Type: Process Essays
Sample donated: Glenda Adkins
Last updated: September 22, 2019
Breastcancer (BC) is the most commonly diagnosed cancer among women, impacting over1.5 million women each year, and also the second leading cause of cancer-relateddeaths in women throughout the world 1,2.
In Iran also, the disease accountsfor 24.4% of all cancers and its incidence has been estimated to be 17.81%, which has increased dramatically inrecent years 3. Unfortunately, because of resource and infrastructure constraints and diagnosingat later stages of breast cancer in low-income countries, there is an enormousdifference in BC survival rates worldwide, with an estimated 5-year survival of80% in developed countries to below 40% for developing countries 4,5. Delayeddiagnosis in developing countries is related, at least partly, to poor breastcancer awareness, especially low level of awareness about early warning signsand symptoms of BS 6,7.Increasing breast cancer awareness is widely accepted as the first step in thebattle against BS, especially in countries that do not have ongoing organizedpopulation-based screening 8,9.
Previous studies have shown that the increased women’s awareness about earlydiagnosis and screening of BS can change people’s screening health-seekingbehavior 6,10,11and self-examination rather than clinical-breast examination lead to earlier BSdiagnosis 8.Therefore, there is an urgent need for improving great BSawareness and its early detection measures among women 12.A vital first step into addressing this need is validinstruments for measuring and monitoring levels of BS awareness, and examiningits associated risk factors 7,9.Only with such standardized instruments can design appropriate interventions inorder to promote BS awareness 7,9.Several BS awareness instruments have been proposed 7–9,12–17.However, some of these instruments contain design and/or methodologicallimitations and are not fully validated. Cancer Research United Kingdom (UK) developedand did attempt to fully validate their instrument, the Breast Cancer AwarenessMeasure (BCAM) in 2010 7.
It is a self-completed questionnaire for assessing knowledge of breast cancersymptoms and age-related risk, and reported frequency of breast checking 7.In UK populations, the readability of the BCAM was reported high and constructvalidity was supported by significant differences between the levels of BSawareness among cancer experts compared to non-medical academics 7,13.However, the BCAM was developed and validated for western populations whereetiologic factors and health policy of BS differ considerably from Asiandeveloping countries 9.In addition, cross-cultural and language differences routinely introducemeasurement biases which affect the quality of data collected 13,18.These limitations reduce its usefulness outside the UK setting. Ina developing community such as Iran where late presentation is predominant andmajority of BS patients are diagnosed at advanced stages of disease 6,there is an urgent need for developing and validating an instrument to assessBS awareness. To the best of our knowledge, there is no accepted and validated instrumentfor assessing BS awareness in Iran. This study aimed to investigate thevalidity, language appropriateness and psychometric properties of the BCAMscale among Iranian women.
Understanding Iranian women’s BS awareness will helphealthcare professionals and policy makers to design and implement healtheducation interventions in order to promote awareness of BS. Methods and MaterialsStudy Design and Participants This cross-sectional study (methodologicalresearch) was conducted from July 2016 through November 2017. Participantswere Iranian women living in Isfahan, a city in central Iran. Nearly one thousand women were selected from differentparts of Isfahan city (such as shopping canters, recreational places,kindergartens, health canters and different streets of the city) to participatein the study. To be eligible for participation in this study, women had to beat least 18 years old, able to read and write Persian, and should be permanentresident of Isfahan. The participants who did not answer to main questions wereexcluded. Eligible women were invited to participate in the study byface-to-face invitation. Interviews were performed by trained interviewers.
After getting oral consent to participate in the study, participants wererequested to complete the BCAM questionnaire. The study was approved by theethics committee of the Isfahan University of Medical Sciences (Project Number:194126).The Breast Cancer Awareness Measure (BCAM)CancerResearch UK developed and validatedan awareness measure specific to BS awareness which called BCAM7.The team generated questionnaire items through areview of the literature on the existing BS awareness measures, a review of the’grey’ literature and the team’s experience during researches on breast cancerpatients.
It includesitems on knowledge of breast cancer symptoms,knowledge of age-related risk, and reported frequency of breast checking. In the current study,this instrument was selected based on its appropriate validity, reliability andreadability, and also its simplicity and generalizability. In UK populations,the readability of the BCAM was reported high and over 90% of women found it acceptable. The analyses oftest– retest reliability of the BCAM showed moderate to good reliability formost items. Good construct validity was approved by significantdifferences between the levels of BS awareness among cancer experts compared tonon-medical academics (50% versus 6%,p = 0.
001) 7,13. We also added questions about age, education level,marital status, job status, personal history of breast problems, family historyof breast cancer and sources of acquiring awareness into the questionnaire.Translation and cross-cultural adaptation The “forward–backward” procedure was applied totranslate the BCAM questionnaire from English into Persian (Iranian language),after seeking permission from the initial developer (Louise Linsell, KingsCollege London, London, UK). Forward translation of the BCAM from English toPersian was independently performed by two professional translators fluent inboth languages. The researchers and two forward translators then compared thetwo translated versions with the original questionnaire and reached a consensusabout the first draft of the Persian version of the BCAM.
The Persian adaptedversion was backward translated into English by abilingual translator. The translated English version was compared withthe original one with respect to conceptual equivalence by researchers and an expert committee. Finally, after a careful reviewand cultural adaptation process, necessary changes were made, and theprovisional Persian version of the BCAM questionnaire was provided. This pre-final Persian BCAM questionnaire was then piloted on50 women aged 18 years old and over who volunteered to participate in thestudy. They were asked to express any difficulty to understand any word orsentences in the questionnaire.
According to the participants’ feedback,the translation quality simplicity, and clarity of the questionnaire wereverified by most pilot study volunteers. Then, the researchers make finaladjustments in response to this feedback, and the final Persian version of BCAMwas developed.Assessment of psychometric propertiesIn this study, psychometric characteristics includereliability (test-retest reliability and internal consistency), validity(construct validity, face validity, criterion (discriminant) validity and contentvalidity). ReliabilityIn this study, we investigated two aspects ofreliability as test-retest reliability and internal consistency. To test the extent to which the measure was repeatable (the stability of the measurement over time), we recruited 50 women aged 18 years old and over.The women were asked to complete the BCAM questionnaire at two separate dayswith a 7-day interval between both periods. Test–retest reliability wasassessed separately for each item using the unweighted kappa statistic(<0.20: poor, 0.
21- 0.40: fair, 0.41- 0.60: moderate, 0.61- 0.
80: good,0.81- 1.00: very good). In addition, Intra class correlation coefficient (ICC)was used to evaluate the relative reliability for the total score of items. ICC? 0.
70 was considered as the evidence of excellent stability. Internal consistency reliability reflects the extentto which several items in a questionnaire assess different aspects of the samegeneral construct. Cronbach’s ? coefficient was used forthe whole questionnaire and ‘warning signs’ section to measure internalconsistency with pre-established values indicating acceptable (>0.
7), good(>0.8), and excellent (>0.9) internal consistency. Data collected in thefirst administration of the BCAM questionnaire was used to evaluate internalconsistency. ValidityFace validityThe face validity was assessed, as mentionedabove, by recruiting 50 women to participant in the pilot study to evaluatewhether the questions in the BCAM questionnaire were understandable, simple,and clear.
Construct validityIn accordance with the scale of theitems of the BCAM subscale of breast cancer warning signs (i.e. “yes-no”questions), the construct validity was investigated byusing latent class analysis (LCA).In the other words, the level of “knowledge” about breast cancer warning signs was considered as a latent construct and it wasevaluated based on having knowledge or lack of knowledge about each item usingLCA. This model examines the pattern of relations among a set of observedcategorical variables and classifies similar individuals into latent classes.We fitted various LCA models with different latent classes. The adequacy offitted models was guided through comparing the Bayesian Information Criterion(BIC), the Akaike information criterion (AIC) and entropy indices acrossmodels. A model with lower “BIC and AIC” and higher “entropy” values indicatebetter fitting and class separation, respectively.
Criterion (Discriminant)validityCriterion validity was assessed based on the BCAMability to discriminant between general women and medical/clinical experts. Thevalidity of the measure is supported if distribution of the BCAM items besignificantly different across two groups. We distributed the BCAMquestionnaire to 965 general women and 113 medical/clinical experts and comparedtheir responses. We tested the difference in the proportion or scores of itemsbetween two groups using Chi?square testor independent Student’s t?test.
Inaddition, Receiver operating characteristic (ROC) curve along with thesensitivity and specificity values, were used to gauge the ability of the BCAMsubscale of awareness level about warning signs of breast cancer todiscriminate between general women and medical/clinical experts. Other statistical analysisIn this paper, quantitative and qualitative variableswere expressed as mean (SD) and number (precent), respectively. Thedeterminants of the level of “awareness” about breastcancer warning signs wereevaluated using “latent class regression” analysis (LCR). In the other words,the prediction of membership into latent class of the level of “awareness” isobtained by multinomial regression of latent class variable on independentvariables. Data analyses were performed using Statistical Package for SocialSciences version 21 (SPSS Inc.
, Chicago, IL, USA) and …software.