Factors related to the practice of breast self examination (BSE) and Pap smear screening among Malaysian women workers in selected electronics factories
Reported, December 30, 2011
The effectiveness of breast self examination (BSE) in lowering breast cancer mortality has been extensively studied. After reviewing studies published between 1966 to October 2000, the Canadian Task Force on Preventive Health Care found no evidence that routine BSE teaching or practice is beneficial in terms of lower risk of breast cancer death, or earlier stage of cancer at diagnosis . Instead, they found that women who were taught BSE and practised it faced a higher rate of physician visits, and higher risk of anxiety and benign biopsies. Based on these findings, they recommended that routine teaching of BSE be discontinued, particularly for women aged 40 to 69 years. Following on this, the final results of a 1011 year randomized controlled trial in Shanghai were published, confirming that intensive instruction in BSE did not reduce breast cancer deaths .
Nevertheless, there is disagreement with the recommendation of discontinuing BSE advocacy among women . Those who disagree point out that many breast tumours are discovered by women themselves, and that the practice of BSE makes women more aware of their breasts and therefore more likely to detect tumours, even if they did not detect them while doing BSE. In developing countries, it is considered to be a simple, inexpensive, non-invasive, and non-hazardous intervention, which is not only acceptable, cost-effective and appropriate, but also encourages women to take an active responsibility in preventive health . It should be pointed out, however, that spending health resources on BSE, if it is ineffective, detracts from focussing on trying to find other ways of prevention.
On the other hand, the utilization of the Pap smear for the early detection of cervical cancer is better established, although the reliability of the test varies and is dependent on the expertise of the health professionals who take the smear as well as those who examine it . In developed countries such as the United Kingdom, the recognition that Pap smear screening could result in false alarms or false reassurance, overdiagnosis and overtreatment has led to a recent emphasis on ‘informed uptake’, that is, that women should be made fully aware of all positive and negative consequences before undergoing screening. In some developing countries, the cost-effectiveness of Pap smear screening programmes has been questioned because they have not resulted in declining cervical cancer rates due to inefficient screening programmes and poor quality tests .
In Malaysia, breast cancer is the leading cause of cancer deaths among women, accounting for about 11% of all medically certified deaths in the country . The national incidence rate is not available, but it is estimated that 1,200 new cases occur every year, and an increasing trend of cases among younger women has been observed. The Ministry of Health promotes the practice of monthly BSE for women above the age of 20 years, and annual clinical breast examination by a medical or paramedical personnel . Mammography is not widely available as a screening method, and it is only recommended for women at special risk of breast cancer, identified as those who have had breast cancer in one breast, and those with a mother or sister who have breast cancer. BSE is primarily taught by nurses to women who attend government health clinics, as well as family planning clinics run by the non-governmental family planning associations.
Unlike breast cancer, mortality from cervical cancer has declined in relative importance, although it is still the second most important cancer among women in Malaysia . The national incidence rate for cervical cancer is not known, but over the last ten years, there have been 2,0003,000 admissions per year to government hospitals. The policy of the Ministry of Health is to promote and provide Pap smear screening to all women between 2065 years of age . Official recommendation is for women to undergo the Pap smear test annually in the initial two years, and subsequently, once every three years, with priorities for sexually active women who are more than 35 years old, have more than five children, have practised contraception for more than five years or who are new acceptors of family planning services, and women diagnosed with sexually transmitted diseases. Women who attend postnatal and family planning services are primary targets.
Although the policy is to target all sexually active women, in practice, married women have more access due to a variety of reasons. One of the reasons is that this is a recent policy change, and prior to 1995, when a nation-wide campaign on prevention of breast and cervical cancer was carried out, the official policy was to provide cervical cancer screening for married women only.
There is currently no system in the country for collecting routine information on the practice of BSE among women, and available information on Pap smear screening is only from government facilities. As such, both were included in the scope of the country’s Second National Health and Morbidity Survey (NHMS) 1996 .
Likewise, reflecting national concerns, a government-funded research project on health status and lifestyle of women workers in the electronics industry also included these two topics. This paper uses data from this recent study to examine the prevalence of BSE and Pap smear screening and the relationship of various socio-demographic and health care factors with the practice of the two screening tests among electronics women workers.
Selection of factories
This was a cross-sectional analytical survey of women workers in selected electronics factories carried out by four research centres Universiti Sains Malaysia, Penang (USM Pg), Universiti Sains Malaysia, Kelantan (USM Kel), Universiti Kebangsaan Malaysia (UKM) and Universiti Putra Malaysia with the help of the National Institute for Occupational Safety and Health (UPM-NIOSH). The inclusion criteria used for selecting factories was that they must be electronics assembly factories, have at least 500 or more women production workers and have been in production for at least two years. Four geographical areas were identified for the research, and each research centre took responsibility for one area USM Pg for Penang (a north-western state), USM Kel for Kota Baru (the capital of the north-eastern state of Kelantan), UKM for Hulu Kelang Free Trade Zone (FTZ) and UPM-NIOSH for Bangi FTZ (both FTZs are in the west-central state of Selangor). A target sample size of 2000 women workers, or 500 per centre, was determined as sufficient for analysis, based upon limited resources.
In Kota Baru, there were three factories which fulfilled the criteria. All three were invited to participate in the study, and one agreed. In the Hulu Kelang FTZ, there were two eligible factories, both of which were invited, but only one agreed. In the Bangi FTZ all seven eligible factories were invited but only five agreed to participate. The UPM-NIOSH centre was not able to meet the target number of 500 respondents from these five factories, and through personal contacts, managed to get the cooperation of another factory located in the Sungei Way FTZ (also in Selangor state). In Penang, 15 factories were purposively selected from 160 in the Penang Development Corporation (Corporate Investment Section) 1995 list based on the inclusion criteria. These 15 factories were invited to participate in the study, but only one agreed. In order to make up the target sample size, the USM Pg centre enlisted the cooperation of a factory in Sungei Petani (in the northwestern state of Kedah) through a personal contact.
In summary therefore, a total of 27 factories in four geographical areas were invited to take part in the study, but only eight factories agreed to participate. In order to achieve the target sample size, two more factories were included, both of which were not within the original four research areas. Finally, therefore, ten factories located in six areas participated in the study.
Selection of respondents and data collection
Varying levels of cooperation were obtained from the ten factories in the selection of respondents and in data collection. It was determined, however, that respondents had to be women between the ages of 17 and 55 years, Malaysian citizens, and had worked at least a year as production workers (below supervisory level) in the factory where they were presently working. The requisite age span was determined based upon the legal age for working and the retirement age. In Kota Baru , full cooperation was obtained from the factory, and all the women workers who fitted the selection criteria were included in the study. In the Penang factory (Factory B), full cooperation was also obtained, and researchers were able to randomly select 250 workers from a list provided by the management. In these two factories, the selected workers were released during working time to take part in the survey, and there were no workers who declined to participate. The percentage of completed questionnaires out of the total number of workers in the sample were 97.6% for Factory A and 98.0% for Factory B.
The sample
In all the other factories, the management gave their cooperation only to the extent of publicising the study (by posting notices and making announcements) and asking for volunteers. The volunteers had to participate in the study either during break or meal times, or in their own free time. Three factories did not permit data collection on factory premises, but allowed researchers access to their hostels; the catchment population in these factories were therefore limited to the hostel occupants. In all these cases, participation was much lower than in Factory A and Factory B, and the percentage of completed questionnaires from the catchment population ranged from 12.4% to 35.7% . The overall response rate, strictly speaking, could not be calculated, but with the above caveats in mind, it may be estimated at 18.2%.
Data collection was carried out between March 1999 and September 2000, with much delay encountered while obtaining consent from factories. During the survey, batches of 210 respondents attended sessions where they were first briefed on the purpose of the survey, and assured confidentiality, before filling in a self-administered questionnaire in the presence of research assistants. The research assistants verbally interviewed those who faced language or literacy barriers in filling in the questionnaires themselves (but these cases were generally less than 5%).
Instrument and pre-test
The questionnaire was in Malay, the national language, and had been pre-tested among 60 women workers who were randomly selected from a factory in Penang (not included in the sample for the study). The pre-test was carried out in September 1998.
Definition of variables and data analysis
The practice of Pap smear screening was defined as having had a test done within the last three years, while the practice of BSE was defined as doing BSE at least once a month. Postnatal and family planning visits were factors of interest since Pap smear screening and BSE are advocated through these two channels in Malaysia. The variable of having at least one young child, that is, preschool age (6 years) or younger, was identified as a proxy measure for having had recent contact with postnatal health care service.
Currently using either the contraceptive pill or intra-uterine device (IUD) was used to reflect contact with family planning services because other methods of contraception used (condom, spermicidal cream, withdrawal, herbal medicine, rhythm) did not require contact with family planning services, while tubal ligation only required a one-off visit. Knowledge was tested by true or false answers to the questions “BSE should be done every month before the menstrual period” and “Pap smear is a test to identify cervical cancer”. The correct answer for the BSE question was ‘false’, and for the Pap smear question, it was ‘true’.
Data were coded prior to entry, merged and analysed using SPSS version 10.0. The chi-square test was used to test the association of sociodemographic and health care factors with the practice of BSE and Pap smear screening. Odds ratios (OR) were calculated and interpreted as positive odds ratios (POR), following the example of Ejlertsson et al. , who had defined the POR as an indicator of positive health or practices rather than the conventional odds ratio that is used as a measure of risk. For ease of interpretation, the OR was consistently calculated for the group with a higher proportion of positive health behaviour compared to the group with a lower proportion of positive health behaviour. Variables of interest were used in logistic regression to yield adjusted odds ratios.
Results
Socio-demographic and health care factors
This was a fairly young group of women, with mean age of 30.1 ± 7.9 years, and more than half (53.7%) less than 30 years old . The majority were Malays (78.9%), and most had reached at least a secondary level of education (31.3% lower secondary, 58.3% upper secondary, 5.8% higher). The sample was almost equally divided into single (48.7%) and married (47.0%) women, with a small proportion who were either divorced or widowed (4.4%). There were 5.9% who were pregnant at the time of the study, while 28.5% of the women had young children who were of preschool age (six years) or younger.
Background characteristics of study population (n = 1720)
While 15.1% of the women were currently using contraception, the types used included condoms, spermicidal cream, herbal medicines, and others, all of which do not require attendance at health clinics. Among this 15.1%, 7.6% were on the contraceptive pill and 2.8% were using the IUD, both of which require women to be in contact with health care services. Women who had tubal ligation (1.7%) would not have had to make use of health care services after the operation had been completed. Among the women, 45.1% reported having had a medical examination within the last five years. The type of examination, however, was not specified, and it could encompass either a pre-employment examination, a specific exposure-related examination related to type of work, or a general medical examination sought by the woman herself.
Practice of BSE and pap smear screening
Although 79.1% of the women had heard about the BSE, and 53.0% knew how to conduct the examination, only 44.8% had ever done the examination, while 24.4% said that they do it once a month . Likewise, although 25.3% had ever had the Pap smear, only 18.4% had their last examination within the last three years.
Practice of breast self-examination and pap smear screening among study population (n = 1720)
Women who were significantly more likely to do BSE every month were older, more highly educated, ever married, ever pregnant, had young children, had a medical examination in the last five years, had a Pap smear within the last three years, and gave a correct response to the question on when to do the BSE . However, BSE practice was not significantly associated with ethnicity or the use of the contraceptive pill or IUD.
Practice of BSE and pap smear screening
Although 79.1% of the women had heard about the BSE, and 53.0% knew how to conduct the examination, only 44.8% had ever done the examination, while 24.4% said that they do it once a month . Likewise, although 25.3% had ever had the Pap smear, only 18.4% had their last examination within the last three years.
Women who were significantly more likely to do BSE every month were older, more highly educated, ever married, ever pregnant, had young children, had a medical examination in the last five years, had a Pap smear within the last three years, and gave a correct response to the question on when to do the BSE . However, BSE practice was not significantly associated with ethnicity or the use of the contraceptive pill or IUD.
Similarly, women who had a Pap smear within the last three years were significantly more likely to be older, ever married, ever pregnant, had young children, had a medical examination in the last five years, answered correctly the question on the purpose of Pap smear, and did BSE every month. In contrast to women who practise BSE however, they were also significantly more likely to be non-Malays, less educated, and using the contraceptive pill or IUD.
The crude and adjusted odds ratios for the practice of BSE and Pap smear screening by the factors of interest. Women who were more than 30 years old had 1.53 times higher odds of doing BSE monthly (95% CI = 1.231.91) and 6.82 times higher odds of having had a Pap smear within the last three years (95% CI = 5.139.07) when compared with women who were 30 years old or younger. The number of never married women who had practised Pap smear screening was so small as to render the analysis imprecise (OR 153, 95% CI = 49478).
The group of electronics women workers in this study is drawn from an important segment of the Malaysian workforce. Although they constitute a group from the lower socio-economic strata, nevertheless, they are largely urban-based and draw a higher wage than women production workers in many other industries.
The sample was not representative of the electronics industry as a whole, and the large proportion of respondents who were volunteers could have led to a tendency to include women who were more active in seeking health information and in accessing health care. As such, the lower BSE and Pap smear screening rates found among these women as compared to the national average for women of a similar age group is a cause for greater concern.
In general, there were more women who know about BSE and the Pap smear than those who conduct them at the proper intervals as part of a regular preventive health strategy. There could be barriers to the regular practice of BSE and Pap smear that are specific to women production workers, and it would be important to identify these barriers, which may include psycho-social as well as economic ones, so that educational and promotional strategies could be more effective. Factory-based cancer screening and education programmes could contribute toward improving health knowledge and screening practices of women production workers.
The association between Pap smear screening and health service variables reflect the success of governmental strategy to disseminate it through postnatal and family planning service outlets. However, its close connection with marital status, to the practical exclusion of single women, is an indication that the health services have not been successful in widening its availability to all women.
The practice of BSE, on the other hand, was not found to be dependent on health service variables, but on educational level. This implies that there is wider interest in this than could be reached through postnatal and family planning services, and that this interest is linked to education. Adequate information and educational services should particularly reach out to women with lower educational levels, and young and single women.
Indeed, the large proportions who did not know the best time for doing BSE, even among those who were practising it once a month, reflect that the methods employed to disseminate information on this subject should be thoroughly reviewed. Many women are taught BSE during one-off postnatal visits, although those who are on oral contraceptives and the IUD receive reinforcement each time they visit the family planning clinic.
In any case, governmental policy on the promotion of BSE should be reviewed in light of recent research findings. Whether or not BSE should be taught and promoted, and how it should be done, should be ascertained through a thorough assessment of current practice and its effects. Information and knowledge about breast cancer could still be widely disseminated, whether or not BSE is advocated, and women should still be encouraged to be aware of their breasts, and any symptoms which could arise.
Credits:HL Chee,Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia
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