1. 1 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

2. 2 Background – Breast Cancer Breast cancer (BC) is a common threat to women’s health worldwide – 23% of global cancer incidence – 14% of global cancer deaths – More than half of these deaths occurred in low–middle 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 2 nd leading cause of premature cancer deaths.

3. 3 Age-standardized Incidence and Mortality Rates* for Female Breast Cancer in Canada, 1979-2009

4. 4 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 30–40%.

5. 5 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 <10 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 women’s 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.

6. 6 Iranian Population in Toronto, Canada

7. 7 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 20–30s) – 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

8. 8 Study Purposes To explore Iranian immigrant women’s breast cancer and screening knowledge and their self-reported breast screening practices. To explore women’s beliefs related to cancer and screening. To explore women’s breast health information needs.

9. 9 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.

10. 10 Results

11. 11

12. 12 Knowledge of Breast Cancer and Screening Overall baseline knowledge scores ranged from 5–18 (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.

13. 13

14. 14 Main correlates: BSE & CBE BSE  Knowledge of breast cancer and screening practices (p=0.005)  The likelihood of “ever performing a BSE” increased by 59% with a 1-unit increase in knowledge.  Interaction between women’s knowledge and their length of stay in Canada (p=0.023) CBE  Length of Stay (p=0.04)

15. 15 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 physician’s 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)

16. 16 Barriers to Practice Breast Health 2.Cultural values and beliefs – God’s will–External 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 one’s 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

17. 17 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

18. 18 Breast Health Information needs 1) 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 cultural—Breast size, reproductive history, marrying and having children at younger age. 2) signs and symptoms of breast cancer and effective treatment options; 3) chances of surviving breast cancer for women in their community; 4) prevention and early detection; 5) Accessibility Breast health resources.

19. 19 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 women’s 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

20. 20 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.

21. 21 Papers Vahabi M. (2010). Iranian Women’s 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

22. 22 Questions/Comments