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Chenyu Shang, PhD Kinta Beaver, PhD Malcolm Campbell, PhD
Social Cultural Influences on Breast Cancer Views and Breast Health Practices Among Chinese Women in the United Kingdom K E Y
W O R D S
Background: Incidence rates for breast cancer have increased significantly
Breast cancer
among Chinese women, accompanied by low utilization of breast screening and
Chinese women
delay in symptom presentation. Objective: The aims of this study were to explore
Health practice
(1) views on breast cancer and breast health among Chinese women in the
Qualitative
United Kingdom and (2) the potential influence of social and cultural context on
Views
views and screening behavior. Methods: Qualitative interviews were carried out with 22 Chinese women. Pertinent aspects of Grounded Theory methods, including simultaneous data collection and analysis, constant comparison, and memo writing, were used. Results: Four themes emerged: cultural views on breast cancer, information sources and knowledge, breast screening practice, and views on healthcare services. The theme views on breast cancer had 3 subthemes: a fearful disease, taboo, and fatalism. Aspects of traditional Chinese culture had important influences on Chinese women’s views on breast cancer. Self-care formed the most significant strategy to promote health and prevent illness. Although the study found high utilization of breast screening when offered, only 6 women reported breast awareness practices. Conclusions: This study found that traditional beliefs were not the sole determinant of breast health behavior. The way in which breast screening services are offered in the United Kingdom may reduce the significance of cultural views and
Author Affiliations: Department of Health Sciences, University of Leicester (Dr Shang); School of Health, University of Central Lancashire, Lancashire (Dr Beaver); and School of Nursing, Midwifery & Social Work, University of Manchester, United Kingdom (Dr Campbell). This study was supported by a PhD Studentship to the lead author from the School of Nursing, Midwifery & Social Work, University of Manchester, United Kingdom.
The authors have no conflicts of interest to disclose. Correspondence: Chenyu Shang, PhD, Department of Health Sciences, 22-28 Princess Road West, Leicester, United Kingdom, LE1 6TP ([email protected]). Accepted for publication June 23, 2014. DOI: 10.1097/NCC.0000000000000195
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shape individuals’ health behavior. Implications for Practice: Findings indicate that information on breast awareness should be delivered to this group of women in Chinese by health professionals through Chinese mass media.
B
reast cancer is a major health problem for Chinese women worldwide. Studies from Beijing, Shanghai, Hong Kong, and Singapore confirm that rates among Chinese women have increased rapidly in recent years and it has become the most common cancer.1Y4 The incidence of breast cancer among Chinese women living in western countries is currently lower than for white women. However, studies from the United States reported that Chinese women who have lived in the United States for a decade or more had an overall 80% higher risk of breast cancer than do more recent immigrants because of environmental and lifestyle factors.5 A similar trend was apparent among Chinese women in Australia.6 Early detection and treatment of breast cancer directly impact on prognosis and survival rates.7 However, low utilization of breast screening and delay in presentation of breast symptoms are reported consistently for Chinese women.8Y14 Sociodemographic factors (eg, English proficiency) and accessibility of health services (eg, cost) have had significant influences on breast screening and help-seeking behavior among Chinese women in the United States.14Y16 Salient barriers in the form of beliefs and attitudes have also been identified. Fatalism, emphasis on self-care, and modesty are reported as having a negative impact on utilization of breast screening.17Y20 Cancer has been described as having negative connotations in Chinese culture.20Y23 Cancer has been associated with death, suffering, and perceived misdeeds committed in a present or previous life.21,23,24 These negative perceptions have led to a cancer diagnosis being particularly stigmatized in Chinese society, a society that advocates strong family networks. Many Chinese people believe that the diagnosis of cancer not only impacts on the affected individual but also devastates the reputation of the whole family.25 To protect the individual’s and the family’s reputation, Chinese people tend to delay seeking professional help for potential cancer symptoms and hide the diagnosis.25 Few studies have explored Chinese women’s beliefs on breast cancer.13,26,27 Research suggests that aspects of traditional culture, such as beliefs in fatalism, reincarnation, and retribution, influence Chinese women’s understandings of the causes of breast cancer. Breast cancer is often believed to be caused by external forces.13,26,27 Because of the unpredictable nature of the disease and potential threats to life and womanhood, Chinese women are generally afraid of this disease.13,27 However, many Chinese women do not think breast cancer is a cause for concern as they believe they are at low risk of developing this disease.13,26 Although previous studies provide valuable insights into Chinese women’s views on cancer in general and breast cancer in particular, most have been conducted in the United States and Australia. Like other developed countries, the United Kingdom has an increasingly culturally diverse health population. However, the lack of understanding of cultural diversities, limited knowledge on cultural needs, and racially stereotyped attitudes among health professionals are posing challenges in providing adequate cancer
care for ethnic groups.28Y32 The Chinese community forms 1 of the largest ethnic groups in the United Kingdom. In 2009, 451 500 Chinese people were known to be living in the United Kingdom, representing 0.8% of the UK population.33 However, there are no existing UK studies that explore Chinese women’s views on breast cancer and breast health practices. Hence, the overall aim of this study was to address this distinct gap in our knowledge by exploring views on breast cancer and breast health practices for Chinese women living in the United Kingdom. The study had the following research questions: What were Chinese women’s views on breast cancer and breast health, and how were these views and their screening practice influenced by social and cultural factors? It was anticipated that the insights gained from this study would assist health professionals and public health workers in the United Kingdom and other nations with a large population of Chinese immigrants to achieve a deeper understanding of Chinese women’s views and practices. By aiding this understanding, tailored culturally sensitive interventions could be developed to promote breast health for this group of women.
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Methods
This study adopted a qualitative approach using semistructured interviews to explore Chinese women’s views on breast cancer and breast health practices in a natural setting, allowing participants to describe their relationships with their environment and surroundings.34,35 Pertinent aspects of Grounded Theory methods, including simultaneous data collection and analysis, constant comparison, and memo writing, were used.36 The rationale of applying these approaches in this study was to ensure that findings were grounded in the data and that meanings were systematically discovered and not influenced by any preconceived ideas held by the research team. Drawing on important aspects of Grounded Theory methods increased the rigor of the study, but at this stage, the intention was to gain an in-depth understanding about Chinese women’s views on breast cancer and breast health practices rather than to develop a formal theory. Ethical approval was obtained from the Committee on the Ethics of Research on Human Beings at the University of Manchester, United Kingdom.
Sample To achieve maximum variation in demographic characteristics, a purposive sampling strategy was used. Demographic characteristics, such as country of birth, age, spoken language, and the length of time living in the United Kingdom, were considered pertinent factors that may have influenced Chinese women’s perceptions of health and illness in general and breast health practices in particular. Participants were purposively selected from Chinese organizations in 2 cities in the North West of England (Manchester and
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Liverpool) with large Chinese populations.37 Eight organizations were approached. Each offered different services for their members, such as senior clubs, English-language classes, and computer classes. Managers of these organizations were contacted initially with information regarding the aims of the study, selection criteria, and data collection procedures. Managers granted permission for information sessions to take place with potential participants, where the study was discussed and written information was provided. Thirty-five Chinese women were provided with this information and 26 agreed to take part. To avoid duplication in demographic characteristics (such as country of birth), 22 participants were purposively chosen from the 26 who agreed to participate. Inclusion criteria for the study were as follows: (1) women who identified their ethnicity as Chinese, (2) women aged from 50 to 70 years, (3) women who had no known diagnosis of breast cancer, and (4) women who were registered with a United KingdomY based general practitioner. In the United Kingdom, the National Health Service (NHS) invites women aged from 50 to 70 years, who are registered with a general practitioner, to attend for breast screening free of charge every 3 years. Twenty-two Chinese women participated in the study. Ages ranged from 50 to 70 years, with a mean age of 62 years. Most had received some level of education and had lived in the United Kingdom for more than 10 years. Hong Kong and mainland China were the most common countries of origin, with a small number of participants originating from Singapore, Malaysia, Macau, Indonesia and Vietnam. Most knew someone with a breast cancer diagnosis. The Table summarizes the demographic characteristics of the sample.
Table & Demographic Background of the Participants No. of Participants (n = 22) Age, y 50Y54 55Y59 60Y64 65Y70 Educational qualification No education Primary Secondary College or university Years in the United Kingdom 1Y10 11Y20 920 Country of birth Hong Kong Mainland China Singapore Others (Malaysia, Macau, Indonesia, and Vietnam) Having friends/relative with breast cancer Yes No
7 3 5 7 4 6 8 4 7 5 10 10 6 2 4
14 8
Data Collection Twenty-two semistructured interviews were conducted at 2 geographical locations (Manchester and Liverpool). All were conducted in Cantonese or Mandarin Chinese at Chinese organizations. The first author (C.S.), who shared a similar social and cultural background with the participants, conducted the interviews, and this proved to be helpful in building up a trusting relationship and encouraging participants to share their personal stories and opinions. An interview guide was developed for the study, informed by the existing literature and the research questions. The guide contained open questions that explored beliefs and knowledge about breast cancer and breast screening services, utilization of breast screening services, sources of information on breast health, general views on the United Kingdom’s healthcare services, and what it was like to be a Chinese person living in the United Kingdom. Questions were further revised and modified throughout the period of data collection. Demographic data, such as age, place of birth, first language, and the length of time the woman had lived in the United Kingdom, were collected at the end of each interview.
Data Analysis All interviews were conducted in the Chinese language. Interviews were initially transcribed in Chinese by C.S. Translation from Chinese to English was carried out subsequently. Backtranslation was used to ensure the quality of translation. An independent translator who was a native speaker of Mandarin and Cantonese Chinese and fluent in English conducted the backtranslation from English to Chinese. A comparison of the 2 Chinese versions of the transcripts was carried out. Any ambiguities and discrepancies in meanings were discussed and clarified or removed. The most appropriate translations for the words with ambiguous meanings were identified. Data analysis was conducted alongside data collection. A constant comparative approach was used to identify the meanings in the data, sort the data with shared meanings, and develop themes and subthemes.38 Transcripts were coded initially line-by-line according to the areas that were explored in the interviews (such as beliefs and knowledge about breast cancer and views on breast screening). This careful initial coding was followed by more focused coding that would explain sections of the data.36 This was then followed by axial coding, a more in-depth analysis of emerging themes. By constant comparison of these developed themes during axial coding, data indicating different aspects of the same theme were divided, leading to subthemes within the theme (eg, a fearful disease, taboo, and fatalism were developed as subthemes under the theme cultural views on breast cancer). Memos were written during data collection to assist with identifying relationships between themes and to direct further data collection.
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Findings
Four main themes emerged from the data: cultural views on breast cancer, information sources and knowledge, breast screening practice, and views on healthcare services.
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Theme 1: Cultural Views on Breast Cancer A FEARFUL DISEASE
Most participants acknowledged medical advances in treating breast cancer and perceived that breast cancer was curable. However, traditional views, in which cancer was closely associated with death, pain, and suffering, were still strongly held. The Chinese term Juezheng ( ), which refers to a disease that is incurable, was often used. When you say breast cancer, I immediately thinkIthe person will die, just sooner or later, becauseIthis disease is a Juezheng. [ID 11] Although the traditional view that breast cancer is a Juezheng seemingly contradicted positive views on cure, these 2 views coexisted. Some were confused about the accuracy of information on cure, particularly if they had known someone who had died from cancer. My daughter told me breast cancer was curable. But I saw many people in my village have died from cancer. So, I don’t know, really. [ID 4] The breast was seen by all participants as a symbol of femininity and feminine beauty. Therefore, for most participants, breast cancer was a doubly fearful disease: It not only was associated with death but also threatened physical attractiveness and psychological well-being. All participants, regardless of age, thought that beauty was very important for women. Breast removal by surgery would destroy that beauty and had a strong psychological impact. Once a breast is cut off, she may feel she is not a true woman. She’s a failure. This depresses her a lot. [ID 14] TABOO
Negative perceptions of breast cancer were often described in terms of feeling scared, miserable, or terrible. Cancer was generally considered a taboo topic that was not for discussion with others. When talking about cancer, it seems like talking about a tiger. People are so scared. So, we don’t like to talk this topic in our everyday lives. [ID 16] Participants reported that a diagnosis of breast cancer was associated with a strong sense of stigma, and disclosure of the disease diagnosis would equate to disclosure of personal failure. Hence, participants perceived that such a disease should be kept hidden, even from close relatives, rather than sharing information about the disease with others. My sister has breast cancer. She doesn’t want to talk me about it. Probably she feels shame, a failure of her life. [ID 10] FATALISM
Some participants held a fatalistic view on breast cancer. They believed that events were predetermined by external forces that humans were powerless to influence; they could only accept their situation. Fate, God, and predestination were the 3 words they often used to describe the external forces.
If it is something that is given by God, nobody can take it from you. If it isn’t, you won’t have it even if you steal. You have to follow your fate. [ID 18] Those who held fatalistic views also tended to comment on aging and losing maternal responsibilities. It was not clear from the data whether these feelings contributed to, or strengthened, fatalistic views. However, these views and feelings were interwoven and simultaneously influenced views on breast cancer.
Theme 2: Information Sources and Knowledge Participants had limited English proficiency, although most had been living in the United Kingdom for more than 10 years. Most participants lived in close Chinese communities, were married to Chinese people, worked in Chinese restaurants, and spoke only Chinese. Not mixing with the English-speaking community, in turn, contributed to their limited English proficiency. Limited English language skills deterred participants from obtaining information on breast cancer, particularly from media sources, in written or spoken English. Their understanding was derived from a diversity of sources, ranging from Chinese television channels, Chinese newspapers, and experiences with people who had been treated for cancer. They compared and contrasted these diverse sources of information and finally formulated their own views of the disease. Participants were generally aware that a lump in the breast was indicative of breast cancer and were also aware that not all breast lumps were cancerous. Four individuals mentioned pain as an indicator of cancer in general and breast cancer in particular. However, pain in the breast was also perceived as a natural part of aging that would not warrant medical attention. Only 6 of 22 participants reported breast awareness practices. None practiced on a regular basis. Four had identified changes in their breasts but did not seek medical help. Instead, they waited to see if the symptoms disappeared or waited until the next breast screening appointment. Some self-diagnosed and self-medicated without a physician’s prescription. Last time when I felt pain of my breast, I took antibiotics. I think that if I’m ill, it would be better that I take some medicines rather than doing nothing at all. [ID 16] Participants were aware that surgery was the mainstay of treatment for breast cancer. Some mentioned other treatments, such as chemotherapy and/or radiotherapy. However, they believed that surgery was the most effective approach for treating breast cancer. Apart from surgery, there should be chemotherapy. However, I think cutting off is the best way of treating breast cancer. [ID 6] Participants had a holistic view about breast cancer prevention, believing they needed to take care of both physical and emotional aspects of their lives to prevent breast cancer. Having a healthy diet, keeping a positive outlook, doing exercise, avoidance of smoking and alcohol, and taking sufficient rest were the essential approaches. Above all, having a healthy and balanced diet was the most crucial, as they believed that the likelihood of developing
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an illness (including breast cancer) would be lower if the body was strong. You should have a variety of food and everything is in moderation. Disease happens when your body is imbalanceIeither you eat too much of this or that. [ID 14]
same Chinese language as formal interpreters, being unaware of available interpreting services, and not understanding how to book the service when required.
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Theme 3: Breast Screening Practice Most held positive views on breast screening, believing it was an effective and beneficial way of identifying breast cancer at an early stage. This may partially explain the relatively high utilization of the service among these women. Of the 22 participants, 19 had attended the service and 18 attended regularly. Three did not attend screening when invited because of time constraints and the distance to the screening center. Although most participants reported language barriers when they sought medical help, they did not report the same barriers when attending breast screening. The screening invitation letter was key to encouraging participants to attend, as the date, time, and venue of the examination were prearranged. This was perceived as being particularly useful, especially for those with limited English proficiency. They arrange it for you, it’s really good. Otherwise, you don’t know how to book the appointment, and where you go. [ID 12] Although the invitation letter was written in English, finding someone to translate was relatively straightforward in comparison with asking someone to book an appointment and translate during consultations. In addition, little conversation was required during mammographic screening, especially if participants had become familiar with the procedures. Some women viewed the invitation letter as mandatory rather than optional. Hence, participants would attend regardless of their views on the value of breast screening. I don’t think breast screening is beneficial. I do it only because it is requested by a doctor. [ID 14]
Theme 4: Views on Healthcare Services Participants reported favorably on the NHS in the United Kingdom being free of charge and trustworthy. However, language barriers, difficulties in making appointments, long waiting times, and lack of knowledge about the health system were 4 significant barriers facing many participants when they sought access to health services. In particular, because of limited English proficiency, participants commented on difficulties when communicating with GPs during consultations. Participants reported having to use dictionaries or gestures, which resulted in feelings of frustration and also losing the opportunities to ask questions and express concerns. I feel very difficult in communicating with GPs. I don’t know how to explain. Sometimes, I have to look at a dictionary. [ID 5] The NHS provides interpreters for people with limited English proficiency. However, participants reported that, on many occasions, interpreting services were not available. Participants commented on a number of perceived barriers that prevented them from using interpreting services, which included not sharing the
Discussion and Conclusion
Discussion This study used a qualitative approach and explored how Chinese women in the United Kingdom view breast cancer and breast health and how their distinctive social and cultural context influences their breast cancer views and screening behavior. This study shows that Chinese women hold complex views on breast cancer. Most acknowledged that breast cancer was curable if it was identified and treated at an early stage. However, traditional views on breast cancer were not entirely abandoned. Breast cancer was still associated with death, misery, and suffering. The negative views shown in this study are consistent with previous studies.18,21,22,24 Negative views on breast cancer and their associated feelings are arguably key to explaining why breast cancer was considered a taboo topic within these ‘‘healthy’’ women. Traditional Chinese medicine considers that the mind, body, and spirit are integral parts of a body.39 An individual’s psychological state directly impacts on their physical health. Physical status, in turn, influences psychological status.39 In this study, breast cancer was believed to evoke strong negative feelings. According to the Chinese etiology of disease, these feelings would directly affect physical functioning and potentially lead to illnesses, including cancer. Therefore, avoidance of talking and thinking about cancer was actually a coping strategy, giving protection from the potential threats of disease. Previous studies have paid much attention to the negative impacts of taboo on accessing information and early detection of cancer.40 This study suggests that avoidance of talking and thinking about breast cancer is not always problematic and can bring psychological benefits. Compared with the fatalism held by African Americans, Chinese women in this study had a different understanding about the determinants of an illness. For African Americans, the final determinant was God, reflecting influences of spiritual beings in affecting human affairs.41 This is in contrast to the ‘‘amoral fatalism’’ held by Chinese women in this study: an impersonal, irrational, and unapproachable force blindly regulating destiny.42 Hence, the development of an illness is unpredictable with no cause.42 Fate and destiny, or development of an illness, thus have nothing to do with individuals’ ethical and social conduct. This ‘‘blind fate’’ released these Chinese women from the fear of wrongdoing and helped them maintain a peaceful psychological status. Apart from maintaining psychological well-being, the Chinese women in this study also used natural approaches, such as having a balanced diet and doing outdoor activities, to promote their physical health and prevent illnesses. These results were comparable with previous studies.39,43 The beliefs behind these approaches were derived from 2 Chinese philosophies, Confucianism and Taoism. Confucians advocate that people should maintain a middle or neutral position when responding to all phenomena in the world.44 In terms of diet, for example, people should take food in moderation, neither feeling hunger nor bloated, neither ex-
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cessively eating 1 type of food while avoiding another. This doctrine is concerned with reaching harmony, which is similar to the theory of Yin/Yang ( ) in Taoism. Taoists believe that health is achieved by finding harmony between the organs of the body and between the body and the external environment.45 A lack of regular access to the natural world may break the harmony between the body and the external environment and then result in sickness. This study shows that self-care, both psychological and physical, formed the most significant strategy used by Chinese women to promote health and prevent illness in their everyday lives. This approach reflected Chinese cultural influences. It is also embedded in their specific lifestyle in the host country, which appeared to be insular and isolated. This study revealed that although these women had lived in a western country for many years, they still lived in close Chinese communities. Undoubtedly, limited English proficiency and other difficulties in accessing the healthcare system prevented these women from interacting and integrating with the host country in general and the healthcare system in particular. The apparent lack of interaction and integration perpetuated the influences of traditional Chinese culture on their health beliefs and views on breast cancer. It may also have resulted in few opportunities to receive information on the significance of breast awareness in the early detection of breast cancer. This may be key to explaining why these women paid little attention to breast awareness although it had been introduced and advocated in the United Kingdom since the early 1990s. Similar findings were also revealed in Hong Kong and American studies.8,46 However, there were occasions when Chinese women in this study actively interacted with the healthcare system. Their high utilization of breast screening corresponded to another UK study47 but was different from studies in United States, Australia, Singapore ,and Hong Kong.8,14,26,48,49 Traditional Chinese culture, such as fatalism, emphasis on self-care, and breast cancer taboo, has been shown as a barrier preventing Chinese American women,14,43 Chinese Australian women,26 and African American women50 from undertaking breast screening. However, this study suggests that Chinese women who held these beliefs still attended breast screening after receiving an invitation letter. The different social contexts may explain the disparity in findings. In the United Kingdom, breast screening is currently offered free of charge every 3 years to all women aged between 50 and 70 years. Women do not have to be proactive in relation to a breast screening appointment; they are sent a date and time and may opt out if they do not wish to attend. Previous studies indicate that cost influences cancer screening behavior among Chinese women in other countries.8,10,19 Free service in the United Kingdom may act as a motivating factor, encouraging women to participate. In addition, for those who experience language barriers to accessing health services, an invitation letter detailing the date, time, and venue of the examination is likely to encourage utilization of the service. Furthermore, in the Chinese culture, health professionals are perceived to have authority, which results in Chinese people respecting and accepting the advice given. It is hence not surprising that Chinese women in this study treated the invitation letter for breast screening as a command rather than a request. The combination of a free service, an organized appointment, and an authoritative invitation may have outweighed traditional views, such
as fatalism and modesty, on breast screening behavior, resulting in the high utilization of screening services. These findings illustrate that traditional beliefs are not the sole determinant of ethnic minority groups’ health behavior in this context. There are factors related to the way in which the breast screening service is organized in the United Kingdom that influence the significance of cultural views and shape individuals’ health behaviors. That is, women in the United Kingdom are offered breast screening free of charge and do not need to be proactive in requesting breast screening; they are sent letters of invitation that contain a date and time when they are expected to attend. This study also suggests that simple emphasis of traditional cultural influences, without careful consideration and examination of how services are provided and received by a target group, may lead to misunderstanding and even failure in service implementation.
Limitations This study limited in the generalizability of findings beyond the sample of Chinese women who participated. Although sampling included women from different geographical locations, the findings may not represent the views of Chinese women living in other parts of the United Kingdom. Participants were recruited from specific Chinese organizations. This recruitment strategy may not have captured the views of Chinese women who do not access these organizations. A national study with a larger sample and a quantitative research design would be an important next step to address the issue of generalizability and recruitment bias. This exploratory study did not aim to generate a formal theory and may not be considered a grounded theory in the purist sense. However, the use of grounded theory methods ensured a systematic and rigorous approach to data collection and analysis.
Conclusion This study explored views on breast cancer and breast health practices among Chinese women in the United Kingdom using qualitative in-depth interviews. Findings support previous studies on the influence of traditional Chinese culture on cancer beliefs among Chinese immigrants. By thoroughly exploring the topic from a social cultural context, this study presents a dynamic picture on the complex and intertwined influences of traditional cancer views and the provision of health services on Chinese women’s breast health practices. This study makes a unique contribution to the existing literature in suggesting that traditional beliefs are not the sole determinant of Chinese women’s health behavior in this context. The way in which breast screening services are organized in the United Kingdom may influence the significance of cultural views and shape individuals’ health behavior. Biomedical concepts are dominant in Western healthcare systems. However, Chinese women in this study still held strong cultural views on breast cancer and followed traditional ways of promoting breast health in their everyday life. Health professionals need to understand and respect these unique views and practices and apply appropriately cultural sensitivity when developing health promotion messages. In addition, the high utilization of breast screening among Chinese women in this study suggests that the way in which breast screening services are organized plays a
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crucial role in moderating traditional cultural influences on Chinese women’s breast screening behavior.
Practical Implication This study has valuable public health implications on how to develop a culturally sensitive educational intervention for Chinese women living in the western world. This study suggests that Chinese women emphasized the function of self-care in promoting health but paid little attention to breast awareness. Therefore, the meanings and importance of breast awareness should be delivered to this group. In addition, information on the factors increasing or reducing the risk of developing breast cancer should be included and will likely be welcomed by this group as it corresponds to their cultural values on self-care. To ensure that information is accessible and acceptable, it should be provided in Chinese with a positive tone. It can be delivered by health professionals (eg, practice nurses or public health workers) through Chinese mass media (Chinese television and radio programs) or leaflets with official logos distributed in Chinese centers, Chinatowns, Chinese supermarkets, and pharmacies.
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18. Kwok C, Sullivan G. Influence of traditional Chinese beliefs on cancer screening behavior among Chinese-Australian women. J Adv Nurs. 2006;54:691Y699. 19. Yu M, Wu T, Mood DW. Cultural affiliation and mammography screening of Chinese women in an urban county of Michigan. J Transcult Nurs. 2005; 16:107Y116. 20. Liang W, Yuan E, Mandelblatt JS, et al. How do older Chinese women view health and cancer screening? Results from focus groups and implications for interventions. Ethn Health. 2004;9:283Y304. 21. Papadopoulos I, Guo F, Lees S, et al. An exploration of the meanings and experiences of cancer of Chinese people living and working in London. Eur J Cancer Care. 2007;16:424Y432. 22. Kwok C, Sullivan G. Chinese-Australian women’s beliefs about cancer: implications for health promotion. Cancer Nurs. 2006;29:E14YE21. 23. Yeo SS, Meiser B, Barlow-Stewart K, et al. Understanding community beliefs of Chinese-Australians about cancer: initial insights using an ethnographic approach. Psychooncology. 2005;14:174Y186. 24. Wong-Kim E, Sun A, DeMattos MC. Assessing cancer beliefs in a Chinese immigrant community. Cancer Control. 2003;10:22Y28. 25. Lui CW, Ip D, Chui WH. Ethnic experience of cancer: a qualitative study of Chinese-Australians in Brisbane, Queensland. Soc Work Health Care. 2009; 48:14Y37. 26. Kwok C, Sullivan G, Cant R. The role of culture in breast health practices among Chinese-Australian women. Patient Educ Couns. 2006;64:268Y276. 27. Ku Y. Chinese cultural beliefs about breast cancer and breast self-examination. 2013. http://ir.fy.edu.tw/ir/retrieve/14186/Chinese%20Culture% 20BSE%20%E5%AE%89%E5%AF%A7%E7%99%82%E8%AD%B7.pdf. Accessed October 17, 2013. 28. Moser K, Patnick J, Beral V. Inequalities in reported use of breast and cervical screening in Great Britain: analysis of cross sectional survey data. BMJ. 2009;338:b2025Yb2033. 29. Wood A, Scanlon K. Same difference: breast awareness is for everyone. http://www.breastcancercare.org.uk/upload/pdf/same_difference_final_ 0_1.pdf. Accessed January 2, 2014. 30. National Cancer Intelligence Network and Cancer Research UK. Cancer incidence and survival by major ethnic group, England, 2002Y2006. http:// www.ncin.org.uk/publications/reports/. Accessed January 2, 2014. 31. Richardson A, Thomas VN, Richardson A. ‘‘Reduced to nods and smiles’’: experiences of professionals caring for people with cancer from black and ethnic minority groups. Eur J Oncol Nurs. 2006;10:93Y101. 32. Vydelingum V. South Asian patients’ lived experience of acute care in an English hospital: a phenomenological study. J Adv Nurs. 2000;32:100Y107. 33. Office of Public Section Information. Population Trends. Office for National Statistics, 2008. http://www.opsi.gov.uk/click-use/index.htm. Accessed April 15, 2013. 34. Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Traditions. London, England: Sage Publications; 1998. 35. Denzin NK, Lincoln YS. The Sage Handbook of Qualitative Research. London, England: Sage Publications; 2005. 36. Charmaz K. Constructing Grounded Theory. London, England: Sage Publications; 2006. 37. Office for National Statistics. Census. London, England: Office for National Statistics; 2001. 38. Glaser BG, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. New York, NY: Aldine de Gruyter; 1967. 39. Lai DWL, Surood S. Chinese health beliefs of older Chinese in Canada. J Aging Health. 2009;21:38Y62. 40. Errico KM, Rowden D. Experiences of breast cancer survivorVadvocates and advocates in countries with limited resources: a shared journey in breast cancer advocacy. Breast J. 2006;12:S111YS116. 41. Kinney AY, Emery G, Dudley WN, et al. Screening behaviors among African American women at high risk for breast cancer: do beliefs about God matter? Oncol Nurs Forum. 2002;29:835Y843. 42. Chen N. Confucius’ view of fate. J Chinese Philos. 1997;24:323Y359. 43. Liang W, Wang JH, Chen M, et al. Developing and validating a measure of Chinese cultural views of health and cancer. Health Educ Behav. 2008;35:361Y375. 44. Kwok C, Sullivan G. The concepts of health and preventive health practices of Chinese Australian women in relation to cancer screening. J Transcult Nurs. 2007;18:118Y126.
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45. Chen YD. Conformity with nature: a theory of Chinese American elders’ health promotion and illness prevention processes. Adv Nurs Sci. 1996;19:17Y26. 46. Lu ZJ. Variables associated with breast self-examination among Chinese women. Cancer Nurs. 1995;18:29Y34. 47. Bansal N, Bhopal RS, Steiner MFC, et al. Major ethnic group differences in breast cancer screening uptake in Scotland are not extinguished by adjustment for indices of geographical residence, area deprivation, long-term illness and education. Br J Cancer. 2012;106:1361Y1366. 48. Kung EYL, Chan AC, Chong YS, et al. Promoting breast screen to Melbourne
Chinese women using ethnic-specific health promotion strategies. Int J Health Promot. 1997. http://rhpeo.net/ijhp-articles/1997/3/index.htm. Accessed September 15, 2013. 49. Seow A, Straughan PT, Ng E, et al. Factors determining acceptability of mammography in an Asian population: a study among women in Singapore. Cancer Cause Control. 1997;8:771Y779. 50. Moy B, Park ER, Feibelmann S, et al. Barriers to repeat mammography: cultural perspectives of African-American, Asian and Hispanic women. Psychooncology. 2006;15:623Y634.
ICCN 2015 Abstract Book Manuscript Oral Sessions: Erratum In the ICCN 2015 Abstracts Supplement, which published online with Volume 38, Issue 4 of Cancer Nursing, oral abstract O-72 was mistakenly left out. That missing abstract appears below, and the error has been noted in the online version of the supplement, which is available at www.cancernursingonline.com.
O-72 Opioid Titration Protocol for Managing Breakthrough Cancer Pain in Emergency Room Hyojung Jang1, Jeong-Hui Ok1, Jinseon Choi2, Yeon Hee Kim2 1
Cancer Emergency Room (CER), Asan Medical Center, Seoul, Korea (The Republic of), 2Department of Nursing, Asan Medical Center, Seoul, Korea (The Republic of) Background: 1728 patients visited with uncontrolled breakthrough pain in Cancer Emergency Room (CER) in 2013. Opioid titration is an effective strategy for rapid treating pain; however, titration is generally impractical in the busy ED. This study was aimed to develop a ‘‘breakthrough cancer pain management protocol,’’ which provides a guideline of pain assessment and opioid titration using intravenous morphine for sudden onset stage. Methods: A prospective study was conducted in patients with moderate to severe cancer pain (numeric rating score [NRS] 94). Pain intensity was measured at admission, dose titration or opioid/route switching within 3 days. Doses of opioids, duration of opioid use were reported. This protocol was designed to calculate rescue dose depending on NRS score and previous used daily opioid dose. After 30 minutes of rescue dose, pain assessment was repeated. If persistent pain (NRS 94), same dose or escalating rescue dose were provided according to NRS score. Despite first 3hrs titration with maximum 6 times of bolus rescue dose, patient with persistent pain (NRS 94) was started morphine IV continuous infusion (starting dose and escalating dose were decided by previous daily dose) and pain assessment and escalating dose’s interval are 30 minutes. This protocol mentioned cautions and action-plan with occurred undesirable event. Pilot assessment of the efficacy and tolerability of protocol was done before study. Results: 87% of 275 was successfully managed pain using this protocol and NRS was reduced (G3). 85% of patients are controlled within 3 hours’ bolus titration. The average staying time decreased 10.1 hrs (p=.004). Re-visit patient with reluctant pain within 1 week was two. Conclusions: This protocol was shown to be effective and tolerated for titration for mod/severe cancer pain relief in both opioid-naBve and tolerant patient. This study warrants prospective and comparative studies with larger samples for more generalized results.
Reference ICCN 2015 Abstract Book Manuscript Oral Sessions. Cancer Nurs. 2015;38(4S).
DOI: 10.1097/NCC.0000000000000304
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Chenyu Shang, PhD Kinta Beaver, PhD Malcolm Campbell, PhD
Social Cultural Influences on Breast Cancer Views and Breast Health Practices Among Chinese Women in the United Kingdom K E Y
W O R D S
Background: Incidence rates for breast cancer have increased significantly
Breast cancer
among Chinese women, accompanied by low utilization of breast screening and
Chinese women
delay in symptom presentation. Objective: The aims of this study were to explore
Health practice
(1) views on breast cancer and breast health among Chinese women in the
Qualitative
United Kingdom and (2) the potential influence of social and cultural context on
Views
views and screening behavior. Methods: Qualitative interviews were carried out with 22 Chinese women. Pertinent aspects of Grounded Theory methods, including simultaneous data collection and analysis, constant comparison, and memo writing, were used. Results: Four themes emerged: cultural views on breast cancer, information sources and knowledge, breast screening practice, and views on healthcare services. The theme views on breast cancer had 3 subthemes: a fearful disease, taboo, and fatalism. Aspects of traditional Chinese culture had important influences on Chinese women’s views on breast cancer. Self-care formed the most significant strategy to promote health and prevent illness. Although the study found high utilization of breast screening when offered, only 6 women reported breast awareness practices. Conclusions: This study found that traditional beliefs were not the sole determinant of breast health behavior. The way in which breast screening services are offered in the United Kingdom may reduce the significance of cultural views and
Author Affiliations: Department of Health Sciences, University of Leicester (Dr Shang); School of Health, University of Central Lancashire, Lancashire (Dr Beaver); and School of Nursing, Midwifery & Social Work, University of Manchester, United Kingdom (Dr Campbell). This study was supported by a PhD Studentship to the lead author from the School of Nursing, Midwifery & Social Work, University of Manchester, United Kingdom.
The authors have no conflicts of interest to disclose. Correspondence: Chenyu Shang, PhD, Department of Health Sciences, 22-28 Princess Road West, Leicester, United Kingdom, LE1 6TP ([email protected]). Accepted for publication June 23, 2014. DOI: 10.1097/NCC.0000000000000195
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shape individuals’ health behavior. Implications for Practice: Findings indicate that information on breast awareness should be delivered to this group of women in Chinese by health professionals through Chinese mass media.
B
reast cancer is a major health problem for Chinese women worldwide. Studies from Beijing, Shanghai, Hong Kong, and Singapore confirm that rates among Chinese women have increased rapidly in recent years and it has become the most common cancer.1Y4 The incidence of breast cancer among Chinese women living in western countries is currently lower than for white women. However, studies from the United States reported that Chinese women who have lived in the United States for a decade or more had an overall 80% higher risk of breast cancer than do more recent immigrants because of environmental and lifestyle factors.5 A similar trend was apparent among Chinese women in Australia.6 Early detection and treatment of breast cancer directly impact on prognosis and survival rates.7 However, low utilization of breast screening and delay in presentation of breast symptoms are reported consistently for Chinese women.8Y14 Sociodemographic factors (eg, English proficiency) and accessibility of health services (eg, cost) have had significant influences on breast screening and help-seeking behavior among Chinese women in the United States.14Y16 Salient barriers in the form of beliefs and attitudes have also been identified. Fatalism, emphasis on self-care, and modesty are reported as having a negative impact on utilization of breast screening.17Y20 Cancer has been described as having negative connotations in Chinese culture.20Y23 Cancer has been associated with death, suffering, and perceived misdeeds committed in a present or previous life.21,23,24 These negative perceptions have led to a cancer diagnosis being particularly stigmatized in Chinese society, a society that advocates strong family networks. Many Chinese people believe that the diagnosis of cancer not only impacts on the affected individual but also devastates the reputation of the whole family.25 To protect the individual’s and the family’s reputation, Chinese people tend to delay seeking professional help for potential cancer symptoms and hide the diagnosis.25 Few studies have explored Chinese women’s beliefs on breast cancer.13,26,27 Research suggests that aspects of traditional culture, such as beliefs in fatalism, reincarnation, and retribution, influence Chinese women’s understandings of the causes of breast cancer. Breast cancer is often believed to be caused by external forces.13,26,27 Because of the unpredictable nature of the disease and potential threats to life and womanhood, Chinese women are generally afraid of this disease.13,27 However, many Chinese women do not think breast cancer is a cause for concern as they believe they are at low risk of developing this disease.13,26 Although previous studies provide valuable insights into Chinese women’s views on cancer in general and breast cancer in particular, most have been conducted in the United States and Australia. Like other developed countries, the United Kingdom has an increasingly culturally diverse health population. However, the lack of understanding of cultural diversities, limited knowledge on cultural needs, and racially stereotyped attitudes among health professionals are posing challenges in providing adequate cancer
care for ethnic groups.28Y32 The Chinese community forms 1 of the largest ethnic groups in the United Kingdom. In 2009, 451 500 Chinese people were known to be living in the United Kingdom, representing 0.8% of the UK population.33 However, there are no existing UK studies that explore Chinese women’s views on breast cancer and breast health practices. Hence, the overall aim of this study was to address this distinct gap in our knowledge by exploring views on breast cancer and breast health practices for Chinese women living in the United Kingdom. The study had the following research questions: What were Chinese women’s views on breast cancer and breast health, and how were these views and their screening practice influenced by social and cultural factors? It was anticipated that the insights gained from this study would assist health professionals and public health workers in the United Kingdom and other nations with a large population of Chinese immigrants to achieve a deeper understanding of Chinese women’s views and practices. By aiding this understanding, tailored culturally sensitive interventions could be developed to promote breast health for this group of women.
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Methods
This study adopted a qualitative approach using semistructured interviews to explore Chinese women’s views on breast cancer and breast health practices in a natural setting, allowing participants to describe their relationships with their environment and surroundings.34,35 Pertinent aspects of Grounded Theory methods, including simultaneous data collection and analysis, constant comparison, and memo writing, were used.36 The rationale of applying these approaches in this study was to ensure that findings were grounded in the data and that meanings were systematically discovered and not influenced by any preconceived ideas held by the research team. Drawing on important aspects of Grounded Theory methods increased the rigor of the study, but at this stage, the intention was to gain an in-depth understanding about Chinese women’s views on breast cancer and breast health practices rather than to develop a formal theory. Ethical approval was obtained from the Committee on the Ethics of Research on Human Beings at the University of Manchester, United Kingdom.
Sample To achieve maximum variation in demographic characteristics, a purposive sampling strategy was used. Demographic characteristics, such as country of birth, age, spoken language, and the length of time living in the United Kingdom, were considered pertinent factors that may have influenced Chinese women’s perceptions of health and illness in general and breast health practices in particular. Participants were purposively selected from Chinese organizations in 2 cities in the North West of England (Manchester and
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Liverpool) with large Chinese populations.37 Eight organizations were approached. Each offered different services for their members, such as senior clubs, English-language classes, and computer classes. Managers of these organizations were contacted initially with information regarding the aims of the study, selection criteria, and data collection procedures. Managers granted permission for information sessions to take place with potential participants, where the study was discussed and written information was provided. Thirty-five Chinese women were provided with this information and 26 agreed to take part. To avoid duplication in demographic characteristics (such as country of birth), 22 participants were purposively chosen from the 26 who agreed to participate. Inclusion criteria for the study were as follows: (1) women who identified their ethnicity as Chinese, (2) women aged from 50 to 70 years, (3) women who had no known diagnosis of breast cancer, and (4) women who were registered with a United KingdomY based general practitioner. In the United Kingdom, the National Health Service (NHS) invites women aged from 50 to 70 years, who are registered with a general practitioner, to attend for breast screening free of charge every 3 years. Twenty-two Chinese women participated in the study. Ages ranged from 50 to 70 years, with a mean age of 62 years. Most had received some level of education and had lived in the United Kingdom for more than 10 years. Hong Kong and mainland China were the most common countries of origin, with a small number of participants originating from Singapore, Malaysia, Macau, Indonesia and Vietnam. Most knew someone with a breast cancer diagnosis. The Table summarizes the demographic characteristics of the sample.
Table & Demographic Background of the Participants No. of Participants (n = 22) Age, y 50Y54 55Y59 60Y64 65Y70 Educational qualification No education Primary Secondary College or university Years in the United Kingdom 1Y10 11Y20 920 Country of birth Hong Kong Mainland China Singapore Others (Malaysia, Macau, Indonesia, and Vietnam) Having friends/relative with breast cancer Yes No
7 3 5 7 4 6 8 4 7 5 10 10 6 2 4
14 8
Data Collection Twenty-two semistructured interviews were conducted at 2 geographical locations (Manchester and Liverpool). All were conducted in Cantonese or Mandarin Chinese at Chinese organizations. The first author (C.S.), who shared a similar social and cultural background with the participants, conducted the interviews, and this proved to be helpful in building up a trusting relationship and encouraging participants to share their personal stories and opinions. An interview guide was developed for the study, informed by the existing literature and the research questions. The guide contained open questions that explored beliefs and knowledge about breast cancer and breast screening services, utilization of breast screening services, sources of information on breast health, general views on the United Kingdom’s healthcare services, and what it was like to be a Chinese person living in the United Kingdom. Questions were further revised and modified throughout the period of data collection. Demographic data, such as age, place of birth, first language, and the length of time the woman had lived in the United Kingdom, were collected at the end of each interview.
Data Analysis All interviews were conducted in the Chinese language. Interviews were initially transcribed in Chinese by C.S. Translation from Chinese to English was carried out subsequently. Backtranslation was used to ensure the quality of translation. An independent translator who was a native speaker of Mandarin and Cantonese Chinese and fluent in English conducted the backtranslation from English to Chinese. A comparison of the 2 Chinese versions of the transcripts was carried out. Any ambiguities and discrepancies in meanings were discussed and clarified or removed. The most appropriate translations for the words with ambiguous meanings were identified. Data analysis was conducted alongside data collection. A constant comparative approach was used to identify the meanings in the data, sort the data with shared meanings, and develop themes and subthemes.38 Transcripts were coded initially line-by-line according to the areas that were explored in the interviews (such as beliefs and knowledge about breast cancer and views on breast screening). This careful initial coding was followed by more focused coding that would explain sections of the data.36 This was then followed by axial coding, a more in-depth analysis of emerging themes. By constant comparison of these developed themes during axial coding, data indicating different aspects of the same theme were divided, leading to subthemes within the theme (eg, a fearful disease, taboo, and fatalism were developed as subthemes under the theme cultural views on breast cancer). Memos were written during data collection to assist with identifying relationships between themes and to direct further data collection.
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Findings
Four main themes emerged from the data: cultural views on breast cancer, information sources and knowledge, breast screening practice, and views on healthcare services.
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Theme 1: Cultural Views on Breast Cancer A FEARFUL DISEASE
Most participants acknowledged medical advances in treating breast cancer and perceived that breast cancer was curable. However, traditional views, in which cancer was closely associated with death, pain, and suffering, were still strongly held. The Chinese term Juezheng ( ), which refers to a disease that is incurable, was often used. When you say breast cancer, I immediately thinkIthe person will die, just sooner or later, becauseIthis disease is a Juezheng. [ID 11] Although the traditional view that breast cancer is a Juezheng seemingly contradicted positive views on cure, these 2 views coexisted. Some were confused about the accuracy of information on cure, particularly if they had known someone who had died from cancer. My daughter told me breast cancer was curable. But I saw many people in my village have died from cancer. So, I don’t know, really. [ID 4] The breast was seen by all participants as a symbol of femininity and feminine beauty. Therefore, for most participants, breast cancer was a doubly fearful disease: It not only was associated with death but also threatened physical attractiveness and psychological well-being. All participants, regardless of age, thought that beauty was very important for women. Breast removal by surgery would destroy that beauty and had a strong psychological impact. Once a breast is cut off, she may feel she is not a true woman. She’s a failure. This depresses her a lot. [ID 14] TABOO
Negative perceptions of breast cancer were often described in terms of feeling scared, miserable, or terrible. Cancer was generally considered a taboo topic that was not for discussion with others. When talking about cancer, it seems like talking about a tiger. People are so scared. So, we don’t like to talk this topic in our everyday lives. [ID 16] Participants reported that a diagnosis of breast cancer was associated with a strong sense of stigma, and disclosure of the disease diagnosis would equate to disclosure of personal failure. Hence, participants perceived that such a disease should be kept hidden, even from close relatives, rather than sharing information about the disease with others. My sister has breast cancer. She doesn’t want to talk me about it. Probably she feels shame, a failure of her life. [ID 10] FATALISM
Some participants held a fatalistic view on breast cancer. They believed that events were predetermined by external forces that humans were powerless to influence; they could only accept their situation. Fate, God, and predestination were the 3 words they often used to describe the external forces.
If it is something that is given by God, nobody can take it from you. If it isn’t, you won’t have it even if you steal. You have to follow your fate. [ID 18] Those who held fatalistic views also tended to comment on aging and losing maternal responsibilities. It was not clear from the data whether these feelings contributed to, or strengthened, fatalistic views. However, these views and feelings were interwoven and simultaneously influenced views on breast cancer.
Theme 2: Information Sources and Knowledge Participants had limited English proficiency, although most had been living in the United Kingdom for more than 10 years. Most participants lived in close Chinese communities, were married to Chinese people, worked in Chinese restaurants, and spoke only Chinese. Not mixing with the English-speaking community, in turn, contributed to their limited English proficiency. Limited English language skills deterred participants from obtaining information on breast cancer, particularly from media sources, in written or spoken English. Their understanding was derived from a diversity of sources, ranging from Chinese television channels, Chinese newspapers, and experiences with people who had been treated for cancer. They compared and contrasted these diverse sources of information and finally formulated their own views of the disease. Participants were generally aware that a lump in the breast was indicative of breast cancer and were also aware that not all breast lumps were cancerous. Four individuals mentioned pain as an indicator of cancer in general and breast cancer in particular. However, pain in the breast was also perceived as a natural part of aging that would not warrant medical attention. Only 6 of 22 participants reported breast awareness practices. None practiced on a regular basis. Four had identified changes in their breasts but did not seek medical help. Instead, they waited to see if the symptoms disappeared or waited until the next breast screening appointment. Some self-diagnosed and self-medicated without a physician’s prescription. Last time when I felt pain of my breast, I took antibiotics. I think that if I’m ill, it would be better that I take some medicines rather than doing nothing at all. [ID 16] Participants were aware that surgery was the mainstay of treatment for breast cancer. Some mentioned other treatments, such as chemotherapy and/or radiotherapy. However, they believed that surgery was the most effective approach for treating breast cancer. Apart from surgery, there should be chemotherapy. However, I think cutting off is the best way of treating breast cancer. [ID 6] Participants had a holistic view about breast cancer prevention, believing they needed to take care of both physical and emotional aspects of their lives to prevent breast cancer. Having a healthy diet, keeping a positive outlook, doing exercise, avoidance of smoking and alcohol, and taking sufficient rest were the essential approaches. Above all, having a healthy and balanced diet was the most crucial, as they believed that the likelihood of developing
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an illness (including breast cancer) would be lower if the body was strong. You should have a variety of food and everything is in moderation. Disease happens when your body is imbalanceIeither you eat too much of this or that. [ID 14]
same Chinese language as formal interpreters, being unaware of available interpreting services, and not understanding how to book the service when required.
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Theme 3: Breast Screening Practice Most held positive views on breast screening, believing it was an effective and beneficial way of identifying breast cancer at an early stage. This may partially explain the relatively high utilization of the service among these women. Of the 22 participants, 19 had attended the service and 18 attended regularly. Three did not attend screening when invited because of time constraints and the distance to the screening center. Although most participants reported language barriers when they sought medical help, they did not report the same barriers when attending breast screening. The screening invitation letter was key to encouraging participants to attend, as the date, time, and venue of the examination were prearranged. This was perceived as being particularly useful, especially for those with limited English proficiency. They arrange it for you, it’s really good. Otherwise, you don’t know how to book the appointment, and where you go. [ID 12] Although the invitation letter was written in English, finding someone to translate was relatively straightforward in comparison with asking someone to book an appointment and translate during consultations. In addition, little conversation was required during mammographic screening, especially if participants had become familiar with the procedures. Some women viewed the invitation letter as mandatory rather than optional. Hence, participants would attend regardless of their views on the value of breast screening. I don’t think breast screening is beneficial. I do it only because it is requested by a doctor. [ID 14]
Theme 4: Views on Healthcare Services Participants reported favorably on the NHS in the United Kingdom being free of charge and trustworthy. However, language barriers, difficulties in making appointments, long waiting times, and lack of knowledge about the health system were 4 significant barriers facing many participants when they sought access to health services. In particular, because of limited English proficiency, participants commented on difficulties when communicating with GPs during consultations. Participants reported having to use dictionaries or gestures, which resulted in feelings of frustration and also losing the opportunities to ask questions and express concerns. I feel very difficult in communicating with GPs. I don’t know how to explain. Sometimes, I have to look at a dictionary. [ID 5] The NHS provides interpreters for people with limited English proficiency. However, participants reported that, on many occasions, interpreting services were not available. Participants commented on a number of perceived barriers that prevented them from using interpreting services, which included not sharing the
Discussion and Conclusion
Discussion This study used a qualitative approach and explored how Chinese women in the United Kingdom view breast cancer and breast health and how their distinctive social and cultural context influences their breast cancer views and screening behavior. This study shows that Chinese women hold complex views on breast cancer. Most acknowledged that breast cancer was curable if it was identified and treated at an early stage. However, traditional views on breast cancer were not entirely abandoned. Breast cancer was still associated with death, misery, and suffering. The negative views shown in this study are consistent with previous studies.18,21,22,24 Negative views on breast cancer and their associated feelings are arguably key to explaining why breast cancer was considered a taboo topic within these ‘‘healthy’’ women. Traditional Chinese medicine considers that the mind, body, and spirit are integral parts of a body.39 An individual’s psychological state directly impacts on their physical health. Physical status, in turn, influences psychological status.39 In this study, breast cancer was believed to evoke strong negative feelings. According to the Chinese etiology of disease, these feelings would directly affect physical functioning and potentially lead to illnesses, including cancer. Therefore, avoidance of talking and thinking about cancer was actually a coping strategy, giving protection from the potential threats of disease. Previous studies have paid much attention to the negative impacts of taboo on accessing information and early detection of cancer.40 This study suggests that avoidance of talking and thinking about breast cancer is not always problematic and can bring psychological benefits. Compared with the fatalism held by African Americans, Chinese women in this study had a different understanding about the determinants of an illness. For African Americans, the final determinant was God, reflecting influences of spiritual beings in affecting human affairs.41 This is in contrast to the ‘‘amoral fatalism’’ held by Chinese women in this study: an impersonal, irrational, and unapproachable force blindly regulating destiny.42 Hence, the development of an illness is unpredictable with no cause.42 Fate and destiny, or development of an illness, thus have nothing to do with individuals’ ethical and social conduct. This ‘‘blind fate’’ released these Chinese women from the fear of wrongdoing and helped them maintain a peaceful psychological status. Apart from maintaining psychological well-being, the Chinese women in this study also used natural approaches, such as having a balanced diet and doing outdoor activities, to promote their physical health and prevent illnesses. These results were comparable with previous studies.39,43 The beliefs behind these approaches were derived from 2 Chinese philosophies, Confucianism and Taoism. Confucians advocate that people should maintain a middle or neutral position when responding to all phenomena in the world.44 In terms of diet, for example, people should take food in moderation, neither feeling hunger nor bloated, neither ex-
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cessively eating 1 type of food while avoiding another. This doctrine is concerned with reaching harmony, which is similar to the theory of Yin/Yang ( ) in Taoism. Taoists believe that health is achieved by finding harmony between the organs of the body and between the body and the external environment.45 A lack of regular access to the natural world may break the harmony between the body and the external environment and then result in sickness. This study shows that self-care, both psychological and physical, formed the most significant strategy used by Chinese women to promote health and prevent illness in their everyday lives. This approach reflected Chinese cultural influences. It is also embedded in their specific lifestyle in the host country, which appeared to be insular and isolated. This study revealed that although these women had lived in a western country for many years, they still lived in close Chinese communities. Undoubtedly, limited English proficiency and other difficulties in accessing the healthcare system prevented these women from interacting and integrating with the host country in general and the healthcare system in particular. The apparent lack of interaction and integration perpetuated the influences of traditional Chinese culture on their health beliefs and views on breast cancer. It may also have resulted in few opportunities to receive information on the significance of breast awareness in the early detection of breast cancer. This may be key to explaining why these women paid little attention to breast awareness although it had been introduced and advocated in the United Kingdom since the early 1990s. Similar findings were also revealed in Hong Kong and American studies.8,46 However, there were occasions when Chinese women in this study actively interacted with the healthcare system. Their high utilization of breast screening corresponded to another UK study47 but was different from studies in United States, Australia, Singapore ,and Hong Kong.8,14,26,48,49 Traditional Chinese culture, such as fatalism, emphasis on self-care, and breast cancer taboo, has been shown as a barrier preventing Chinese American women,14,43 Chinese Australian women,26 and African American women50 from undertaking breast screening. However, this study suggests that Chinese women who held these beliefs still attended breast screening after receiving an invitation letter. The different social contexts may explain the disparity in findings. In the United Kingdom, breast screening is currently offered free of charge every 3 years to all women aged between 50 and 70 years. Women do not have to be proactive in relation to a breast screening appointment; they are sent a date and time and may opt out if they do not wish to attend. Previous studies indicate that cost influences cancer screening behavior among Chinese women in other countries.8,10,19 Free service in the United Kingdom may act as a motivating factor, encouraging women to participate. In addition, for those who experience language barriers to accessing health services, an invitation letter detailing the date, time, and venue of the examination is likely to encourage utilization of the service. Furthermore, in the Chinese culture, health professionals are perceived to have authority, which results in Chinese people respecting and accepting the advice given. It is hence not surprising that Chinese women in this study treated the invitation letter for breast screening as a command rather than a request. The combination of a free service, an organized appointment, and an authoritative invitation may have outweighed traditional views, such
as fatalism and modesty, on breast screening behavior, resulting in the high utilization of screening services. These findings illustrate that traditional beliefs are not the sole determinant of ethnic minority groups’ health behavior in this context. There are factors related to the way in which the breast screening service is organized in the United Kingdom that influence the significance of cultural views and shape individuals’ health behaviors. That is, women in the United Kingdom are offered breast screening free of charge and do not need to be proactive in requesting breast screening; they are sent letters of invitation that contain a date and time when they are expected to attend. This study also suggests that simple emphasis of traditional cultural influences, without careful consideration and examination of how services are provided and received by a target group, may lead to misunderstanding and even failure in service implementation.
Limitations This study limited in the generalizability of findings beyond the sample of Chinese women who participated. Although sampling included women from different geographical locations, the findings may not represent the views of Chinese women living in other parts of the United Kingdom. Participants were recruited from specific Chinese organizations. This recruitment strategy may not have captured the views of Chinese women who do not access these organizations. A national study with a larger sample and a quantitative research design would be an important next step to address the issue of generalizability and recruitment bias. This exploratory study did not aim to generate a formal theory and may not be considered a grounded theory in the purist sense. However, the use of grounded theory methods ensured a systematic and rigorous approach to data collection and analysis.
Conclusion This study explored views on breast cancer and breast health practices among Chinese women in the United Kingdom using qualitative in-depth interviews. Findings support previous studies on the influence of traditional Chinese culture on cancer beliefs among Chinese immigrants. By thoroughly exploring the topic from a social cultural context, this study presents a dynamic picture on the complex and intertwined influences of traditional cancer views and the provision of health services on Chinese women’s breast health practices. This study makes a unique contribution to the existing literature in suggesting that traditional beliefs are not the sole determinant of Chinese women’s health behavior in this context. The way in which breast screening services are organized in the United Kingdom may influence the significance of cultural views and shape individuals’ health behavior. Biomedical concepts are dominant in Western healthcare systems. However, Chinese women in this study still held strong cultural views on breast cancer and followed traditional ways of promoting breast health in their everyday life. Health professionals need to understand and respect these unique views and practices and apply appropriately cultural sensitivity when developing health promotion messages. In addition, the high utilization of breast screening among Chinese women in this study suggests that the way in which breast screening services are organized plays a
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crucial role in moderating traditional cultural influences on Chinese women’s breast screening behavior.
Practical Implication This study has valuable public health implications on how to develop a culturally sensitive educational intervention for Chinese women living in the western world. This study suggests that Chinese women emphasized the function of self-care in promoting health but paid little attention to breast awareness. Therefore, the meanings and importance of breast awareness should be delivered to this group. In addition, information on the factors increasing or reducing the risk of developing breast cancer should be included and will likely be welcomed by this group as it corresponds to their cultural values on self-care. To ensure that information is accessible and acceptable, it should be provided in Chinese with a positive tone. It can be delivered by health professionals (eg, practice nurses or public health workers) through Chinese mass media (Chinese television and radio programs) or leaflets with official logos distributed in Chinese centers, Chinatowns, Chinese supermarkets, and pharmacies.
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ICCN 2015 Abstract Book Manuscript Oral Sessions: Erratum In the ICCN 2015 Abstracts Supplement, which published online with Volume 38, Issue 4 of Cancer Nursing, oral abstract O-72 was mistakenly left out. That missing abstract appears below, and the error has been noted in the online version of the supplement, which is available at www.cancernursingonline.com.
O-72 Opioid Titration Protocol for Managing Breakthrough Cancer Pain in Emergency Room Hyojung Jang1, Jeong-Hui Ok1, Jinseon Choi2, Yeon Hee Kim2 1
Cancer Emergency Room (CER), Asan Medical Center, Seoul, Korea (The Republic of), 2Department of Nursing, Asan Medical Center, Seoul, Korea (The Republic of) Background: 1728 patients visited with uncontrolled breakthrough pain in Cancer Emergency Room (CER) in 2013. Opioid titration is an effective strategy for rapid treating pain; however, titration is generally impractical in the busy ED. This study was aimed to develop a ‘‘breakthrough cancer pain management protocol,’’ which provides a guideline of pain assessment and opioid titration using intravenous morphine for sudden onset stage. Methods: A prospective study was conducted in patients with moderate to severe cancer pain (numeric rating score [NRS] 94). Pain intensity was measured at admission, dose titration or opioid/route switching within 3 days. Doses of opioids, duration of opioid use were reported. This protocol was designed to calculate rescue dose depending on NRS score and previous used daily opioid dose. After 30 minutes of rescue dose, pain assessment was repeated. If persistent pain (NRS 94), same dose or escalating rescue dose were provided according to NRS score. Despite first 3hrs titration with maximum 6 times of bolus rescue dose, patient with persistent pain (NRS 94) was started morphine IV continuous infusion (starting dose and escalating dose were decided by previous daily dose) and pain assessment and escalating dose’s interval are 30 minutes. This protocol mentioned cautions and action-plan with occurred undesirable event. Pilot assessment of the efficacy and tolerability of protocol was done before study. Results: 87% of 275 was successfully managed pain using this protocol and NRS was reduced (G3). 85% of patients are controlled within 3 hours’ bolus titration. The average staying time decreased 10.1 hrs (p=.004). Re-visit patient with reluctant pain within 1 week was two. Conclusions: This protocol was shown to be effective and tolerated for titration for mod/severe cancer pain relief in both opioid-naBve and tolerant patient. This study warrants prospective and comparative studies with larger samples for more generalized results.
Reference ICCN 2015 Abstract Book Manuscript Oral Sessions. Cancer Nurs. 2015;38(4S).
DOI: 10.1097/NCC.0000000000000304
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