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Table 1. Pilot Interview Demographics

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Table 1. Pilot Interview Demographics Singaporean Women’s Perceptions and Barriers to Breast and Cervical Cancer Screening By Junyang Wang Duke Global Health Institute Duke University Date:_______________________ Approved: ___________________________ Eric Finkelstein, Supervisor ___________________________ Kearsley Stewart ___________________________ Yousuf Zafar Thesis submitted in partial fulfillment of the requirements for the degree of Masters of Science in Duke Global Health Institute in the Graduate School of Duke University 2014 ABSTRACT Singaporean Women’s Perceptions and Barriers to Breast and Cervical Cancer Screening By Junyang Wang Duke Global Health Institute Duke University Date:_______________________ Approved: ___________________________ Eric Finkelstein, Supervisor ___________________________ Kearsley Stewart ___________________________ Yousuf Zafar Thesis submitted in partial fulfillment of the requirements for the degree of Masters of Science in Duke Global Health Institute in the Graduate School of Duke University 2014 Copyright by Junyang Wang 2014 Abstract Objectives: To understand the key factors guiding women’s decision of whether or not to use breast and cervical cancer screening services (in order to determine how to cost effectively increase screening uptake in following conjoint). Methods: We conducted eight focus groups, with Singaporean women aged between 40 and 64 for breast cancer screening, and between 25 and 64 years for cervical cancer screening, to identify the key factors that drive cancer screening. Using the Health Belief Model to guide our focus group questions, we analyzed the responses and compared similarities and differences among screeners and non-screeners. Results: Singaporean women understand the severity of both breast and cervical cancer and fear the associated lifestyle challenges that come with a cancer diagnosis. With the exception of several non-screeners in the breast cancer group, all women reported they believed they were at risk of developing cancer. All women reported the benefits of early detection and accuracy of preventative screening. Both screeners and non-screeners feared cancer detection during screening and saw the screening clinic as a place of possible cancer diagnosis. Conclusion: How women perceive their cancer diagnosis, accepting the cancer reality or succumbing to fatalist beliefs, greatly impacts their decision to screen. Screeners were more likely to report that they had recommendations from friends, referrals from doctors, and influences from promotion campaigns. Non- iv screeners were more likely to have perceive fatalistic views (lack of control over a diagnosis (fatalism) was a unique barrier reported by non-screeners. v Contents Abstract ................................................................................................................... iv Contents ................................................................................................................... vi List of Tables ......................................................................................................... viii Acknowledgements ................................................................................................ ix 1. Background .......................................................................................................... 1 1.1 A Global Burden: Breast and Cervical Cancer .......................................... 1 1.2 Singapore: Country Background ................................................................ 2 1.3 Singapore: Breast and Cervical Cancer Prevalence .................................. 3 1.4 Screening intervention efficacy ................................................................... 5 1.5 Health Belief Model Conceptual Framework ........................................... 9 2. Purpose of the Study ......................................................................................... 11 3. Methods .............................................................................................................. 12 3.1 Setting and Study Population ................................................................... 12 3.2 Health Belief Conceptual Framework ..................................................... 13 3.3 Demographics ............................................................................................. 15 3.3 Data Analysis ............................................................................................... 17 4. Results ................................................................................................................. 20 4.1 Breast Cancer ............................................................................................... 20 4.2 Cervical Cancer ........................................................................................... 29 5. Discussion .......................................................................................................... 37 5.1 Cancer Diagnosis: Fatalism versus Acceptance ........................................... 38 5.2 Social Support as a Key Motivator ............................................................... 41 vi 5.3 Limitations ..................................................................................................... 48 Conclusion .............................................................................................................. 52 Appendix A: Focus Group Guide Example .......................................................... 53 Appendix B: Participant Information Sheet and Focus Group Consent Form .... 55 References ............................................................................................................... 61 vii List of Tables Table 1: Summary Table, Breast Cancer Focus Groups ........................................... 23 Table 2: Summary Table, Cervical Cancer Focus Groups ....................................... 24 Table 3: Summary of Findings - Health Belief Model and Breast Cancer ............. 27 Table 4: Summary of Findings - Health Belief Model and Cervical Cancer ......... 35 viii Acknowledgements The opportunity to work on this project would have never been possible without the support of a number of individuals. First and foremost, I would like to express my appreciation to my thesis advisor Dr. Eric Finkelstein, at Duke- National University of Singapore and Duke Global Health Institute who not only gave me the opportunity to conduct this study, but helped every step of the way by adapting research plans to fit a pressing thesis deadline, identifying committee advisors, and ceaselessly responding to any email inquiries. I would also like to thank Dr. Chetna Malhotra and Dr. Marcel Bilger who both mentored my research on the ground and my coding partner, Junxing Chay, who brought me up to speed on the research and worked with me tirelessly on coding. Dr. Kearsley Stewart at the Duke Global Health Institute, was an invaluable resource in guiding my writing upon return to Durham. Finally, I’d like to thank all those who lent a pair of eyes to this thesis not mentioned above, with special consideration to Dr. Truls Ostbye and Dr. Yousuf Zafar. Finally, this project could not have happened without the collaborative efforts of the Duke-National University of Singapore partnership and the exchange of academia in both Singapore and Durham. Last but certainly not least, I would like to thank all the women who agreed to participate in the study and willing to share their stories in an effort to improve the lives of future Singaporean women. To all those mentioned I express my appreciation and sincere gratitude. ix 1. Background 1.1 A Global Burden: Breast and Cervical Cancer Among women, breast and cervical cancer account for a large percent of worldwide deaths today. The leading type of malignancy among women is breast cancer, yet cervical cancer is more common in some African nations (Cancer, 2014). From 1980 to 2000, global breast cancer incidence increased at an annual rate of 3.1% whereas global cervical cancer incidence increased by 0.6% (Forouzanfar et al., 2011). Challenges of modernization bring lifestyle changes, including urbanization, diet, obesity, tobacco and alcohol use, changes in reproductive patterns, chronic infection and increasing lifespans that all contribute to an ever-increasing cancer burden in Asian countries (Sankaranarayanan, Ramadas, & Qiao, 2014). Although there are few recent descriptive reports detailing the epidemiology of breast cancer among Southeastern Asian populations, several studies show the incidence of breast cancer is rising in Asian countries; breast cancer is the most common cancer among Asian women and is expected to continue to grow for the next decade (Shin et al., 2010). Cervical cancer follows closely behind breast cancer and is the second most common cancer among Southeast Asian women. Although cervical cancer rates are decreasing in Singapore, they are dropping less rapidly among Chinese than any other 1 population (Cheah, Looi, & Sivanesaratnam, 1999). Still, South Asian women tend to be at lower risk for breast cancer than their white or black counterparts by 18% and 15%, respectively (Januszewski, Tanna, & Stebbing, 2014). 1.2 Singapore: Country Background An island republic with a total population of 5.31 million, Singapore has a diverse resident demographic that consists of Chinese (74.2%), Malays (13.3%), Indians (9.2%), and other ethnic groups (3.3%) (Health, 2012). The majority of women are between the ages of 15-64, with a median age of residents
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