening in Immigrant women

• Use of BC screening is suboptimal esp. among
  minority women.
• In 2008, 57 of female recent immigrants (in
  Canada lt10 years) were non-users, compared with
  26 of Canadian-born women.
• Ethnicity is a significant predictor of the stage
  at which breast cancer is diagnosed.
• Ethnic minority women are reported to have
• High prevalence of advanced breast cancer
• Poor five year survival rates
• High rates of breast cancer mortality
• Low utilization partly attributed to womens
  cultural beliefs, language barriers, and limited
  BC and screening knowledge
• As researchers/professionals we have limited
  understanding of how different cultural groups
  perceive and manage cancer.

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Iranian Population in Toronto, Canada
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Breast Cancer among Iranian Women

• Canadian cancer data does not include information
  about ethnicity.
• Studies conducted in Iran
• BC is one of the top three leading causes of
  death for women in Iran
• BC contributes to 14 of all deaths
• High prevalence of advanced BC, particularly
  among younger women (late 2030s)
• Lack of awareness and knowledge of BC and
  screening
• Lack of systematic screening programs and
  policies for early detection of BC in Iran
• In Iran there is more emphasis on treatment than
  prevention
• Iran lacks universal health care

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Study Purposes

• To explore Iranian immigrant womens breast
  cancer and screening knowledge and their
  self-reported breast screening practices.
• To explore womens beliefs related to cancer and
  screening.
• To explore womens breast health information
  needs.

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Methods

• Design A cross sectional exploratory
  mixed-methods
• Sampling A convenience sample of 50 Iranian
  women
• Target population Included women who
• were Toronto residents and identified themselves
  as Iranian
• were 25 years or older
• were able to communicate in Persian
• had emigrated to Canada within the last 10 years
• had no history of breast cancer.  
• Interviews conducted in Persian by a bilingual
  RA Study instruments were translated into
  Persian and then back-translated into English.

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Results
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Knowledge of Breast Cancer and Screening

• Overall baseline knowledge scores ranged from
  518 (out of a possible 19)
• mean score was 9.8 (SD 2.9)
• median and mode was 10
• Some differences in the mean knowledge by
  socio-demographic and clinical characteristic but
  not significant.

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• Main correlates BSE CBE
• BSE
• Knowledge of breast cancer and screening
  practices (p0.005)
• The likelihood of ever performing a BSE
  increased by 59 with a 1-unit increase in
  knowledge.
• Interaction between womens knowledge and their
  length of stay in Canada (p0.023)
• CBE
• Length of Stay (p0.04)

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Barriers to Practice

• 1. Limited knowledge about BC screening
  practices
• Not knowing what to look for
• Not used to going to doctor if no problem
• women explained that in Iran they only visited
  doctors when they experienced serious health
  problems
• women reported feeling ashamed about wasting
  their physicians time when there was no problem
  present
• Not being aware of the need for BC screening in
  the absence of symptoms
• women considered themselves healthy when they
  were not experiencing any symptoms
• Majority of participants had heard of mammography
  and indicated it was useful (but mainly as a
  diagnostic tool)

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Barriers to Practice Breast Health

• 2. Cultural values and beliefs
• Gods willExternal locus of control
• I Cannot change my destiny if God has decided
  it BC already
• Fear of finding a lump
• Death sentence
• Lack of time to devote to ones health/giving
  more priority to family (gender role)
• women explained that limited social support,
  being the primary family caregiver, and financial
  worries after migration leave them barely any
  time to think about their own health

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Barriers to Practice

• 3. Systemic barriers
• Limited English proficiency
• Insufficient information and care by attending
  physicians
• My doctor should at least tell me when to go for
  screening or to
• go for physical check up. We are not used to
  these things back
• home.
• Unfamiliarity with the Canadian healthcare
  system
• different from homeland limited knowledge about
  breast cancer and breast health practices and
  where to find information
• Transportation

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Breast Health Information needs

• causes of BC and risk factors
• Environmental risk factors --water/air pollution,
  radiation released into the environment as
  fallout (pre-migration)
• Psychosocial Stress, depression (post-migration)
• Physiological and culturalBreast size,
  reproductive history, marrying and having
  children at younger age.
• signs and symptoms of breast cancer and effective
  treatment options
• chances of surviving breast cancer for women in
  their community
• prevention and early detection
• Accessibility Breast health resources.

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Discussion Recommendations

• Overall low knowledge of BC and screening
  practices among Iranian immigrant women in
  Toronto.
• Breast cancer knowledge gap continues to exist
  even after the migration to host country.
• Merely translating and disseminating existing
  English health education materials to people from
  minority ethnic groups is ineffective.
• Need for design and implementation of
  culturally-sensitive breast health information.
• Develop culturally sensitive and appropriate
  breast health educational materials that address
  Iranian womens specific breast health
  information needs and challenge their
  pre-existing beliefs. Some examples
• use of third person
• positive framing
• non-fear provoking messaging
• Discuss environmental/psychosocial as well as
  physiological BC risk factors

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Discussion Recommendations

• Inform and educate physicians and other health
  care providers about breast health communication
  with minority women and encourage them to
  incorporate breast health teaching during any
  health encounter.
• Physicians should also send reminders to patients
  about their annual check-up and use the encounter
  to promote health prevention behaviours.

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Papers

• Vahabi M. (2010). Iranian Womens Perception and
  Beliefs about Breast Cancer, Health Care for
  Women International, 31(9)817-830.
• Vahabi M. (2011). Knowledge of Breast Cancer and
  screening practices among Iranian immigrant
  Women, Journal of Community Health, 36(2)265-273
• Vahabi M. (2011) Breast Health Information Needs
  and Preferred Communication Medium Among Iranian
  Immigrant Women in Toronto, Health and Social
  Care in the Community, 19(6) 626-635

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Questions/Comments