The effect of women’s breast cancer fear and social support perceptions on the process of participating in screening

Abstract

Introduction:

Social support and fear have been shown to be important factors affecting women’s participation in breast cancer screening. This study aimed to determine the effect of women’s perceived breast cancer fear and social support on participating in the breast cancer screening process, and to investigate the relationship between the perception of breast cancer fear and social support.

Methods:

This is a descriptive study, carried out in a state hospital on 198 women. The data were collected through a Socio-Demographic Data Form, Multidimensional Scale of Perceived Social Support (MSPSS), and Breast Cancer Fear Scale (BCFS) by the researchers by means of face-to-face interview.

Results:

There was no statistically significant difference between the women’s perceptions of social support and breast cancer fear and screening behaviors (p > 0.05). It was found that the mean BCFS score of those who had a family history of breast cancer was high, and the MSPSS score was lower (p < 0.05). There was a quite weak and statistically insignificant positive relationship between the women’s BCFS scores and perceived social support (r = 0.08, p > 0.05), friend support (r = 0.04, p > 0.05) and support from a special person (r = 0.14, p > 0.05).

Conclusion:

We found no statistically significant difference between breast cancer fear, social support and the women’s screening behavior. However, breast cancer fear and the effect of social support on screening attitude may be important. Nurses and other health workers should particularly focus on social support and breast cancer fear in their health education programs. Formative research into the use of social support to promote positive empowering messages should be carried out and incorporated in future health promotion campaigns to improve the breast cancer screening process.

Keywords

fear social support breast cancer screening

Introduction

Breast cancer is the most common type of cancer among women throughout the world, and it accounts for nearly 30% of all cancer types and 18% of cancer-bound mortality (1). It is estimated that one out of every eight women living in Western countries is likely to experience breast cancer (2). While breast cancer incidence in Turkey was 37.6 per 100,000 in 2006, this proportion increased to 41.6 in 2008 (3).

Screening programs are the most common approaches to prevention worldwide. However, it has been emphasized in the literature that the rate of women’s consultation for early diagnosis for breast cancer is low, and there are some barriers to participation in the early diagnosis of breast cancer. When the factors affecting women’s attitudes in early diagnosis are examined, the following issues have been found to top the list: lack of health insurance and information about early diagnosis applications; inadequate transportation facilities; support of family, friend and husband; health beliefs; age; education; lack of transportation vehicles; lack of training on the issue (4,5); neglect; embarrassment; lack of education; financial issues and women’s fears (losing the breast, death, change in body image, etc.) (6 –8).

The fear experienced by women about participating in cancer screening has been shown among both supportive and inhibitive factors by qualitative and quantitative studies (2,9 –15). Social support has been shown as another important factor affecting women’s participation in breast cancer screening (16 –19). However, there are some studies claiming that the influence of social support does not exist (20,21). Determining the effects of factors likely to be influential in terms of socio-cultural aspects on participation in breast cancer screening can be effective in increasing the speed of breast cancer screening. Breast cancer screening plays an important role among health promotion activities and it can be effective in early diagnosis of breast cancer by creating awareness (22). Nurses play an active role in the protection and promotion of health in every stage of individuals’ lives, training and counseling for early diagnosis, evaluation of health, and delivery and screening practices (14). Public health nurses and other health disciplines need to be aware of the needs of women for participation in screening, understand their fears and worries about their health, and recognize screening barriers and facilitating factors. Therefore the current study was carried out to determine the effect of women’s breast cancer fear and social support perceptions on participation in screening, and to investigate the relationship between the perception of breast cancer fear and social support.

Methods

Setting

The study was carried out in Tokat central county State Hospital in Turkey. This cross-sectional and descriptive study consisted of 198 women aged 40 years or over with no breast cancer history who volunteered to participate in the study. They either visited a gynecology, surgery and CEDSECs (Cancer Early Diagnosis, Screening and Education Centers) clinic with any complaints or had mammography in Tokat State Hospital between 15 February 2014 and 15 May 2014.

Data collection

Data were collected through a Socio-Demographic Data Form, Breast Cancer Fear Scale (BCFS) and Multidimensional Scale of Perceived Social Support (MSPSS) to measure the social support perceived by women.

Socio-Demographic Characteristics Data Form

This form consisted of 13 items questioning women’s age, education, marital status, employment, health insurance, economic state, family type, number of children, households, family history of breast, self-breast examination (SBE), clinical breast examination (CBE) and mammography frequency, and socio-demographic features.

Multidimensional Scale of Perceived Social Support

The MSPSS was developed by Zimmet et al. in 1988 and it determines the social support aspects perceived by individuals (23). Internal consistency Cronbach alpha values were found to range between 0.80 and 0.95. It is a seven-point Likert-type evaluation scale consisting of a total of 12 items involving three sub-dimensions regarding the source of the support, each of which has four items (family 3, 4, 8, 11; friend 6, 7, 9, 12; special person 1, 2, 5, 10). The scoring of the scale is based on the total score of each sub-group score. The lowest score that can be obtained from the sub-groups is 4 and the highest is 28. The lowest score from the whole scale is 12 and the highest is 84. A high score indicates a high level of perceived social support. The MSPSS Cronbach alpha value in this study was found to be 0.91 and the Cronbach alpha values of the sub-dimensions ranged between 0.96 and 0.91.

Breast Cancer Fear Scale

The BCFS was developed by Champion et al. in 2004 (10). The Cronbach alpha coefficient for the whole scale is 0.91. The validity and reliability test of the scale in Turkey was conducted by Secginli in 2012 (2). The Turkish version of the scale consists of eight items. The minimum score is 8 and the maximum is 40. The scoring of the scale ranges between 1 point (‘strongly disagree’) and 5 points (‘strongly agree’). A high score means a high level of breast cancer fear. The Cronbach alpha coefficient is 0.90. The Cronbach alpha value of BCFS for this study was 0.94.

Dependent and independent variables

The independent variables of this study were socio-demographic characteristics and breast cancer screening attitudes of women. The dependent variables were the level of women’s breast cancer fear and perceived social support.

Evaluation of the data

The data were analyzed using SPSS 15 software. The statistical significance of the data was based on p < 0.05 level. Percentage, mean, t-test and correlation analyses were used in the evaluation of the data.

Study ethics

The institutional permission of Tokat State Hospital and Gaziosmanpaşa University Clinical Ethics Committee permission was granted for the study. All the women participating in the study were informed verbally about the study and their written consent forms were taken. The questionnaires were filled in by the researchers through face-to-face interviews.

Results

The mean age of the women was 52.35 ± 8.14 years, 50% were primary school graduates, 91.4% were married, 83.3% were unemployed, 89.9% had social security and 82.8% did not have a family history of breast cancer (Table 1).

Table 1.

Distribution of the women based on their socio-demographic characteristics (N = 198).

Socio-demographic characteristics	n	(%)
Age (X ± SD)	52.35 ± 8.14
Education
Illiterate	63	31.8
Primary school	99	50.0
Secondary school	9	4.5
High school	16	8.1
University	11	5.6
Marital status
Married	181	91.4
Single	17	8.6
Employment
Employed	33	16.7
Unemployed	165	83.3
Social security
Yes	178	89.9
No	20	10.1
Income
Less income than expenses	33	16.7
Equal or more income than expenses	165	83.3
Family type
Nuclear family	137	69.2
Extended family	55	27.8
Broken family	6	3.0
Households
Alone	12	6.1
Spouse	36	18.2
Spouse and children	121	61.1
Spouse, children and relatives	29	14.6
Breast cancer history in family	34	17.2
Yes
No	164	82.8
Total	198	100.0

It was determined that there was no statistically significant difference between women’s breast cancer fear and social support perceptions and their screening attitudes (p > 0.05). It was found that the mean BCFS score of those who had a family history of breast cancer was higher than those who did not, and that there was a statistically significant difference between the two (p < 0.05). It was determined that the mean MSPSS score of those who had a family history of breast cancer was lower than those who did not, and that there was a statistically significant difference between the two (p < 0.05) (Table 2).

Table 2.

The relationship between women’s perceived breast cancer fear and social support and their screening attitudes and breast cancer history in the family (N = 198).

Screening attitudes	n	%	BCFSX ±SD		tp	MSPSSX±SD		tp
SBE
Irregular	174	87.9	30.22	8.02	0.666	65.62	16.50	0.418
Regular	24	12.1	29.08	6.14	0.506	64.13	15.91	0.676
CBE
Irregular	170	85 .9	29.71	7.98	−1.645	66.24	15.63	1.704
Regular	28	14.1	32.32	6.38	0.102	60.57	20.11	0.090
Mammography
Irregular	172	86.9	30.03	7.93	−0.239	65.48	16.18	0.095
Regular	26	13.1	30.42	7.09	0.811	65.15	18.07	0.924
Breast cancer history in the family
Yes	34	17.2	32.79	6.67	2,248	53.38	21.32	−3,814
No	164	82.8	29.52	7.93	0.026	67.94	14.01	0.000^*

p < 0.001.

It was determined that the mean BCFS score of the women was 30.08 ± 7.81 and the mean MSPSS score was 65.44 ± 16.40. When the scores of the MSPSS sub-dimensions were examined, they were found to be 25.49 ± 4.17, 20.41 ± 7.69 and 19.54 ± 8.50 for family support, friend support and support from a special person, respectively.

It was determined that there was a quite weak statistically insignificant positive relationship between the women’s BCFS scores and perceived social support (r = 0.08; p > 0.05), friend support (r = 0.04, p > 0.05) and support from a special person (r = 0.14, p > 0.05). It was also found that there was a quite weak negative (r = −0.07, p > 0.05) but statistically insignificant relationship between the women’s BCFS scores and perceived family support (Table 3).

Table 3.

The relationship between the women’s MSPSS and sub-dimension perceptions and BCFS perceptions (N = 198).

Scales	BCFS
Scales	r	p
MSPSS Sub-Dimensions
Family support	−0.07	0.35
Friend support	0.04	0.57
Support from a special person	0.14	0.04
Total	0.08	0.29

Discussion

This cross-sectional descriptive study was conducted to determine the effect of women’s perceived breast cancer fear and social support on participating in the breast cancer screening process, and to investigate the relationship between the perception of breast cancer fear and social support. There is no research in the literature investigating these factors together in the process of women’s participation in breast cancer screening. It was found that the mean age of the participants was 52.35 ± 8.14 years in this study. In addition, the majority of the women were primary school graduates, married, and unemployed; had social security, equal or more income than expenses; and lived with their husband and children.

The fear factor has been shown to be associated with participation in screening in many studies (11,15,24,27). The mean BCFS score in this study was determined to be 30.08 ± 7.81, 29–30 points in participation in breast cancer screening groups, and higher fear level with breast cancer history in the family, with a mean score of 32.79 ± 6.67. While one of the prospective studies reported a moderate fear level increase with participation in screening (28), another study showed that there was a negative relationship between mammography and anxiety/fear (29). Breast cancer fear (β = 0.22, p <0.001) was found to be moderate and significant for perceived obstacles in mammography (13). Anderson et al. (24) emphasized that the anxiety/fear about breast cancer risk was associated with mammography screening, and that the level of fear was likely to be important. Serious anxiety/fear was found to be dissuasive in mammography screening regardless of family history. The women who reported they experienced little or no anxiety had frequent mammography screening. Medium-level anxiety was not found to be statistically significant in increasing mammography screening (24). It may be ideal to give individual messages in women’s education for increasing mammography screening participation, due to individual change about risk awareness and fear. Champion et al. (10) determined a medium level of breast cancer fear with a score of 16–23. Those who had medium-level breast cancer fear had higher mammography participation with respect to those who had a lower fear level. There was no difference between high-level fear and low-level fear in terms of participation in mammography screening. Perceived threat, benefit, self-efficacy and fatalism were shown have effects on fear (10).

Miles et al. (30) reported that high-level breast cancer fear was inhibitive for obtaining information, and this was associated with perceived seriousness of cancer. This study found that those who had high-level cancer fear and fatalism had more negative attitudes towards cancer control, and therefore it is necessary to study how to give positive messages for cancer control and cancer protection to these people. A meta-analysis study reported that breast cancer fear could motivate screening attitudes, and that a high level of breast cancer fear was rare (31). Fear of breast cancer diagnosis was not determined to be a notable obstacle in Arabic women’s participation in screening (25). On the contrary, fear in Israeli Arabic women was found to be motivating in having SBE (32). In a study conducted in Turkey, it was found that breast cancer fear was not decisive in mammography screening, and that the level of breast cancer fear was high with a score of 27.14 ± 6.32. There was no statistically significant difference between those who had mammography screening and those who did not with respect to breast cancer fear score (2). Breast cancer in Turkey is diagnosed at later stages of the disease. Therefore, the groups participating in screening and those not participating were influenced by the negative consequences of breast cancer in a similar way, and no statistically significant difference was found between the two. A high level of fear might have prevented the women from participating in screening, which also supports other studies.

These results suggest that the breast cancer fear of Turkish women was quite high, and this requires the development of anxiety-reducing strategies. Health education programs should include applications to develop women’s health beliefs and reduce fear. Examining these results with experimental studies could be a useful strategy. More studies are needed to investigate the effect of breast cancer fear and social support in Turkish women.

The findings of the study indicated that the means of MSPSS and sub-dimension scores were medium level, perceived social support did not have an effect on breast cancer screenings (BSE, CBE, mammography), and that the perceived social support of those who had a family history of breast cancer was lower and statistically significant. This suggests that women need more social support. Social support is a social variable accepted to be associated with human health. Awareness of the importance of inadequate social support, which is likely to negatively affect women’s participation in breast cancer screening, is gradually increasing. Studies show that social support has an effect on participation in breast cancer screening (33,34). It has been reported that women not participating in breast cancer screening (SBE and CBE) have less social support (18). A study in Iran comparing women intending to have mammography with those not found the social effect to be very low. The findings of the study were unexpected, since women who did not have mammography stated that social networks such as friends, family and doctors were effective. Social effects in Iran do not show the same results as in other regions of the world. This study stated that the information obtained from social networks could not be used, as the discussion of specific issues in some Asian countries, as well as cancer attitudes, was culturally suppressed (17,20,21). The findings of this study did not show the effect of social effects on participation in screening. Similarly, Gamarra et al. (17) reported that social support networks such as family and friends providing a high or low level of emotional support in women’s decisions to participate in screening did not have a relationship with SBE and CBE. Dahlui et al. (16) found the social support of those who participated in screening was high in comparison with those who never did. However, while this study did not find social support effective in having mammography and SBE, it determined social support as effective in participating in CBE. Ma et al. (35) reported that participation in breast cancer screening increased in those who had a family or friend having mammography, and that factors such as culture, health beliefs and social support should be included in screening programs. The literature shows that social support networks (employer, colleagues, family and friends) increased by health education campaigns may have a positive effect on the realization of preventive health attitudes (19,26). This study revealed that the social support of women who had breast cancer history was lower than those who did not.

Some studies report that lack of encouragement from family members and doctors decreases participation in breast cancer screening (36). The findings of this study suggested that the level of social support in Turkish women was inadequate, the women who had a family history of breast cancer had lower social support, and that strategy development was necessary to increase the social support for women, especially for risk groups. Perhaps the number of people encouraging the participation in screening may be more important than the amount of social support for women’s participation in screening. In this sense, it is important that family members, friends and related sections of the community should have awareness in encouraging women to participate in screening, and put it into practice. A qualitative study conducted in Turkey in older women reports that a family history of breast cancer and social support are facilitating factors in helping women participate in screening (14).

In this study, women received most support from families and it was determined that there was a rather weak statistically insignificant positive relationship between the women’s BCFS scores and perceived social support (r = 0.08, p > 0.05), friend support (r = 0.04, p > 0.05) and support from a special person (r = 0.14, p > 0.05). It was found that there was a fairly weak negative (r = −0.07, p > 0.05) yet statistically insignificant relationship between the women’s BCFS scores and perceived family support. However, it was determined that the mean MSPSS score of the women who had a family history of breast cancer was lower than those who did not, and that the mean BCFS score of the former was higher (p < 0.05).

Conclusion and suggestions

As a result of this study, it was determined that there was no statistically significant difference between breast cancer fear, social support and the women’s screening attitudes. A fairly weak yet statistically insignificant difference was found between the women’s social support levels and breast cancer fear. Therefore, it is suggested that increasing women’s social support might increase their participation in breast cancer screening, reducing their breast cancer fear. In addition, breast cancer fear and the effect of social support on screening attitude may be important; however, experimental studies together with health education processes might be needed. It is necessary to research how to give positive messages to increase prevention and control of cancer in women who have little social support and high breast cancer fear, particularly in high-risk groups. To do this, nurses and other health workers should particularly focus on social support and breast cancer fear in their health education programs. It is also recommended that longitudinal and experimental studies are carried out to investigate the effects of increasing women’s social support and reducing their breast cancer fear in the long term.

Footnotes

Declaration of conflicting interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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