A cross sectional study on the motivators for Asian women to attend opportunistic mammography screening in a private hospital in Malaysia: the MyMammo study

The incidence of breast cancer is rising in most parts of Asia and Asian governments, particularly those from low and middle-income countries, face significant challenges in providing cost-effective and equitable screening for breast cancer. To date, the majority of low and middle-income Asian countries only offer opportunistic screening and the aspiration is that through health education and community health programmes, awareness and uptake of screening can help to ensure earlier presentation. In this study, we show that the majority of women attending opportunistic screening have an estimated <2 % risk of breast cancer in the next ten years, a threshold which is often considered where the benefits of screening outweigh the potential harms of over-diagnosis. This suggests that opportunistic screening in a private hospital in Malaysia does not target the women at high risk of breast cancer.

Previous studies using logistic regression have demonstrated a number of variables are associated with participation in mammography screening, but these studies provide limited information on how to target different groups of women [17, 18, 22]. In our study, we applied a different analytical method and suggest that functional clustering has provided insight into how screening messages should be framed for more effective promotion of mammography screening in the future. First, women with a higher risk of breast cancer on the basis of family history of breast cancer were more likely to attend screening at a younger age and they were motivated to participate in screening by various avenues. This suggests that health education focusing on the familial risk of breast cancer could be a strong motivator for Asian women to participate in screening but this approach has not hitherto been explored. Second, highly educated women could be motivated through a number of avenues including by their doctors, by family and friends or by public campaigns. Third, women in lower socio-economic classes were more likely to be motivated by their doctors to participate in screening. Taken together, this suggests that whilst highly educated women were accessible through public campaigns, women in lower socio-economic classes may not respond similarly to such campaigns. This is consistent with a systematic review of interventions to increase uptake of screening mammography among Asian women which suggests that media campaigns alone may be ineffective in increasing screening uptake [9]. In addition, our data suggests that doctors remain a significant avenue for educating women in lower socio-economic groups about screening and health education should specifically encourage primary care physicians to educate their clients about the potential benefits of screening. This is consistent with studies in Indian, Pakistani and Bangladeshi women in the UK where cultural awareness training for healthcare workers was found to increase mammography uptake [23].

The strength of the MyMammo study is the relatively large sample size and availability of data on breast cancer risk factors, which in turns enable the determination of the estimated risk of breast cancer. To date, reports on barriers and motivators among developing Asian countries have been limited to small cohorts, with limited information about breast cancer risk factors. However, the MyMammo study has a number of limitations. First, the study is conducted in a private hospital and study participants were asked to contribute a blood sample for research to determine genetic determinants of mammographic density. It is unknown whether these would have affected participation levels and the profiles of participating women. Second, as this is an opportunistic screening program, findings from this study cannot be extrapolated to the general population as it only represents a subset of women that came forward for screening.