Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cannas Kwok, PhD

Daniel Y. T. Fong, PhD

Breast Cancer Screening Practices Among

Hong Kong Chinese Women
K E Y W O R D S Background: Although the incidence rates of breast cancer have been increasing
Breast cancer screening remarkably in Hong Kong over the last 2 decades, little is known on breast cancer
practices screening practices among this group of women. Objectives: This study aimed to
Chinese women report breast cancer screening practices among Hong Kong Chinese women and to
Culturally sensitive examine the relationship between (1) demographic factors and (2) the modified
instrument
Chinese Breast Cancer Screening Beliefs Questionnaire (CBCSB) score and women’s
breast screening behaviors. Methods: A descriptive and cross-sectional method was
used. Both English and Chinese versions of the modified CBCSB were administered.
Of 946 Hong Kong Chinese women older than 18 years and invited to participate in
the study, 753 (79.6%) completed and returned the questionnaire. Results: The
majority of participants (70%Y90%) had heard of breast self-examination (BSE),
clinical breast examination (CBE), and mammograms. Only 33.3% performed a BSE
monthly; 37.8% and 32.7% of women within the targeted age group had a CBE
annually and had a mammogram every 2 years, respectively. Being married and
part-time employment were positively associated with women who performed BSE as
recommended. In terms of modified CBCSB score, women who had BSE, CBE,
and mammogram as recommended had significantly higher scores on the subscale
attitudes to health check-up. Conclusion: Attitudes toward health check-up
was influential in compliance with breast cancer screening practices among
Chinese-Australian women. Implications for Practice: Effort should be focused
on specific subgroups of Hong Kong Chinese women, to fully understand the
barriers involved in participating in breast cancer screening practices.

Author Affiliations: School of Nursing and Midwifery, University of
Western Sydney, Australia (Dr Kwok); and School of Nursing, University of
Hong Kong (Dr Fong).
This study was supported by Early Career Development Fellowship from
the Cancer Institute of New South Wales.
The authors have no conflicts of interest to disclose.
Correspondence: Cannas Kwok, PhD, School of Nursing and Midwifery,
University of Western Sydney, EB Building, LG Rm51, Parramatta South
Campus, Locked Bag 1797, NSW 2751 (c.kwok@uws.edu.au).
Accepted for publication November 13, 2012.
DOI: 10.1097/NCC.0b013e31827f0a9d

Breast Cancer Screening Practices Cancer NursingTM, Vol. 37, No. 1, 2014 n 59

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
B
reast cancer is a significant global public health threat
affecting women of all socioeconomic levels in developed
and developing countries.1 Although historically the
incidence rates of breast cancer are higher in white population,
the rate has increased rapidly in Asian countries particularly in
developed and Westernized countries such as Hong Kong.2
Hong Kong has the highest crude incident rate in Asia (Hong
Kong, 59.4; Singapore, 59.0; Japan, 49.6; China, 20.1 per
100 000 population).3,4 In Hong Kong, breast cancer has over-
taken lung cancer to become the highest cancer incidence rate
in women. During the last 2 decades, the age-standardized in-
cidence rates of breast cancer have been increasing, along
with global trends, from 38.2 per 100 000 in 1990 to 46.6 per
100 000 in 2000 and further increased to 54.0 per 100 000 in
2009.5 In addition, the incidence of breast cancer peaks at age
40 years in Hong Kong Chinese, earlier than in whites.6
Hong Kong has been undergoing a demographic transition
since it was handed over to the People’s Republic of China in
1997. The migration of mainland Chinese to Hong Kong, es-
pecially younger aged women through marriage, has increased
remarkably over the last 10 years,7 so that the population age
profile for women is such that greater numbers of women are
approaching ages at which the risk of breast cancer is very high.
In addition, studies have shown that the incidence of breast
cancer in mainland China ranges from 10 to 52 per 100 000.
In more developed and Westernized cities, such as Shanghai,
there is a higher incidence rate of breast cancer.8 As more mainland
Chinese women migrate to Hong Kong and are exposed to more
Westernized lifestyles in the next decade, there is likely to be an
acceleration of incidence rates of breast cancer. An important
public issue is the promotion of breast cancer screening practices.
The causes of breast cancer are largely unknown. Therefore,
early detection through screening is considerably important as
secondary preventive measures. In Hong Kong, it is recom-
mended that women perform breast cancer screening practices
regularly. For asymptomatic women, breast cancer screening
practices include a monthly breast self-examination (BSE), an
annual clinical breast examination (CBE) by a health profes-
sional for women older than 40 years, and a mammography
every 2 years between the ages 50 and 69 years.9 It is acknowl-
edged that the focus of some Western countries has shifted
from BSE to breast awareness. This is due to BSE alone not
reducing breast cancer mortality10 and more recently to a growing
recognition that women did not perform BSE because of fear
about not knowing the correct technique.11 Nevertheless, BSE
remained the focus at the time of the current study. There is
no existing population screening of breast cancer in Hong Kong.
However, nonprofit organizations such as The Well Women
Clinics and Hong Kong Breast Cancer Foundation provide
screening services on a self-financed and self-referred basis.12
Internationally, considerable research effort has been made to
examine breast cancer screening behaviors among Chinese women
in Western countries such as Australia, United States, and Canada.
The majority of the evidence points to relatively low breast cancer
screening rates among Chinese women in these countries.13Y15
Although 98% of the Hong Kong population is Chinese,16 and
the incidence of breast cancer has been increasing remarkably,
60 n Cancer NursingTM, Vol. 37, No. 1, 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
little is known on breast cancer screening practices among women
in Hong Kong.
Identifying factors that are associated with women’s screen-
ing behaviors is extremely important. Overseas studies demon-
strated that compliance with breast cancer screening practices
has been reported to vary by education level, employment status,
and marital status.16Y19 In addition, culturally influenced be-
liefs about cancer have been clearly identified as key barriers to
the use of screening services among women from minority cul-
tures. For example, in African, Arabic, and Chinese cultures,
the cause of breast cancer is believed to be fate, and therefore,
screening has no value.20Y22 With reference to the Chinese health
promotion paradigm, the idea of screening for asymptomatic
cancer is foreign. Furthermore, a study of Chinese women in
Australia23 and the United States24 reported that women do not
appreciate the value of screening when they feel asymptomatic
and have therefore no reason to suspect that they have disease.
Other barriers to mammographic screening include modesty
and embarrassment among immigrant Chinese women.25 How-
ever, to our knowledge, there have been no existent studies exam-
ining how these demographic and cultural factors impact on
screening practices among Chinese women in Hong Kong,
where Chinese and Western health beliefs are intertwined.
This study forms part of a larger study to investigate Chinese
women’s beliefs, knowledge, and attitude toward breast cancer
and screening practices in Australia and Hong Kong. The Chinese
Breast Cancer Screening Beliefs Questionnaire (CBCSB) was
originally developed to assess Chinese-Australian women’s be-
liefs, knowledge, and attitudes toward breast cancer and screening
practices.26 The modified CBCSB was derived from the orig-
inal 13-item CBCSB and requires its cultural adaptability in a
Chinese-speaking community in Hong Kong to be assessed. The
current study aimed, first, to assess the psychometric perfor-
mance of the modified CBCSB with a sample of Chinese women
in Hong Kong. A detailed description of the development and
psychometric testing of the modified CBCSB has been re-
ported elsewhere.27 Second, the aims of the current article were
(1) to report breast cancer screening practices (BSE, CBE, and
mammogram) among Chinese women in Hong Kong, (2) to ex-
amine the relationship between demographic factors and women’s
screening behaviors, and (3) to examine the relationship between
the modified CBCSB scores and women’s screening behaviors.
n Methods
This descriptive and cross-sectional study used a self-administered
survey and was conducted from May to October 2008. The study
protocol was approved by the appropriate human research ethics
committee.
Participants
The target population was Chinese women in Hong Kong,
older than 18 years, who were able to read traditional Chinese
and had no history of breast cancer. Women with a history of
Kwok and Fong
breast cancer were excluded because the experience of being tices. Breast screening practices were used to divide the participants
diagnosed might have had a direct impact on their beliefs, knowl- into the following subgroups: (1) those participants who had
edge, and attitudes toward breast cancer and screening behaviors. ever heard of them; (2) if, having heard of any of the practices,
A total of 31 centers of nonprofit organizations throughout participants ever performed it; and (3) if, having heard of a prac-
Hong Kong participated in sample recruitment. Women who tice, it was performed as recommended for the appropriate tar-
visited these centers were approached by research assistants to geted age group. The impact of demographic factors on the
assess their study eligibility, and all eligible women were invited likelihood of having a screening practice as recommended was
to participate. Participants were given an information statement, assessed by a logistic regression with model adequacy checked by
and they were made aware of that participation was voluntary the Hosmer-Lemeshow test.28 The level of statistical signifi-
and that they would not be identified in research reports. Those cance was set at P G .05, and a 95% confidence interval for an
who were willing to participate were asked to sign an informed estimate was reported where appropriate.
consent form before they completed a questionnaire. The ques-
tionnaire took about 20 minutes to complete.
Nine hundred forty-six women were invited to participate in
the study. Seven hundred fifty-three women completed and re- n Results
turned the questionnaire, resulting in a response rate of 79.6%.
Twenty-three women were excluded from the study because of a Demographic Characteristics of the Participants
prior history of breast cancer, with a final sample size of 730.
The mean age of the 730 participants was 42.9 (SD, 11.7) years;
the range was from 18 to 80 years, with 25.6% of women older
Instrument than 50 years. Most participants were married (68%), had com-
The modified CBCSB questionnaire, designed as a culturally sen- pleted secondary school (59%), and/or were employed (55%).
sitive instrument, included 11 items in 3 scales: attitudes toward The demographic characteristics of the participants are presented
general health check-ups (4 items), knowledge and perceptions in Table 1.
about breast cancer (4 items), and barriers to mammographic
screening (3 items).27 The modified CBCSB requires respon- Breast Cancer Screening Practices
dents to make ratings for each subscale along a 5-point Likert
scale ranging from ‘‘strongly agree’’ (score of 1) to ‘‘strongly dis- Breast self-examination was defined in the CBCSB as ‘‘you ex-
agree’’ (score of 5). A ‘‘don’t know’’ option was included for amine your own breasts.’’ Clinical breast examination is defined
each item. The mean response to the items within a subscale was
then calculated and converted to range between 0 and 100. If
a participant scored all items within a subscale as 5, the final Table 1 & Sociodemographic Characteristics of
score is 100, and if a participant scaled all items as 1, the final Participant (n = 730)
score is 0. Subscale scores of 65 or higher are indicative of a
Variable n %
more positive attitude toward health check-ups, more accurate
knowledge, and less fatalistic perceptions about breast cancer Age, y (missing data: n = 71)
and less perceived barriers to having mammograms compared Mean (SD) 42.9 (11.7)
with scores of less than 65. Because of the wording of the items, Range 18Y80
responding either ‘‘disagree’’ or ‘‘strongly disagree’’ was indicative Marital Status (missing data: n = 7)
of a more proactive approach, more accurate knowledge about Single 155 21.4
breast cancer, and less perceived barriers. Participants who pre- Married 492 68.0
Cohabited 5 0.7
dominantly either disagreed or strongly disagreed with the
Divorced/Separated 49 6.8
items had subscale scores of 65 or higher, and this was there- Widowed 22 3.0
fore chosen as a value for delineating scores. Educational level (missing data: n = 5)
In addition to the 3 subscales, the CBCSB also collected Never attended school 10 1.4
information on demographic variables such as age, marital status, Primary school 133 18.3
and highest level of education. Information was also collected on Secondary school 424 58.5
participants’ breast cancer screening practices. This involved Institutional training 54 7.4
asking participants if they had ever heard of BSE, CBE, and Tertiary or above 104 14.3
mammograms and, if so, how regularly they self-examined or Occupation (missing data: n = 33)
had clinical examinations and/or mammograms. Full-time 265 38.0
Part-time 120 17.2
Unemployed: seeking work 78 11.1
Data Analysis Unemployed: not seeking work 102 14.6
Retired 106 15.2
Data were entered into and analyzed using SPSS 18 (SPSS Inc, Housewife 24 3.4
Chicago, Illinois). Descriptive statistics were reported for demo- Student 2 0.3
graphic variables and participants’ breast cancer screening prac-

Breast Cancer Screening Practices Cancer NursingTM, Vol. 37, No. 1, 2014 n 61

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Table 2 & Breast Cancer Screening Practices

.118
.126

.047
.223
.160

.07
P
(n = 730)

Have Mammogram as Recommended

(at Least Once Every 2 y) (n = 150)
Table 3 & Demographic Factors and Breast Cancer Screening Practices Among Those Who Have Heard of Practice and in the Target Age Group
n %

95% Confidence

1.02Y21.20
0.49Y20.81
0.98Y1.16

0.45Y1.14

0.94Y4.56
Interval
Breast self-examination

V
Ever heard of it 641/707 90.7
Ever performed 512/621 82.4
Performed as recommended (monthly) 207/621 33.3
CBE
Ever heard of it 496/708 70.1

Odds
Ratio
1.07

4.65
3.20
0.72

2.07
Ever performed 403/487 82.8

1
Performed as recommended 121/320 37.8
(annually) in target group

.197 150 0.022

.117 149 0.051

.943 148 0.019

145 0.033
R2
(Q40 y and ‘‘heard of CBE’’)
Mammogram

n
Ever heard of it 507/710 71.4
Ever performed 214/488 43.9

.069
.462

.494
V
P
Performed as recommended 49/150 32.7

Performed Clinical Breast Examination as

(every e2 y) in target group

Recommended (Annually) (n = 320)

95% Confidence
(50Y69 y and ‘‘heard of

0.94Y1.01

0.94Y6.14
0.49Y4.87
0.76Y1.29

0.74Y1.86
mammogram’’)

Interval

V
Abbreviation: CBE, clinical breast examination.

as ‘‘breast examination by a doctor or a nurse.’’ Mammogram is

referred as having a radiograph of the breast taken by a machine.

Odds
Ratio
0.98

2.40
1.54
0.99

1.18
Results are shown in Table 2.

1
The majority of participants had heard of BSE, CBE, and

.443 320 0.007

.002 319 0.020

.844 318 0.000

309 0.002
mammograms. Although slightly more than 80% had performed R2
a BSE or had a CBE at some time, only 33.3% performed a BSE
when recommended (monthly), and only 37.8% of women within
n

the targeted age group (40+ years) had a CBE when recommended
G.001
.126

.005
(annually). Less than half of the participants (43.9%) had ever had
V
P

a mammogram, and only 32.7% of women within the targeted

Performed Breast Self-examination as
Recommended (Monthly) (n = 621)

95% Confidence

age group (50Y69 years) reported they had a mammogram when

0.99Y1.02

1.50Y4.02
0.85Y3.75
0.70Y1.02

1.16Y2.30
recommended (every e2 years).
Interval

V
Demographic Factors and Breast Cancer
Screening Practices
Odds
Ratio
1.01

2.45
1.79
0.84

1.63

Table 3 shows the demographic factors associated on bivariate

1

analysis with breast cancer screening practices as recommended.

Women who had performed a regular BSE as recommended
562 0.001
614 0.032

617 0.007

594 0.018
R2

were more likely to be married and to have part-time employment.

However, no such association was found in women who did or
n

did not have a CBE or mammogram as recommended. Age and

education level were not significantly related to any breast cancer
seeking work/students/retired
Full-time/unemployed: seeking

screening practices.
school; 4 = tertiary or above)
Divorced/separated/widowed

Part-time/unemployed: not
Education level (0 = never in
Demographic Variables

Married or cohabited

Modified CBCSB and Breast Cancer

work/housewife
Employment status

Screening Practices
Marital status

Results for the modified CBCSB scores and breast cancer screen-
ing practices are shown in Table 4. Women who had BSE, CBE,
Single

and mammograms as recommended had significantly higher scores

Age, y

on the ‘‘attitudes to health check-ups’’ subscale. There were no

statistically significant differences in breast cancer knowledge

62 n Cancer NursingTM, Vol. 37, No. 1, 2014 Kwok and Fong

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Table 4 & Chinese Breast Cancer Screening Beliefs Questionnaire and Breast Cancer Screening Practices
Attitude to Health Breast Cancer Knowledge Barriers to Mammographic
Check-ups and Perceptions Screening

Mean SD Mean SD Mean SD

Total sample 51.62 19.95 70.90 15.81 61.52 18.51
95% Confidence interval 50.14Y53.09 69.73Y72.06 60.15Y62.88
BSE as recommendeda
Yes 54.33 19.75 72.71 14.95 63.77 18.24
No 50.22 19.07 71.09 15.36 61.87 18.25
P 0.012 0.211 0.218
Clinical breast examination as recommended in targeted age groupa
Yes 57.39 19.11 71.66 14.44 67.29 15.37
No 51.79 19.32 71.53 14.31 63.62 18.07
P 0.012 0.940 0.052
Mammogram as recommended in target groupa
Yes 57.27 19.49 70.88 16.89 64.97 18.16
No 49.13 21.39 71.43 15.02 62.09 19.61
P 0.020 0.838 0.368
Abbreviation: BSE, breast self examination.
a
Includes only those who have heard of the screening practice.

and perceptions between women who did or did not engage in
screening practices as recommended.
n Discussion
This study has provided important data about the status of
breast cancer screening practices among women in Hong Kong.
The findings indicate that 70.1% to 90.7% of the participants
had heard of the 3 breast cancer screening practices, and 43.9%
to 82.8% had engaged in a particular type of screening. In
contrast to the high numbers of participants who had heard of
breast cancer screening practices, there was relatively low propor-
tion of the participants who have actually practiced them as
recommended (32.7%Y37.8%). These findings suggest a signifi-
cant gap between the number of participants who had breast
cancer screening practices and the number that actually practiced
it as recommended. The findings of BSE and CBE are com-
parable with other local studies14,29 and their counterparts in
Australia13 and United States.15 The possible explanation may
lie in the fact that some Chinese women are more conservative
and believe that unnecessary touching of their bodies is inap-
propriate. Another explanation may be consistent with the study
conducted by Wong-Kim and colleagues,30 indicating a lack of
knowledge and awareness in the prevention and early detection
of breast cancer among women in Hong Kong. Given the in-
crease in incidence rates of breast cancer and considering the peak
incidences at younger age in Hong Kong Chinese population, our
findings point to an urgent need that an additional effort has to
be put in place to promote breast cancer screening practices and
in particular BSE and CBE, as these are the importance measures
to detect early breast cancer for women younger than 50 years.
Regarding the mammographic screening participation, the
rates are extremely low (32.7%) compared with their counterparts
in Australia (74.4%),29 United States (58%),31 and in Canada
(60%).32 There is an alarmingly low rate of screening in Hong
Kong, a Westernized and developed city. International studies
have identified cost as a key barrier to cancer screening services
among women.19,31 Cancer screening services are provided as
an out-of-pocket expense and are not covered by health insurance
if it is requested as a preventive measure. This may account for
low levels of screening. In addition to cultural influences, our study
reveals that screening policies such as provision of population-
based screening programs where mammographic services are
provided at low/no cost are equally important to combat this
public health concern and to meet increasing demand from cit-
izens. Moreover, this study has demonstrated implications for
public health policy for countries where currently there is no
population-based screening programs.
This sample resembles the Hong Kong population of females
in terms of education level and employment status.33 Education
for females is not common in Hong Kong. Given the age range
of this group of women, it is not surprising that more than
3 quarters of the sample attained only either primary or secondary
school. Similar to education levels, slightly more than half of the
sample engages either in full-time or part-time employment,
which is similar to the female population in Hong Kong.33
In examining demographic variables associated with breast
cancer screening practices as recommended, our bivariate analyses
showed marital status and employment status are significant
predictors for BSE. Being married and part-time employment
status are positively associated with performing BSE as rec-
ommended. This is consistent with studies by Lin18 and Kwok
et al.29 The relationship observed between age, education level,
and breast cancer screening practices in our study was incon-
sistent with the findings from previous studies, which indicated
that younger age and higher education level were significantly
associated with breast cancer screening practice.14,18,19
Kwok and Sullivan23 revealed that some Chinese women per-
ceive that fulfilling the gender role and taking care of the family
are necessary for a woman to stay healthy. Following this line of
thinking, married women are more likely to be health conscious

Breast Cancer Screening Practices Cancer NursingTM, Vol. 37, No. 1, 2014 n 63

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and may have more sources of health knowledge therefore more
awareness of the value of performing BSE. Nevertheless, such
association did not appear for CBE or mammograms. Cost may
be a reason. A study conducted by Kwong and colleagues12 sug-
gests that Hong Kong women’s participation in breast cancer
screening practices is influenced by cost concerns because health-
care services are provided mainly on a private basis. Having cost
concerns, people usually pay a medical visit only when they are
sick, particularly as preventive care is not common in Hong Kong.
Therefore, although married women are health conscious, cost
may have excluded women from going for a CBE or mammogram.
Part-time employment status compared with full-time employ-
ment status was significantly positively associated with performing
regular BSE. This may indirectly reflect that full-time-working
women have busy life and are less likely to have time for health
issues particularly preventive care. A previous study also in-
dicates that full-time workers tend to have less time or have less
exposure to the media and do not have the same level of knowl-
edge about cancer screening practices.18 Our findings suggest
that further research is necessary to focus on specific groups,
such as full-time workers and single women, to fully understand
the barriers involved in breast cancer screening practices.
Among the 3 subscales examining the relationship between
cultural beliefs and women’s screening behaviors, no significant
differences for the subscales ‘‘breast cancer knowledge and per-
ception’’ and ‘‘barriers to mammographic screening’’ emerged
as related with any screening practices. This is consistent with
the findings reported previously that knowledge of breast cancer
is not associated with immigrant Chinese women’s screening
behaviors.34 Although fatalism and barriers such as pain and
embarrassment appear as prominent factors that negatively af-
fect Chinese women’s screening behaviors in Australia23 and
United States,35 our study does not support the claim. This is
parallel to the study conducted by Kwong and colleagues,12 which
suggested that only 0.2% of Hong Kong Chinese women
found a mammogram as intolerable procedure, and only 3.3%
of the women found the procedure uncomfortable. Rather, our
study found that attitudes toward health check-ups appeared to
have influential impact on women’s screening behaviors.
Women in this study who performed the 3 screening prac-
tices examined had a more positive attitude toward health check-
ups. This is consistent with the findings of their counterparts
who migrated to Australia.13 Our study demonstrates how culture
plays a vital role in determining preventive health behavior.
Cancer screening is a preventive measure within Western health
promotion paradigm. Although Hong Kong was colonized
under British government for more than a hundred years, and
healthcare services have been provided based on biomedical
model, the population in Hong Kong retained their adherence
to traditional Chinese health beliefs and placed a strong em-
phasis on promoting health through exercise, diet, massage, and
mediation.36 Going for a health check-up as preventive measure
for early detection of disease remains uncommon among Chinese
people. As evident in the study by Wu et al24 in the United
States and Kwok and Sullivan23 in Australia, Chinese women
do not perceive themselves as needing a mammogram because
they do not have signs and symptoms. For cancer screening to be
64 n Cancer NursingTM, Vol. 37, No. 1, 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
promoted effectively in a Chinese community, taking cultural
beliefs and traditional health practices into account is essential for
designing programs. Although it is important to promote breast
cancer awareness and to stress the advantage of early detection,
promoting a proactive approach to health check-ups appears to
promise more effective breast cancer screening practices.
Fifty-seven percent of the world population is Asian and 20%
is Chinese,37 many of whom have migrated to Western countries.
Although the health systems of various countries vary, there is re-
markable consistency in terms of culture and health beliefs of
Chinese immigrants in these countries. Therefore, this study has
provided public health implications on a global level because it
serves as a basis from which to formulate and tailor-make culturally
sensitive interventions for promoting breast cancer screening prac-
tices among Chinese women, not only in Hong Kong but also in
countries where there is a substantial population of Chinese people.
n Limitations
There were some limitations to this study. First, the study used
self-reported measures of breast cancer screening practices that
could have been overreported or underreported. Further studies
with a design of adequate verification of self-reported informa-
tion are warranted. Second, the participants formed a conve-
nience sample recruited exclusively from nonprofit organizations
in Hong Kong. Thus, the results cannot be generalized to all
Hong Kong Chinese women. However, the findings of this
descriptive study can provide a foundation for future intervention
studies of Hong Kong Chinese women and a comparison with
Chinese women elsewhere.
n Conclusion
Given its escalating trend of the incidence rate in Hong Kong,
breast cancer is an important public health issue. The low rates
of breast cancer screening practices (BSE, CBE, and mammog-
raphy) used by this group of women are of concern and suggest
an urgent need for breast health education and to promote the
importance of these screening practices in Hong Kong. With
regard to variables associated with Hong Kong Chinese women’s
breast cancer screening practices, our study identified that atti-
tudes toward health check-ups were influential in compliance to
all breast cancer screening practices. Therefore, it is important to
take this information into account while designing breast health
education about the benefits of screening.
ACKNOWLEDGMENT
The authors thank the Chinese-Australian women who participated.
References
1. Parkin D, Fernandez L. Use of statistics to assess the global burden of
breast cancer. Breast J. 2006;12:S70YS80.
2. Parkin D, Bray F, Ferau J, et al. Global cancer statistics, 2002. CA Cancer J
Clin. 2005;55:74Y108.
Kwok and Fong
 3. Agarwal G, Pradeep P, Aggarwal V, et al. Spectrum of breast cancer in
Asian women. World J Surg. 2007;31:1031Y1040.
4. Hospital Authority. Hong Kong Cancer Statistics. 2008. Web site. http://
www3.ha.org.hk/cancereg/Summary%20of%20CanStat%202009.pdf.
Accessed March 15, 2012.
5. Hospital Authority. Hong Kong Cancer Statistics. 2010. Web site. http://
www3.ha.org.hk/cancereg/e_topic.asp. Accessed March 15, 2012.
6. Kwong A, Cheung P, Chan S, et al. Breast cancer in Chinese women
younger than age 40: are they different from their older counterparts?
World J Surg. 2008;32:2554Y2561.
7. Census and Statistics Department. Hong Kong Statistics. 2010. Web
site. http://www.censtatd.gov.hk/hkstat/sub/bbs.jsp. Accessed July 2012.
8. Yang L, Parkin DM, Whelan S, et al. Statistics on cancer in China:
cancer registration in 2002. Eur J Cancer Prev. 2005;14:329Y335.
9. Hong Kong Breast Cancer Foundation. Early detection. Web site. http://
www.hkbcf.org/content.php?cid=20&tid=3&lang=eng. Accessed July 2012.
10. Tavafian S, Hasani L, Aghamolaei T, et al. Prediction of breast self-
examination in a sample of Iranian women: an application of the Health
Belief Model. BMC Womens Health. 2009;9:37.
11. Cohen M. Breast cancer early detection, health beliefs, and cancer worries
in randomly selected women with and without a family history of breast
cancer. Psychooncology. 2006;15(10):873Y883.
12. Kwong A, Cheung P, Wong A, et al. The acceptance and feasibility of
breast cancer screening in the East. Breast. 2008;17:44Y52.
13. Kwok C, Fethney J, White K. Breast cancer screening practices among
Chinese-Australian women. Eur J Oncol Nurs. 2012;16:247Y252.
14. Todd L, Harvey E, Hoffman-Goetz L. Predicting breast and colon cancer
screening among English-as-a-second-language older Chinese immigrant
women to Canada. J Cancer Educ. 2010;26(1):161Y169.
15. Wong-Kim E, Wang C. Breast self-examination among Chinese immi-
grant women. Health Educ Behav. 2006;33(5):580Y590.
16. Census and Statistics Department. Hong Kong Statistics. 2010. Web site:
http://www.censtatd.gov.hk/hkstat/sub/bbs.jsp. Accessed July 2012.
17. Leung D, Leung A, Chi I. Breast and colorectal cancer screening and associated
correlates among Chinese older women. Asian Pac J Cancer Prev.
2012;13:282Y287.
18. Lin S. Factors influencing the uptake of screening services for breast and
cervical cancer in Taiwan. Perspect Public Health. 2008;128:327Y335.
19. Wu T, Hsie H, West B. Demographics and perceptions of barriers
toward breast cancer screening among Asian-American women. Women
Health. 2011;48(3):261Y281.
20. Kwok C, Sullivan G. The influence of traditional Chinese beliefs on cancer
screening behaviours among Chinese-Australian women. J Adv Nurs. 2006;
54(6):691Y699.
Breast Cancer Screening Practices
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
21. Powe B, Finnie R. Cancer fatalism: the state of the science. Cancer Nurs.
2003;18(2):118Y126.
22. Spurlock W, Cullins L. Cancer fatalism and breast cancer screening in
African American women. ABNF J. 2006;17(1):38Y43.
23. Kwok C, Sullivan G. The concepts of health and preventive health
practices of Chinese-Australian women in relation to cancer screening.
J Transcult. 2007;18(2):118Y126.
24. Wu T, West B, Chen Y, et al. Health beliefs and practices related to
breast cancer screening in Filipino, Chinese and Asian-Indian women.
Cancer Detect Prev. 2006;30:58Y66.
25. Tang T, Solomon L, McCracken L. Cultural barriers to mammography,
clinical breast exam, and breast self-exam among Chinese-American women
60 and older. Prev Med. 2000;31(5):575Y583.
26. Kwok C, Fethney J, White K. Chinese Breast Cancer Screening Beliefs
Questionnaire: development and psychometric testing with Chinese-
Australian women. J Adv Nurs. 2010;66(1):191Y200.
27. Fong D, Kwok C, White K. Psychometric properties of the Chinese
Breast Cancer Screening Beliefs questionnaire. Eur J Oncol Nurs. 2012;
16(5):505Y511.
28. Hosmer D, Lemeshow S. Applied Logistic Regression. New York: A Wiley-
Interscience Publication; 2000.
29. Kwok C, Fethney J, White K. Mammographic screening practices among
Chinese-Australian women. J Nurs Scholarsh. 2012;44:11Y18.
30. Wong-Kim E, Sormanti M, Tang K, et al. Talking cancer, saving lives:
breast cancer awareness training for health professionals in Hong Kong.
Appl Health Eval. 2008;284:305Y318.
31. Yu M, Wu T, Wood D. Cultural affiliation and mammography screening
of Chinese women in an urban country of Michigan. J Transcult Nurs.
2005;16(2):107Y116.
32. Sun Z, Xiong H, Kearney A, et al. Breast cancer screening among Asian
immigrant women in Canada. Cancer Epidemiol. 2010;34:73Y78.
33. Women’s Commission. Hong Kong Women in Figures 2007. Hong Kong:
Hong Kong Census Department; 2008.
34. Lee-Lin F, Menon U, Pett M, et al. Breast cancer beliefs and mammography
screening practices among Chinese American immigrants. J Gynaecol Neonatal
Nurs. 2007;36:212Y221.
35. Facione N, Giancarlo C, Chan L. Perceived risk and help-seeking behaviour
for breast cancer: a Chinese-American perspective. Cancer Nurs. 2000;23(4):
258Y267.
36. Simpson P. Family beliefs about diet and traditional Chinese medicine
for Hong Kong women with breast cancer. Oncol Nursing Forum. 2003;
30(5):834Y840.
37. United Nations. World Population Trend. 2008. Web site. www.un.org/esa/
population/publications/I/WorldPop2300final.pdf. Accessed July 2012.
Cancer NursingTM, Vol. 37, No. 1, 2014 n 65