Refining a questionnaire to assess breast cancer knowledge and barriers to screening in Kenya: Psychometric assessment of the BCAM

Among all cancers, breast cancer has the highest cancer-related morbidity and mortality rates in sub-Saharan Africa [1–4], and these rates are on the rise [2]. It is reported that 70–90% of the women affected by breast cancer in this region present with late-stage disease with poor outcomes as a result [4]. Even though approaches to enhancing early diagnosis and treatment have been advocated [3, 5], the region is faced with a number of challenges to achieving earlier diagnosis and care, including limited funds for health care services, underfunded health care facilities, lack of mammography equipment, and low levels of community awareness of breast cancer [3–7]. Taken together, these limitations have had a major adverse impact on efforts to reduce the stage at which breast cancer is diagnosed and treated.

In spite of these many challenges, screening programs that feature self and clinician breast exams as well as mammograms (where available) have been advocated as important stepping stones to promote public awareness, timely diagnosis and treatment and cancer prevention [2, 5]. Even when preventive services are available, however, community participation in these activities has been variable and limited. Breast cancer screening uptake in developed countries has been associated with factors such as being older in age, married, having a higher socio-economic status, more physician endorsement and having a higher social status [8]. Unfortunately, there is little or no comparable information in resource-scarce environments in sub-Saharan Africa. In the context of initial efforts to develop appropriate approaches to breast cancer screening in western Kenya, we felt the need to have a better understanding of the levels of public awareness, perceptions of breast cancer, and screening practices in various communities served by a health care delivery system. If a well-formed and valid survey instrument could be developed to characterize these matters, we believed that educational programs for the public could be focused to fill gaps in knowledge and perhaps stimulate greater volunteerism for screening.

Contemplating the use of a questionnaire that could be used to characterize citizen opinions of relevance to breast cancer screening, we unfortunately found no validated scales that had been field-tested in a Kenyan population. The literature however revealed that a number of validated scales had been developed for North American or European populations [8–11], scales whose psychometric properties would need to be evaluated if we were to adapt them for use in a Kenyan population. The value of assessing the psychometric properties of a scale to determine its validity and reliability within a specific cultural setting cannot be overstated [12, 13]. Cross-cultural and language differences routinely introduce measurement biases that affect the quality of data collected [12, 13].

After review of measures, we adopted a validated breast module of cancer awareness measure (BCAM), originally developed to determine level of cancer awareness and associated factors for the UK population [11]. The BCAM was attractive to us because it included measures of breast cancer awareness and perceived barriers to breast cancer screening. Our system’s oncologists considered both of these cognitive domains to constitute major impediments to timely screening for the detection of early-stage breast cancer. In UK populations, BCAM readability had been found to be high and the measure was acceptable to women. Construct validity was supported by significant differences between the levels of cancer awareness among cancer professionals compared to non-medical academics (50% vs. 6%, p?=?0.001) attending cancer screening programs [11].

In order to the use the BCAM in western Kenya, collaborative research group (the Walther Project group) believed that new descriptive work to assess the psychometric characteristics of the BCAM should be carried out. Our overall study objectives were to assess the face validity, language appropriateness and internal reliability of the BCAM among adult women in western Kenya. We were also interested in exploratory factor analyses to discover any internal structure within the data from BCAM when administered to our catchment area populations. In psychometrics, ‘internal structure’ refers to a pattern of responses to items in a questionnaire. Items that cohere together illuminate the instrument’s dimensionality. In this communication, we report the procedures and findings of our work as a potential guide to others undertaking analogous work.