Breast cancer screening behavior, attitude, barriers among middle-aged Chinese women in Macao, China

Breast cancer screening behavior, attitude, barriers among middle-aged Chinese women in Macao, China Abstract Background Breast cancer is the third leading cause of death from cancer among females in Macao, but little is known about local practice of breast cancer screening. The study aims to evaluate breast cancer screening behaviors and to identify the predictors of insufficient knowledge and attitudes towards breast cancer and its screening among female residents. Methods This was a cross-sectional study conducted from April to June 2016 in Macao. Quota sampling of women completed the modified Chinese Breast Cancer Screening Beliefs questionnaire (CBCSB) to assess their breast cancer-related perceptions, screening attitudes and behaviors. Univariate and multivariate logistic regressions were performed to identify the predictors of poor-screening practices, attitudes, knowledge and perceived barriers to mammography. Result A total of 417 women (mean age±SD: 50.5±5.7) completed surveys, with 160 (38.4%), 196 (47.0%) and 103 (24.7%) women received breast self-examination, clinical breast examination and mammography as recommended, respectively. Nulliparity (OR=2.56, 95% CI = 1.14−5.73) and low education (OR = 1.72, 95% CI = 1.04−2.84) were significantly associated with negative attitude towards health check-ups. Women did not know anyone with breast cancer (OR = 2.30, 95% CI = 1.50−3.55) were more likely to have insufficient knowledge about breast cancer. Low education (OR = 1.95, 95% CI = 1.25−3.04) and not knowing anyone with breast cancer (OR = 2.02, 95% CI = 1.31−3.13) were identified as predictors for perceived barriers to mammography. Conclusion Recommendations for breast cancer screening are poorly followed by the residents in Macao, and a culturally tailored educational program is urgently needed to raise the public’s awareness of the disease and the screening practices. attitude, breast cancer, health check-ups, screening behaviors Introduction As the most prevalent cancer among women, breast cancer poses a significant health threat worldwide. Although higher incidence rates are generally observed in the industrialized countries, the numbers of new cases are on the rise in the developing world.1 In China, breast cancer leads all types of cancer in women, with an age-standardized incidence rate (ASR) of 22.1 per 100 000 population.1 In fact, the ASRs of breast cancer vary greatly nationwide and are much higher in the coastal regions that are heavily urbanized and more socioeconomically developed. The incidence rates in some cities even reach the levels of high-income countries such as Japan, partly due to the adoption of Western lifestyles.2 As expected, a similar trend is noted in Macao. Macau is a Special Administrative Region in southern China, which was once administrated by the Portuguese Empire and adopted a highly westernized lifestyle. More than 80% of its local population is Chinese and female makes up 51% of the population. Driven by the rapid expansion of its gambling industry, Macao has become one of the most developed regions in China. A local report reveals a constant increase in new cases of breast cancer, with a crude incidence rate of 55.7 per 100 000 women in 2014.3 The mortality rate of breast cancer has been stable over the past decade. However, it remains the third leading cause of death from cancer among women in Macao.3 In order to reduce the burden of this highly treatable disease, routine screening and early treatment are imperative because the 5-year relative survival rate can significant reduce from 98.9 to 26.9% if a patient is diagnosed at late stage.4 Breast self-examination (BSE), clinical breast examination (CBE), and mammography are the major strategies to detect for breast cancer, with mammography being the only screening tool proven to decrease breast cancer-related deaths.5 Compared to their Caucasian counterparts, Chinese women have lower screening rates for breast cancer.6 In mainland China, there has been no nationwide breast cancer screening program and the overall screening rate was only 21.7% in 2010.2,7 The situation is not much better in more developed and Westernized regions such as Hong Kong; a survey conducted in 2014 showed that only 43.9% of women in Hong Kong had received a mammogram and most of these women did not comply to recommended guidelines.8 In Taiwan, the participation rate was only 43% over a 5-year period9, even with the avail of universal healthcare and free access to mammographic screening. Some common barriers to breast cancer screening encountered by Chinese women include cultural perceptions or fear of cancer9–13, discomfort9, embarrassment10,11,14 and cost.12,13,15 The research exploring Chinese women’s screening attitudes and beliefs has largely been conducted in the Western countries and the relevant data about those living in Asia remains relatively limited. In addition, little is known about the practices of breast cancer screening in the female population in Macao. This study was designed to evaluate breast cancer screening behaviors, and to identify the predictors of negative attitudes and limited knowledge towards the disease and its screening among middle-aged Chinese women in Macao. It provides more information for developing breast cancer-related education programs and screening policies for Chinese women in Macao and other countries where Chinese account for a significant proportion of the population. Methods Study design and participants This was a cross-sectional survey conducted in Macao from April to June 2016. All Chinese women who were 40–60 years of age and had never received a diagnosis of any malignancies were eligible to participate in this study. Non-residents such as tourists and foreign domestic workers were excluded from analysis. All participants received a US$ 6 voucher for their participation in this study. Sampling and data collection A quota sampling approach was taken for this study. Macao is officially composed of seven administrative divisions, five of which are located in the main peninsula and two of which are islands.16 For this study, two adjacent, demographically similar divisions in the peninsula were grouped together as one sampling district. For the same reason, the two island divisions were also combined into a single sampling district. As a result, a total of five sampling districts within Macao were planned in this study. Women who appeared to be ethnically Chinese were approached and invited to participate in the survey near supermarkets, schools, churches and coffee shops in each district. All information was collected face to face using a structured questionnaire, which consisted of three main sections that assessed: (i) breast cancer-related perceptions, screening attitudes and behaviors; (ii) demographic and health-related characteristics; and (iii) symptoms related to fatigue, depression and anxiety. To minimize bias, all interviewers received extensive training to administer the structured questionnaire. Instruments Participants’ practices and attitudes towards breast cancer screening were evaluated using the modified Chinese Breast Cancer Screening Beliefs questionnaire (CBCSB).17 The original CBCSB included 13 items and it was well tested among Chinese Australian women.18 The Chinese version of the modified questionnaire was developed after omitting two items that were not applicable in Hong Kong, and was shown to be valid, reliable and culturally sensitive.17 As Macao is culturally similar to Hong Kong, with a colonial past and a mix of Eastern and Western influences, the modified version of CBCSB was considered more appropriate and thus selected for this study. The modified CBCSB comprised three subscales: attitudes towards health check-ups (four items), knowledge and perceptions about breast cancer (four items), and barriers to mammographic screening (three items). Each item was scored on a five-point Likert scale, ranging from 1 (strongly agree) to 5 (strongly disagree) with ‘don’t know’ as the mid-point. The raw score of each subscale was converted into a standardized score between 0 and 100.17 A standardized score lower than 65 suggested negative attitudes towards health check-ups, insufficient knowledge about breast cancer, and more perceived barriers to mammographic screening.8 Furthermore, the modified CBCSB included some questions evaluating how often participants performed a BSE, and had a CBE or a mammogram. Participants were deemed to be compliant with the three screening practices as recommended if they performed a BSE monthly and had a CBE or a mammogram at a minimum of every 2 years.19 The presence and severity of symptoms associated with anxiety and depression were measured with the Chinese versions of the Beck Anxiety Inventory20,21 and the Beck Depression Inventory, respectively.22,23 Fatigue levels were assessed using the Chinese version of the Brief Fatigue Inventory.24,25 With respect to demographic and health-related characteristics, all participants were asked about their age, marital status, education level, employment status, medical history, family history of breast cancer, age at menarche, current menopausal status, past obstetric history, breastfeeding experience and history of contraceptive use. Self-reported height and weight were used for calculating body mass index (BMI), with 23 and 25 kg/m2 as the cut-off points for overweight and obesity for Asian adults, respectively.26 Statistical analysis and sample size calculation Descriptive statistics were used for reporting the demographic characteristics, fatigue and mental health status, perceptions about breast cancer, as well as behaviors and attitudes towards cancer screening. The Pearson chi-square test was conducted to correlate different characteristics with poor screening practices, attitudes, knowledge and high perceived barriers to mammography. In order to identify the independent predictors of these outcomes, multivariate logistic regression analysis (with backward elimination) was performed on the characteristics with P < 0.05 in the univariate analysis. All statistical analysis was conducted using SPSS for Windows, version 20.0, with a P-value of 0.05 as the cut-off point for statistical significance. The minimum sample size was calculated to be 383 to achieve a confidence interval width of 0.1, with a confidence level of 95% and an expected response rate of 50%. This is based on the total population of women aged 40–60 years in Macao, which was estimated to be 102 946.16 A quota sampling approach was adopted to achieve an even distribution of four age subgroups (40–45, 46–50, 51–55 and 56–60 years) based on the census data.16 A predetermined sample size of each district was also calculated based on the respective population of middle-aged women16 in each individual district. Results Demographic and health-related characteristics Among 689 women who were invited, 417 completed the survey, with a response rate of 60.5% (Fig. 1 ). The participants’ mean age (±SD) was 50.5 ± 5.7 years and most of them were married (84.2%), currently employed (71.0%), and had children (89.2%). Approximately half of them were postmenopausal (47.2%) and had breastfeeding experience (53.2%). A total of 120 participants (28.8%) had low education level, meaning that they did not have formal education or had only primary education. In total, 16 participants (3.8%) reported to have a family history of breast cancer while 138 participants (33.1%) were aware that one of their friends had the disease (Table 1). Table 1 Demographic and health-related characteristics of participants (N = 417) n % Age  Mean (SD) 50.5 (5.7) Body mass index  Mean (SD) 22.7 (3.3)   Underweight (<18.5) 34 8.2   Normal (18.5–23) 221 53.0   Overweight (23–24.9) 80 19.2   Obese (≥25) 80 19.2   Refused to answer 2 0.5 Marital status   Single 31 7.4   Married 351 84.2   Cohabiting 3 0.7   Divorced or separated 25 6.0   Widowed 7 1.7 Highest education level   No formal education 2 0.5   Primary school 118 28.3   Secondary school 217 52.0   Higher diploma or associate’s degree 31 7.4   Bachelor’s or master’s degree 49 11.8 Employment status   Currently employed (full-time) 283 67.9   Currently employed (part-time) 13 3.1   Unemployed (actively seeking work) 15 3.6   Unemployed (not seeking work) 64 15.3   Full-time students 1 0.2   Retired 39 9.4   Refused to answer 2 0.5 Currently postmenopausal 197 47.2 Early menarche (<12 years old) 15 3.6 Nulliparity 45 10.8 Late age at first childbirth (≥30 years old) 61 14.6 Previous use of oral contraceptives 108 25.9 Never breastfeeding 193 46.3 Regular use of alcohol (≥3 drinks/week) 16 3.8 Having immediate family members with breast cancer 16 3.8 Having friends with breast cancer 138 33.1 n % Age  Mean (SD) 50.5 (5.7) Body mass index  Mean (SD) 22.7 (3.3)   Underweight (<18.5) 34 8.2   Normal (18.5–23) 221 53.0   Overweight (23–24.9) 80 19.2   Obese (≥25) 80 19.2   Refused to answer 2 0.5 Marital status   Single 31 7.4   Married 351 84.2   Cohabiting 3 0.7   Divorced or separated 25 6.0   Widowed 7 1.7 Highest education level   No formal education 2 0.5   Primary school 118 28.3   Secondary school 217 52.0   Higher diploma or associate’s degree 31 7.4   Bachelor’s or master’s degree 49 11.8 Employment status   Currently employed (full-time) 283 67.9   Currently employed (part-time) 13 3.1   Unemployed (actively seeking work) 15 3.6   Unemployed (not seeking work) 64 15.3   Full-time students 1 0.2   Retired 39 9.4   Refused to answer 2 0.5 Currently postmenopausal 197 47.2 Early menarche (<12 years old) 15 3.6 Nulliparity 45 10.8 Late age at first childbirth (≥30 years old) 61 14.6 Previous use of oral contraceptives 108 25.9 Never breastfeeding 193 46.3 Regular use of alcohol (≥3 drinks/week) 16 3.8 Having immediate family members with breast cancer 16 3.8 Having friends with breast cancer 138 33.1 Table 1 Demographic and health-related characteristics of participants (N = 417) n % Age  Mean (SD) 50.5 (5.7) Body mass index  Mean (SD) 22.7 (3.3)   Underweight (<18.5) 34 8.2   Normal (18.5–23) 221 53.0   Overweight (23–24.9) 80 19.2   Obese (≥25) 80 19.2   Refused to answer 2 0.5 Marital status   Single 31 7.4   Married 351 84.2   Cohabiting 3 0.7   Divorced or separated 25 6.0   Widowed 7 1.7 Highest education level   No formal education 2 0.5   Primary school 118 28.3   Secondary school 217 52.0   Higher diploma or associate’s degree 31 7.4   Bachelor’s or master’s degree 49 11.8 Employment status   Currently employed (full-time) 283 67.9   Currently employed (part-time) 13 3.1   Unemployed (actively seeking work) 15 3.6   Unemployed (not seeking work) 64 15.3   Full-time students 1 0.2   Retired 39 9.4   Refused to answer 2 0.5 Currently postmenopausal 197 47.2 Early menarche (<12 years old) 15 3.6 Nulliparity 45 10.8 Late age at first childbirth (≥30 years old) 61 14.6 Previous use of oral contraceptives 108 25.9 Never breastfeeding 193 46.3 Regular use of alcohol (≥3 drinks/week) 16 3.8 Having immediate family members with breast cancer 16 3.8 Having friends with breast cancer 138 33.1 n % Age  Mean (SD) 50.5 (5.7) Body mass index  Mean (SD) 22.7 (3.3)   Underweight (<18.5) 34 8.2   Normal (18.5–23) 221 53.0   Overweight (23–24.9) 80 19.2   Obese (≥25) 80 19.2   Refused to answer 2 0.5 Marital status   Single 31 7.4   Married 351 84.2   Cohabiting 3 0.7   Divorced or separated 25 6.0   Widowed 7 1.7 Highest education level   No formal education 2 0.5   Primary school 118 28.3   Secondary school 217 52.0   Higher diploma or associate’s degree 31 7.4   Bachelor’s or master’s degree 49 11.8 Employment status   Currently employed (full-time) 283 67.9   Currently employed (part-time) 13 3.1   Unemployed (actively seeking work) 15 3.6   Unemployed (not seeking work) 64 15.3   Full-time students 1 0.2   Retired 39 9.4   Refused to answer 2 0.5 Currently postmenopausal 197 47.2 Early menarche (<12 years old) 15 3.6 Nulliparity 45 10.8 Late age at first childbirth (≥30 years old) 61 14.6 Previous use of oral contraceptives 108 25.9 Never breastfeeding 193 46.3 Regular use of alcohol (≥3 drinks/week) 16 3.8 Having immediate family members with breast cancer 16 3.8 Having friends with breast cancer 138 33.1 Fig. 1 View largeDownload slide Flow diagram of the study population. Fig. 1 View largeDownload slide Flow diagram of the study population. Table 2 summarized the participants’ fatigue and mental health status. The majority of participants had no or mild symptoms associated with anxiety (94.2%) and depression (92.1%). Around half of the participants (55.4%) suffered from mild fatigue. Table 2 Fatigue and mental health status of participants (N = 417) n % Symptoms of anxiety (per BAI scores)  No or mild (0–21) 393 94.2  Moderate (22–35) 22 5.3  Severe (≥36) 2 0.5 Symptoms of depression (per BDI scores)  Normal (0–10) 278 66.7  Mild or borderline (11–20) 106 25.4  Moderate (21–30) 25 6.0  Severe (≥31) 6 1.4  Could not be determined 2 0.5 Fatigue levels (per BFI scores)  Mild (0–3) 231 55.4  Moderate (4–6) 165 39.6  Severe (7–10) 21 5.0 n % Symptoms of anxiety (per BAI scores)  No or mild (0–21) 393 94.2  Moderate (22–35) 22 5.3  Severe (≥36) 2 0.5 Symptoms of depression (per BDI scores)  Normal (0–10) 278 66.7  Mild or borderline (11–20) 106 25.4  Moderate (21–30) 25 6.0  Severe (≥31) 6 1.4  Could not be determined 2 0.5 Fatigue levels (per BFI scores)  Mild (0–3) 231 55.4  Moderate (4–6) 165 39.6  Severe (7–10) 21 5.0 BAI = Beck Anxiety Inventory; BDI=Beck Depression Inventory; BFI=Brief Fatigue Inventory. Table 2 Fatigue and mental health status of participants (N = 417) n % Symptoms of anxiety (per BAI scores)  No or mild (0–21) 393 94.2  Moderate (22–35) 22 5.3  Severe (≥36) 2 0.5 Symptoms of depression (per BDI scores)  Normal (0–10) 278 66.7  Mild or borderline (11–20) 106 25.4  Moderate (21–30) 25 6.0  Severe (≥31) 6 1.4  Could not be determined 2 0.5 Fatigue levels (per BFI scores)  Mild (0–3) 231 55.4  Moderate (4–6) 165 39.6  Severe (7–10) 21 5.0 n % Symptoms of anxiety (per BAI scores)  No or mild (0–21) 393 94.2  Moderate (22–35) 22 5.3  Severe (≥36) 2 0.5 Symptoms of depression (per BDI scores)  Normal (0–10) 278 66.7  Mild or borderline (11–20) 106 25.4  Moderate (21–30) 25 6.0  Severe (≥31) 6 1.4  Could not be determined 2 0.5 Fatigue levels (per BFI scores)  Mild (0–3) 231 55.4  Moderate (4–6) 165 39.6  Severe (7–10) 21 5.0 BAI = Beck Anxiety Inventory; BDI=Beck Depression Inventory; BFI=Brief Fatigue Inventory. Screening practices and predictors of never having a BSE, CBE and mammogram Out of the 417 participants, 160 (38.4%) performed a BSE as often as recommended (once a month) while 128 (30.7%) had never done it before (Table 3). The most common reasons for not doing a BSE included ‘never heard of it’ (60.9%), ‘did not know how to perform it’ (14.1%) and ‘did not feel necessary to do it’ (10.2%). In the univariate analysis, low education level, unemployed/retired status, and having no friends/family members with breast cancer were associated with never performing a BSE (Table 4). After adjustment in the multivariate analysis, low education level (OR = 1.63; 95% CI = 1.00–2.64) and not knowing anyone with breast cancer (OR = 1.90; 95% CI = 1.14–3.15) remained the significant predictors of poor practices of BSE. Participants who never breastfed (OR = 1.65; 95% CI = 1.03–2.65) became significantly associated with poor practice of BSE. Negative attitude towards health check-ups (OR = 1.95, 95% CI = 1.13–3.35), limited knowledge about breast cancer (OR = 1.90; 95% CI = 1.19–3.02), and high barriers to mammographic screening (OR = 1.89; 95% CI = 1.18–3.00) also shown negative influence on BSE practice (Table 7). Table 3 Participants’ screening practices for breast cancer (N = 417) n % Breast self-examination (BSE)  Ever heard of BSE 339 81.3  Frequency of performing a BSE   Never 128 30.7   At least once a montha 160 38.4   Once every few months 77 18.5   Once a year 48 11.5   Once every 3–4 years 3 0.7   Refused to answer 1 0.2 Clinical breast examination (CBE)  Ever heard of CBE 302 72.4  Last CBE   Never 152 36.5   ≤1 year agoa 138 33.1   1–2 years agoa 58 13.9   2–3 years ago 35 8.4   >3 years ago 33 7.9   Refused to answer 1 0.2 Mammogram  Ever heard of mammogram 245 58.8  Frequency of having a mammogram   Never 257 61.6   Once a yeara 45 10.8   Once every 2 yearsa 58 13.9   Once every 3 years or more 56 13.5   Refused to answer 1 0.2 n % Breast self-examination (BSE)  Ever heard of BSE 339 81.3  Frequency of performing a BSE   Never 128 30.7   At least once a montha 160 38.4   Once every few months 77 18.5   Once a year 48 11.5   Once every 3–4 years 3 0.7   Refused to answer 1 0.2 Clinical breast examination (CBE)  Ever heard of CBE 302 72.4  Last CBE   Never 152 36.5   ≤1 year agoa 138 33.1   1–2 years agoa 58 13.9   2–3 years ago 35 8.4   >3 years ago 33 7.9   Refused to answer 1 0.2 Mammogram  Ever heard of mammogram 245 58.8  Frequency of having a mammogram   Never 257 61.6   Once a yeara 45 10.8   Once every 2 yearsa 58 13.9   Once every 3 years or more 56 13.5   Refused to answer 1 0.2 aConsidered as often as recommended by the Hong Kong Breast Cancer Foundation. Table 3 Participants’ screening practices for breast cancer (N = 417) n % Breast self-examination (BSE)  Ever heard of BSE 339 81.3  Frequency of performing a BSE   Never 128 30.7   At least once a montha 160 38.4   Once every few months 77 18.5   Once a year 48 11.5   Once every 3–4 years 3 0.7   Refused to answer 1 0.2 Clinical breast examination (CBE)  Ever heard of CBE 302 72.4  Last CBE   Never 152 36.5   ≤1 year agoa 138 33.1   1–2 years agoa 58 13.9   2–3 years ago 35 8.4   >3 years ago 33 7.9   Refused to answer 1 0.2 Mammogram  Ever heard of mammogram 245 58.8  Frequency of having a mammogram   Never 257 61.6   Once a yeara 45 10.8   Once every 2 yearsa 58 13.9   Once every 3 years or more 56 13.5   Refused to answer 1 0.2 n % Breast self-examination (BSE)  Ever heard of BSE 339 81.3  Frequency of performing a BSE   Never 128 30.7   At least once a montha 160 38.4   Once every few months 77 18.5   Once a year 48 11.5   Once every 3–4 years 3 0.7   Refused to answer 1 0.2 Clinical breast examination (CBE)  Ever heard of CBE 302 72.4  Last CBE   Never 152 36.5   ≤1 year agoa 138 33.1   1–2 years agoa 58 13.9   2–3 years ago 35 8.4   >3 years ago 33 7.9   Refused to answer 1 0.2 Mammogram  Ever heard of mammogram 245 58.8  Frequency of having a mammogram   Never 257 61.6   Once a yeara 45 10.8   Once every 2 yearsa 58 13.9   Once every 3 years or more 56 13.5   Refused to answer 1 0.2 aConsidered as often as recommended by the Hong Kong Breast Cancer Foundation. Table 4 Univariate analysis of predictors of never having a BSE, CBE and mammogram Never performed BSE (n = 128) P Never had CBE (n = 152) P Never had mammogram (n = 257) P Age  ≤50 years old (n = 210) 59 (28.1%) 0.206 79 (37.6%) 0.692 124 (59.0%) 0.232  >50 years old (n = 207) 70 (33.8%) 74 (35.7%) 134 (64.7%) BMI  Underweight or normal (n = 255) 84 (32.9%) 0.206 102 (40.0%) 0.059 161 (63.1%) 0.490  Overweight or obese (n = 159) 43 (27.0%) 49 (30.8%) 95 (59.7%) Education level  Primary school or lower (n = 120) 48 (40.0%) 0.011* 51 (42.5%) 0.118 89 (74.2%) 0.001*  Secondary school or higher (n = 297) 81 (27.3%) 102 (34.3%) 169 (56.9%) Marital status  Single, divorced, or widowed (n = 63) 26 (41.3%) 0.054 34 (54.0%) 0.002* 44 (69.8%) 0.157  Married or cohabiting (n = 354) 103 (29.1%) 119 (33.6%) 214 (60.5%) Employment Status  Unemployed or retired (n = 118) 47 (39.8%) 0.015* 56 (47.5%) 0.005* 87 (73.7%) 0.002*  Employed or studying (n = 297) 82 (27.6%) 97 (32.7%) 171 (57.6%) Having children  Yes (n = 370) 110 (29.7%) 0.269 126 (34.1%) 0.005* 224 (60.5%) 0.168  No (n = 45) 17 (37.8%) 25 (55.6%) 32 (71.1%) Friends/family with breast cancer  Yes (n = 145) 30 (20.7%) 0.001* 38 (26.2%) 0.001* 76 (52.4%) 0.004*  No or don’t know (n = 271) 98 (36.2%) 114 (42.1%) 181 (66.8%) Breastfeeding  No (n = 193) 53 (27.5%) 0.164 73 (37.8%) 0.707 121 (62.7%) 0.764  Yes (n = 222) 75 (33.8%) 80 (36.0%) 136 (61.3%) Menopausal status  Pre-menopausal (n = 220) 67 (30.5%) 0.822 84 (38.2%) 0.504 141 (64.1%) 0.324  Post-menopausal (n = 197) 62 (31.5%) 69 (35.0%) 117 (59.4%) Contraceptive usage  No (n = 307) 97 (31.6%) 0.626 117 (38.7%) 0.315 183 (59.6%) 0.112  Yes (n = 110) 32 (29.1%) 36 (32.7%) 75 (68.2%) Attitude towards health check-ups  Negative (n = 284) 104 (36.6%) <0.001* 126 (44.4%) <0.001* 196 (69.0%) <0.001*  Positive (n = 133) 25 (18.8%) 27 (20.3%) 62 (46.6%) Knowledge about breast cancer  Poor (n = 174) 76 (43.7%) <0.001* 94 (54.0%) <0.001* 127 (73.0%) <0.001*  Good (n = 233) 53 (21.8%) 59 (24.3%) 131 (53.9%) Barriers to mammographic screening  High (n = 176) 77 (43.8%) <0.001* 76 (43.2%) 0.019* 125 (71.0%) 0.001*  Low or no (n = 231) 52 (21.6%) 77 (32.0%) 133 (55.2%) Never performed BSE (n = 128) P Never had CBE (n = 152) P Never had mammogram (n = 257) P Age  ≤50 years old (n = 210) 59 (28.1%) 0.206 79 (37.6%) 0.692 124 (59.0%) 0.232  >50 years old (n = 207) 70 (33.8%) 74 (35.7%) 134 (64.7%) BMI  Underweight or normal (n = 255) 84 (32.9%) 0.206 102 (40.0%) 0.059 161 (63.1%) 0.490  Overweight or obese (n = 159) 43 (27.0%) 49 (30.8%) 95 (59.7%) Education level  Primary school or lower (n = 120) 48 (40.0%) 0.011* 51 (42.5%) 0.118 89 (74.2%) 0.001*  Secondary school or higher (n = 297) 81 (27.3%) 102 (34.3%) 169 (56.9%) Marital status  Single, divorced, or widowed (n = 63) 26 (41.3%) 0.054 34 (54.0%) 0.002* 44 (69.8%) 0.157  Married or cohabiting (n = 354) 103 (29.1%) 119 (33.6%) 214 (60.5%) Employment Status  Unemployed or retired (n = 118) 47 (39.8%) 0.015* 56 (47.5%) 0.005* 87 (73.7%) 0.002*  Employed or studying (n = 297) 82 (27.6%) 97 (32.7%) 171 (57.6%) Having children  Yes (n = 370) 110 (29.7%) 0.269 126 (34.1%) 0.005* 224 (60.5%) 0.168  No (n = 45) 17 (37.8%) 25 (55.6%) 32 (71.1%) Friends/family with breast cancer  Yes (n = 145) 30 (20.7%) 0.001* 38 (26.2%) 0.001* 76 (52.4%) 0.004*  No or don’t know (n = 271) 98 (36.2%) 114 (42.1%) 181 (66.8%) Breastfeeding  No (n = 193) 53 (27.5%) 0.164 73 (37.8%) 0.707 121 (62.7%) 0.764  Yes (n = 222) 75 (33.8%) 80 (36.0%) 136 (61.3%) Menopausal status  Pre-menopausal (n = 220) 67 (30.5%) 0.822 84 (38.2%) 0.504 141 (64.1%) 0.324  Post-menopausal (n = 197) 62 (31.5%) 69 (35.0%) 117 (59.4%) Contraceptive usage  No (n = 307) 97 (31.6%) 0.626 117 (38.7%) 0.315 183 (59.6%) 0.112  Yes (n = 110) 32 (29.1%) 36 (32.7%) 75 (68.2%) Attitude towards health check-ups  Negative (n = 284) 104 (36.6%) <0.001* 126 (44.4%) <0.001* 196 (69.0%) <0.001*  Positive (n = 133) 25 (18.8%) 27 (20.3%) 62 (46.6%) Knowledge about breast cancer  Poor (n = 174) 76 (43.7%) <0.001* 94 (54.0%) <0.001* 127 (73.0%) <0.001*  Good (n = 233) 53 (21.8%) 59 (24.3%) 131 (53.9%) Barriers to mammographic screening  High (n = 176) 77 (43.8%) <0.001* 76 (43.2%) 0.019* 125 (71.0%) 0.001*  Low or no (n = 231) 52 (21.6%) 77 (32.0%) 133 (55.2%) BMI = body mass index; BSE = breast self-examination; CBE = clinical breast examination. *Statistically significant under Pearson Chi-square test, P < 0.05. Table 4 Univariate analysis of predictors of never having a BSE, CBE and mammogram Never performed BSE (n = 128) P Never had CBE (n = 152) P Never had mammogram (n = 257) P Age  ≤50 years old (n = 210) 59 (28.1%) 0.206 79 (37.6%) 0.692 124 (59.0%) 0.232  >50 years old (n = 207) 70 (33.8%) 74 (35.7%) 134 (64.7%) BMI  Underweight or normal (n = 255) 84 (32.9%) 0.206 102 (40.0%) 0.059 161 (63.1%) 0.490  Overweight or obese (n = 159) 43 (27.0%) 49 (30.8%) 95 (59.7%) Education level  Primary school or lower (n = 120) 48 (40.0%) 0.011* 51 (42.5%) 0.118 89 (74.2%) 0.001*  Secondary school or higher (n = 297) 81 (27.3%) 102 (34.3%) 169 (56.9%) Marital status  Single, divorced, or widowed (n = 63) 26 (41.3%) 0.054 34 (54.0%) 0.002* 44 (69.8%) 0.157  Married or cohabiting (n = 354) 103 (29.1%) 119 (33.6%) 214 (60.5%) Employment Status  Unemployed or retired (n = 118) 47 (39.8%) 0.015* 56 (47.5%) 0.005* 87 (73.7%) 0.002*  Employed or studying (n = 297) 82 (27.6%) 97 (32.7%) 171 (57.6%) Having children  Yes (n = 370) 110 (29.7%) 0.269 126 (34.1%) 0.005* 224 (60.5%) 0.168  No (n = 45) 17 (37.8%) 25 (55.6%) 32 (71.1%) Friends/family with breast cancer  Yes (n = 145) 30 (20.7%) 0.001* 38 (26.2%) 0.001* 76 (52.4%) 0.004*  No or don’t know (n = 271) 98 (36.2%) 114 (42.1%) 181 (66.8%) Breastfeeding  No (n = 193) 53 (27.5%) 0.164 73 (37.8%) 0.707 121 (62.7%) 0.764  Yes (n = 222) 75 (33.8%) 80 (36.0%) 136 (61.3%) Menopausal status  Pre-menopausal (n = 220) 67 (30.5%) 0.822 84 (38.2%) 0.504 141 (64.1%) 0.324  Post-menopausal (n = 197) 62 (31.5%) 69 (35.0%) 117 (59.4%) Contraceptive usage  No (n = 307) 97 (31.6%) 0.626 117 (38.7%) 0.315 183 (59.6%) 0.112  Yes (n = 110) 32 (29.1%) 36 (32.7%) 75 (68.2%) Attitude towards health check-ups  Negative (n = 284) 104 (36.6%) <0.001* 126 (44.4%) <0.001* 196 (69.0%) <0.001*  Positive (n = 133) 25 (18.8%) 27 (20.3%) 62 (46.6%) Knowledge about breast cancer  Poor (n = 174) 76 (43.7%) <0.001* 94 (54.0%) <0.001* 127 (73.0%) <0.001*  Good (n = 233) 53 (21.8%) 59 (24.3%) 131 (53.9%) Barriers to mammographic screening  High (n = 176) 77 (43.8%) <0.001* 76 (43.2%) 0.019* 125 (71.0%) 0.001*  Low or no (n = 231) 52 (21.6%) 77 (32.0%) 133 (55.2%) Never performed BSE (n = 128) P Never had CBE (n = 152) P Never had mammogram (n = 257) P Age  ≤50 years old (n = 210) 59 (28.1%) 0.206 79 (37.6%) 0.692 124 (59.0%) 0.232  >50 years old (n = 207) 70 (33.8%) 74 (35.7%) 134 (64.7%) BMI  Underweight or normal (n = 255) 84 (32.9%) 0.206 102 (40.0%) 0.059 161 (63.1%) 0.490  Overweight or obese (n = 159) 43 (27.0%) 49 (30.8%) 95 (59.7%) Education level  Primary school or lower (n = 120) 48 (40.0%) 0.011* 51 (42.5%) 0.118 89 (74.2%) 0.001*  Secondary school or higher (n = 297) 81 (27.3%) 102 (34.3%) 169 (56.9%) Marital status  Single, divorced, or widowed (n = 63) 26 (41.3%) 0.054 34 (54.0%) 0.002* 44 (69.8%) 0.157  Married or cohabiting (n = 354) 103 (29.1%) 119 (33.6%) 214 (60.5%) Employment Status  Unemployed or retired (n = 118) 47 (39.8%) 0.015* 56 (47.5%) 0.005* 87 (73.7%) 0.002*  Employed or studying (n = 297) 82 (27.6%) 97 (32.7%) 171 (57.6%) Having children  Yes (n = 370) 110 (29.7%) 0.269 126 (34.1%) 0.005* 224 (60.5%) 0.168  No (n = 45) 17 (37.8%) 25 (55.6%) 32 (71.1%) Friends/family with breast cancer  Yes (n = 145) 30 (20.7%) 0.001* 38 (26.2%) 0.001* 76 (52.4%) 0.004*  No or don’t know (n = 271) 98 (36.2%) 114 (42.1%) 181 (66.8%) Breastfeeding  No (n = 193) 53 (27.5%) 0.164 73 (37.8%) 0.707 121 (62.7%) 0.764  Yes (n = 222) 75 (33.8%) 80 (36.0%) 136 (61.3%) Menopausal status  Pre-menopausal (n = 220) 67 (30.5%) 0.822 84 (38.2%) 0.504 141 (64.1%) 0.324  Post-menopausal (n = 197) 62 (31.5%) 69 (35.0%) 117 (59.4%) Contraceptive usage  No (n = 307) 97 (31.6%) 0.626 117 (38.7%) 0.315 183 (59.6%) 0.112  Yes (n = 110) 32 (29.1%) 36 (32.7%) 75 (68.2%) Attitude towards health check-ups  Negative (n = 284) 104 (36.6%) <0.001* 126 (44.4%) <0.001* 196 (69.0%) <0.001*  Positive (n = 133) 25 (18.8%) 27 (20.3%) 62 (46.6%) Knowledge about breast cancer  Poor (n = 174) 76 (43.7%) <0.001* 94 (54.0%) <0.001* 127 (73.0%) <0.001*  Good (n = 233) 53 (21.8%) 59 (24.3%) 131 (53.9%) Barriers to mammographic screening  High (n = 176) 77 (43.8%) <0.001* 76 (43.2%) 0.019* 125 (71.0%) 0.001*  Low or no (n = 231) 52 (21.6%) 77 (32.0%) 133 (55.2%) BMI = body mass index; BSE = breast self-examination; CBE = clinical breast examination. *Statistically significant under Pearson Chi-square test, P < 0.05. Only 196 participants (47.0%) had a CBE at a recommended interval (at least every 2 years) (Table 3). In contrast, 152 participants (36.5%) had never received a CBE because they had never heard of it (75.7%), did not feel necessary to receive it (9.2%) or found no problems from BSE (3.9%). The univariate analysis revealed that women who were single/divorced/widowed, unemployed/retired, had no children, and did not know anyone with breast cancer were less likely to receive a CBE (Table 4). Among these variables, marital status (OR = 2.39; 95% CI = 1.33–4.31), employment status (OR = 1.82; 95% CI = 1.14–2.92), not knowing anybody with breast cancer (OR = 1.73; 95% CI = 1.07–2.80) and having negative attitude towards health check-ups (OR = 2.38; 95% CI = 1.43–3.98) and limited knowledge about breast cancer (OR = 2.87; 95% CI = 1.84–4.49) were independently associated with never having a CBE (Table 7). Approximately one-fourth of the participants (24.7%) were compliant with regular mammographic screening as recommended (at least every 2 years) but the majority (61.9%) had never obtained a mammogram (Table 3) for the reasons such as ‘never heard of it’ (66.9%), ‘did not feel necessary’ (17.1%), and ‘physicians did not recommend it’ (3.9%). Based on the univariate and multivariate analysis, having no friends/family members with breast cancer (OR = 1.84; 95% CI = 1.20–2.83), unemployed/retired status (OR = 1.66; 95% CI = 1.01–2.72) and low education level (OR = 1.99; 95% CI = 1.21–3.28) were the significant predictors of never obtaining a mammogram (Tables 4 and 7). In addition, those who were poorly educated (OR = 1.95; 95% CI = 1.13–3.35), having negative attitude towards health check-ups (OR = 2.05; 95% CI = 1.31–3.21) and insufficient knowledge about breast cancer (OR = 1.86; 95% CI = 1.19–2.91) were less likely to have a mammogram as often as recommended. Attitudes towards health check-ups, perceptions and knowledge about breast cancer, and perceived barriers to mammographic screening Among all participants, the mean score (±SD) of participants on attitudes towards health check-ups was 51.2 (±1.2), on perceptions and knowledge about breast cancer was 65.9 (±0.9), and on barriers to mammographic screening was 61.7 (±1.0). Overall, 284 participants (68.1%) had negative overall attitudes towards health check-ups and most of them believed that they should consult a physician or have a check-up only when they had a health problem. In total, 174 participants (41.7%) were found to have insufficient knowledge about breast cancer based on their responses to the four corresponding statements of the modified CBCSB. With respect to mammographic screening, 42.2% of participants had more perceived barriers. Most participants were not concerned about potential harm or exposing their breasts during the procedure but 31.7% of participants admitted that having a mammogram was embarrassing (Table 5). Univariate analysis revealed that women with negative attitudes towards health check-ups or insufficient knowledge about breast cancer were less likely to use any of the three screening methods (P < 0.001). As expected, there was also a strong association between more perceived barriers and a lack of mammographic screening (P = 0.001). Table 5 Participants’ attitudes towards health check-ups, perceptions and knowledge about breast cancer and perceived barriers to mammographic screening (n = 417) Agree Do not know Disagree Attitudes towards health check-ups If I feel well, it is not necessary to have a health check-up. 159 (38.1%) 17 (4.1%) 241 (57.8%) If I follow a healthy lifestyle such as a balanced diet and regular exercise, I don’t feel it is necessary to have a regular health check-up. 121 (29.0%) 22 (5.3%) 274 (65.7%) I see a doctor or have my health check-up only when I have a health problem. 223 (53.5%) 11 (5.3%) 183 (43.9%) If I feel healthy, I do not need to see the doctor. 257 (61.6%) 17 (4.1%) 143 (34.3%)  Poor attitude towards health check-upsa 284 (68.1%) Perceptions and knowledge about breast cancer Breast cancer is like a death sentence; if you get it, you will surely die from it. 59 (14.1%) 69 (16.5%) 289 (69.3%) Breast cancer cannot be cured; you can only prolong the suffering. 63 (15.1%) 68 (16.3%) 286 (68.6%) Even if breast cancer is detected early, there is very little a woman can do to reduce the chances of dying from it. 50 (12.0%) 82 (19.7%) 285 (68.3%) If a woman is fated to get breast cancer, she will get breast cancer; there is nothing she can do to change fate. 61 (14.6%) 73 (17.5%) 283 (67.9%)  Insufficient knowledge about breast cancera 174 (41.7%) Perceived barriers to mammographic screening I’m worried that having a mammogram will hurt my breasts. 61 (14.6%) 101 (24.2%) 255 (61.2%) I don’t want to go for a mammogram because I would need to take off my clothes and expose my breasts. 82 (19.7%) 42 (10.1%) 293 (70.3%) Having a mammogram is embarrassing. 132 (31.7%) 30 (7.2%) 255 (61.2%)  High barriers to mammographic screeninga 176 (42.2%) Agree Do not know Disagree Attitudes towards health check-ups If I feel well, it is not necessary to have a health check-up. 159 (38.1%) 17 (4.1%) 241 (57.8%) If I follow a healthy lifestyle such as a balanced diet and regular exercise, I don’t feel it is necessary to have a regular health check-up. 121 (29.0%) 22 (5.3%) 274 (65.7%) I see a doctor or have my health check-up only when I have a health problem. 223 (53.5%) 11 (5.3%) 183 (43.9%) If I feel healthy, I do not need to see the doctor. 257 (61.6%) 17 (4.1%) 143 (34.3%)  Poor attitude towards health check-upsa 284 (68.1%) Perceptions and knowledge about breast cancer Breast cancer is like a death sentence; if you get it, you will surely die from it. 59 (14.1%) 69 (16.5%) 289 (69.3%) Breast cancer cannot be cured; you can only prolong the suffering. 63 (15.1%) 68 (16.3%) 286 (68.6%) Even if breast cancer is detected early, there is very little a woman can do to reduce the chances of dying from it. 50 (12.0%) 82 (19.7%) 285 (68.3%) If a woman is fated to get breast cancer, she will get breast cancer; there is nothing she can do to change fate. 61 (14.6%) 73 (17.5%) 283 (67.9%)  Insufficient knowledge about breast cancera 174 (41.7%) Perceived barriers to mammographic screening I’m worried that having a mammogram will hurt my breasts. 61 (14.6%) 101 (24.2%) 255 (61.2%) I don’t want to go for a mammogram because I would need to take off my clothes and expose my breasts. 82 (19.7%) 42 (10.1%) 293 (70.3%) Having a mammogram is embarrassing. 132 (31.7%) 30 (7.2%) 255 (61.2%)  High barriers to mammographic screeninga 176 (42.2%) aAs indicated by the standardized scores of corresponding CBCSB subscales lower than 65. Table 5 Participants’ attitudes towards health check-ups, perceptions and knowledge about breast cancer and perceived barriers to mammographic screening (n = 417) Agree Do not know Disagree Attitudes towards health check-ups If I feel well, it is not necessary to have a health check-up. 159 (38.1%) 17 (4.1%) 241 (57.8%) If I follow a healthy lifestyle such as a balanced diet and regular exercise, I don’t feel it is necessary to have a regular health check-up. 121 (29.0%) 22 (5.3%) 274 (65.7%) I see a doctor or have my health check-up only when I have a health problem. 223 (53.5%) 11 (5.3%) 183 (43.9%) If I feel healthy, I do not need to see the doctor. 257 (61.6%) 17 (4.1%) 143 (34.3%)  Poor attitude towards health check-upsa 284 (68.1%) Perceptions and knowledge about breast cancer Breast cancer is like a death sentence; if you get it, you will surely die from it. 59 (14.1%) 69 (16.5%) 289 (69.3%) Breast cancer cannot be cured; you can only prolong the suffering. 63 (15.1%) 68 (16.3%) 286 (68.6%) Even if breast cancer is detected early, there is very little a woman can do to reduce the chances of dying from it. 50 (12.0%) 82 (19.7%) 285 (68.3%) If a woman is fated to get breast cancer, she will get breast cancer; there is nothing she can do to change fate. 61 (14.6%) 73 (17.5%) 283 (67.9%)  Insufficient knowledge about breast cancera 174 (41.7%) Perceived barriers to mammographic screening I’m worried that having a mammogram will hurt my breasts. 61 (14.6%) 101 (24.2%) 255 (61.2%) I don’t want to go for a mammogram because I would need to take off my clothes and expose my breasts. 82 (19.7%) 42 (10.1%) 293 (70.3%) Having a mammogram is embarrassing. 132 (31.7%) 30 (7.2%) 255 (61.2%)  High barriers to mammographic screeninga 176 (42.2%) Agree Do not know Disagree Attitudes towards health check-ups If I feel well, it is not necessary to have a health check-up. 159 (38.1%) 17 (4.1%) 241 (57.8%) If I follow a healthy lifestyle such as a balanced diet and regular exercise, I don’t feel it is necessary to have a regular health check-up. 121 (29.0%) 22 (5.3%) 274 (65.7%) I see a doctor or have my health check-up only when I have a health problem. 223 (53.5%) 11 (5.3%) 183 (43.9%) If I feel healthy, I do not need to see the doctor. 257 (61.6%) 17 (4.1%) 143 (34.3%)  Poor attitude towards health check-upsa 284 (68.1%) Perceptions and knowledge about breast cancer Breast cancer is like a death sentence; if you get it, you will surely die from it. 59 (14.1%) 69 (16.5%) 289 (69.3%) Breast cancer cannot be cured; you can only prolong the suffering. 63 (15.1%) 68 (16.3%) 286 (68.6%) Even if breast cancer is detected early, there is very little a woman can do to reduce the chances of dying from it. 50 (12.0%) 82 (19.7%) 285 (68.3%) If a woman is fated to get breast cancer, she will get breast cancer; there is nothing she can do to change fate. 61 (14.6%) 73 (17.5%) 283 (67.9%)  Insufficient knowledge about breast cancera 174 (41.7%) Perceived barriers to mammographic screening I’m worried that having a mammogram will hurt my breasts. 61 (14.6%) 101 (24.2%) 255 (61.2%) I don’t want to go for a mammogram because I would need to take off my clothes and expose my breasts. 82 (19.7%) 42 (10.1%) 293 (70.3%) Having a mammogram is embarrassing. 132 (31.7%) 30 (7.2%) 255 (61.2%)  High barriers to mammographic screeninga 176 (42.2%) aAs indicated by the standardized scores of corresponding CBCSB subscales lower than 65. Predictors of negative attitudes towards health check-ups, limited knowledge about breast cancer and high barriers to mammographic screening Never breastfeeding was shown to be related to negative attitudes towards health check-ups (Table 6), but the association did not persist after adjustment in the multivariate model. Nulliparity (OR = 2.56; 95% CI = 1.14–5.73) and low education (OR = 1.72; 95% CI = 1.04–2.84) were shown significantly associated with the negative attitude (Table 7). Women who did not know anyone with breast cancer were more likely to have insufficient knowledge about the disease (OR = 2.30; 95% CI = 1.50–3.55). Moreover, multiple characteristics were found to be associated with high barriers to mammographic screening, including low education level, being single/divorced/widowed, unemployed/retired status, nulliparity, and having no friends/family members with breast cancer (Table 6). Following the multivariate logistic regression analysis, low education level (OR = 1.95; 95% CI = 1.25–3.04) and not knowing anyone with breast cancer (OR = 2.02; 95% CI = 1.31–3.13) were identified as the independent predictors of high perceived barriers to mammography (Table 7). Table 6 Univariate analysis of predictors of negative attitudes towards health check-ups, insufficient knowledge about breast cancer, and high perceived barriers to mammographic screening Negative attitudes towards health check-ups (n = 284) P Insufficient knowledge about breast cancer (n = 174) P High barriers to mammographic screening (n = 176) P Age  ≤50 years old (n = 210) 136 (64.8%) 0.140 80 (38.1%) 0.130 88 (41.9%) 0.900  >50 years old (n = 207) 148 (71.5%) 94 (45.4%) 88 (42.5%) BMI  Underweight or normal (n = 255) 175 (68.6%) 0.710 110 (43.1%) 0.528 106 (41.6%) 0.662  Overweight or obese (n = 160) 107 (66.9%) 64 (40.0%) 70 (43.8%) Education level  Primary school or lower (n = 120) 90 (75.0%) 0.055 53 (44.2%) 0.521 62 (51.7%) 0.013*  Secondary school or higher (n = 297) 194 (65.3%) 121 (40.7%) 114 (38.4%) Marital status  Single, divorced, or widowed (n = 63) 47 (74.6%) 0.230 30 (47.6%) 0.303 36 (57.1%) 0.009*  Married or cohabiting (n = 354) 237 (66.9%) 144 (40.7%) 140 (39.5%) Employment status  Unemployed or retired (n = 118) 84 (71.2%) 0.409 54 (45.8%) 0.318 60 (50.8%) 0.028*  Employed or studying (n = 297) 199 (67.0%) 120 (40.4%) 116 (39.1%) Having children  Yes (n = 371) 246 (66.3%) 0.031* 152 (41.0%) 0.464 147 (39.6%) 0.004*  No (n = 45) 37 (82.2%) 21 (46.7%) 28 (62.2%) Breastfeeding  Yes (n = 222) 141 (63.5%) 0.028* 91 (41.0%) 0.758 89 (40.1%) 0.358  No (n = 193) 142 (73.6%) 82 (42.5%) 86 (44.6%) Friends/family with breast cancer  Yes (n = 145) 91 (62.8%) 0.087 43 (29.7%) <0.001* 47 (32.4%) 0.003*  No or don’t know (n = 272) 193 (71.0%) 131 (48.2%) 129 (47.4%) Menopausal status  Pre-menopausal (n = 220) 153 (69.5%) 0.505 92 (41.8%) 0.968 91 (41.4%) 0.713  Post-menopausal (n = 197) 131 (66.5%) 82 (41.6%) 85 (43.1%) Contraceptive usage  No (n = 307) 207 (67.4%) 0.619 124 (40.4%) 0.355 137 (44.6%) 0.095  Yes (n = 110) 77 (70.0%) 50 (45.5%) 39 (35.5%) Negative attitudes towards health check-ups (n = 284) P Insufficient knowledge about breast cancer (n = 174) P High barriers to mammographic screening (n = 176) P Age  ≤50 years old (n = 210) 136 (64.8%) 0.140 80 (38.1%) 0.130 88 (41.9%) 0.900  >50 years old (n = 207) 148 (71.5%) 94 (45.4%) 88 (42.5%) BMI  Underweight or normal (n = 255) 175 (68.6%) 0.710 110 (43.1%) 0.528 106 (41.6%) 0.662  Overweight or obese (n = 160) 107 (66.9%) 64 (40.0%) 70 (43.8%) Education level  Primary school or lower (n = 120) 90 (75.0%) 0.055 53 (44.2%) 0.521 62 (51.7%) 0.013*  Secondary school or higher (n = 297) 194 (65.3%) 121 (40.7%) 114 (38.4%) Marital status  Single, divorced, or widowed (n = 63) 47 (74.6%) 0.230 30 (47.6%) 0.303 36 (57.1%) 0.009*  Married or cohabiting (n = 354) 237 (66.9%) 144 (40.7%) 140 (39.5%) Employment status  Unemployed or retired (n = 118) 84 (71.2%) 0.409 54 (45.8%) 0.318 60 (50.8%) 0.028*  Employed or studying (n = 297) 199 (67.0%) 120 (40.4%) 116 (39.1%) Having children  Yes (n = 371) 246 (66.3%) 0.031* 152 (41.0%) 0.464 147 (39.6%) 0.004*  No (n = 45) 37 (82.2%) 21 (46.7%) 28 (62.2%) Breastfeeding  Yes (n = 222) 141 (63.5%) 0.028* 91 (41.0%) 0.758 89 (40.1%) 0.358  No (n = 193) 142 (73.6%) 82 (42.5%) 86 (44.6%) Friends/family with breast cancer  Yes (n = 145) 91 (62.8%) 0.087 43 (29.7%) <0.001* 47 (32.4%) 0.003*  No or don’t know (n = 272) 193 (71.0%) 131 (48.2%) 129 (47.4%) Menopausal status  Pre-menopausal (n = 220) 153 (69.5%) 0.505 92 (41.8%) 0.968 91 (41.4%) 0.713  Post-menopausal (n = 197) 131 (66.5%) 82 (41.6%) 85 (43.1%) Contraceptive usage  No (n = 307) 207 (67.4%) 0.619 124 (40.4%) 0.355 137 (44.6%) 0.095  Yes (n = 110) 77 (70.0%) 50 (45.5%) 39 (35.5%) *Statistically significant under Pearson Chi-square test, P < 0.05. Table 6 Univariate analysis of predictors of negative attitudes towards health check-ups, insufficient knowledge about breast cancer, and high perceived barriers to mammographic screening Negative attitudes towards health check-ups (n = 284) P Insufficient knowledge about breast cancer (n = 174) P High barriers to mammographic screening (n = 176) P Age  ≤50 years old (n = 210) 136 (64.8%) 0.140 80 (38.1%) 0.130 88 (41.9%) 0.900  >50 years old (n = 207) 148 (71.5%) 94 (45.4%) 88 (42.5%) BMI  Underweight or normal (n = 255) 175 (68.6%) 0.710 110 (43.1%) 0.528 106 (41.6%) 0.662  Overweight or obese (n = 160) 107 (66.9%) 64 (40.0%) 70 (43.8%) Education level  Primary school or lower (n = 120) 90 (75.0%) 0.055 53 (44.2%) 0.521 62 (51.7%) 0.013*  Secondary school or higher (n = 297) 194 (65.3%) 121 (40.7%) 114 (38.4%) Marital status  Single, divorced, or widowed (n = 63) 47 (74.6%) 0.230 30 (47.6%) 0.303 36 (57.1%) 0.009*  Married or cohabiting (n = 354) 237 (66.9%) 144 (40.7%) 140 (39.5%) Employment status  Unemployed or retired (n = 118) 84 (71.2%) 0.409 54 (45.8%) 0.318 60 (50.8%) 0.028*  Employed or studying (n = 297) 199 (67.0%) 120 (40.4%) 116 (39.1%) Having children  Yes (n = 371) 246 (66.3%) 0.031* 152 (41.0%) 0.464 147 (39.6%) 0.004*  No (n = 45) 37 (82.2%) 21 (46.7%) 28 (62.2%) Breastfeeding  Yes (n = 222) 141 (63.5%) 0.028* 91 (41.0%) 0.758 89 (40.1%) 0.358  No (n = 193) 142 (73.6%) 82 (42.5%) 86 (44.6%) Friends/family with breast cancer  Yes (n = 145) 91 (62.8%) 0.087 43 (29.7%) <0.001* 47 (32.4%) 0.003*  No or don’t know (n = 272) 193 (71.0%) 131 (48.2%) 129 (47.4%) Menopausal status  Pre-menopausal (n = 220) 153 (69.5%) 0.505 92 (41.8%) 0.968 91 (41.4%) 0.713  Post-menopausal (n = 197) 131 (66.5%) 82 (41.6%) 85 (43.1%) Contraceptive usage  No (n = 307) 207 (67.4%) 0.619 124 (40.4%) 0.355 137 (44.6%) 0.095  Yes (n = 110) 77 (70.0%) 50 (45.5%) 39 (35.5%) Negative attitudes towards health check-ups (n = 284) P Insufficient knowledge about breast cancer (n = 174) P High barriers to mammographic screening (n = 176) P Age  ≤50 years old (n = 210) 136 (64.8%) 0.140 80 (38.1%) 0.130 88 (41.9%) 0.900  >50 years old (n = 207) 148 (71.5%) 94 (45.4%) 88 (42.5%) BMI  Underweight or normal (n = 255) 175 (68.6%) 0.710 110 (43.1%) 0.528 106 (41.6%) 0.662  Overweight or obese (n = 160) 107 (66.9%) 64 (40.0%) 70 (43.8%) Education level  Primary school or lower (n = 120) 90 (75.0%) 0.055 53 (44.2%) 0.521 62 (51.7%) 0.013*  Secondary school or higher (n = 297) 194 (65.3%) 121 (40.7%) 114 (38.4%) Marital status  Single, divorced, or widowed (n = 63) 47 (74.6%) 0.230 30 (47.6%) 0.303 36 (57.1%) 0.009*  Married or cohabiting (n = 354) 237 (66.9%) 144 (40.7%) 140 (39.5%) Employment status  Unemployed or retired (n = 118) 84 (71.2%) 0.409 54 (45.8%) 0.318 60 (50.8%) 0.028*  Employed or studying (n = 297) 199 (67.0%) 120 (40.4%) 116 (39.1%) Having children  Yes (n = 371) 246 (66.3%) 0.031* 152 (41.0%) 0.464 147 (39.6%) 0.004*  No (n = 45) 37 (82.2%) 21 (46.7%) 28 (62.2%) Breastfeeding  Yes (n = 222) 141 (63.5%) 0.028* 91 (41.0%) 0.758 89 (40.1%) 0.358  No (n = 193) 142 (73.6%) 82 (42.5%) 86 (44.6%) Friends/family with breast cancer  Yes (n = 145) 91 (62.8%) 0.087 43 (29.7%) <0.001* 47 (32.4%) 0.003*  No or don’t know (n = 272) 193 (71.0%) 131 (48.2%) 129 (47.4%) Menopausal status  Pre-menopausal (n = 220) 153 (69.5%) 0.505 92 (41.8%) 0.968 91 (41.4%) 0.713  Post-menopausal (n = 197) 131 (66.5%) 82 (41.6%) 85 (43.1%) Contraceptive usage  No (n = 307) 207 (67.4%) 0.619 124 (40.4%) 0.355 137 (44.6%) 0.095  Yes (n = 110) 77 (70.0%) 50 (45.5%) 39 (35.5%) *Statistically significant under Pearson Chi-square test, P < 0.05. Table 7 Multivariate logistic regression analysis of predictors of poor screening practices, negative attitudes towards health check-ups, insufficient knowledge about breast cancer, and high perceived barriers to mammographic screening Never performed BSE Never had a CBE Never had a mammogram Negative attitudes towards health check-ups Insufficient knowledge about breast cancer High barriers to mammographic screening OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P No friends/family with breast cancer 1.90 (1.14–3.15) 0.014* 1.73 (1.07–2.80) 0.025* 1.62 (1.04–2.52) 0.032* – – 2.30 (1.50–3.55) <0.001* 2.02 (1.31–3.13) 0.002* Unemployed or retired – – 1.82 (1.14–2.92) 0.013* 1.73 (1.04–2.86) 0.033* – – – – – – Primary education or lower 1.63 (1.00–2.64) 0.049* – – 1.91 (1.15–3.17) 0.012* 1.72 (1.04–2.84) 0.034* – – 1.95 (1.25–3.04) 0.003* Single, divorced or widowed 1.85 (1.00–3.41) 0.051 2.39 (1.33–4.31) 0.004* – – – – – – 1.74 (0.92–3.30) 0.091 Nulliparity – – – – – – 2.56 (1.14–5.73) 0.022* – – 2.00 (0.96–4.21) 0.066 Never breastfeeding 1.65 (1.03–2.65) 0.036* – – – – – – – – – – Negative attitudes towards health check-ups 1.95 (1.13–3.35) 0.017* 2.38 (1.43–3.98) 0.001* 2.05 (1.31–3.21) 0.002* – – – – – – Insufficient knowledge about breast cancer 1.90 (1.19–3.02) 0.007* 2.87 (1.84–4.49) <0.001* 1.86 (1.19–2.91) 0.007* – – – – – – High barriers to mammographic screening 1.89 (1.18–3.00) 0.008* – – – – – – – – – – Never performed BSE Never had a CBE Never had a mammogram Negative attitudes towards health check-ups Insufficient knowledge about breast cancer High barriers to mammographic screening OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P No friends/family with breast cancer 1.90 (1.14–3.15) 0.014* 1.73 (1.07–2.80) 0.025* 1.62 (1.04–2.52) 0.032* – – 2.30 (1.50–3.55) <0.001* 2.02 (1.31–3.13) 0.002* Unemployed or retired – – 1.82 (1.14–2.92) 0.013* 1.73 (1.04–2.86) 0.033* – – – – – – Primary education or lower 1.63 (1.00–2.64) 0.049* – – 1.91 (1.15–3.17) 0.012* 1.72 (1.04–2.84) 0.034* – – 1.95 (1.25–3.04) 0.003* Single, divorced or widowed 1.85 (1.00–3.41) 0.051 2.39 (1.33–4.31) 0.004* – – – – – – 1.74 (0.92–3.30) 0.091 Nulliparity – – – – – – 2.56 (1.14–5.73) 0.022* – – 2.00 (0.96–4.21) 0.066 Never breastfeeding 1.65 (1.03–2.65) 0.036* – – – – – – – – – – Negative attitudes towards health check-ups 1.95 (1.13–3.35) 0.017* 2.38 (1.43–3.98) 0.001* 2.05 (1.31–3.21) 0.002* – – – – – – Insufficient knowledge about breast cancer 1.90 (1.19–3.02) 0.007* 2.87 (1.84–4.49) <0.001* 1.86 (1.19–2.91) 0.007* – – – – – – High barriers to mammographic screening 1.89 (1.18–3.00) 0.008* – – – – – – – – – – BSE = breast self-examination; CBE = clinical breast examination; CI = confidence interval; OR = odd ratio. Gray shades indicate those fields that did not apply (instead of not value). *Statistically significant under binary logistic regression, P < 0.05. Table 7 Multivariate logistic regression analysis of predictors of poor screening practices, negative attitudes towards health check-ups, insufficient knowledge about breast cancer, and high perceived barriers to mammographic screening Never performed BSE Never had a CBE Never had a mammogram Negative attitudes towards health check-ups Insufficient knowledge about breast cancer High barriers to mammographic screening OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P No friends/family with breast cancer 1.90 (1.14–3.15) 0.014* 1.73 (1.07–2.80) 0.025* 1.62 (1.04–2.52) 0.032* – – 2.30 (1.50–3.55) <0.001* 2.02 (1.31–3.13) 0.002* Unemployed or retired – – 1.82 (1.14–2.92) 0.013* 1.73 (1.04–2.86) 0.033* – – – – – – Primary education or lower 1.63 (1.00–2.64) 0.049* – – 1.91 (1.15–3.17) 0.012* 1.72 (1.04–2.84) 0.034* – – 1.95 (1.25–3.04) 0.003* Single, divorced or widowed 1.85 (1.00–3.41) 0.051 2.39 (1.33–4.31) 0.004* – – – – – – 1.74 (0.92–3.30) 0.091 Nulliparity – – – – – – 2.56 (1.14–5.73) 0.022* – – 2.00 (0.96–4.21) 0.066 Never breastfeeding 1.65 (1.03–2.65) 0.036* – – – – – – – – – – Negative attitudes towards health check-ups 1.95 (1.13–3.35) 0.017* 2.38 (1.43–3.98) 0.001* 2.05 (1.31–3.21) 0.002* – – – – – – Insufficient knowledge about breast cancer 1.90 (1.19–3.02) 0.007* 2.87 (1.84–4.49) <0.001* 1.86 (1.19–2.91) 0.007* – – – – – – High barriers to mammographic screening 1.89 (1.18–3.00) 0.008* – – – – – – – – – – Never performed BSE Never had a CBE Never had a mammogram Negative attitudes towards health check-ups Insufficient knowledge about breast cancer High barriers to mammographic screening OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P No friends/family with breast cancer 1.90 (1.14–3.15) 0.014* 1.73 (1.07–2.80) 0.025* 1.62 (1.04–2.52) 0.032* – – 2.30 (1.50–3.55) <0.001* 2.02 (1.31–3.13) 0.002* Unemployed or retired – – 1.82 (1.14–2.92) 0.013* 1.73 (1.04–2.86) 0.033* – – – – – – Primary education or lower 1.63 (1.00–2.64) 0.049* – – 1.91 (1.15–3.17) 0.012* 1.72 (1.04–2.84) 0.034* – – 1.95 (1.25–3.04) 0.003* Single, divorced or widowed 1.85 (1.00–3.41) 0.051 2.39 (1.33–4.31) 0.004* – – – – – – 1.74 (0.92–3.30) 0.091 Nulliparity – – – – – – 2.56 (1.14–5.73) 0.022* – – 2.00 (0.96–4.21) 0.066 Never breastfeeding 1.65 (1.03–2.65) 0.036* – – – – – – – – – – Negative attitudes towards health check-ups 1.95 (1.13–3.35) 0.017* 2.38 (1.43–3.98) 0.001* 2.05 (1.31–3.21) 0.002* – – – – – – Insufficient knowledge about breast cancer 1.90 (1.19–3.02) 0.007* 2.87 (1.84–4.49) <0.001* 1.86 (1.19–2.91) 0.007* – – – – – – High barriers to mammographic screening 1.89 (1.18–3.00) 0.008* – – – – – – – – – – BSE = breast self-examination; CBE = clinical breast examination; CI = confidence interval; OR = odd ratio. Gray shades indicate those fields that did not apply (instead of not value). *Statistically significant under binary logistic regression, P < 0.05. Discussion This was the first study that investigated the attitudes towards health check-ups, perceptions of breast cancer, and barriers to mammographic screening among the female population in Macao. As the Macao Health Bureau has not outlined the frequency of performing breast cancer screening yet, local healthcare providers usually make recommendations based on the guidelines used in nearby regions like Hong Kong. The Hong Kong Breast Cancer Foundation currently suggests that women above age 40 should perform a BSE once a month, go for a CBE and have a mammogram every 2 years.19 This study showed that the majority of local middle-aged women failed to follow the screening recommendations. In particular, only one-fourth of the participants received mammographic screening at a recommended interval. When confined to those who had heard of the screening method, the compliance rate became 42%, which was not much higher than that reported in Hong Kong (32.7%).8 While both Special Administrative Regions of China do not have an organized population-based screening program in place, the degrees of access to screening services are quite different. In Hong Kong, cost can be a major barrier to such services because they are usually paid out of pocket.8 On the contrary, while having the option to utilize medical services provided by the private sector, all residents in Macao are also entitled to free primary care services at the government-run health centers. Therefore, local residents can request to have a CBE for free at those health centers and may be further referred for a mammogram based on the CBE results and their physicians’ clinical judgment. The surprisingly poor compliance with screening recommendations in Macao might be due to the long waiting time for free services in some health centers, a lack of awareness of these medical benefits by many local residents, limited knowledge regarding screening guidelines, and the high cost in the private sector. It also highlighted the necessity to identify and address a range of barriers in order to enhance the screening rates among Chinese women. In this study, most Chinese women were found to have good knowledge and perceptions about breast cancer and had heard of the three screening methods. Nevertheless, about one-third of all participants had never performed a BSE or received a CBE, and over 60% of them had never obtained a mammogram. One of the reasons behind these conflicting results could be the inadequate levels of health literacy among this female population. Nowadays, people can easily get access to various health information through the Internet or social media. However, as the Chinese women aged 40–60 years were relatively less educated than the younger generation, it was very likely that they had low health literacy levels and incomplete understanding of breast cancer screening, resulting in the low compliance rates.27,28 For example, some middle-aged women might not fully know the purposes and techniques for performing a BSE even though they had heard of it. Moreover, this study demonstrated that the negative attitudes towards health check-ups could be a key barrier to screening practices. One of the top reasons for the lack of breast cancer screening was that they did not see it as necessary, which was consistent with the results of previous studies of Chinese women in mainland China,10 Taiwan9 and the USA.14,29 It is a popular Chinese belief that without any pain or acute diseases, one should avoid seeing a physician.30 There is also a cultural belief that talking about a disease may cause it to actually happen.31 In addition, a few participants believed that there was no need for mammographic screening as long as they performed a BSE regularly. More efforts should be made to clear up the public’s confusion about the differences and benefits of these screening practices. Interestingly, a lack of recommendations by physicians was also a reason for the low mammographic screening rates among this study population. Chinese women tend to trust their physicians so implicitly that they would believe breast cancer screening is unnecessary if their physicians do not discuss it with them.11 Previous literature also showed that having physicians as an information source was a predictor of positive screening behaviors.32 At the frontline of the healthcare system, general practitioners can play a vital role in facilitating people’s decisions about cancer screening. It is crucial for them to keep up with the updated guidelines, address common misconceptions, and make screening recommendations accordingly. In general, the Chinese culture places the family above individual interests, which can potentially explain why being single was a predictor of never receiving a CBE. A sense of responsibility to family can motivate people to pay more attention to their health and participate in cancer screening.13 Although no significant relationship was observed between marital status and mammographic screening practices, women who never had children were found to have a negative attitude towards health screening and high barriers to having a mammogram. Other than the impact of cultural beliefs, this finding might be attributable to the local health policies offering free medical care and check-ups for residents during their pregnancy and post-partum period. Consequently, women who had children should be more knowledgeable about women’s health issues and their medical benefits as a Macao resident. These factors indicate that it is essential to educate women and their family to enhance their understandings of breast cancer, in order to improve women’s compliance with screening practices. Another noteworthy finding of this study was that retired or unemployed women, including housewives, were less likely to have ever had a CBE or a mammogram. Binary logistic regression demonstrated that this group of participants were significantly less educated, of older age and most of them had little contact with breast cancer survivors. In other words, this group of participants may not be able to afford health insurance. They may have limited access to private medical care and they have poor health literacy level and knowledge about breast cancer. Hence, such an association between employment status and health screening performance could be partially explained. Nevertheless, as this is one of the groups most in need for education on breast cancer screening, the barriers encountered by them should be thoroughly investigated in the future. There were several limitations in this study. First, the selection of participants was not random, leading to questionable generalizability of the findings. However, a quota sampling method was adopted, and the resulting distribution of certain demographic characteristics such as education level, marital status and age was comparable to the census data.16 Second, as all information was obtained on a self-report basis, recall bias could be an issue. It was highly difficult to verify participants’ screening behaviors in the absence of a universal medical record system in Macao. Third, breast cancer was a sensitive topic and some participants might be reluctant to reveal their true beliefs to interviewers. To minimize this limitation, only well-trained female interviewers were assigned to perform data collection. Finally, the practice of ultrasound screening was not assessed in this study because its routine use for women with average risk was not recommended.5,19 Nevertheless, the use of ultrasound screening as an adjunct to mammography can improve cancer detection rates, especially for those with dense breasts.33 As Chinese women generally have denser breasts than their Caucasian counterparts,34 the use of this screening method may be more common than expected among Chinese population and should be evaluated in future studies. Conclusions In conclusion, in spite of free access to breast cancer screening, the participation rates were strikingly low among the middle-aged female population in Macao. Most women had good knowledge and perceptions about breast cancer but negative attitudes towards health check-ups. The independent factors associated with poor mammographic screening practices included unemployed/retired status, low education level, and not knowing anybody with breast cancer. As the incidence rate of breast cancer is rising and early detection is an important strategy of cancer control, a culturally tailored education and promotion program should be developed to raise the public’s awareness of the disease and the screening practices. More efforts should be made to educate local women on the availability and benefits of different screening practices. Meanwhile, all levels of healthcare providers, particularly general practitioners, should receive more relevant training in order to better address the public’s concerns and provide appropriate screening recommendations. Further studies are needed to evaluate the effectiveness of different educational interventions for Chinese women, as well as the cost-effectiveness and feasibility of a population-based screening program in Macao and other Asian countries with a significant Chinese population. Conflict of interest The authors declare no conflicts of interest. Acknowledgements This study was financially supported by the National Medical Research Council Singapore (NMRC/CIRG/1386/2014). The authors are grateful to Dr Kate White and Dr Cannes Kwok for providing the original CBCSB. The authors would also like to acknowledge Ms Ka-Lei Lam, Ms Sok-Teng Fong and other students of Macao Polytechnic Institute for their contribution to data collection and entry. References 1 Ferlay J , Soerjomataram I , Ervik M et al. . GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. In. Lyon, France: International Agency for Research on Cancer 2013 . 2 Fan L , Strasser-Weippl K , Li JJ et al. . Breast cancer in China . Lancet Oncol 2014 ; 15 : e279 – 89 . Google Scholar CrossRef Search ADS PubMed 3 Taskforce for Annual Report of Macao Cancer Registry . Annual report of Macao cancer registry. Macao: Health Bureau of the Government of Macao Special Administrative Region 2016 . 4 Howlader N , Noone AM , Krapcho M et al. . SEER Cancer Statistics Review 1975–2014 . Bethesda, MD : National Cancer Institute , 2017 . 5 National Comprehensive Cancer Network . Breast cancer screening and diagnosis (Version 1.2017) 2017 . 6 Kagawa-Singer M , Pourat N . Asian American and Pacific Islander breast and cervical carcinoma screening rates and healthy people 2000 objectives . Cancer 2000 ; 89 : 696 – 705 . Google Scholar CrossRef Search ADS PubMed 7 Wang B , He M , Wang L et al. . Breast cancer screening among adult women in China, 2010 . Prev Chronic Dis 2013 ; 10 : E183 . Google Scholar CrossRef Search ADS PubMed 8 Kwok C , Fong DY . Breast cancer screening practices among Hong Kong Chinese women . Cancer Nurs 2014 ; 37 : 59 – 65 . Google Scholar CrossRef Search ADS PubMed 9 Wu TY , Chung S , Yeh MC et al. . Understanding breast cancer screening practices in Taiwan: a country with universal health care . Asian Pac J Cancer Prev 2012 ; 13 : 4289 – 94 . Google Scholar CrossRef Search ADS PubMed 10 Huang Y , Zhou K , Li H et al. . knowledge, attitudes, and behaviour regarding breast cancer screening among women from different socio-economic regions in southwest China: a cross-sectional study . Asian Pac J Cancer Prev 2011 ; 12 : 203 – 9 . Google Scholar PubMed 11 Kwok C , Cant R , Sullivan G . Factors associated with mammographic decisions of Chinese-Australian women . Health Educ Res 2005 ; 20 : 739 – 47 . Google Scholar CrossRef Search ADS PubMed 12 Lam WW , Tsuchiya M , Chan M et al. . Help-seeking patterns in Chinese women with symptoms of breast disease: a qualitative study . J Public Health (Oxf) 2009 ; 31 : 59 – 68 . Google Scholar CrossRef Search ADS PubMed 13 Lee-Lin F , Menon U , Nail L et al. . Findings from focus groups indicating what Chinese American immigrant women think about breast cancer and breast cancer screening . J Obstet Gynecol Neonatal Nurs 2012 ; 41 : 627 – 37 . Google Scholar CrossRef Search ADS PubMed 14 Yu ES , Kim KK , Chen EH et al. . Breast and cervical cancer screening among Chinese American women . Cancer Pract 2001 ; 9 : 81 – 91 . Google Scholar CrossRef Search ADS PubMed 15 Chua MS , Mok TS , Kwan WH et al. . Knowledge, perceptions, and attitudes of Hong Kong Chinese women on screening mammography and early breast cancer management . Breast J 2005 ; 11 : 52 – 6 . Google Scholar CrossRef Search ADS PubMed 16 Statistics and Census Service . Results of 2011 population census. Macao: Statistics and Census Service of the Government of Macao Special Administrative Region 2012 . 17 Fong DY , Kwok C , White K . Psychometric properties of the Chinese Breast Cancer Screening Beliefs questionnaire . Eur J Oncol Nurs 2012 ; 16 : 505 – 11 . Google Scholar CrossRef Search ADS PubMed 18 Kwok C , Fethney J , White K . Chinese Breast Cancer Screening Beliefs Questionnaire: development and psychometric testing with Chinese-Australian women . J Adv Nurs 2010 ; 66 : 191 – 200 . Google Scholar CrossRef Search ADS PubMed 19 Hong K . Breast Cancer Foundation. Breast Cancer Facts You Should Know . Hong Kong : Hong Kong Breast Cancer Foundation , 2017 . 20 Beck AT , Epstein N , Brown G et al. . An inventory for measuring clinical anxiety: psychometric properties . J Consult Clin Psychol 1988 ; 56 : 893 – 7 . Google Scholar CrossRef Search ADS PubMed 21 Che HH , Lu ML , Chen HC et al. . Validation of the Chinese version of the Beck Anxiety Inventory . J Formos Med Assoc 2006 ; 10 : 447 – 54 . 22 Beck AT , Ward CH , Mendelson M et al. . An inventory for measuring depression . Arch Gen Psychiatry 1961 ; 4 : 561 – 71 . Google Scholar CrossRef Search ADS PubMed 23 Shek DT . Reliability and factorial structure of the Chinese version of the Beck Depression Inventory . J Clin Psychol 1990 ; 46 : 35 – 43 . Google Scholar CrossRef Search ADS PubMed 24 Mendoza TR , Wang XS , Cleeland CS et al. . The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory . Cancer 1999 ; 85 : 1186 – 96 . Google Scholar CrossRef Search ADS PubMed 25 Wang XS , Hao XS , Wang Y et al. . Validation study of the Chinese version of the Brief Fatigue Inventory (BFI-C) . J Pain Symptom Manage 2004 ; 27 : 322 – 32 . Google Scholar CrossRef Search ADS PubMed 26 World Health Organization . The Asia-Pacific Perspective: Redefining Obesity and its Treatment . Sydney : Health Communications Australia , 2000 . 27 Sentell T , Braun KL , Davis J et al. . Health literacy and meeting breast and cervical cancer screening guidelines among Asians and whites in California . SpringerPlus 2015 ; 4 : 432 . eCollection 2015. Google Scholar CrossRef Search ADS PubMed 28 Wu Y , Wang L , Cai Z et al. . Prevalence and risk factors of low health literacy: a community-based study in Shanghai, China . Int J Environ Res Public Health 2017 ; 14 : E628 . Google Scholar CrossRef Search ADS PubMed 29 Tang TS , Solomon LJ , McCracken LM . Cultural barriers to mammography, clinical breast exam, and breast self-exam among Chinese-American women 60 and older . Prev Med 2000 ; 31 : 575 – 83 . Google Scholar CrossRef Search ADS PubMed 30 Garcia HB , Lee PCY . Knowledge about cancer and use of health care services among Hispanic-and Asian-American older adults . J Psychosoc Oncol 1989 ; 6 : 157 – 77 . Google Scholar CrossRef Search ADS 31 McLaughlin LA , Braun KL . Asian and Pacific Islander cultural values: considerations for health care decision making . Health Soc Work 1998 ; 23 : 116 – 26 . Google Scholar CrossRef Search ADS PubMed 32 Su X , Ma GX , Seals B et al. . Breast cancer early detection among Chinese women in the Philadelphia area . J Womens Health (Larchmt) (2002) 2006 ; 15 : 507 – 19 . Google Scholar CrossRef Search ADS PubMed 33 Berg WA , Blume JD , Cormack JB et al. . Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer . J Am Med Assoc 2008 ; 299 : 2151 – 63 . Google Scholar CrossRef Search ADS 34 Maskarinec G , Meng L , Ursin G . Ethnic differences in mammographic densities . Int J Epidemiol 2001 ; 30 : 959 – 65 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Public Health Oxford University Press

Breast cancer screening behavior, attitude, barriers among middle-aged Chinese women in Macao, China

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Abstract

Abstract Background Breast cancer is the third leading cause of death from cancer among females in Macao, but little is known about local practice of breast cancer screening. The study aims to evaluate breast cancer screening behaviors and to identify the predictors of insufficient knowledge and attitudes towards breast cancer and its screening among female residents. Methods This was a cross-sectional study conducted from April to June 2016 in Macao. Quota sampling of women completed the modified Chinese Breast Cancer Screening Beliefs questionnaire (CBCSB) to assess their breast cancer-related perceptions, screening attitudes and behaviors. Univariate and multivariate logistic regressions were performed to identify the predictors of poor-screening practices, attitudes, knowledge and perceived barriers to mammography. Result A total of 417 women (mean age±SD: 50.5±5.7) completed surveys, with 160 (38.4%), 196 (47.0%) and 103 (24.7%) women received breast self-examination, clinical breast examination and mammography as recommended, respectively. Nulliparity (OR=2.56, 95% CI = 1.14−5.73) and low education (OR = 1.72, 95% CI = 1.04−2.84) were significantly associated with negative attitude towards health check-ups. Women did not know anyone with breast cancer (OR = 2.30, 95% CI = 1.50−3.55) were more likely to have insufficient knowledge about breast cancer. Low education (OR = 1.95, 95% CI = 1.25−3.04) and not knowing anyone with breast cancer (OR = 2.02, 95% CI = 1.31−3.13) were identified as predictors for perceived barriers to mammography. Conclusion Recommendations for breast cancer screening are poorly followed by the residents in Macao, and a culturally tailored educational program is urgently needed to raise the public’s awareness of the disease and the screening practices. attitude, breast cancer, health check-ups, screening behaviors Introduction As the most prevalent cancer among women, breast cancer poses a significant health threat worldwide. Although higher incidence rates are generally observed in the industrialized countries, the numbers of new cases are on the rise in the developing world.1 In China, breast cancer leads all types of cancer in women, with an age-standardized incidence rate (ASR) of 22.1 per 100 000 population.1 In fact, the ASRs of breast cancer vary greatly nationwide and are much higher in the coastal regions that are heavily urbanized and more socioeconomically developed. The incidence rates in some cities even reach the levels of high-income countries such as Japan, partly due to the adoption of Western lifestyles.2 As expected, a similar trend is noted in Macao. Macau is a Special Administrative Region in southern China, which was once administrated by the Portuguese Empire and adopted a highly westernized lifestyle. More than 80% of its local population is Chinese and female makes up 51% of the population. Driven by the rapid expansion of its gambling industry, Macao has become one of the most developed regions in China. A local report reveals a constant increase in new cases of breast cancer, with a crude incidence rate of 55.7 per 100 000 women in 2014.3 The mortality rate of breast cancer has been stable over the past decade. However, it remains the third leading cause of death from cancer among women in Macao.3 In order to reduce the burden of this highly treatable disease, routine screening and early treatment are imperative because the 5-year relative survival rate can significant reduce from 98.9 to 26.9% if a patient is diagnosed at late stage.4 Breast self-examination (BSE), clinical breast examination (CBE), and mammography are the major strategies to detect for breast cancer, with mammography being the only screening tool proven to decrease breast cancer-related deaths.5 Compared to their Caucasian counterparts, Chinese women have lower screening rates for breast cancer.6 In mainland China, there has been no nationwide breast cancer screening program and the overall screening rate was only 21.7% in 2010.2,7 The situation is not much better in more developed and Westernized regions such as Hong Kong; a survey conducted in 2014 showed that only 43.9% of women in Hong Kong had received a mammogram and most of these women did not comply to recommended guidelines.8 In Taiwan, the participation rate was only 43% over a 5-year period9, even with the avail of universal healthcare and free access to mammographic screening. Some common barriers to breast cancer screening encountered by Chinese women include cultural perceptions or fear of cancer9–13, discomfort9, embarrassment10,11,14 and cost.12,13,15 The research exploring Chinese women’s screening attitudes and beliefs has largely been conducted in the Western countries and the relevant data about those living in Asia remains relatively limited. In addition, little is known about the practices of breast cancer screening in the female population in Macao. This study was designed to evaluate breast cancer screening behaviors, and to identify the predictors of negative attitudes and limited knowledge towards the disease and its screening among middle-aged Chinese women in Macao. It provides more information for developing breast cancer-related education programs and screening policies for Chinese women in Macao and other countries where Chinese account for a significant proportion of the population. Methods Study design and participants This was a cross-sectional survey conducted in Macao from April to June 2016. All Chinese women who were 40–60 years of age and had never received a diagnosis of any malignancies were eligible to participate in this study. Non-residents such as tourists and foreign domestic workers were excluded from analysis. All participants received a US$ 6 voucher for their participation in this study. Sampling and data collection A quota sampling approach was taken for this study. Macao is officially composed of seven administrative divisions, five of which are located in the main peninsula and two of which are islands.16 For this study, two adjacent, demographically similar divisions in the peninsula were grouped together as one sampling district. For the same reason, the two island divisions were also combined into a single sampling district. As a result, a total of five sampling districts within Macao were planned in this study. Women who appeared to be ethnically Chinese were approached and invited to participate in the survey near supermarkets, schools, churches and coffee shops in each district. All information was collected face to face using a structured questionnaire, which consisted of three main sections that assessed: (i) breast cancer-related perceptions, screening attitudes and behaviors; (ii) demographic and health-related characteristics; and (iii) symptoms related to fatigue, depression and anxiety. To minimize bias, all interviewers received extensive training to administer the structured questionnaire. Instruments Participants’ practices and attitudes towards breast cancer screening were evaluated using the modified Chinese Breast Cancer Screening Beliefs questionnaire (CBCSB).17 The original CBCSB included 13 items and it was well tested among Chinese Australian women.18 The Chinese version of the modified questionnaire was developed after omitting two items that were not applicable in Hong Kong, and was shown to be valid, reliable and culturally sensitive.17 As Macao is culturally similar to Hong Kong, with a colonial past and a mix of Eastern and Western influences, the modified version of CBCSB was considered more appropriate and thus selected for this study. The modified CBCSB comprised three subscales: attitudes towards health check-ups (four items), knowledge and perceptions about breast cancer (four items), and barriers to mammographic screening (three items). Each item was scored on a five-point Likert scale, ranging from 1 (strongly agree) to 5 (strongly disagree) with ‘don’t know’ as the mid-point. The raw score of each subscale was converted into a standardized score between 0 and 100.17 A standardized score lower than 65 suggested negative attitudes towards health check-ups, insufficient knowledge about breast cancer, and more perceived barriers to mammographic screening.8 Furthermore, the modified CBCSB included some questions evaluating how often participants performed a BSE, and had a CBE or a mammogram. Participants were deemed to be compliant with the three screening practices as recommended if they performed a BSE monthly and had a CBE or a mammogram at a minimum of every 2 years.19 The presence and severity of symptoms associated with anxiety and depression were measured with the Chinese versions of the Beck Anxiety Inventory20,21 and the Beck Depression Inventory, respectively.22,23 Fatigue levels were assessed using the Chinese version of the Brief Fatigue Inventory.24,25 With respect to demographic and health-related characteristics, all participants were asked about their age, marital status, education level, employment status, medical history, family history of breast cancer, age at menarche, current menopausal status, past obstetric history, breastfeeding experience and history of contraceptive use. Self-reported height and weight were used for calculating body mass index (BMI), with 23 and 25 kg/m2 as the cut-off points for overweight and obesity for Asian adults, respectively.26 Statistical analysis and sample size calculation Descriptive statistics were used for reporting the demographic characteristics, fatigue and mental health status, perceptions about breast cancer, as well as behaviors and attitudes towards cancer screening. The Pearson chi-square test was conducted to correlate different characteristics with poor screening practices, attitudes, knowledge and high perceived barriers to mammography. In order to identify the independent predictors of these outcomes, multivariate logistic regression analysis (with backward elimination) was performed on the characteristics with P < 0.05 in the univariate analysis. All statistical analysis was conducted using SPSS for Windows, version 20.0, with a P-value of 0.05 as the cut-off point for statistical significance. The minimum sample size was calculated to be 383 to achieve a confidence interval width of 0.1, with a confidence level of 95% and an expected response rate of 50%. This is based on the total population of women aged 40–60 years in Macao, which was estimated to be 102 946.16 A quota sampling approach was adopted to achieve an even distribution of four age subgroups (40–45, 46–50, 51–55 and 56–60 years) based on the census data.16 A predetermined sample size of each district was also calculated based on the respective population of middle-aged women16 in each individual district. Results Demographic and health-related characteristics Among 689 women who were invited, 417 completed the survey, with a response rate of 60.5% (Fig. 1 ). The participants’ mean age (±SD) was 50.5 ± 5.7 years and most of them were married (84.2%), currently employed (71.0%), and had children (89.2%). Approximately half of them were postmenopausal (47.2%) and had breastfeeding experience (53.2%). A total of 120 participants (28.8%) had low education level, meaning that they did not have formal education or had only primary education. In total, 16 participants (3.8%) reported to have a family history of breast cancer while 138 participants (33.1%) were aware that one of their friends had the disease (Table 1). Table 1 Demographic and health-related characteristics of participants (N = 417) n % Age  Mean (SD) 50.5 (5.7) Body mass index  Mean (SD) 22.7 (3.3)   Underweight (<18.5) 34 8.2   Normal (18.5–23) 221 53.0   Overweight (23–24.9) 80 19.2   Obese (≥25) 80 19.2   Refused to answer 2 0.5 Marital status   Single 31 7.4   Married 351 84.2   Cohabiting 3 0.7   Divorced or separated 25 6.0   Widowed 7 1.7 Highest education level   No formal education 2 0.5   Primary school 118 28.3   Secondary school 217 52.0   Higher diploma or associate’s degree 31 7.4   Bachelor’s or master’s degree 49 11.8 Employment status   Currently employed (full-time) 283 67.9   Currently employed (part-time) 13 3.1   Unemployed (actively seeking work) 15 3.6   Unemployed (not seeking work) 64 15.3   Full-time students 1 0.2   Retired 39 9.4   Refused to answer 2 0.5 Currently postmenopausal 197 47.2 Early menarche (<12 years old) 15 3.6 Nulliparity 45 10.8 Late age at first childbirth (≥30 years old) 61 14.6 Previous use of oral contraceptives 108 25.9 Never breastfeeding 193 46.3 Regular use of alcohol (≥3 drinks/week) 16 3.8 Having immediate family members with breast cancer 16 3.8 Having friends with breast cancer 138 33.1 n % Age  Mean (SD) 50.5 (5.7) Body mass index  Mean (SD) 22.7 (3.3)   Underweight (<18.5) 34 8.2   Normal (18.5–23) 221 53.0   Overweight (23–24.9) 80 19.2   Obese (≥25) 80 19.2   Refused to answer 2 0.5 Marital status   Single 31 7.4   Married 351 84.2   Cohabiting 3 0.7   Divorced or separated 25 6.0   Widowed 7 1.7 Highest education level   No formal education 2 0.5   Primary school 118 28.3   Secondary school 217 52.0   Higher diploma or associate’s degree 31 7.4   Bachelor’s or master’s degree 49 11.8 Employment status   Currently employed (full-time) 283 67.9   Currently employed (part-time) 13 3.1   Unemployed (actively seeking work) 15 3.6   Unemployed (not seeking work) 64 15.3   Full-time students 1 0.2   Retired 39 9.4   Refused to answer 2 0.5 Currently postmenopausal 197 47.2 Early menarche (<12 years old) 15 3.6 Nulliparity 45 10.8 Late age at first childbirth (≥30 years old) 61 14.6 Previous use of oral contraceptives 108 25.9 Never breastfeeding 193 46.3 Regular use of alcohol (≥3 drinks/week) 16 3.8 Having immediate family members with breast cancer 16 3.8 Having friends with breast cancer 138 33.1 Table 1 Demographic and health-related characteristics of participants (N = 417) n % Age  Mean (SD) 50.5 (5.7) Body mass index  Mean (SD) 22.7 (3.3)   Underweight (<18.5) 34 8.2   Normal (18.5–23) 221 53.0   Overweight (23–24.9) 80 19.2   Obese (≥25) 80 19.2   Refused to answer 2 0.5 Marital status   Single 31 7.4   Married 351 84.2   Cohabiting 3 0.7   Divorced or separated 25 6.0   Widowed 7 1.7 Highest education level   No formal education 2 0.5   Primary school 118 28.3   Secondary school 217 52.0   Higher diploma or associate’s degree 31 7.4   Bachelor’s or master’s degree 49 11.8 Employment status   Currently employed (full-time) 283 67.9   Currently employed (part-time) 13 3.1   Unemployed (actively seeking work) 15 3.6   Unemployed (not seeking work) 64 15.3   Full-time students 1 0.2   Retired 39 9.4   Refused to answer 2 0.5 Currently postmenopausal 197 47.2 Early menarche (<12 years old) 15 3.6 Nulliparity 45 10.8 Late age at first childbirth (≥30 years old) 61 14.6 Previous use of oral contraceptives 108 25.9 Never breastfeeding 193 46.3 Regular use of alcohol (≥3 drinks/week) 16 3.8 Having immediate family members with breast cancer 16 3.8 Having friends with breast cancer 138 33.1 n % Age  Mean (SD) 50.5 (5.7) Body mass index  Mean (SD) 22.7 (3.3)   Underweight (<18.5) 34 8.2   Normal (18.5–23) 221 53.0   Overweight (23–24.9) 80 19.2   Obese (≥25) 80 19.2   Refused to answer 2 0.5 Marital status   Single 31 7.4   Married 351 84.2   Cohabiting 3 0.7   Divorced or separated 25 6.0   Widowed 7 1.7 Highest education level   No formal education 2 0.5   Primary school 118 28.3   Secondary school 217 52.0   Higher diploma or associate’s degree 31 7.4   Bachelor’s or master’s degree 49 11.8 Employment status   Currently employed (full-time) 283 67.9   Currently employed (part-time) 13 3.1   Unemployed (actively seeking work) 15 3.6   Unemployed (not seeking work) 64 15.3   Full-time students 1 0.2   Retired 39 9.4   Refused to answer 2 0.5 Currently postmenopausal 197 47.2 Early menarche (<12 years old) 15 3.6 Nulliparity 45 10.8 Late age at first childbirth (≥30 years old) 61 14.6 Previous use of oral contraceptives 108 25.9 Never breastfeeding 193 46.3 Regular use of alcohol (≥3 drinks/week) 16 3.8 Having immediate family members with breast cancer 16 3.8 Having friends with breast cancer 138 33.1 Fig. 1 View largeDownload slide Flow diagram of the study population. Fig. 1 View largeDownload slide Flow diagram of the study population. Table 2 summarized the participants’ fatigue and mental health status. The majority of participants had no or mild symptoms associated with anxiety (94.2%) and depression (92.1%). Around half of the participants (55.4%) suffered from mild fatigue. Table 2 Fatigue and mental health status of participants (N = 417) n % Symptoms of anxiety (per BAI scores)  No or mild (0–21) 393 94.2  Moderate (22–35) 22 5.3  Severe (≥36) 2 0.5 Symptoms of depression (per BDI scores)  Normal (0–10) 278 66.7  Mild or borderline (11–20) 106 25.4  Moderate (21–30) 25 6.0  Severe (≥31) 6 1.4  Could not be determined 2 0.5 Fatigue levels (per BFI scores)  Mild (0–3) 231 55.4  Moderate (4–6) 165 39.6  Severe (7–10) 21 5.0 n % Symptoms of anxiety (per BAI scores)  No or mild (0–21) 393 94.2  Moderate (22–35) 22 5.3  Severe (≥36) 2 0.5 Symptoms of depression (per BDI scores)  Normal (0–10) 278 66.7  Mild or borderline (11–20) 106 25.4  Moderate (21–30) 25 6.0  Severe (≥31) 6 1.4  Could not be determined 2 0.5 Fatigue levels (per BFI scores)  Mild (0–3) 231 55.4  Moderate (4–6) 165 39.6  Severe (7–10) 21 5.0 BAI = Beck Anxiety Inventory; BDI=Beck Depression Inventory; BFI=Brief Fatigue Inventory. Table 2 Fatigue and mental health status of participants (N = 417) n % Symptoms of anxiety (per BAI scores)  No or mild (0–21) 393 94.2  Moderate (22–35) 22 5.3  Severe (≥36) 2 0.5 Symptoms of depression (per BDI scores)  Normal (0–10) 278 66.7  Mild or borderline (11–20) 106 25.4  Moderate (21–30) 25 6.0  Severe (≥31) 6 1.4  Could not be determined 2 0.5 Fatigue levels (per BFI scores)  Mild (0–3) 231 55.4  Moderate (4–6) 165 39.6  Severe (7–10) 21 5.0 n % Symptoms of anxiety (per BAI scores)  No or mild (0–21) 393 94.2  Moderate (22–35) 22 5.3  Severe (≥36) 2 0.5 Symptoms of depression (per BDI scores)  Normal (0–10) 278 66.7  Mild or borderline (11–20) 106 25.4  Moderate (21–30) 25 6.0  Severe (≥31) 6 1.4  Could not be determined 2 0.5 Fatigue levels (per BFI scores)  Mild (0–3) 231 55.4  Moderate (4–6) 165 39.6  Severe (7–10) 21 5.0 BAI = Beck Anxiety Inventory; BDI=Beck Depression Inventory; BFI=Brief Fatigue Inventory. Screening practices and predictors of never having a BSE, CBE and mammogram Out of the 417 participants, 160 (38.4%) performed a BSE as often as recommended (once a month) while 128 (30.7%) had never done it before (Table 3). The most common reasons for not doing a BSE included ‘never heard of it’ (60.9%), ‘did not know how to perform it’ (14.1%) and ‘did not feel necessary to do it’ (10.2%). In the univariate analysis, low education level, unemployed/retired status, and having no friends/family members with breast cancer were associated with never performing a BSE (Table 4). After adjustment in the multivariate analysis, low education level (OR = 1.63; 95% CI = 1.00–2.64) and not knowing anyone with breast cancer (OR = 1.90; 95% CI = 1.14–3.15) remained the significant predictors of poor practices of BSE. Participants who never breastfed (OR = 1.65; 95% CI = 1.03–2.65) became significantly associated with poor practice of BSE. Negative attitude towards health check-ups (OR = 1.95, 95% CI = 1.13–3.35), limited knowledge about breast cancer (OR = 1.90; 95% CI = 1.19–3.02), and high barriers to mammographic screening (OR = 1.89; 95% CI = 1.18–3.00) also shown negative influence on BSE practice (Table 7). Table 3 Participants’ screening practices for breast cancer (N = 417) n % Breast self-examination (BSE)  Ever heard of BSE 339 81.3  Frequency of performing a BSE   Never 128 30.7   At least once a montha 160 38.4   Once every few months 77 18.5   Once a year 48 11.5   Once every 3–4 years 3 0.7   Refused to answer 1 0.2 Clinical breast examination (CBE)  Ever heard of CBE 302 72.4  Last CBE   Never 152 36.5   ≤1 year agoa 138 33.1   1–2 years agoa 58 13.9   2–3 years ago 35 8.4   >3 years ago 33 7.9   Refused to answer 1 0.2 Mammogram  Ever heard of mammogram 245 58.8  Frequency of having a mammogram   Never 257 61.6   Once a yeara 45 10.8   Once every 2 yearsa 58 13.9   Once every 3 years or more 56 13.5   Refused to answer 1 0.2 n % Breast self-examination (BSE)  Ever heard of BSE 339 81.3  Frequency of performing a BSE   Never 128 30.7   At least once a montha 160 38.4   Once every few months 77 18.5   Once a year 48 11.5   Once every 3–4 years 3 0.7   Refused to answer 1 0.2 Clinical breast examination (CBE)  Ever heard of CBE 302 72.4  Last CBE   Never 152 36.5   ≤1 year agoa 138 33.1   1–2 years agoa 58 13.9   2–3 years ago 35 8.4   >3 years ago 33 7.9   Refused to answer 1 0.2 Mammogram  Ever heard of mammogram 245 58.8  Frequency of having a mammogram   Never 257 61.6   Once a yeara 45 10.8   Once every 2 yearsa 58 13.9   Once every 3 years or more 56 13.5   Refused to answer 1 0.2 aConsidered as often as recommended by the Hong Kong Breast Cancer Foundation. Table 3 Participants’ screening practices for breast cancer (N = 417) n % Breast self-examination (BSE)  Ever heard of BSE 339 81.3  Frequency of performing a BSE   Never 128 30.7   At least once a montha 160 38.4   Once every few months 77 18.5   Once a year 48 11.5   Once every 3–4 years 3 0.7   Refused to answer 1 0.2 Clinical breast examination (CBE)  Ever heard of CBE 302 72.4  Last CBE   Never 152 36.5   ≤1 year agoa 138 33.1   1–2 years agoa 58 13.9   2–3 years ago 35 8.4   >3 years ago 33 7.9   Refused to answer 1 0.2 Mammogram  Ever heard of mammogram 245 58.8  Frequency of having a mammogram   Never 257 61.6   Once a yeara 45 10.8   Once every 2 yearsa 58 13.9   Once every 3 years or more 56 13.5   Refused to answer 1 0.2 n % Breast self-examination (BSE)  Ever heard of BSE 339 81.3  Frequency of performing a BSE   Never 128 30.7   At least once a montha 160 38.4   Once every few months 77 18.5   Once a year 48 11.5   Once every 3–4 years 3 0.7   Refused to answer 1 0.2 Clinical breast examination (CBE)  Ever heard of CBE 302 72.4  Last CBE   Never 152 36.5   ≤1 year agoa 138 33.1   1–2 years agoa 58 13.9   2–3 years ago 35 8.4   >3 years ago 33 7.9   Refused to answer 1 0.2 Mammogram  Ever heard of mammogram 245 58.8  Frequency of having a mammogram   Never 257 61.6   Once a yeara 45 10.8   Once every 2 yearsa 58 13.9   Once every 3 years or more 56 13.5   Refused to answer 1 0.2 aConsidered as often as recommended by the Hong Kong Breast Cancer Foundation. Table 4 Univariate analysis of predictors of never having a BSE, CBE and mammogram Never performed BSE (n = 128) P Never had CBE (n = 152) P Never had mammogram (n = 257) P Age  ≤50 years old (n = 210) 59 (28.1%) 0.206 79 (37.6%) 0.692 124 (59.0%) 0.232  >50 years old (n = 207) 70 (33.8%) 74 (35.7%) 134 (64.7%) BMI  Underweight or normal (n = 255) 84 (32.9%) 0.206 102 (40.0%) 0.059 161 (63.1%) 0.490  Overweight or obese (n = 159) 43 (27.0%) 49 (30.8%) 95 (59.7%) Education level  Primary school or lower (n = 120) 48 (40.0%) 0.011* 51 (42.5%) 0.118 89 (74.2%) 0.001*  Secondary school or higher (n = 297) 81 (27.3%) 102 (34.3%) 169 (56.9%) Marital status  Single, divorced, or widowed (n = 63) 26 (41.3%) 0.054 34 (54.0%) 0.002* 44 (69.8%) 0.157  Married or cohabiting (n = 354) 103 (29.1%) 119 (33.6%) 214 (60.5%) Employment Status  Unemployed or retired (n = 118) 47 (39.8%) 0.015* 56 (47.5%) 0.005* 87 (73.7%) 0.002*  Employed or studying (n = 297) 82 (27.6%) 97 (32.7%) 171 (57.6%) Having children  Yes (n = 370) 110 (29.7%) 0.269 126 (34.1%) 0.005* 224 (60.5%) 0.168  No (n = 45) 17 (37.8%) 25 (55.6%) 32 (71.1%) Friends/family with breast cancer  Yes (n = 145) 30 (20.7%) 0.001* 38 (26.2%) 0.001* 76 (52.4%) 0.004*  No or don’t know (n = 271) 98 (36.2%) 114 (42.1%) 181 (66.8%) Breastfeeding  No (n = 193) 53 (27.5%) 0.164 73 (37.8%) 0.707 121 (62.7%) 0.764  Yes (n = 222) 75 (33.8%) 80 (36.0%) 136 (61.3%) Menopausal status  Pre-menopausal (n = 220) 67 (30.5%) 0.822 84 (38.2%) 0.504 141 (64.1%) 0.324  Post-menopausal (n = 197) 62 (31.5%) 69 (35.0%) 117 (59.4%) Contraceptive usage  No (n = 307) 97 (31.6%) 0.626 117 (38.7%) 0.315 183 (59.6%) 0.112  Yes (n = 110) 32 (29.1%) 36 (32.7%) 75 (68.2%) Attitude towards health check-ups  Negative (n = 284) 104 (36.6%) <0.001* 126 (44.4%) <0.001* 196 (69.0%) <0.001*  Positive (n = 133) 25 (18.8%) 27 (20.3%) 62 (46.6%) Knowledge about breast cancer  Poor (n = 174) 76 (43.7%) <0.001* 94 (54.0%) <0.001* 127 (73.0%) <0.001*  Good (n = 233) 53 (21.8%) 59 (24.3%) 131 (53.9%) Barriers to mammographic screening  High (n = 176) 77 (43.8%) <0.001* 76 (43.2%) 0.019* 125 (71.0%) 0.001*  Low or no (n = 231) 52 (21.6%) 77 (32.0%) 133 (55.2%) Never performed BSE (n = 128) P Never had CBE (n = 152) P Never had mammogram (n = 257) P Age  ≤50 years old (n = 210) 59 (28.1%) 0.206 79 (37.6%) 0.692 124 (59.0%) 0.232  >50 years old (n = 207) 70 (33.8%) 74 (35.7%) 134 (64.7%) BMI  Underweight or normal (n = 255) 84 (32.9%) 0.206 102 (40.0%) 0.059 161 (63.1%) 0.490  Overweight or obese (n = 159) 43 (27.0%) 49 (30.8%) 95 (59.7%) Education level  Primary school or lower (n = 120) 48 (40.0%) 0.011* 51 (42.5%) 0.118 89 (74.2%) 0.001*  Secondary school or higher (n = 297) 81 (27.3%) 102 (34.3%) 169 (56.9%) Marital status  Single, divorced, or widowed (n = 63) 26 (41.3%) 0.054 34 (54.0%) 0.002* 44 (69.8%) 0.157  Married or cohabiting (n = 354) 103 (29.1%) 119 (33.6%) 214 (60.5%) Employment Status  Unemployed or retired (n = 118) 47 (39.8%) 0.015* 56 (47.5%) 0.005* 87 (73.7%) 0.002*  Employed or studying (n = 297) 82 (27.6%) 97 (32.7%) 171 (57.6%) Having children  Yes (n = 370) 110 (29.7%) 0.269 126 (34.1%) 0.005* 224 (60.5%) 0.168  No (n = 45) 17 (37.8%) 25 (55.6%) 32 (71.1%) Friends/family with breast cancer  Yes (n = 145) 30 (20.7%) 0.001* 38 (26.2%) 0.001* 76 (52.4%) 0.004*  No or don’t know (n = 271) 98 (36.2%) 114 (42.1%) 181 (66.8%) Breastfeeding  No (n = 193) 53 (27.5%) 0.164 73 (37.8%) 0.707 121 (62.7%) 0.764  Yes (n = 222) 75 (33.8%) 80 (36.0%) 136 (61.3%) Menopausal status  Pre-menopausal (n = 220) 67 (30.5%) 0.822 84 (38.2%) 0.504 141 (64.1%) 0.324  Post-menopausal (n = 197) 62 (31.5%) 69 (35.0%) 117 (59.4%) Contraceptive usage  No (n = 307) 97 (31.6%) 0.626 117 (38.7%) 0.315 183 (59.6%) 0.112  Yes (n = 110) 32 (29.1%) 36 (32.7%) 75 (68.2%) Attitude towards health check-ups  Negative (n = 284) 104 (36.6%) <0.001* 126 (44.4%) <0.001* 196 (69.0%) <0.001*  Positive (n = 133) 25 (18.8%) 27 (20.3%) 62 (46.6%) Knowledge about breast cancer  Poor (n = 174) 76 (43.7%) <0.001* 94 (54.0%) <0.001* 127 (73.0%) <0.001*  Good (n = 233) 53 (21.8%) 59 (24.3%) 131 (53.9%) Barriers to mammographic screening  High (n = 176) 77 (43.8%) <0.001* 76 (43.2%) 0.019* 125 (71.0%) 0.001*  Low or no (n = 231) 52 (21.6%) 77 (32.0%) 133 (55.2%) BMI = body mass index; BSE = breast self-examination; CBE = clinical breast examination. *Statistically significant under Pearson Chi-square test, P < 0.05. Table 4 Univariate analysis of predictors of never having a BSE, CBE and mammogram Never performed BSE (n = 128) P Never had CBE (n = 152) P Never had mammogram (n = 257) P Age  ≤50 years old (n = 210) 59 (28.1%) 0.206 79 (37.6%) 0.692 124 (59.0%) 0.232  >50 years old (n = 207) 70 (33.8%) 74 (35.7%) 134 (64.7%) BMI  Underweight or normal (n = 255) 84 (32.9%) 0.206 102 (40.0%) 0.059 161 (63.1%) 0.490  Overweight or obese (n = 159) 43 (27.0%) 49 (30.8%) 95 (59.7%) Education level  Primary school or lower (n = 120) 48 (40.0%) 0.011* 51 (42.5%) 0.118 89 (74.2%) 0.001*  Secondary school or higher (n = 297) 81 (27.3%) 102 (34.3%) 169 (56.9%) Marital status  Single, divorced, or widowed (n = 63) 26 (41.3%) 0.054 34 (54.0%) 0.002* 44 (69.8%) 0.157  Married or cohabiting (n = 354) 103 (29.1%) 119 (33.6%) 214 (60.5%) Employment Status  Unemployed or retired (n = 118) 47 (39.8%) 0.015* 56 (47.5%) 0.005* 87 (73.7%) 0.002*  Employed or studying (n = 297) 82 (27.6%) 97 (32.7%) 171 (57.6%) Having children  Yes (n = 370) 110 (29.7%) 0.269 126 (34.1%) 0.005* 224 (60.5%) 0.168  No (n = 45) 17 (37.8%) 25 (55.6%) 32 (71.1%) Friends/family with breast cancer  Yes (n = 145) 30 (20.7%) 0.001* 38 (26.2%) 0.001* 76 (52.4%) 0.004*  No or don’t know (n = 271) 98 (36.2%) 114 (42.1%) 181 (66.8%) Breastfeeding  No (n = 193) 53 (27.5%) 0.164 73 (37.8%) 0.707 121 (62.7%) 0.764  Yes (n = 222) 75 (33.8%) 80 (36.0%) 136 (61.3%) Menopausal status  Pre-menopausal (n = 220) 67 (30.5%) 0.822 84 (38.2%) 0.504 141 (64.1%) 0.324  Post-menopausal (n = 197) 62 (31.5%) 69 (35.0%) 117 (59.4%) Contraceptive usage  No (n = 307) 97 (31.6%) 0.626 117 (38.7%) 0.315 183 (59.6%) 0.112  Yes (n = 110) 32 (29.1%) 36 (32.7%) 75 (68.2%) Attitude towards health check-ups  Negative (n = 284) 104 (36.6%) <0.001* 126 (44.4%) <0.001* 196 (69.0%) <0.001*  Positive (n = 133) 25 (18.8%) 27 (20.3%) 62 (46.6%) Knowledge about breast cancer  Poor (n = 174) 76 (43.7%) <0.001* 94 (54.0%) <0.001* 127 (73.0%) <0.001*  Good (n = 233) 53 (21.8%) 59 (24.3%) 131 (53.9%) Barriers to mammographic screening  High (n = 176) 77 (43.8%) <0.001* 76 (43.2%) 0.019* 125 (71.0%) 0.001*  Low or no (n = 231) 52 (21.6%) 77 (32.0%) 133 (55.2%) Never performed BSE (n = 128) P Never had CBE (n = 152) P Never had mammogram (n = 257) P Age  ≤50 years old (n = 210) 59 (28.1%) 0.206 79 (37.6%) 0.692 124 (59.0%) 0.232  >50 years old (n = 207) 70 (33.8%) 74 (35.7%) 134 (64.7%) BMI  Underweight or normal (n = 255) 84 (32.9%) 0.206 102 (40.0%) 0.059 161 (63.1%) 0.490  Overweight or obese (n = 159) 43 (27.0%) 49 (30.8%) 95 (59.7%) Education level  Primary school or lower (n = 120) 48 (40.0%) 0.011* 51 (42.5%) 0.118 89 (74.2%) 0.001*  Secondary school or higher (n = 297) 81 (27.3%) 102 (34.3%) 169 (56.9%) Marital status  Single, divorced, or widowed (n = 63) 26 (41.3%) 0.054 34 (54.0%) 0.002* 44 (69.8%) 0.157  Married or cohabiting (n = 354) 103 (29.1%) 119 (33.6%) 214 (60.5%) Employment Status  Unemployed or retired (n = 118) 47 (39.8%) 0.015* 56 (47.5%) 0.005* 87 (73.7%) 0.002*  Employed or studying (n = 297) 82 (27.6%) 97 (32.7%) 171 (57.6%) Having children  Yes (n = 370) 110 (29.7%) 0.269 126 (34.1%) 0.005* 224 (60.5%) 0.168  No (n = 45) 17 (37.8%) 25 (55.6%) 32 (71.1%) Friends/family with breast cancer  Yes (n = 145) 30 (20.7%) 0.001* 38 (26.2%) 0.001* 76 (52.4%) 0.004*  No or don’t know (n = 271) 98 (36.2%) 114 (42.1%) 181 (66.8%) Breastfeeding  No (n = 193) 53 (27.5%) 0.164 73 (37.8%) 0.707 121 (62.7%) 0.764  Yes (n = 222) 75 (33.8%) 80 (36.0%) 136 (61.3%) Menopausal status  Pre-menopausal (n = 220) 67 (30.5%) 0.822 84 (38.2%) 0.504 141 (64.1%) 0.324  Post-menopausal (n = 197) 62 (31.5%) 69 (35.0%) 117 (59.4%) Contraceptive usage  No (n = 307) 97 (31.6%) 0.626 117 (38.7%) 0.315 183 (59.6%) 0.112  Yes (n = 110) 32 (29.1%) 36 (32.7%) 75 (68.2%) Attitude towards health check-ups  Negative (n = 284) 104 (36.6%) <0.001* 126 (44.4%) <0.001* 196 (69.0%) <0.001*  Positive (n = 133) 25 (18.8%) 27 (20.3%) 62 (46.6%) Knowledge about breast cancer  Poor (n = 174) 76 (43.7%) <0.001* 94 (54.0%) <0.001* 127 (73.0%) <0.001*  Good (n = 233) 53 (21.8%) 59 (24.3%) 131 (53.9%) Barriers to mammographic screening  High (n = 176) 77 (43.8%) <0.001* 76 (43.2%) 0.019* 125 (71.0%) 0.001*  Low or no (n = 231) 52 (21.6%) 77 (32.0%) 133 (55.2%) BMI = body mass index; BSE = breast self-examination; CBE = clinical breast examination. *Statistically significant under Pearson Chi-square test, P < 0.05. Only 196 participants (47.0%) had a CBE at a recommended interval (at least every 2 years) (Table 3). In contrast, 152 participants (36.5%) had never received a CBE because they had never heard of it (75.7%), did not feel necessary to receive it (9.2%) or found no problems from BSE (3.9%). The univariate analysis revealed that women who were single/divorced/widowed, unemployed/retired, had no children, and did not know anyone with breast cancer were less likely to receive a CBE (Table 4). Among these variables, marital status (OR = 2.39; 95% CI = 1.33–4.31), employment status (OR = 1.82; 95% CI = 1.14–2.92), not knowing anybody with breast cancer (OR = 1.73; 95% CI = 1.07–2.80) and having negative attitude towards health check-ups (OR = 2.38; 95% CI = 1.43–3.98) and limited knowledge about breast cancer (OR = 2.87; 95% CI = 1.84–4.49) were independently associated with never having a CBE (Table 7). Approximately one-fourth of the participants (24.7%) were compliant with regular mammographic screening as recommended (at least every 2 years) but the majority (61.9%) had never obtained a mammogram (Table 3) for the reasons such as ‘never heard of it’ (66.9%), ‘did not feel necessary’ (17.1%), and ‘physicians did not recommend it’ (3.9%). Based on the univariate and multivariate analysis, having no friends/family members with breast cancer (OR = 1.84; 95% CI = 1.20–2.83), unemployed/retired status (OR = 1.66; 95% CI = 1.01–2.72) and low education level (OR = 1.99; 95% CI = 1.21–3.28) were the significant predictors of never obtaining a mammogram (Tables 4 and 7). In addition, those who were poorly educated (OR = 1.95; 95% CI = 1.13–3.35), having negative attitude towards health check-ups (OR = 2.05; 95% CI = 1.31–3.21) and insufficient knowledge about breast cancer (OR = 1.86; 95% CI = 1.19–2.91) were less likely to have a mammogram as often as recommended. Attitudes towards health check-ups, perceptions and knowledge about breast cancer, and perceived barriers to mammographic screening Among all participants, the mean score (±SD) of participants on attitudes towards health check-ups was 51.2 (±1.2), on perceptions and knowledge about breast cancer was 65.9 (±0.9), and on barriers to mammographic screening was 61.7 (±1.0). Overall, 284 participants (68.1%) had negative overall attitudes towards health check-ups and most of them believed that they should consult a physician or have a check-up only when they had a health problem. In total, 174 participants (41.7%) were found to have insufficient knowledge about breast cancer based on their responses to the four corresponding statements of the modified CBCSB. With respect to mammographic screening, 42.2% of participants had more perceived barriers. Most participants were not concerned about potential harm or exposing their breasts during the procedure but 31.7% of participants admitted that having a mammogram was embarrassing (Table 5). Univariate analysis revealed that women with negative attitudes towards health check-ups or insufficient knowledge about breast cancer were less likely to use any of the three screening methods (P < 0.001). As expected, there was also a strong association between more perceived barriers and a lack of mammographic screening (P = 0.001). Table 5 Participants’ attitudes towards health check-ups, perceptions and knowledge about breast cancer and perceived barriers to mammographic screening (n = 417) Agree Do not know Disagree Attitudes towards health check-ups If I feel well, it is not necessary to have a health check-up. 159 (38.1%) 17 (4.1%) 241 (57.8%) If I follow a healthy lifestyle such as a balanced diet and regular exercise, I don’t feel it is necessary to have a regular health check-up. 121 (29.0%) 22 (5.3%) 274 (65.7%) I see a doctor or have my health check-up only when I have a health problem. 223 (53.5%) 11 (5.3%) 183 (43.9%) If I feel healthy, I do not need to see the doctor. 257 (61.6%) 17 (4.1%) 143 (34.3%)  Poor attitude towards health check-upsa 284 (68.1%) Perceptions and knowledge about breast cancer Breast cancer is like a death sentence; if you get it, you will surely die from it. 59 (14.1%) 69 (16.5%) 289 (69.3%) Breast cancer cannot be cured; you can only prolong the suffering. 63 (15.1%) 68 (16.3%) 286 (68.6%) Even if breast cancer is detected early, there is very little a woman can do to reduce the chances of dying from it. 50 (12.0%) 82 (19.7%) 285 (68.3%) If a woman is fated to get breast cancer, she will get breast cancer; there is nothing she can do to change fate. 61 (14.6%) 73 (17.5%) 283 (67.9%)  Insufficient knowledge about breast cancera 174 (41.7%) Perceived barriers to mammographic screening I’m worried that having a mammogram will hurt my breasts. 61 (14.6%) 101 (24.2%) 255 (61.2%) I don’t want to go for a mammogram because I would need to take off my clothes and expose my breasts. 82 (19.7%) 42 (10.1%) 293 (70.3%) Having a mammogram is embarrassing. 132 (31.7%) 30 (7.2%) 255 (61.2%)  High barriers to mammographic screeninga 176 (42.2%) Agree Do not know Disagree Attitudes towards health check-ups If I feel well, it is not necessary to have a health check-up. 159 (38.1%) 17 (4.1%) 241 (57.8%) If I follow a healthy lifestyle such as a balanced diet and regular exercise, I don’t feel it is necessary to have a regular health check-up. 121 (29.0%) 22 (5.3%) 274 (65.7%) I see a doctor or have my health check-up only when I have a health problem. 223 (53.5%) 11 (5.3%) 183 (43.9%) If I feel healthy, I do not need to see the doctor. 257 (61.6%) 17 (4.1%) 143 (34.3%)  Poor attitude towards health check-upsa 284 (68.1%) Perceptions and knowledge about breast cancer Breast cancer is like a death sentence; if you get it, you will surely die from it. 59 (14.1%) 69 (16.5%) 289 (69.3%) Breast cancer cannot be cured; you can only prolong the suffering. 63 (15.1%) 68 (16.3%) 286 (68.6%) Even if breast cancer is detected early, there is very little a woman can do to reduce the chances of dying from it. 50 (12.0%) 82 (19.7%) 285 (68.3%) If a woman is fated to get breast cancer, she will get breast cancer; there is nothing she can do to change fate. 61 (14.6%) 73 (17.5%) 283 (67.9%)  Insufficient knowledge about breast cancera 174 (41.7%) Perceived barriers to mammographic screening I’m worried that having a mammogram will hurt my breasts. 61 (14.6%) 101 (24.2%) 255 (61.2%) I don’t want to go for a mammogram because I would need to take off my clothes and expose my breasts. 82 (19.7%) 42 (10.1%) 293 (70.3%) Having a mammogram is embarrassing. 132 (31.7%) 30 (7.2%) 255 (61.2%)  High barriers to mammographic screeninga 176 (42.2%) aAs indicated by the standardized scores of corresponding CBCSB subscales lower than 65. Table 5 Participants’ attitudes towards health check-ups, perceptions and knowledge about breast cancer and perceived barriers to mammographic screening (n = 417) Agree Do not know Disagree Attitudes towards health check-ups If I feel well, it is not necessary to have a health check-up. 159 (38.1%) 17 (4.1%) 241 (57.8%) If I follow a healthy lifestyle such as a balanced diet and regular exercise, I don’t feel it is necessary to have a regular health check-up. 121 (29.0%) 22 (5.3%) 274 (65.7%) I see a doctor or have my health check-up only when I have a health problem. 223 (53.5%) 11 (5.3%) 183 (43.9%) If I feel healthy, I do not need to see the doctor. 257 (61.6%) 17 (4.1%) 143 (34.3%)  Poor attitude towards health check-upsa 284 (68.1%) Perceptions and knowledge about breast cancer Breast cancer is like a death sentence; if you get it, you will surely die from it. 59 (14.1%) 69 (16.5%) 289 (69.3%) Breast cancer cannot be cured; you can only prolong the suffering. 63 (15.1%) 68 (16.3%) 286 (68.6%) Even if breast cancer is detected early, there is very little a woman can do to reduce the chances of dying from it. 50 (12.0%) 82 (19.7%) 285 (68.3%) If a woman is fated to get breast cancer, she will get breast cancer; there is nothing she can do to change fate. 61 (14.6%) 73 (17.5%) 283 (67.9%)  Insufficient knowledge about breast cancera 174 (41.7%) Perceived barriers to mammographic screening I’m worried that having a mammogram will hurt my breasts. 61 (14.6%) 101 (24.2%) 255 (61.2%) I don’t want to go for a mammogram because I would need to take off my clothes and expose my breasts. 82 (19.7%) 42 (10.1%) 293 (70.3%) Having a mammogram is embarrassing. 132 (31.7%) 30 (7.2%) 255 (61.2%)  High barriers to mammographic screeninga 176 (42.2%) Agree Do not know Disagree Attitudes towards health check-ups If I feel well, it is not necessary to have a health check-up. 159 (38.1%) 17 (4.1%) 241 (57.8%) If I follow a healthy lifestyle such as a balanced diet and regular exercise, I don’t feel it is necessary to have a regular health check-up. 121 (29.0%) 22 (5.3%) 274 (65.7%) I see a doctor or have my health check-up only when I have a health problem. 223 (53.5%) 11 (5.3%) 183 (43.9%) If I feel healthy, I do not need to see the doctor. 257 (61.6%) 17 (4.1%) 143 (34.3%)  Poor attitude towards health check-upsa 284 (68.1%) Perceptions and knowledge about breast cancer Breast cancer is like a death sentence; if you get it, you will surely die from it. 59 (14.1%) 69 (16.5%) 289 (69.3%) Breast cancer cannot be cured; you can only prolong the suffering. 63 (15.1%) 68 (16.3%) 286 (68.6%) Even if breast cancer is detected early, there is very little a woman can do to reduce the chances of dying from it. 50 (12.0%) 82 (19.7%) 285 (68.3%) If a woman is fated to get breast cancer, she will get breast cancer; there is nothing she can do to change fate. 61 (14.6%) 73 (17.5%) 283 (67.9%)  Insufficient knowledge about breast cancera 174 (41.7%) Perceived barriers to mammographic screening I’m worried that having a mammogram will hurt my breasts. 61 (14.6%) 101 (24.2%) 255 (61.2%) I don’t want to go for a mammogram because I would need to take off my clothes and expose my breasts. 82 (19.7%) 42 (10.1%) 293 (70.3%) Having a mammogram is embarrassing. 132 (31.7%) 30 (7.2%) 255 (61.2%)  High barriers to mammographic screeninga 176 (42.2%) aAs indicated by the standardized scores of corresponding CBCSB subscales lower than 65. Predictors of negative attitudes towards health check-ups, limited knowledge about breast cancer and high barriers to mammographic screening Never breastfeeding was shown to be related to negative attitudes towards health check-ups (Table 6), but the association did not persist after adjustment in the multivariate model. Nulliparity (OR = 2.56; 95% CI = 1.14–5.73) and low education (OR = 1.72; 95% CI = 1.04–2.84) were shown significantly associated with the negative attitude (Table 7). Women who did not know anyone with breast cancer were more likely to have insufficient knowledge about the disease (OR = 2.30; 95% CI = 1.50–3.55). Moreover, multiple characteristics were found to be associated with high barriers to mammographic screening, including low education level, being single/divorced/widowed, unemployed/retired status, nulliparity, and having no friends/family members with breast cancer (Table 6). Following the multivariate logistic regression analysis, low education level (OR = 1.95; 95% CI = 1.25–3.04) and not knowing anyone with breast cancer (OR = 2.02; 95% CI = 1.31–3.13) were identified as the independent predictors of high perceived barriers to mammography (Table 7). Table 6 Univariate analysis of predictors of negative attitudes towards health check-ups, insufficient knowledge about breast cancer, and high perceived barriers to mammographic screening Negative attitudes towards health check-ups (n = 284) P Insufficient knowledge about breast cancer (n = 174) P High barriers to mammographic screening (n = 176) P Age  ≤50 years old (n = 210) 136 (64.8%) 0.140 80 (38.1%) 0.130 88 (41.9%) 0.900  >50 years old (n = 207) 148 (71.5%) 94 (45.4%) 88 (42.5%) BMI  Underweight or normal (n = 255) 175 (68.6%) 0.710 110 (43.1%) 0.528 106 (41.6%) 0.662  Overweight or obese (n = 160) 107 (66.9%) 64 (40.0%) 70 (43.8%) Education level  Primary school or lower (n = 120) 90 (75.0%) 0.055 53 (44.2%) 0.521 62 (51.7%) 0.013*  Secondary school or higher (n = 297) 194 (65.3%) 121 (40.7%) 114 (38.4%) Marital status  Single, divorced, or widowed (n = 63) 47 (74.6%) 0.230 30 (47.6%) 0.303 36 (57.1%) 0.009*  Married or cohabiting (n = 354) 237 (66.9%) 144 (40.7%) 140 (39.5%) Employment status  Unemployed or retired (n = 118) 84 (71.2%) 0.409 54 (45.8%) 0.318 60 (50.8%) 0.028*  Employed or studying (n = 297) 199 (67.0%) 120 (40.4%) 116 (39.1%) Having children  Yes (n = 371) 246 (66.3%) 0.031* 152 (41.0%) 0.464 147 (39.6%) 0.004*  No (n = 45) 37 (82.2%) 21 (46.7%) 28 (62.2%) Breastfeeding  Yes (n = 222) 141 (63.5%) 0.028* 91 (41.0%) 0.758 89 (40.1%) 0.358  No (n = 193) 142 (73.6%) 82 (42.5%) 86 (44.6%) Friends/family with breast cancer  Yes (n = 145) 91 (62.8%) 0.087 43 (29.7%) <0.001* 47 (32.4%) 0.003*  No or don’t know (n = 272) 193 (71.0%) 131 (48.2%) 129 (47.4%) Menopausal status  Pre-menopausal (n = 220) 153 (69.5%) 0.505 92 (41.8%) 0.968 91 (41.4%) 0.713  Post-menopausal (n = 197) 131 (66.5%) 82 (41.6%) 85 (43.1%) Contraceptive usage  No (n = 307) 207 (67.4%) 0.619 124 (40.4%) 0.355 137 (44.6%) 0.095  Yes (n = 110) 77 (70.0%) 50 (45.5%) 39 (35.5%) Negative attitudes towards health check-ups (n = 284) P Insufficient knowledge about breast cancer (n = 174) P High barriers to mammographic screening (n = 176) P Age  ≤50 years old (n = 210) 136 (64.8%) 0.140 80 (38.1%) 0.130 88 (41.9%) 0.900  >50 years old (n = 207) 148 (71.5%) 94 (45.4%) 88 (42.5%) BMI  Underweight or normal (n = 255) 175 (68.6%) 0.710 110 (43.1%) 0.528 106 (41.6%) 0.662  Overweight or obese (n = 160) 107 (66.9%) 64 (40.0%) 70 (43.8%) Education level  Primary school or lower (n = 120) 90 (75.0%) 0.055 53 (44.2%) 0.521 62 (51.7%) 0.013*  Secondary school or higher (n = 297) 194 (65.3%) 121 (40.7%) 114 (38.4%) Marital status  Single, divorced, or widowed (n = 63) 47 (74.6%) 0.230 30 (47.6%) 0.303 36 (57.1%) 0.009*  Married or cohabiting (n = 354) 237 (66.9%) 144 (40.7%) 140 (39.5%) Employment status  Unemployed or retired (n = 118) 84 (71.2%) 0.409 54 (45.8%) 0.318 60 (50.8%) 0.028*  Employed or studying (n = 297) 199 (67.0%) 120 (40.4%) 116 (39.1%) Having children  Yes (n = 371) 246 (66.3%) 0.031* 152 (41.0%) 0.464 147 (39.6%) 0.004*  No (n = 45) 37 (82.2%) 21 (46.7%) 28 (62.2%) Breastfeeding  Yes (n = 222) 141 (63.5%) 0.028* 91 (41.0%) 0.758 89 (40.1%) 0.358  No (n = 193) 142 (73.6%) 82 (42.5%) 86 (44.6%) Friends/family with breast cancer  Yes (n = 145) 91 (62.8%) 0.087 43 (29.7%) <0.001* 47 (32.4%) 0.003*  No or don’t know (n = 272) 193 (71.0%) 131 (48.2%) 129 (47.4%) Menopausal status  Pre-menopausal (n = 220) 153 (69.5%) 0.505 92 (41.8%) 0.968 91 (41.4%) 0.713  Post-menopausal (n = 197) 131 (66.5%) 82 (41.6%) 85 (43.1%) Contraceptive usage  No (n = 307) 207 (67.4%) 0.619 124 (40.4%) 0.355 137 (44.6%) 0.095  Yes (n = 110) 77 (70.0%) 50 (45.5%) 39 (35.5%) *Statistically significant under Pearson Chi-square test, P < 0.05. Table 6 Univariate analysis of predictors of negative attitudes towards health check-ups, insufficient knowledge about breast cancer, and high perceived barriers to mammographic screening Negative attitudes towards health check-ups (n = 284) P Insufficient knowledge about breast cancer (n = 174) P High barriers to mammographic screening (n = 176) P Age  ≤50 years old (n = 210) 136 (64.8%) 0.140 80 (38.1%) 0.130 88 (41.9%) 0.900  >50 years old (n = 207) 148 (71.5%) 94 (45.4%) 88 (42.5%) BMI  Underweight or normal (n = 255) 175 (68.6%) 0.710 110 (43.1%) 0.528 106 (41.6%) 0.662  Overweight or obese (n = 160) 107 (66.9%) 64 (40.0%) 70 (43.8%) Education level  Primary school or lower (n = 120) 90 (75.0%) 0.055 53 (44.2%) 0.521 62 (51.7%) 0.013*  Secondary school or higher (n = 297) 194 (65.3%) 121 (40.7%) 114 (38.4%) Marital status  Single, divorced, or widowed (n = 63) 47 (74.6%) 0.230 30 (47.6%) 0.303 36 (57.1%) 0.009*  Married or cohabiting (n = 354) 237 (66.9%) 144 (40.7%) 140 (39.5%) Employment status  Unemployed or retired (n = 118) 84 (71.2%) 0.409 54 (45.8%) 0.318 60 (50.8%) 0.028*  Employed or studying (n = 297) 199 (67.0%) 120 (40.4%) 116 (39.1%) Having children  Yes (n = 371) 246 (66.3%) 0.031* 152 (41.0%) 0.464 147 (39.6%) 0.004*  No (n = 45) 37 (82.2%) 21 (46.7%) 28 (62.2%) Breastfeeding  Yes (n = 222) 141 (63.5%) 0.028* 91 (41.0%) 0.758 89 (40.1%) 0.358  No (n = 193) 142 (73.6%) 82 (42.5%) 86 (44.6%) Friends/family with breast cancer  Yes (n = 145) 91 (62.8%) 0.087 43 (29.7%) <0.001* 47 (32.4%) 0.003*  No or don’t know (n = 272) 193 (71.0%) 131 (48.2%) 129 (47.4%) Menopausal status  Pre-menopausal (n = 220) 153 (69.5%) 0.505 92 (41.8%) 0.968 91 (41.4%) 0.713  Post-menopausal (n = 197) 131 (66.5%) 82 (41.6%) 85 (43.1%) Contraceptive usage  No (n = 307) 207 (67.4%) 0.619 124 (40.4%) 0.355 137 (44.6%) 0.095  Yes (n = 110) 77 (70.0%) 50 (45.5%) 39 (35.5%) Negative attitudes towards health check-ups (n = 284) P Insufficient knowledge about breast cancer (n = 174) P High barriers to mammographic screening (n = 176) P Age  ≤50 years old (n = 210) 136 (64.8%) 0.140 80 (38.1%) 0.130 88 (41.9%) 0.900  >50 years old (n = 207) 148 (71.5%) 94 (45.4%) 88 (42.5%) BMI  Underweight or normal (n = 255) 175 (68.6%) 0.710 110 (43.1%) 0.528 106 (41.6%) 0.662  Overweight or obese (n = 160) 107 (66.9%) 64 (40.0%) 70 (43.8%) Education level  Primary school or lower (n = 120) 90 (75.0%) 0.055 53 (44.2%) 0.521 62 (51.7%) 0.013*  Secondary school or higher (n = 297) 194 (65.3%) 121 (40.7%) 114 (38.4%) Marital status  Single, divorced, or widowed (n = 63) 47 (74.6%) 0.230 30 (47.6%) 0.303 36 (57.1%) 0.009*  Married or cohabiting (n = 354) 237 (66.9%) 144 (40.7%) 140 (39.5%) Employment status  Unemployed or retired (n = 118) 84 (71.2%) 0.409 54 (45.8%) 0.318 60 (50.8%) 0.028*  Employed or studying (n = 297) 199 (67.0%) 120 (40.4%) 116 (39.1%) Having children  Yes (n = 371) 246 (66.3%) 0.031* 152 (41.0%) 0.464 147 (39.6%) 0.004*  No (n = 45) 37 (82.2%) 21 (46.7%) 28 (62.2%) Breastfeeding  Yes (n = 222) 141 (63.5%) 0.028* 91 (41.0%) 0.758 89 (40.1%) 0.358  No (n = 193) 142 (73.6%) 82 (42.5%) 86 (44.6%) Friends/family with breast cancer  Yes (n = 145) 91 (62.8%) 0.087 43 (29.7%) <0.001* 47 (32.4%) 0.003*  No or don’t know (n = 272) 193 (71.0%) 131 (48.2%) 129 (47.4%) Menopausal status  Pre-menopausal (n = 220) 153 (69.5%) 0.505 92 (41.8%) 0.968 91 (41.4%) 0.713  Post-menopausal (n = 197) 131 (66.5%) 82 (41.6%) 85 (43.1%) Contraceptive usage  No (n = 307) 207 (67.4%) 0.619 124 (40.4%) 0.355 137 (44.6%) 0.095  Yes (n = 110) 77 (70.0%) 50 (45.5%) 39 (35.5%) *Statistically significant under Pearson Chi-square test, P < 0.05. Table 7 Multivariate logistic regression analysis of predictors of poor screening practices, negative attitudes towards health check-ups, insufficient knowledge about breast cancer, and high perceived barriers to mammographic screening Never performed BSE Never had a CBE Never had a mammogram Negative attitudes towards health check-ups Insufficient knowledge about breast cancer High barriers to mammographic screening OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P No friends/family with breast cancer 1.90 (1.14–3.15) 0.014* 1.73 (1.07–2.80) 0.025* 1.62 (1.04–2.52) 0.032* – – 2.30 (1.50–3.55) <0.001* 2.02 (1.31–3.13) 0.002* Unemployed or retired – – 1.82 (1.14–2.92) 0.013* 1.73 (1.04–2.86) 0.033* – – – – – – Primary education or lower 1.63 (1.00–2.64) 0.049* – – 1.91 (1.15–3.17) 0.012* 1.72 (1.04–2.84) 0.034* – – 1.95 (1.25–3.04) 0.003* Single, divorced or widowed 1.85 (1.00–3.41) 0.051 2.39 (1.33–4.31) 0.004* – – – – – – 1.74 (0.92–3.30) 0.091 Nulliparity – – – – – – 2.56 (1.14–5.73) 0.022* – – 2.00 (0.96–4.21) 0.066 Never breastfeeding 1.65 (1.03–2.65) 0.036* – – – – – – – – – – Negative attitudes towards health check-ups 1.95 (1.13–3.35) 0.017* 2.38 (1.43–3.98) 0.001* 2.05 (1.31–3.21) 0.002* – – – – – – Insufficient knowledge about breast cancer 1.90 (1.19–3.02) 0.007* 2.87 (1.84–4.49) <0.001* 1.86 (1.19–2.91) 0.007* – – – – – – High barriers to mammographic screening 1.89 (1.18–3.00) 0.008* – – – – – – – – – – Never performed BSE Never had a CBE Never had a mammogram Negative attitudes towards health check-ups Insufficient knowledge about breast cancer High barriers to mammographic screening OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P No friends/family with breast cancer 1.90 (1.14–3.15) 0.014* 1.73 (1.07–2.80) 0.025* 1.62 (1.04–2.52) 0.032* – – 2.30 (1.50–3.55) <0.001* 2.02 (1.31–3.13) 0.002* Unemployed or retired – – 1.82 (1.14–2.92) 0.013* 1.73 (1.04–2.86) 0.033* – – – – – – Primary education or lower 1.63 (1.00–2.64) 0.049* – – 1.91 (1.15–3.17) 0.012* 1.72 (1.04–2.84) 0.034* – – 1.95 (1.25–3.04) 0.003* Single, divorced or widowed 1.85 (1.00–3.41) 0.051 2.39 (1.33–4.31) 0.004* – – – – – – 1.74 (0.92–3.30) 0.091 Nulliparity – – – – – – 2.56 (1.14–5.73) 0.022* – – 2.00 (0.96–4.21) 0.066 Never breastfeeding 1.65 (1.03–2.65) 0.036* – – – – – – – – – – Negative attitudes towards health check-ups 1.95 (1.13–3.35) 0.017* 2.38 (1.43–3.98) 0.001* 2.05 (1.31–3.21) 0.002* – – – – – – Insufficient knowledge about breast cancer 1.90 (1.19–3.02) 0.007* 2.87 (1.84–4.49) <0.001* 1.86 (1.19–2.91) 0.007* – – – – – – High barriers to mammographic screening 1.89 (1.18–3.00) 0.008* – – – – – – – – – – BSE = breast self-examination; CBE = clinical breast examination; CI = confidence interval; OR = odd ratio. Gray shades indicate those fields that did not apply (instead of not value). *Statistically significant under binary logistic regression, P < 0.05. Table 7 Multivariate logistic regression analysis of predictors of poor screening practices, negative attitudes towards health check-ups, insufficient knowledge about breast cancer, and high perceived barriers to mammographic screening Never performed BSE Never had a CBE Never had a mammogram Negative attitudes towards health check-ups Insufficient knowledge about breast cancer High barriers to mammographic screening OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P No friends/family with breast cancer 1.90 (1.14–3.15) 0.014* 1.73 (1.07–2.80) 0.025* 1.62 (1.04–2.52) 0.032* – – 2.30 (1.50–3.55) <0.001* 2.02 (1.31–3.13) 0.002* Unemployed or retired – – 1.82 (1.14–2.92) 0.013* 1.73 (1.04–2.86) 0.033* – – – – – – Primary education or lower 1.63 (1.00–2.64) 0.049* – – 1.91 (1.15–3.17) 0.012* 1.72 (1.04–2.84) 0.034* – – 1.95 (1.25–3.04) 0.003* Single, divorced or widowed 1.85 (1.00–3.41) 0.051 2.39 (1.33–4.31) 0.004* – – – – – – 1.74 (0.92–3.30) 0.091 Nulliparity – – – – – – 2.56 (1.14–5.73) 0.022* – – 2.00 (0.96–4.21) 0.066 Never breastfeeding 1.65 (1.03–2.65) 0.036* – – – – – – – – – – Negative attitudes towards health check-ups 1.95 (1.13–3.35) 0.017* 2.38 (1.43–3.98) 0.001* 2.05 (1.31–3.21) 0.002* – – – – – – Insufficient knowledge about breast cancer 1.90 (1.19–3.02) 0.007* 2.87 (1.84–4.49) <0.001* 1.86 (1.19–2.91) 0.007* – – – – – – High barriers to mammographic screening 1.89 (1.18–3.00) 0.008* – – – – – – – – – – Never performed BSE Never had a CBE Never had a mammogram Negative attitudes towards health check-ups Insufficient knowledge about breast cancer High barriers to mammographic screening OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P OR (95%CI) P No friends/family with breast cancer 1.90 (1.14–3.15) 0.014* 1.73 (1.07–2.80) 0.025* 1.62 (1.04–2.52) 0.032* – – 2.30 (1.50–3.55) <0.001* 2.02 (1.31–3.13) 0.002* Unemployed or retired – – 1.82 (1.14–2.92) 0.013* 1.73 (1.04–2.86) 0.033* – – – – – – Primary education or lower 1.63 (1.00–2.64) 0.049* – – 1.91 (1.15–3.17) 0.012* 1.72 (1.04–2.84) 0.034* – – 1.95 (1.25–3.04) 0.003* Single, divorced or widowed 1.85 (1.00–3.41) 0.051 2.39 (1.33–4.31) 0.004* – – – – – – 1.74 (0.92–3.30) 0.091 Nulliparity – – – – – – 2.56 (1.14–5.73) 0.022* – – 2.00 (0.96–4.21) 0.066 Never breastfeeding 1.65 (1.03–2.65) 0.036* – – – – – – – – – – Negative attitudes towards health check-ups 1.95 (1.13–3.35) 0.017* 2.38 (1.43–3.98) 0.001* 2.05 (1.31–3.21) 0.002* – – – – – – Insufficient knowledge about breast cancer 1.90 (1.19–3.02) 0.007* 2.87 (1.84–4.49) <0.001* 1.86 (1.19–2.91) 0.007* – – – – – – High barriers to mammographic screening 1.89 (1.18–3.00) 0.008* – – – – – – – – – – BSE = breast self-examination; CBE = clinical breast examination; CI = confidence interval; OR = odd ratio. Gray shades indicate those fields that did not apply (instead of not value). *Statistically significant under binary logistic regression, P < 0.05. Discussion This was the first study that investigated the attitudes towards health check-ups, perceptions of breast cancer, and barriers to mammographic screening among the female population in Macao. As the Macao Health Bureau has not outlined the frequency of performing breast cancer screening yet, local healthcare providers usually make recommendations based on the guidelines used in nearby regions like Hong Kong. The Hong Kong Breast Cancer Foundation currently suggests that women above age 40 should perform a BSE once a month, go for a CBE and have a mammogram every 2 years.19 This study showed that the majority of local middle-aged women failed to follow the screening recommendations. In particular, only one-fourth of the participants received mammographic screening at a recommended interval. When confined to those who had heard of the screening method, the compliance rate became 42%, which was not much higher than that reported in Hong Kong (32.7%).8 While both Special Administrative Regions of China do not have an organized population-based screening program in place, the degrees of access to screening services are quite different. In Hong Kong, cost can be a major barrier to such services because they are usually paid out of pocket.8 On the contrary, while having the option to utilize medical services provided by the private sector, all residents in Macao are also entitled to free primary care services at the government-run health centers. Therefore, local residents can request to have a CBE for free at those health centers and may be further referred for a mammogram based on the CBE results and their physicians’ clinical judgment. The surprisingly poor compliance with screening recommendations in Macao might be due to the long waiting time for free services in some health centers, a lack of awareness of these medical benefits by many local residents, limited knowledge regarding screening guidelines, and the high cost in the private sector. It also highlighted the necessity to identify and address a range of barriers in order to enhance the screening rates among Chinese women. In this study, most Chinese women were found to have good knowledge and perceptions about breast cancer and had heard of the three screening methods. Nevertheless, about one-third of all participants had never performed a BSE or received a CBE, and over 60% of them had never obtained a mammogram. One of the reasons behind these conflicting results could be the inadequate levels of health literacy among this female population. Nowadays, people can easily get access to various health information through the Internet or social media. However, as the Chinese women aged 40–60 years were relatively less educated than the younger generation, it was very likely that they had low health literacy levels and incomplete understanding of breast cancer screening, resulting in the low compliance rates.27,28 For example, some middle-aged women might not fully know the purposes and techniques for performing a BSE even though they had heard of it. Moreover, this study demonstrated that the negative attitudes towards health check-ups could be a key barrier to screening practices. One of the top reasons for the lack of breast cancer screening was that they did not see it as necessary, which was consistent with the results of previous studies of Chinese women in mainland China,10 Taiwan9 and the USA.14,29 It is a popular Chinese belief that without any pain or acute diseases, one should avoid seeing a physician.30 There is also a cultural belief that talking about a disease may cause it to actually happen.31 In addition, a few participants believed that there was no need for mammographic screening as long as they performed a BSE regularly. More efforts should be made to clear up the public’s confusion about the differences and benefits of these screening practices. Interestingly, a lack of recommendations by physicians was also a reason for the low mammographic screening rates among this study population. Chinese women tend to trust their physicians so implicitly that they would believe breast cancer screening is unnecessary if their physicians do not discuss it with them.11 Previous literature also showed that having physicians as an information source was a predictor of positive screening behaviors.32 At the frontline of the healthcare system, general practitioners can play a vital role in facilitating people’s decisions about cancer screening. It is crucial for them to keep up with the updated guidelines, address common misconceptions, and make screening recommendations accordingly. In general, the Chinese culture places the family above individual interests, which can potentially explain why being single was a predictor of never receiving a CBE. A sense of responsibility to family can motivate people to pay more attention to their health and participate in cancer screening.13 Although no significant relationship was observed between marital status and mammographic screening practices, women who never had children were found to have a negative attitude towards health screening and high barriers to having a mammogram. Other than the impact of cultural beliefs, this finding might be attributable to the local health policies offering free medical care and check-ups for residents during their pregnancy and post-partum period. Consequently, women who had children should be more knowledgeable about women’s health issues and their medical benefits as a Macao resident. These factors indicate that it is essential to educate women and their family to enhance their understandings of breast cancer, in order to improve women’s compliance with screening practices. Another noteworthy finding of this study was that retired or unemployed women, including housewives, were less likely to have ever had a CBE or a mammogram. Binary logistic regression demonstrated that this group of participants were significantly less educated, of older age and most of them had little contact with breast cancer survivors. In other words, this group of participants may not be able to afford health insurance. They may have limited access to private medical care and they have poor health literacy level and knowledge about breast cancer. Hence, such an association between employment status and health screening performance could be partially explained. Nevertheless, as this is one of the groups most in need for education on breast cancer screening, the barriers encountered by them should be thoroughly investigated in the future. There were several limitations in this study. First, the selection of participants was not random, leading to questionable generalizability of the findings. However, a quota sampling method was adopted, and the resulting distribution of certain demographic characteristics such as education level, marital status and age was comparable to the census data.16 Second, as all information was obtained on a self-report basis, recall bias could be an issue. It was highly difficult to verify participants’ screening behaviors in the absence of a universal medical record system in Macao. Third, breast cancer was a sensitive topic and some participants might be reluctant to reveal their true beliefs to interviewers. To minimize this limitation, only well-trained female interviewers were assigned to perform data collection. Finally, the practice of ultrasound screening was not assessed in this study because its routine use for women with average risk was not recommended.5,19 Nevertheless, the use of ultrasound screening as an adjunct to mammography can improve cancer detection rates, especially for those with dense breasts.33 As Chinese women generally have denser breasts than their Caucasian counterparts,34 the use of this screening method may be more common than expected among Chinese population and should be evaluated in future studies. Conclusions In conclusion, in spite of free access to breast cancer screening, the participation rates were strikingly low among the middle-aged female population in Macao. Most women had good knowledge and perceptions about breast cancer but negative attitudes towards health check-ups. The independent factors associated with poor mammographic screening practices included unemployed/retired status, low education level, and not knowing anybody with breast cancer. As the incidence rate of breast cancer is rising and early detection is an important strategy of cancer control, a culturally tailored education and promotion program should be developed to raise the public’s awareness of the disease and the screening practices. More efforts should be made to educate local women on the availability and benefits of different screening practices. Meanwhile, all levels of healthcare providers, particularly general practitioners, should receive more relevant training in order to better address the public’s concerns and provide appropriate screening recommendations. Further studies are needed to evaluate the effectiveness of different educational interventions for Chinese women, as well as the cost-effectiveness and feasibility of a population-based screening program in Macao and other Asian countries with a significant Chinese population. Conflict of interest The authors declare no conflicts of interest. Acknowledgements This study was financially supported by the National Medical Research Council Singapore (NMRC/CIRG/1386/2014). The authors are grateful to Dr Kate White and Dr Cannes Kwok for providing the original CBCSB. The authors would also like to acknowledge Ms Ka-Lei Lam, Ms Sok-Teng Fong and other students of Macao Polytechnic Institute for their contribution to data collection and entry. References 1 Ferlay J , Soerjomataram I , Ervik M et al. . GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. In. Lyon, France: International Agency for Research on Cancer 2013 . 2 Fan L , Strasser-Weippl K , Li JJ et al. . Breast cancer in China . Lancet Oncol 2014 ; 15 : e279 – 89 . Google Scholar CrossRef Search ADS PubMed 3 Taskforce for Annual Report of Macao Cancer Registry . Annual report of Macao cancer registry. Macao: Health Bureau of the Government of Macao Special Administrative Region 2016 . 4 Howlader N , Noone AM , Krapcho M et al. . SEER Cancer Statistics Review 1975–2014 . Bethesda, MD : National Cancer Institute , 2017 . 5 National Comprehensive Cancer Network . Breast cancer screening and diagnosis (Version 1.2017) 2017 . 6 Kagawa-Singer M , Pourat N . Asian American and Pacific Islander breast and cervical carcinoma screening rates and healthy people 2000 objectives . Cancer 2000 ; 89 : 696 – 705 . Google Scholar CrossRef Search ADS PubMed 7 Wang B , He M , Wang L et al. . Breast cancer screening among adult women in China, 2010 . Prev Chronic Dis 2013 ; 10 : E183 . Google Scholar CrossRef Search ADS PubMed 8 Kwok C , Fong DY . Breast cancer screening practices among Hong Kong Chinese women . Cancer Nurs 2014 ; 37 : 59 – 65 . Google Scholar CrossRef Search ADS PubMed 9 Wu TY , Chung S , Yeh MC et al. . Understanding breast cancer screening practices in Taiwan: a country with universal health care . Asian Pac J Cancer Prev 2012 ; 13 : 4289 – 94 . Google Scholar CrossRef Search ADS PubMed 10 Huang Y , Zhou K , Li H et al. . knowledge, attitudes, and behaviour regarding breast cancer screening among women from different socio-economic regions in southwest China: a cross-sectional study . Asian Pac J Cancer Prev 2011 ; 12 : 203 – 9 . Google Scholar PubMed 11 Kwok C , Cant R , Sullivan G . Factors associated with mammographic decisions of Chinese-Australian women . Health Educ Res 2005 ; 20 : 739 – 47 . Google Scholar CrossRef Search ADS PubMed 12 Lam WW , Tsuchiya M , Chan M et al. . Help-seeking patterns in Chinese women with symptoms of breast disease: a qualitative study . J Public Health (Oxf) 2009 ; 31 : 59 – 68 . Google Scholar CrossRef Search ADS PubMed 13 Lee-Lin F , Menon U , Nail L et al. . Findings from focus groups indicating what Chinese American immigrant women think about breast cancer and breast cancer screening . J Obstet Gynecol Neonatal Nurs 2012 ; 41 : 627 – 37 . Google Scholar CrossRef Search ADS PubMed 14 Yu ES , Kim KK , Chen EH et al. . Breast and cervical cancer screening among Chinese American women . Cancer Pract 2001 ; 9 : 81 – 91 . Google Scholar CrossRef Search ADS PubMed 15 Chua MS , Mok TS , Kwan WH et al. . Knowledge, perceptions, and attitudes of Hong Kong Chinese women on screening mammography and early breast cancer management . Breast J 2005 ; 11 : 52 – 6 . Google Scholar CrossRef Search ADS PubMed 16 Statistics and Census Service . Results of 2011 population census. Macao: Statistics and Census Service of the Government of Macao Special Administrative Region 2012 . 17 Fong DY , Kwok C , White K . Psychometric properties of the Chinese Breast Cancer Screening Beliefs questionnaire . Eur J Oncol Nurs 2012 ; 16 : 505 – 11 . Google Scholar CrossRef Search ADS PubMed 18 Kwok C , Fethney J , White K . Chinese Breast Cancer Screening Beliefs Questionnaire: development and psychometric testing with Chinese-Australian women . J Adv Nurs 2010 ; 66 : 191 – 200 . Google Scholar CrossRef Search ADS PubMed 19 Hong K . Breast Cancer Foundation. Breast Cancer Facts You Should Know . Hong Kong : Hong Kong Breast Cancer Foundation , 2017 . 20 Beck AT , Epstein N , Brown G et al. . An inventory for measuring clinical anxiety: psychometric properties . J Consult Clin Psychol 1988 ; 56 : 893 – 7 . Google Scholar CrossRef Search ADS PubMed 21 Che HH , Lu ML , Chen HC et al. . Validation of the Chinese version of the Beck Anxiety Inventory . J Formos Med Assoc 2006 ; 10 : 447 – 54 . 22 Beck AT , Ward CH , Mendelson M et al. . An inventory for measuring depression . Arch Gen Psychiatry 1961 ; 4 : 561 – 71 . Google Scholar CrossRef Search ADS PubMed 23 Shek DT . Reliability and factorial structure of the Chinese version of the Beck Depression Inventory . J Clin Psychol 1990 ; 46 : 35 – 43 . Google Scholar CrossRef Search ADS PubMed 24 Mendoza TR , Wang XS , Cleeland CS et al. . The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory . Cancer 1999 ; 85 : 1186 – 96 . Google Scholar CrossRef Search ADS PubMed 25 Wang XS , Hao XS , Wang Y et al. . Validation study of the Chinese version of the Brief Fatigue Inventory (BFI-C) . J Pain Symptom Manage 2004 ; 27 : 322 – 32 . Google Scholar CrossRef Search ADS PubMed 26 World Health Organization . The Asia-Pacific Perspective: Redefining Obesity and its Treatment . Sydney : Health Communications Australia , 2000 . 27 Sentell T , Braun KL , Davis J et al. . Health literacy and meeting breast and cervical cancer screening guidelines among Asians and whites in California . SpringerPlus 2015 ; 4 : 432 . eCollection 2015. Google Scholar CrossRef Search ADS PubMed 28 Wu Y , Wang L , Cai Z et al. . Prevalence and risk factors of low health literacy: a community-based study in Shanghai, China . Int J Environ Res Public Health 2017 ; 14 : E628 . Google Scholar CrossRef Search ADS PubMed 29 Tang TS , Solomon LJ , McCracken LM . Cultural barriers to mammography, clinical breast exam, and breast self-exam among Chinese-American women 60 and older . Prev Med 2000 ; 31 : 575 – 83 . Google Scholar CrossRef Search ADS PubMed 30 Garcia HB , Lee PCY . Knowledge about cancer and use of health care services among Hispanic-and Asian-American older adults . J Psychosoc Oncol 1989 ; 6 : 157 – 77 . Google Scholar CrossRef Search ADS 31 McLaughlin LA , Braun KL . Asian and Pacific Islander cultural values: considerations for health care decision making . Health Soc Work 1998 ; 23 : 116 – 26 . Google Scholar CrossRef Search ADS PubMed 32 Su X , Ma GX , Seals B et al. . Breast cancer early detection among Chinese women in the Philadelphia area . J Womens Health (Larchmt) (2002) 2006 ; 15 : 507 – 19 . Google Scholar CrossRef Search ADS PubMed 33 Berg WA , Blume JD , Cormack JB et al. . Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer . J Am Med Assoc 2008 ; 299 : 2151 – 63 . Google Scholar CrossRef Search ADS 34 Maskarinec G , Meng L , Ursin G . Ethnic differences in mammographic densities . Int J Epidemiol 2001 ; 30 : 959 – 65 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Journal of Public HealthOxford University Press

Published: May 8, 2018

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