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Self-Breast Examinations in 20-30 year-old Females in a Bhutanese Community of Syracuse,

New York

Bikash Regmi

State University of New York Polytechnic Institute



The morbidity and mortality rate caused by breast cancer can be decreased with early

detection through a self-breast exam. The objective of this study is to assess whether the women

between ages 20-30 of the Bhutanese Community of Syracuse (BCS), New York practice

monthly self-breast examinations. These women are originally from Bhutan and have resided in

Syracuse, New York, since 2008. Data will be collected using self-made dichotomous and

multiple-choice questionnaires. Descriptive statistics will be used in the analysis of the data. The

Health Promotion Model, designed by Nola J. Pender will be use as the theorist. A Health

Promotion Model focuses on helping people achieve higher levels of well-being. A lack of

knowledge of preventative health care within the Bhutanese Community affects the frequency of

self-breast examinations. Women need to be informed about when and how to perform self-

breast examinations.

Key Words: Bhutanese, refugee, Syracuse, breast cancer, self-breast exam


Self-Breast Examination



According to the United Nations (2015), there were approximately 15.1 million refugees in

2015. This is the highest number in the last twenty years (UNCHR, 2015). In 2015,

approximately 70,000 refugees resettled in the United States (US Department of State, 2015).

About 85,000 Bhutanese refugees were resettled in the United States from 2008 to 2015

(International Organization of Migration, 2015). Refugees from Bhutan have a complex history.

Many of their ancestors migrated to Southern Bhutan from Nepal in the late 1700s in search of

better jobs (Haworth, Margalit, Ross, and Nepal, 2014). They peacefully lived in the southern

part of Bhutan while maintaining their Nepali culture and tradition. In the mid 1980s, the

government of Bhutan became threatened by the growing population of the Nepali speaking

Bhutanese in the southern part of the country. As a result, these people were forcefully evicted

from Bhutan. They stayed in Nepal as refugees for 17 years. After years of failed negotiation

attempts by Nepal and Bhutan, the resettlement process began with the first arrival of Bhutanese

refugees to the United States in 2008 (Haworth et al., 2014). According to the Bhutanese

community of Syracuse (BCS), there are about 2,800 Bhutanese refugees who have resettled in

Syracuse. 60 % of the Bhutanese refugees who have resettled in the United States are between

the ages of 15-44, 15% are 45-64, 5% are over 65, and the rest are under 15 years old with a

fairly equal gender distribution (Haworth et. al, 2014).


Problem Statement

Self-breast examination is a technique, which allows an individual to examine his/her

breast tissue for any physical or visual changes (Maurer Foundation, 2015). It is often used as an

early detection method for breast cancer. According to American Cancer Society (2015), about 1

in 8 women in the US will develop invasive breast cancer during their lifetime. In 2016, about

246,660 new cases of invasive breast cancer will be diagnosed and about 40,450 women will die

from it (American Cancer Society, 2016). Breast cancer is the second leading cause of cancer

death in women. Health research with Bhutanese refugee communities has primarily focused on

mental health, particularly depression and post-traumatic stress disorder (Haworth et al., 2014).

However, there is very little documentation regarding self-breast examinations among Bhutanese



A self-breast examination is an important screening practice and a simple, economical

and non-invasive screening method for early detection of breast cancer (Erdem & Toktas, 2016).

It is important to encourage women to be breast aware in order to detect any changes in their

body; especially 80% of breast cancer survivors detected their own lumps (Ogunbode &

Fatiregum, 2015). Self-breast exam is a process in which women examine their breasts regularly

to detect any abnormalities such as lumps, bumps, and swelling. Women are encouraged to

perform self-breast exams at least once a month. The best time to do a monthly self-breast exam

is about 3-5 days after the period because the breasts are not as tender or lumpy at this time in the

monthly cycle (NIH, 2015). The practice of the self-breast exam is routine in a well-developed

country like the U.S, but it is not well established in developing countries like Bhutan and Nepal

where breast health education is not practiced. There is also a dearth of knowledge about the

self-breast examination in women of the Bhutanese Community of Syracuse. The purpose of this

study is to assess the practice of self-breast examination between the ages of 20 -30 years female

of the Bhutanese Community of Syracuse.

Statement of Applicable Theory

For this research, the Health Promotion Model designed by Nola J Pender will be used by

using culturally specific language and strategies. Pender defines health as a positive dynamic

state; not merely absence of disease (Alligood, 2010). This theory is chosen because it is directed

at increasing a patients level of well-being. Health promotion behavior such as self-breast

examination helps in early detection of breast cancer, which is crucial for early treatment and

reduction of mortality. It is intended to be used in any situation in which it is desirable for clients

to seek changing their behavior and possibly the environment to support healthy behaviors

(George, 2010). Some examples of health promoting behavior are maintaining a healthy diet,

exercising regularly, managing stress, obtaining adequate rest, performing self-breast

examinations, and building positive relationships.

The Health Promotion Model of Pender focuses on three areas (Alligood, 2012).

- Individual characteristics and experiences

-Behavior specific cognitions and affect and

-Behavioral outcomes

-The health promotion model notes that each person has unique personal characteristics and

experiences that affect subsequent actions.

-The set of variables for behavior specific knowledge and affect have important motivational


-These variables can be modified through nursing actions.

-Health promotional behavior is the desired behavior outcome and is the end point in the health

promotional model.

-Health promotional behaviors should result in improved health enhanced functional ability and

better quality of life at all stages of development

-The final behavior demand is also influenced by the immediate competing demand and

preferences, which can derail and intend health-promoting actions. (Nursing Theories, 2010)

The figure below is the Health Promotional Model of Pender.


(Source: Alligood, 2012)

Literature Review

Multiple literatures were reviewed and analyzed to understand the self-breast

examination in women of 20 -30 years of the Bhutanese Community of Syracuse. The data was

collected using the CINAHL database, Medline, and Google scholar. Librarian Theodore Pfohls

help was taken to find the appropriate journals. The various key used in the search were,

Bhutanese, refugee, Syracuse, breast cancer, and self-breast exam.

Ten articles were found using the library databases using the above-mentioned key terms.

Out of ten articles, only two articles match with my research. The rest of the articles were

disregarded. The first article discusses breast cancer screening in refugee women using culturally

tailored patient navigation. The second article addresses breast cancer and self-breast

examinations in Vietnamese, Bosnian, Cuban, and other newly arrived refugee women. However,

there are no articles relating to Bhutanese Refugees and self-breast examinations.

Lima, Ashburner, Bond, Oo & Atlas, (2013) conducted the study for breast cancer

screening of Somali, Arabic, and Bosnian-speaking refugee women. These groups were

compared with English speaking and Spanish speaking women. Researchers argue that women

who immigrated to the United States within the last ten years were less likely to have self-breast

exams and mammograms within two years. It is largely due to lack of the knowledge about

preventative health care, self-breast exams, mammograms, fears about the procedure, or racial

discrimination. Arabic immigrant women are more likely to avoid cancer screening because of

the embarrassment and fear of cancer diagnosis and therefore have lower self-breast and

mammogram rates than other groups. Researchers want to evaluate whether culturally tailored

patient navigation programs for refugee women decrease disparities in breast cancer screening.

The study was conducted at the Massachusetts General Hospital Chelsea HealthCare Center. In

the study there were 188 refugees (36 Somali, 48 Arabic, 104 Bosnian), 2,027 English speaking

and 2,014 Spanish-speaking women. The data was analyzed by using two sample t tests or chi-

square tests. The researchers found in the year prior to implementing the culturally tailored

patient navigation, the mammography and self-breast exam rates were lower in refugee women

compared to English-speaking and Spanish-speaking women. However, after two years of

implementing the culturally tailored patient navigation, screening rates increased in refugee

women, which were similar to the rate of English-speaking and Spanish-speaking women.

Barnes and Harrison (2010) also conducted similar research about the screening rate for

breast cancer for newly arrived (less than 90 days) refugees in the United States. This study

explored the breast cancer screening of newly arrived Bosnian, Cuban, Vietnamese, and other

refugee women in the United States. The author argues that refugee women lack knowledge

about breast cancer screening, such as breast self-exam, mammogram, and are less likely to

receive screening compared to non-refugees. 74 participants all over age 40 were asked whether

they had a mammogram or self-breast exam. Only 10 women (14%) had at least one

mammogram and self-breast exam. 64 (86%) had never had a mammogram or a self-breast

exam. In contrast, 67% of women in the United States age 40 or older have had at least one

mammogram and self breast exam as a screening for breast cancer (Barnes & Harrison, 2010).

To assess whether the U.S. and refugee womens rate of mammograms and self-breast exams

differed, the author performed a z approximation test comparing the two population rates. They

found p (z=15.78) < .001, 95% confidence intervals =0.0556 and 0.2146. Results showed that

there is a significant difference in the rate of refugee women in the sample who have ever had a

mammogram and self-breast exam as compared to U.S. women in general. The research focuses

on the mammogram and self-breast examination for the refugee population. Unfortunately, there

was no research regarding self-breast examinations or mammograms for Bhutanese refugees,

which validates the need to further, explore this amongst the Bhutanese refugee community.

Research Question

Do women between the ages of 20-30 of the Bhutanese Community of Syracuse, New

York, perform monthly self-breast examinations?

Methods and Procedure

Descriptive quantitative research

A descriptive survey will be used to guide the research. This survey allows researchers to

obtain data about the practice of self-breast examination of women of BCS. According to Grove,

Gray & Burns (2012) descriptive research is the exploration and description of phenomena in a

real-life situation. The purpose of descriptive research is to observe, describe, and document

aspects of a situation as it naturally occurs and some time serves as the starting point for

hypotheses, generational, or theory development (Polit and Beck (2012).

Description of setting

The sample will be gathered from Bhutanese women who are located in Upstate NY. They

should be between the ages of 20-30. These women must be willing to voluntarily participate in

research and must be able to give consent (Appendix B). Cognitively impaired samples will be

excluded from the study. A paper copy of the questionnaire will be given to the participants

(Appendix A).

Sampling Procedure and Characteristics

Participants will be informed through posters, social media (Facebook) and the website of

BCS. Posters will be made for this research study. The poster will be placed in the main

doorway and on the bulletin board of the BCS Center at least 20 days prior to the study. The

same information will be posted on the BCSs Facebook page and website. Forty-five

participants between ages 20 -30 will be selected. Women who had bilateral mastectomies will

be excluded. Participants will be invited to the BCS center to participate. If the location is not

favorable to the participants, a new location will be found with mutual understandings. They will

be given an explanation about the objective of the study and eligibility to participate. Participants

will be informed that this is voluntary with no known risks. They may withdraw from the study

any time. Confidentiality will be assured and valid consent (Appendix B) will be obtained from

each participants. The participants will be asked to fill out the questionnaire (Appendix A). The

researcher will stay with the participants as they complete the questionnaire. Varying times will

be chosen in order to maximize the opportunity to all women of ages 20-30.

Ethical Considerations

Permission will be requested from the Institute Review Board (IRB) of SUNY Poly.

Appropriate protocol and consent is used from the IRB of New York State Education Department

with permission. This is a human subject research. It is very important to respect the ethical

consideration. Once the permission is granted from the IRB, the research may begin.

Measurement Instrument

Participants will be asked to complete a self-made dichotomous and multiple-choice

questionnaire. The group A questions are related to demographic and group B are related to self-

breast exam (Appendix A). Nominal and intervals level of measurement will be collected.

Nominal is the lowest level of measurement, which involves assigning numbers to classify

characteristics into category such as gender and marital status (Polit & Beck, 2012). Interval

measurement occurs when researchers can specify rank ordering on an attribute and can assume

equivalent distance between them (Polit & Beck, 2012). The question will be piloted in six

Bhutanese women to insure the content validity. Content validity concerns the degree to which

an instrument has an appropriate sample of items for the construct being measured and

adequately covers the construct domain (Polit & Beck, 2012). The reliability will be obtained by

using Cronbachs alpha. It is the most widely used method for evaluating internal consistency

(Polit & Beck, 2012). The value of the alpha coefficient lies between .00 and +1.00. The higher

the score, the higher the internal consistency.

Data collection strategies

Data will be collected by asking participants to complete a self-made, dichotomous, and

multiple-choice questionnaire (Appendix A) after obtaining the consent. The researchers will

stay in the room to answers any questions while the participants complete the questionnaire.

Plan for Analysis

The goal of data analysis is to provide the answers to the research question. Data will be

analyzed using SPSS software. SPSS is a widely used program for statistical analysis in health

research. Statistics included in the SPSS software includes descriptive, bivariate, prediction for

numerical outcomes, and prediction for identifying groups (Kara, Acikel, 2013). Descriptive

statistics includes mean, median, standard deviation (SD), frequency distributions and

percentages. Frequency distribution will be used to organize the data. Frequency distribution is

an organized tabulation/graphical representation of the number of the individuals in each

category. It allows the researchers to have a glance at the completed data conveniently.

It gives the researchers a picture of women ages 20-30 who perform self-breast examinations.

Chi-square test will be used to compare the performance of self-breast examinations in Hindu

and Christian women.


Many people of the Bhutanese Community do not speak English. Language and culture are

the main limitations of the study. Bhutanese women are very reluctant to discuss personal

matters, such as the self-breast exam; especially with the opposite sex. The sample size is also

very small.

Dissemination of Findings

The results of this research studies will be shared with the participants at the BCS center.

The feedback will be gathered from the participants to enhance my final report. The final paper

will be presented to the SUNY Poly IRB, nursing department, and classmates in a PowerPoint

presentation. The paper will be available for peer review in a nurse practitioner journal. The last

step will be to publish the paper in various journals such as Journal of Nursing, Nurse

Practitioner Journal and the Journal of Oncology


Breast cancer is the most common cancer and second leading cancer death in

women. Early detection methods of breast cancer include the self-breast exam. It is

recommended that all women check their breasts for lumps, thickness, or other changes monthly.

Self-breast exam is a non-invasive method for early detection of breast disease and an

inexpensive way to provide the early detection. It is imperative to perform this procedure at the

same time each month so that changes due to monthly hormonal differences can be differentiated

form the norm. Refugee women are lacking the knowledge of how to perform self-breast exam.

The refugee population is increasing day by day in the United States. Unfortunately, breast

cancer screening is significantly lower in the refugee population. The recommendation for future

research is to track the number of the female Bhutanese refugees who actively perform self-

breast exams.


American Cancer Society. (2015, March). Breast Cancer Facts & Figures. Retrieved February

11, 2016, from


Barnes, D., & Harrison, C. (2010). Refugee women's reproductive health in early resettlement.

Journal of Obstetric, Gynecologic & Neonatal Nursing, 33(6), 723-728.

Bhutanese Community of Syracuse. (2016, May). Refugee at a Glance. Retrieved April 13, 2016,


Erdem, B., & Toktas, C. (2016). Breast cancer screening in refugee. Journal of Community

Health, 22(3), 210-220.

George, B. (2010). Nola Pender. In nursing theorists (3 ed., pp. 201-215). Maryland Heights:

Mosby Elsevier.

Grove, S., Gray, J., & Burns, N. (2011). Introduction to quantitative research. Understanding

Nursing Research: Building an Evidence-Based Practice (6 ed., p. 33). Maryland

Heights: Elsevier.

Haworth, R., Margalit, R., Ross, C., & Nepal, T. (2014). Knowledge, attitudes and practices for

cervical screening among Bhutanese community in Omaha, Nebraska. Journal of


Community Health, 39(10), 872-878.

Institutional Review Board. (2015, June). IRB rule and responsibility. Retrieved April 12, 2016,


International Organization of Migration. (2015, November). Resettlement of refugees from

Bhutan tops 100,000. Retrieved March 21, 2016, from


Kara, B., & Acikel, C. (2009). Health belief and breast self-examination in a sample of Turkish

nursing students and their mother. Journal of Clinical Nursing, 18(10), 1412-1421.

Lima, S., Ashburner, J., Bond, B., Oo, S., & Atlas, S. (2013). Decreasing disparities in breast

cancer screening in refugee women using culturally tailored patient navigation. Journal

of General Internal Medicine, 28(11), 1463-1468.

Maurer Foundation. (2015, June). Self breast exam. Retrieved from

National Library Of Medicine. (2015, May). Breast self-exam. Retrieved April 13, 2016, from

Nursing Theories. (2014, May). Nola J Pender. Retrieved April 13, 2016, from

Ogunbode, A., & Fatiregun, A. (2015). Breast self-examination practices in Nigerian women

attending a tertiary outpatient clinic. Indian Journal of Cancer, 52(4), 520-524.

Polit, D., & Beck, C. (2014). Quantitative research design. Nursing research generating and

assessing evidence for nursing practice (9 ed., p. 227). New Delhi, India: Wolters

Kluwer India Pvt Ltd,.

U.S. Department of State. (2015, June). Refugee admissions statistics. Retrieved April 13, 2016,


UNCHR. (2015, July). Statistics. Retrieved March 21, 2016, from

UNHCR. (2015, May). Refugee statistics and operational data. Retrieved April 13, 2016, from

Appendix A
Group A

1. Years in the United States

1. Less that 1
2. 1-2
3. 2-3
4. 2-4
5. 4 +
Prefer not to answer

2. Education level
1. Primary
2. Secondary
3. University/College
4. Prefer not to answer

3. Literacy level (native language)

1. Read
2. Write
3. Speak

4. Age
1. 20-23
2. 23-26
3. 26-30

5. Marital status:
1. Single (divorced/ widow/separated)
2. Single (never been married)
3 Married
4. Prefer not to answer

6. Religion
1. Hindu
2. Buddhist
3. Christianity
4. Prefer not to answer

Group B

Self Breast Exam

1. Have you heard or read about self-breast examination?

1. Yes
2. No

2. Have you ever done the self-breast exam?

1. Yes
2. No

3. Frequency of examination in the past five years

1. Once a month
2. Once every two months
3. Once every three to six months
4. Annually
5. Never

Appendix B
Consent for Participation in Research

I volunteer to participate in a research project conducted by Dr. [Name of the Principle

Investigator] from SUNY Poly. I understand that the project is designed to gather information
about academic work of faculty on campus. I will be one of approximately 35 people being
interviewed for this research.
1. My participation in this project is voluntary. I understand that I will not be paid for my
participation. I may withdraw and discontinue participation at any time without penalty. If I
decline to participate or withdraw from the study, no one on my campus will be told.

2. I understand that most interviewees will find the discussion interesting and thought-
provoking. If, however, I feel uncomfortable in any way during the interview session, I have the
right to decline to answer any question or to end the interview.

3. Participation involves being interviewed by researchers from SUNY Poly. The

interview will last approximately 20 minutes.

4. I understand that the researcher will not identify me by name in any reports using
information obtained from this interview, and that my confidentiality as a participant in this
study will remain secure. Subsequent use of records and data will be subject to standard data use
policies, which protect the anonymity of individuals and institutions.

5. I understand that this research study has been reviewed and approved by the
Institutional Review Board (IRB) for Studies Involving Human Subjects: Behavioral Sciences
Committee at SUNY Poly. For research problems or questions regarding subjects, the
Institutional Review Board may be contacted through [information of the contact person at IRB
office of SUNY Poly].

7. I have read and understand the explanation provided to me. I have had all my questions
answered to my satisfaction, and I voluntarily agree to participate in this study.

8. I have been given a copy of this consent form.

____________________________ ________________________
My Signature Date

____________________________ ________________________
My Printed Name Signature of the Investigator
For further information, please contact:

Dr. [Name of Principle Researcher]


[Contact Information of PI]