Psychological factors and demands for breast and cervical cancer screening
Introduction
Breast and cervical cancer screening (BCS/CCS) has been introduced in many countries for decades [[1], [2]]. However, their cost-effectiveness depends heavily on uptake of the service [3]. Inadequate use of the screening directly prevents the target women from benefiting; while overuse and disproportionate use leads to resource wastage and reduction in cost-efficiency [4]. BCS/CCS uptake varies greatly between nations even between population groups within a given nation. Reported uptake rate of ever getting BCS ranged from 3.2% to 52.8% in different states of the United States [5] and 76.2% for the Norwegian Breast Cancer Screening Program [6]; while uptake of CCS by different age groups, ragned broadly from 1.5% to 73.2% in the U.S. [7] and from 15.17% to 29.86% in the United Kingdom [8]. The literature also documented marked disparities in results between locale (rural versus urban areas), income (poor versus wealthy), and ethnicity [[9], [10]]. Overall, most programs require repeated screening for the same individuals every few years, yet uptake of the second and third screenings reflect marked decreases. For example, the Norwegian Breast Cancer Screening Program approached 1,383,032 women, approximately 80% of whom participated in an initial screening, yet only 4.6% and 2.6% returned for the second and third screenings respectively [11].
Although researchers hold different perspectives on the optimal uptake rate of cancer screening (CS), there is a clear need for cost-effective measures in modulating the service utilization, correcting under-, over- and disproportionate use. Factors contributing to screening uptake are complex and not well-understood in the literature, but can be summarized into two broad categories: (1) demographics (e.g., age, gender, education, household income, occupation, and availability of screening) [[12], [13], [14]]; and (2) psychological determinants (e.g., perceptions about risks of cancer and perceived barriers to screening) [[13], [14]]. While most studies reviewed have focused on associations between screening behaviors and socio-demographic and structural factors, there is a growing interest in exploring values and beliefs about sexual behavior, fatalism, and concepts about disease and health etc., and identifying the roles of such factors in women’s decisions and behaviors regarding CS [[13], [14], [15]]. However, these values and beliefs increase or decrease the likelihood of CS use dynamically via direct and indirect pathways and thus pose a challenge for understanding and promoting the screening behaviors [[15], [16], [17], [18]]. Psychological theories provide systematic views for tackling these challenges [[14], [17], [18], [19]]. The current study analyzes psychological determinants of the demands for BCS/CCS among adult residents in Hefei, a representative city of the majority cities in China using the health belief model (HBM) as the guiding framework. Applied to the specific case of breast and cervical cancer screening, HBM holds that a person’s use of the service is a function of the following beliefs: 1) perceived risks (PR) to cancer (“Am I at risk for cancer?”); 2) perceived severity (PS) of the condition (“How will cancer affect my life?”); 3) perceived effectiveness (PE) of CS (“Is cancer screening effective in detecting early stage cancers?”); 4) perceived benefits (PB) of CS (“If I participate in cancer screening, can I avoid the disease?”); 5) perceived difficulties (PD) to using CS (“I don’t have time to seek cancer screening”).
Developed in the 1950s, the HBM has been widely used as a systematic method to explain and predict health behaviors [[17], [18], [19], [20], [21]]. However, empirical evidence about using HBM constructs in exploring BCS/CCS remains scant and the few published studies uncovered interesting findings. Some of the HBM constructs (e.g., PB and PD of the screening) identifiied strong links with BCS/CCS; while others (e.g., PR and PS of the cancers), demostrated relatively weak or no relations. Furthermore, these associations between screening behaviors and patient perception varied substantially across different ethnic groups [[18], [19], [20]]. China is a nation with unique and strong traditional values and concepts about cancer and related health services. How HBM constructs affect BCS/CCS in China merits particular attention. More importantly, the nation has a population of over 1.3 billion with an estimated annual incidence and mortality of 187,213 and 47,984 respectively due to breast cancer and 61,691 and 29,526 due to cervical cancer in 2012 [22]. With funding by the central government, China has been piloting free BCS/CCS since 1986 [23]. Since 2012, the nation has sped up expansion of these screening programs. However, uptake of the screening remains very low [[24], [25]]. These all point to a clear need for better understanding of the underlying causes and inform future efforts for promoting CS in China. The current study aims to investigate relationships between demands for BCS/CCS and related HBM constructs.
Section snippets
Study design and content
The study adopted a cross-sectional design and a cluster-randomized sampling in which 960 female residents were selected from 8 communities in Hefei, China. The sampling and recruitment proceeded in the following steps: a) random selection of 1 community from each of the 8 districts in Hefei; b) random selection of 1 index household from each of the community selected; c) randomly selection of one eligible member as the respondent from the household selected; d) door-by-door recruitment of one
Social-demographic characteristics of informants
Among the 960 eligible informants, Eight hundred and eighteen (85.2%) agreed to participate and 805 (98.4%) completed the survey. About one quarter (24.3%) of informants had no education with the 60- to 70-year-old age group being the least educated. Approximately three-fourths (72.9%) of informants lived in a household with 3–6 persons. Nearly half (47.7%) of the respondents’ annual family income fell within the category of 20–59 thousand RMB(Renminbi). In general, the older the respondents,
Discussion
This study uncovered interesting findings about demands for BCS/CCS among female residents in Hefei city, China. The huge discrepancy between willingness to uptake and actual practice has important implications for policy-making and intervention designing. Acceptance of BCS/CCS does not necessarily follow uptake and simply raising the awareness of the service may not work. The differences in the acceptance of free and paid CS, being some 20% for BCS and CCS may indicate that demand for the
Conflicts of interest
The authors declare no conflicts of interest.
Funding
Development of the primitive protocol was supported by the National Natural Science Foundation of China (grant number: 71503009). Refinement and implementation of the protocol is lead and supported by the Collaboration Center for Cancer Control of Anhui Medical University and Hefei Center for Diseases Control and Prevention.
Authors’ contributions
TJ and DW contributed equally in conceiving the study and drafting the manuscript. JZ and XZ implemented field data collection. RF, RS and XS designed the instruments and performed the data analysis. DW provided expertise for overall design of the study and revised and finalized the manuscript. We declare no financial disclosures were reported by the authors of this paper.
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Tao Jiang and Donghua Wei are equal first authors.