This article was downloaded by: [83.37.2.197]On: 22 October 2014, At: 22:31Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Health Care for Women InternationalPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/uhcw20

Effect of Educational Level onKnowledge and Use of Breast CancerScreening Practices in BangladeshiWomenRafia S. Rasu a , Nahid J. Rianon b , Sheikh M. Shahidullah c , Abu J.Faisel c & Beatrice J. Selwyn da Department of Pharmacy Practice and Administration, School ofPharmacy , University of Missouri , Kansas City, Kansas City, Missouri,USAb Department of Medicine , Baylor College of Medicine , Houston,Texas, USAc Engender Health Bangladesh , Dhaka, Bangladeshd Division of Management, Policy and Community Health, School ofPublic Health , University of Texas , Houston, Texas, USAPublished online: 18 Feb 2011.

To cite this article: Rafia S. Rasu , Nahid J. Rianon , Sheikh M. Shahidullah , Abu J. Faisel &Beatrice J. Selwyn (2011) Effect of Educational Level on Knowledge and Use of Breast CancerScreening Practices in Bangladeshi Women, Health Care for Women International, 32:3, 177-189, DOI:10.1080/07399332.2010.529213

To link to this article: http://dx.doi.org/10.1080/07399332.2010.529213

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

Health Care for Women International, 32:177–189, 2011Copyright © Taylor & Francis Group, LLCISSN: 0739-9332 print / 1096-4665 onlineDOI: 10.1080/07399332.2010.529213

Effect of Educational Level on Knowledgeand Use of Breast Cancer Screening Practices

in Bangladeshi Women

RAFIA S. RASU

Department of Pharmacy Practice and Administration, School of Pharmacy,University of Missouri, Kansas City, Kansas City, Missouri, USA

NAHID J. RIANON

Department of Medicine, Baylor College of Medicine, Houston, Texas, USA

SHEIKH M. SHAHIDULLAH and ABU J. FAISEL

Engender Health Bangladesh, Dhaka, Bangladesh

BEATRICE J. SELWYN

Division of Management, Policy and Community Health, School of Public Health,University of Texas, Houston, Texas, USA

The Breast Health Global Initiative 2007 emphasized educationand cultural values for promoting breast cancer screening in de-veloping countries. This cross-sectional study investigated if edu-cational level and cultural beliefs affect breast cancer screeningpractices in 152 women 40 years or older in Dhaka, Bangladesh.Women with a higher (>12 years) educational level were morelikely to know about breast self-examination (BSE; ORadj, 95%CI =22, 6.39–76.76), to know about mammograms (6, 2.49–15.70),and to practice BSE (3, 1.27–6.83) compared with those with alower educational level. Breast cancer screening practices or knowl-edge was not affected by perceiving barriers to having mammo-grams.

Received 12 August 2009; accepted 20 September 2010.Address correspondence to Rafia S. Rasu, Department of Pharmacy Practice and Adminis-

tration, School of Pharmacy, University of Missouri, Kansas City, 2464 Charlotte Street, KansasCity, MO 64108, USA. E-mail: rasur@umkc.edu

177

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

178 R. S. Rasu et al.

Breast cancer, one of the leading causes of death in women throughoutthe world (Sadler et al., 2001), is the second most common cancer amongBangladeshi women (“Breast cancer foremost,” 2009). Most breast cancercases diagnosed each year in Bangladesh are based on lumps (U.S. Embassy,2006) that could be detected earlier with proper knowledge and aware-ness of breast cancer screening practices. No information is available on theknowledge and awareness about breast cancer and breast cancer screeningpractices among Bangladeshi women from the literature review performedin CINAHL and Medline as of December 2008.

The Breast Health Global Initiative (BHGI) 2007 identified educationand cultural values as important factors for breast cancer screening practicespromoting early detection of breast cancer in the low- and middle-incomecountries (Yip et al., 2008). Bangladesh is a south Asian developing countrywith about a 40% literacy rate for girls who have primary level education(Ahammed, 2003). Bangladeshi women are known to assume a lower so-cial rank than men and lack decision-making power in life including healthmatters (Schuler, Hashemi, Riley, & Akhter, 1996). Besides, women oftenare reluctant to let others know about any breast-related problems even ifit is a cancer, and they may avoid health visits to prevent undressing infront of a male health professional (U.S. Embassy, 2006). Preservation ofmodesty was reported as a cultural barrier negatively affecting Asian In-dian Muslim women’s attitude and behavior toward breast cancer screening(Matin & LeBaron, 2004; Wu, West, Chen, & Hergert, 2006). Avoidance ofbreast cancer screening due to barriers from cultural or religious beliefs wasreported in Middle Eastern and central Asian countries with predominantlyMuslim populations (Jadalla & Sharaya, 1998; Petro-Nustas, 2001; Yavari &Pourhoseingholi, 2007). Bangladesh, a predominantly Muslim country insouth Asia with a different sociocultural background than countries men-tioned in previous studies (Jadalla & Sharaya, 1998; Petro-Nustas, 2001;Yavari & Pourhoseingholi, 2007), offers a unique view on how its womenmake health care decisions.

The health belief model supports an association among increasedknowledge, awareness, and perception of being at risk of a disease withpositive health behavior, that is, screening for prevention (Janz, Champion,& Strecher, 2002). While knowledge about a health problem improved pre-ventive behavior (Janz et al., 2002; Rianon et al., 2009; Sloss & Munier,1991) and empowered women to engage in breast cancer screening (Pillay,2002), a lower level of formal education has been related to inadequateknowledge and breast cancer screening practices in women (Webster &Austoker, 2006; Yavari & Pourhoseingholi, 2007). We investigated if educa-tional level and the cultural belief of perceiving there are barriers for gettinga mammogram are affecting breast cancer screening practices in Bangladeshiwomen.

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

Breast Cancer Screening Practices in Bangladeshi Women 179

METHODS

Recruitment

A total of 152 women living in Dhaka, Bangladesh, participated in this cross-sectional study. Participants were recruited by convenience sampling fromemployees of various universities and colleges in the Dhaka metropolitanarea in 2004. Selected employees came from a variety of jobs, ranging fromcleaners/dining room assistants who never attended school to highly edu-cated faculty members. Given the gap in literature on women’s knowledge ofbreast cancer and screening practices in a cultural setting such as Bangladesh,we chose to interview women in academic institutions assuming they wouldbe pioneers in embracing new practices and excluded employees of healthcare institutions assuming they would likely have increased knowledge byvirtue of their working environment.

Simple random sampling was used to select 10 universities and collegeslocated in the Dhaka metropolitan area that incorporates about 59.40 squaremiles (“Dhaka,” 2001).University/college principals or appropriate authoritieswere approached for their institutional approval and assistance in identify-ing places where employees congregated. Any woman employee 40 years orolder with no prior history of breast cancer in the selected schools was eligi-ble to participate in this study. Employees were approached in the commonareas of congregation for determining eligibility to participate in the study.Those who met the eligibility criteria and agreed to participate by signingthe informed consent were later interviewed in person at a time convenientfor them.

The Bangladesh Medical Research Council (BMRC) approved the currentstudy. The English language questionnaire was translated into Bangla, withconsideration of the lowest educational level of the target population.

Data Collection

Trained interviewers used a semistructured questionnaire to interviewwomen face-to-face. The questionnaire was developed and then pretestedwith a five-member focus group between 40 and 65 years of age with edu-cational levels anticipated to be similar to our study participants.

Age (continuous variable), education, job title, and monthly incomewere collected as demographic information via the questionnaire. Othervariables collected with the questionnaire follow:

1. Smoker (have you smoked at least 100 cigarettes in your lifetime): yes orno;

2. Physical activity (leisure time physical activity at least 10 minutes thatcauses sweating—reported in times per week): no (0 to once per week)and yes (at least two times or more per week);

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

180 R. S. Rasu et al.

3. Self-reported health status (SRHS): poor (collapsed from fair and poor)and good (collapsed from excellent, very good, and good);

4. Knowledge of breast cancer (have you heard about breast cancer): yesor no;

5. Source of knowledge about breast cancer (how did you hear about it):physician, friends, or family (collapsed from colleagues, friends, or fam-ily members), and media (collapsed from TV, radio, newspaper, othermagazines);

6. Family history of breast cancer: history of breast cancer in mother, sister,maternal aunt, grandmother or first cousin;

7. Knowing about BSE (breast self-exam) or mammogram;8. Reported practice of BSE or having a mammogram;9. Perception of being at risk of getting breast cancer;

10. Perception of barriers to having a mammogram;11. Willingness to pay for mammogram: how much are you willing to pay

for getting a mammogram done (open ended in Taka, local Bangladeshicurrency): considered evidence of a positive attitude toward breast cancerscreening practices.

Since no known recommendations for breast cancer screening in Bangladeshwere available, we relied on information gathered from focus group discus-sion to determine appropriate questions to ask about breast cancer screeningpractices resulting in questions about mammogram and BSE.

We developed a conceptual framework (see Figure 1) for our analysisfollowing the health belief model that supports a “cognitive factor,” that is,perceiving susceptibility to a disease (breast cancer), predisposing a personto a health behavior with a belief or expectation that the negative healthoutcome can be avoided by taking a recommended action (“Health beliefmodel,” 2009).

Statistical Analysis

Data analyses were conducted using STATA R© version 9.0. Frequency dis-tributions for key variables were reported with descriptive statistics. Morethan 12 years of school in about 65% of participants led us to recode edu-cation into two categories: less than or equal to and more than 12 years ofschool. Bivariate analysis was conducted between population characteristics,independent and dependent variables. The two main independent variablesare educational level and cultural variable of the perception of barriers tomammography. The two outcome variables follow: (a) knowledge of BSEor mammography, and (b) practicing BSE or having a mammogram. Bivari-ate analysis used the chi-square test (Fisher’s exact for variables with <5 ineach cell) for categorical variables and logistic regression for the continuous

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

Breast Cancer Screening Practices in Bangladeshi Women 181

Individual Perception Modifying Factors Likelihood of Action

Demographics: age, knowledge level, socio-economic & environmental factors, personal and family medical history

Perceived benefit of prevention of BC versus barriers to behavioral change, e.g., practice mammogram & BSE

Perceived susceptibility of disease, e.g., perception of being at risk of getting breast cancer

Perceived threat of disease, e.g., breast cancer

Likelihood of behavioral change, e.g., practicing mammogram /BSE (outcome)

Cues to action, e.g., education, source of information, e.g., media

FIGURE 1 Conceptual framework. Note. Conceptual framework is adopted from Janz et al.,2002.

variable of age. The level of statistical significance used was .05. A multivari-ate logistic regression model was developed to adjust for covariables thatwere significant at p < .10 from bivariate analysis. Results were reported inodds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

The population (N = 152) was mostly educated (65% > 12 years of school)with 50% representing faculty members, 43% as administrative staff, and 7%as cleaners or dining room assistant lacking any formal education. From the56% of those who reported income, 57% had a basic salary of less than Taka7500.00 per month (U.S. $125 approximately with a conversion rate of U.S.$1.00 = Taka 60.00 at the time of the study; Bangladesh Bank, 2009). Mostparticipants were married (78%), nonsmokers (99%), and reported once aweek or less of physical activity (55%). Forty-eight percent reported goodSRHS, while 11% perceived themselves to be at risk of getting breast cancer(see Table 1).

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

182 R. S. Rasu et al.

TABLE 1 Population Characteristics by Education Level for Bangladeshi Women

Educationp value (χ 2

≤ 12 years of > 12 years of or Fisher’sPopulation Total % school (%) school (%) exact if <5characteristics Categories N = 152 N = 53 N = 99 in a cell)

Age Mean ± SD 47 ± 6 47 ± 6 47 ± 6 .70Income/month Tk. ≤ 7500.00 56 84 40 < .01SRHS Poor 52 57 44 .17Smoker Yes 1 0 2 .54Physical activity ≤ Once/week 55 75 45 < .01Have you heard about

breast cancerNo 11 30 1 < .01

Source of information Physician 23 14 29Friend/family 20 25 16News media 57 61 55

Family history Yes 24 15 29 .07Do you know about

mammogramNo 30 59 14 < .01

Did you havemammogram done

No 86 94 82 .03

Do you know aboutBSE

No 24 55 7 < .01

Do you practice BSE No 47 66 37 < .01Barrier for

mammogramYes 49 47 51 .71

Are you at risk forgetting breast cancer

No 89 91 88 .80

How much are youwilling to pay formammogram

Tk. ≤ 1000.00 89 96 85 .09

Note. Smoker = have you smoked at least 100 cigarette in your life-time; Physical activity = leisure timephysical activity at least 10 minutes that causes sweating; SRHS = self-reported health status; BSE = Breastself-examination; Tk. = taka (Bangladeshi currency: $1.00 = Tk. 60.00 at the time of data collection in2004).

About 11% of the women reported not having heard about breast can-cer. Of those who reported hearing about breast cancer, the majority heardabout breast cancer from the media (see Table 1). Although most of thosewho heard about breast cancer reported knowing about mammograms (79%)and BSE (86%), only 16% had a mammogram done in their lifetime, while59%reported practicing BSE. About 72% of those who heard about breastcancer reported a positive family history of breast cancer. Half (51%) of ourparticipants reported not perceiving any barrier for getting a mammogramdone. Only 11% of the 130 participants who reported a willingness to pay fora mammogram said they would spend more than Taka 1000.00 (U.S.$17.00approximately with a conversion rate of U.S.$1.00 = Taka 60.00 at the timeof the study) for the test. There was a statistically significant positive asso-ciation between 12+ years of education and hearing about breast cancer,

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

Breast Cancer Screening Practices in Bangladeshi Women 183

TABLE 2 Population Characteristics by Perception of Barriers to Mammography inBangladeshi Women

Barriersperceived

p value (χ 2 orPopulation Total % No (%) Yes (%) Fisher’s exact ifcharacteristics Categories N = 134 N = 68 N = 66 < 5 in a cell)

Age Mean ± SD 47 ± 6 47 ± 6 48 ± 6 .40Education ≤ 12 years school 35 34 30 .71Income/month Tk. ≤ 7500.00 56 56 54 .65SRHS Poor 52 58 50 .38Smoker No 1 2 2 1.00Physical activity ≤ Once/week 55 49 53 .60Have you heard about

breast cancerNo 11 7 9 .76

Source of information Physician 23 26 29Friend/family 20 18 21News media 57 57 50

Family history Yes 24 29 24 .56Do you know about

mammogramNo 30 24 29 .56

Did you havemammogram done

No 86 79 89 .15

Do you know about BSE No 24 19 21 .83Do you practice BSE No 47 50 44 .50Are you at risk for getting

breast cancerNo 89 88 86 .80

How much are youwilling to pay formammogram

Tk. ≤1000.00 89 90 88 .77

Note. Smoker = have you smoked at least 100 cigarette in your life-time; Physical activity = leisure timephysical activity at least 10 minutes that causes sweating; SRHS = self-reported health status; BSE = breastself-examination; Tk. = Taka (Bangladeshi currency: $1.00 = Tk. 60.00 at the time of data collection in2004).

knowing about its screening practices, and acting to perform BSE or have amammogram (see Table 1).

No statistically significant association was found between perception ofbarriers for mammography and hearing about breast cancer or knowing of itsscreening practices or practicing BSE and mammography (see Table 2). Noneof the demographic variables were statistically associated with a perceptionof barriers to having a mammogram (see Table 2).

Although money and fear were factors mentioned as barriers to getting amammogram by our participants, the two most frequently mentioned factorswere deeming the test not necessary and admitting to not practicing “goodhealth behavior” (see Table 3).

Income was excluded from the multivariate model to avoid colinearitywith education. After adjusting for other covariates, we found that womenwith more than 12 years of school had statistically significantly higher odds of

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

184 R. S. Rasu et al.

TABLE 3 Self-Reported Barriers for Getting a Mammogram Done

Total N = 66Stated barriers (percent = 51%)

Lack of good health behavior 21 (16%)Not necessary 21 (16%)Carelessness 13 (10%)No time 6 (5%)Fear 3 (2%)Economic reason 2 (2%)

knowing about BSE and mammogram, as well as practicing BSE (see Table 4)compared with those with a lower educational level. Each unit (year) ofadvanced age showed a 15% higher odds of getting a mammogram done(see Table 4). Women who had a mammogram done were five times morelikely to report a family history positive for breast cancer (Table 4). Morephysically active (twice or more per week) women had two to four timesthe odds of practicing BSE or knowing about mammograms, respectively,compared with less physically active women.

DISCUSSION

Education showed a positive impact on knowledge and practice of breastcancer screening activities in Bangladeshi women. Women with higher ed-ucational levels were more likely to know about BSE (ORadj, 95% CI = 22,6.39–76.76), about mammograms (6, 2.49–15.70), and to practice BSE (3,1.27–6.83) compared with those with lower educational levels. Although ourresults are in agreement with previous studies that reported a positive effectof education on cancer screening behavior (Pillay, 2002; Webster & Aus-toker, 2007; Yavari & Pourhoseingholi, 2007; Yip et al., 2008), in our study,after adjusting for covariates, receiving a mammogram was not statisticallysignificantly associated with educational level. Nevertheless, there was a pos-itive association between having a mammogram and having a positive familyhistory of breast cancer, poor SRHS, and older age. These associations mayindicate a health belief model impact (Kim et al., 2008) in our participants thatsupports the association of a perception of being at risk of breast cancer withthe health behavior of having a mammogram, as explained in our Figure 1conceptual framework (Janz et al., 2002; Parsa, Kandiah, Rahman, & Zulke-fli, 2006). While cultural perception of barriers to having a mammogramdid not show any statistically significant association with breast cancerscreening practices knowledge and behavior, our participants lived in thecity with exposure to the modern media and with a higher than averageeducational level (Ahammed, 2003) than the country as a whole, which is afactor that may have played a role in this outcome.

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

TA

BLE

4D

eter

min

ants

ofB

reas

tCan

cer

Scre

enin

gK

now

ledge

and

Pra

ctic

ein

Ban

glad

eshiW

om

en

Outc

om

eva

riab

les

Bre

astca

nce

rsc

reen

ing

know

ledge

Bre

astca

nce

rsc

reen

ing

pra

ctic

e

Do

you

know

Do

you

know

Do

you

Do

you

get

aboutB

SE?

aboutm

amm

ogr

ams

?pra

ctic

eB

SE?

mam

mogr

ams

done

?

Ris

kfa

ctors

Res

ults

reported

inO

Rad

j(9

5%CI)

±

Age

0.95

(0.8

6to

1.04

)1.

04(0

.96

to1.

13)

0.98

(0.9

2to

1.05

)1.

15(1

.03

to1.

28)∗

Educa

tion

22.1

5(6

.39

to76

.76)

∗6.

25(2

.49

to15

.70)

∗2.

94(1

.27

to6.

83)∗

1.69

(0.3

6to

7.90

)Phys

ical

activ

ity2.

63(0

.73

to9.

49)

4.73

(1.5

8to

14.1

9)∗

2.84

(1.2

9to

6.26

)∗1.

70(.46

to6.

26)

SRH

S1.

21(0

.39

to3.

69)

1.27

(0.5

0to

3.26

)1.

24(0

.57

to2.

70)

10.3

3(1

.97

to54

.05)

∗

Fam

ilyhis

tory

1.97

(0.4

9to

8.00

)1.

46(0

.47

to4.

54)

1.26

(0.5

3to

3.01

)5.

27(1

.52

to18

.31)

∗

How

much

would

you

pay

for

am

amm

ogr

am2.

35(0

.21

to26

.40)

2.43

(0.4

1to

14.4

3)0.

94(0

.29

to3.

03)

4.22

5(0

.73

to24

.37)

Not

e.∗

p<

.05.

±Eac

hodds

ratio

sis

adju

sted

for

allth

eoth

erva

riab

les

inth

eta

ble

=O

Rad

j;B

SE=

bre

astse

lf-e

xam

inat

ion;SR

HS

=se

lf-r

eported

hea

lthst

atus.

Age

was

consi

der

eda

contin

uous

variab

lein

the

multi

variat

em

odel

.

185

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

186 R. S. Rasu et al.

The current study adds valuable knowledge bridging the informationgap regarding knowledge, attitude, and behavior about breast cancer screen-ing practices in Bangladeshi women. Results from our study demonstratedgeneral awareness about breast cancer and its screening practices (both BSEand mammogram; see Tables 1 and 2) in the participants. The majority of ourparticipants reported knowing about breast cancer and yet less than a fifthof those with breast cancer awareness have ever had a mammogram done.More women knew and practiced BSE compared with those who reportedthe same about mammogram. Of note, about half of the study participantsdid not perceive any barriers to getting a mammogram and 86% were willingto pay for it. Participants reported a discrepancy between their knowledgeand behavior regarding breast cancer screening practices. A lower percent-age of women reported practicing BSE or getting a mammogram comparedwith those who reported knowing about them. Lack of targeted health educa-tion may explain the discrepancy between knowledge and behavior (Rianonet al., 2009) for a health problem; that is, women may have heard aboutbreast cancer but be unaware of the specific health consequences of it or ofthe benefits of screening practices.

Lack of available testing facilities was reported as a barrier to breastcancer screening practice of mammography in some countries includingBangladesh (U.S. Embassy, 2006; Pillay, 2002). Mammography was intro-duced to the Bangladeshi health care market in the early 1990s (Banglape-dia, 2008). It is available only at a few private clinics, situated mostly in thecapital city of Dhaka (Banglapedia, 2008), and is mainly used for diagnosticpurposes. A commercial mammogram costs about Taka 3000.00 (personalcommunication by author SMS, April 2008) in Dhaka, Bangladesh. Lack ofaccess to care (U.S. Embassy, 2006), low availability (Pillay, 2002), and highercost than their expectation may be responsible for the low rate of mammo-grams in our participants. It is beyond the scope of this study to investigateif the required amount of money for the commercial test is cost effective orcustomer friendly for the Bangladeshi women, but the information would behelpful in planning targeted interventions.

Frequently reported barriers for mammogram practices in our studywere deeming the test unnecessary, admitting not practicing “good health be-havior,” fear, time and financial constraints, plus carelessness. Unlike womenin a Jordanian study, our participants did not report “fatalism” and “God’swill” as barriers for screening practices (Petro-Nustas, 2001). Despite thecommonality of the dominant religion practiced in both Muslim countries,no religious belief or gender-related intimidation or hesitancy was reportedby our participants. The differences in study findings on cultural factors be-tween our study and studies from other Muslim countries (Azaiza & Cohen,2006; Jadalla & Sharaya, 1998; Matin & LeBaron, 2004; Petro-Nustas, 2001;Wu et al., 2006)may be due to the differences in the background of the pop-ulation studied. The population for the current study consisted of womenwho were older (≥ 40 years) and were working outside their homes in

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

Breast Cancer Screening Practices in Bangladeshi Women 187

institutions of advanced learning as opposed to the Jordanian study popu-lation who were younger (≤ 45 years) and were visiting one of the largestmaternal and child health centers in Amman. Only about a quarter of theJordanian women had a college-level education, while two-thirds of ourpopulation had 12 or more years of education. The city life of our popula-tion with media exposure also may have influenced our participants’ attitudetoward breast cancer screening practices.

Our results are limited to the women living in Dhaka, Bangladesh.Caution is recommended while interpreting the results for women from otherparts of the country, including rural areas.

The Bangladeshi women in our study reported they were not at risk ofgetting breast cancer, and only one-fourth of the group reported a familyhistory positive for breast cancer, yet those who had a mammogram werefive times more likely to report a similar positive history. Learning aboutthe perceived risk for breast cancer and culturally perceived barriers towardbreast cancer screening practices will assist in developing health educationaland promotional materials for cancer screening. Countries with similar so-cial values, for example, south Asian countries, may replicate this model topredict their citizens’ attitude towards breast cancer screening. Our resultsalso may help understanding breast cancer related issues among immigrantwomen from the south Asian countries, specifically from Bangladesh, to theWestern world.

CONCLUSIONS

A higher educational level has a positive impact on breast cancer screeningpractices in Bangladeshi women. Cultural belief in terms of perception ofbarriers for mammography did not show any effect on breast cancer screen-ing practices in these women. Our participants were aware of breast cancerand its common screening practices. More women practiced BSE than hada mammogram. Our findings also indicate the influence of personal riskperception based on a positive family history for breast cancer or on theirown health status (SRHS and older age) on mammogram practice in the par-ticipants. The discrepancy between knowledge about and actual screeningwith mammogram needs further investigation. Health education focusing onpotential severe health consequences from breast cancer may help improvebreast cancer screening practices in Bangladeshi women. Future studies arerecommended for confirming our study findings in the Bangladeshi womenin the general population, especially those in rural areas.

REFERENCES

Ahammed, K. (2003). Country report on accelerating progress on girl’s education inBangladesh. Fourth meeting of the working group on Education for All, Paris,

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

188 R. S. Rasu et al.

July 22–23, by the Joint Secretary of Development, Ministry of Primary andMass Education, Bangladesh. Retrieved from http://209.85.173.132/search?q=cache:mPuoHnWa9TUJ:www.unesco.org/education/efa/global co/workinggroup/WGEFA4 Bangladesh.ppt± literacy±rate±for±girls±in±Bangladesh±Paris±report&hl=en&ct=clnk&cd=1&gl=us

Azaiza, F., & Cohen, M. (2006). Health beliefs and rates of breast cancer screeningamong Arab women. Journal of Women’s Health, 15, 520–530.

Bangladesh Bank. (2009). Central Bank of Bangladesh exchange rate. Retrieved fromhttp://www.bangladesh-bank.org

Banglapedia. (2008). Cancer. Retrieved from http://banglapedia.search.com.bd/HT/C 0033.htm

“Breast cancer foremost among Bangladeshi women.” (2009, April 21). TheNew Nation. Retrieved from http://nation.ittefaq.com/issues/2009/04/21/news0957.htm

“Dhaka.” (2011). Wikipedia, the. free encyclopedia. Retrieved fromhttp://enowikipedia.org/wiki/Dhaka geography

Health belief model. (2009). Encyclopedia of Public Health. Retrieved fromhttp://www.enotes.com/public-health-encyclopedia/health-belief-model

Jadalla, A., & Sharaya, H. (1998). A Jordanian view about cancer knowledge andattitudes. Cancer Nursing, 21, 269–273.

Janz, N., Champion, V., & Strecher, V. (2002). The health belief model. In K. Glanz,B. Rimer, & F. Lewis (Eds.). Health behavior and health education: Theory,research and practice (pp. 45–66). San Franscisco, CA: Wiley & Sons.

Kim, S., Perez-Stable, E., Wong, S., Gregorich, S., Sawaya, G., Walsh, J., & Kaplan,C. (2008). Association between cancer risk perception and screening behavioramong diverse women. Archives of Internal Medicine, 14, 728–734.

Matin, M., & LeBaron, S. (2004). Attitudes toward cervical cancer screening amongMuslim women: A pilot study. Women Health, 39, 63–77.

Parsa, P., Kandiah, M., Rahman, H., & Zulkefli, N. (2006). Barriers for breast cancerscreening among Asian women: A mini literature review. Asian Pacific Journalof Cancer Prevention, 7, 509–514.

Petro-Nustas, W. (2001). Young Jordanian women’s health beliefs about mammog-raphy. Journal of Community Health Nursing, 18, 177–194.

Pillay, A. (2002). Rural and urban South African women’s awareness of cancers ofbreast and cervix. Ethnicity and Health, 7, 103–114.

Rianon, N., Selwyn, B., Shahidullah, S., Swint, M., Franzini, L., & Rasu, R. (2009).Cost of health education to increase STD awareness in female garment workersin Bangladesh. International Electronic Journal of Health Education, 12, 135–149.

Sadler, G., Dhanjal, S., Shah, N., Shah, R., Ko, C., Anghel, M., & Harshburger, R.(2001). Asian Indian Women: Knowledge, attitude and behaviors toward breastcancer early detection. Public Health Nursing, 18, 357–363.

Schuler, S., Hashemi, S., Riley, A., & Akhter, S. (1996). Credit programs, patriarchyand men’s violence against women in rural Bangladesh. Social Science andMedicine, 46, 1729–1742.

Sloss, L., & Munier, A. (1991). Women’s health education in rural Bangladesh. SocialScience and Medicine, 32, 959–961.

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4

Breast Cancer Screening Practices in Bangladeshi Women 189

U.S. Embassy. (2006). Hope for breast cancer in Bangladesh (Report). Retrieved fromhttp://dhaka.usembassy.gov/uploads/images/RVRAbXXI8 SGTMhP8fKz8w/pre1jun26 06.pdf

Webster, P., & Austoker, J. (2006). Women’s knowledge about breast cancer riskand their views of the purpose and implications of breast screening—A ques-tionnaire survey. Journal of Public Health (Oxford), 28, 197–202.

Wu, T., West, B., Chen, Y.-W., & Hergert, C. (2006). Health beliefs and practicesrelated to breast cancer screening in Filipino, Chinese and Asian-Indian women.Cancer Detection and Prevention, 30, 58–66.

Yavari, P., & Pourhoseingholi, M. (2007). Socioeconomic factors association withknowledge and practice of breast self-examination among Iranian women.Asian Pacific Journal of Cancer Prevention, 8, 618–622.

Yip, C., Smith, R., Anderson, B., Miller, A., Thomas, D., Ang, E., Caffarella, R.,Corbex, M., Kreps, G., & McTiernan, A., Breast Health Global Initiative (BHGI)Early Detection Panel. (2008). Guideline implementation for breast healthcare inlow- and middle-income countries: Early detection resource allocation. Cancer,113, 2244–2256.

Dow

nloa

ded

by [

83.3

7.2.

197]

at 2

2:31

22

Oct

ober

201

4