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      Validation of an Eastern Armenian breast cancer health belief survey

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          Abstract

          With the fourth highest breast cancer mortality rate in the world, breast cancer prevention and early detection is a priority for Armenia. The Ministry of Health recently initiated efforts to expand access to breast cancer screening. However, little is known about the population’s understanding and perception of breast cancer screening programs. This cross-sectional telephone-based study sought to develop and validate an Eastern Armenian language version of the Champion’s Health Belief Model Scale (CHBMS) for future use. The English-language CHBMS survey was first rigorously translated by two Armenian nationals and evaluated for face validity. Telephone surveys were then administered to randomly-selected women of approximately screening age (35–65 years) with no prior history of breast cancer living in Armenia’s capital between 2019–2020 (n = 103). The translated survey’s psychometric properties were evaluated, examining (1) content equivalence, (2) test-retest reliability and (3) internal consistency. Content equivalence and test-retest reliability of the Armenian CHBMS were characterized using correlational analysis with Pearson’s coefficient ranging from 0.76–0.97 (p<0.001) and 0.72–0.97 (p<0.001), respectively, for all five CHBMS domains. The translated survey’s internal consistency was comparable to the original English-language CHBMS with a Cronbach’s alpha greater than 0.7 for all five domains (0.75–0.94 (p<0.001). The translated Eastern Armenian version of CHBMS is a valid, internally-consistent, and reliable research tool that is ready for imminent use among screening-age women to investigate breast cancer perceptions and beliefs as the Armenian government seeks to expand screening access.

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          Sample size used to validate a scale: a review of publications on newly-developed patient reported outcomes measures

          Purpose New patient reported outcome (PRO) measures are regularly developed to assess various aspects of the patients’ perspective on their disease and treatment. For these instruments to be useful in clinical research, they must undergo a proper psychometric validation, including demonstration of cross-sectional and longitudinal measurement properties. This quantitative evaluation requires a study to be conducted on an appropriate sample size. The aim of this research was to list and describe practices in PRO and proxy PRO primary psychometric validation studies, focusing primarily on the practices used to determine sample size. Methods A literature review of articles published in PubMed between January 2009 and September 2011 was conducted. Three selection criteria were applied including a search strategy, an article selection strategy, and data extraction. Agreements between authors were assessed, and practices of validation were described. Results Data were extracted from 114 relevant articles. Within these, sample size determination was low (9.6%, 11/114), and were reported as either an arbitrary minimum sample size (n = 2), a subject to item ratio (n = 4), or the method was not explicitly stated (n = 5). Very few articles (4%, 5/114) compared a posteriori their sample size to a subject to item ratio. Content validity, construct validity, criterion validity and internal consistency were the most frequently measurement properties assessed in the validation studies. Approximately 92% of the articles reported a subject to item ratio greater than or equal to 2, whereas 25% had a ratio greater than or equal to 20. About 90% of articles had a sample size greater than or equal to 100, whereas 7% had a sample size greater than or equal to 1000. Conclusions The sample size determination for psychometric validation studies is rarely ever justified a priori. This emphasizes the lack of clear scientifically sound recommendations on this topic. Existing methods to determine the sample size needed to assess the various measurement properties of interest should be made more easily available. Electronic supplementary material The online version of this article (doi:10.1186/s12955-014-0176-2) contains supplementary material, which is available to authorized users.
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            Screening for breast cancer with mammography

            A variety of estimates of the benefits and harms of mammographic screening for breast cancer have been published and national policies vary. To assess the effect of screening for breast cancer with mammography on mortality and morbidity. We searched PubMed (22 November 2012) and the World Health Organization's International Clinical Trials Registry Platform (22 November 2012). Randomised trials comparing mammographic screening with no mammographic screening. Two authors independently extracted data. Study authors were contacted for additional information. Eight eligible trials were identified. We excluded a trial because the randomisation had failed to produce comparable groups.The eligible trials included 600,000 women in the analyses in the age range 39 to 74 years. Three trials with adequate randomisation did not show a statistically significant reduction in breast cancer mortality at 13 years (relative risk (RR) 0.90, 95% confidence interval (CI) 0.79 to 1.02); four trials with suboptimal randomisation showed a significant reduction in breast cancer mortality with an RR of 0.75 (95% CI 0.67 to 0.83). The RR for all seven trials combined was 0.81 (95% CI 0.74 to 0.87). We found that breast cancer mortality was an unreliable outcome that was biased in favour of screening, mainly because of differential misclassification of cause of death. The trials with adequate randomisation did not find an effect of screening on total cancer mortality, including breast cancer, after 10 years (RR 1.02, 95% CI 0.95 to 1.10) or on all-cause mortality after 13 years (RR 0.99, 95% CI 0.95 to 1.03).Total numbers of lumpectomies and mastectomies were significantly larger in the screened groups (RR 1.31, 95% CI 1.22 to 1.42), as were number of mastectomies (RR 1.20, 95% CI 1.08 to 1.32). The use of radiotherapy was similarly increased whereas there was no difference in the use of chemotherapy (data available in only two trials). If we assume that screening reduces breast cancer mortality by 15% and that overdiagnosis and overtreatment is at 30%, it means that for every 2000 women invited for screening throughout 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress including anxiety and uncertainty for years because of false positive findings. To help ensure that the women are fully informed before they decide whether or not to attend screening, we have written an evidence-based leaflet for lay people that is available in several languages on www.cochrane.dk. Because of substantial advances in treatment and greater breast cancer awareness since the trials were carried out, it is likely that the absolute effect of screening today is smaller than in the trials. Recent observational studies show more overdiagnosis than in the trials and very little or no reduction in the incidence of advanced cancers with screening.
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              The benefits and harms of breast cancer screening: an independent review

              (2012)
              Whether breast cancer screening does more harm than good has been debated extensively. The main questions are how large the benefit of screening is in terms of reduced breast cancer mortality and how substantial the harm is in terms of overdiagnosis, which is defined as cancers detected at screening that would not have otherwise become clinically apparent in the woman's lifetime. An independent Panel was convened to reach conclusions about the benefits and harms of breast screening on the basis of a review of published work and oral and written evidence presented by experts in the subject. To provide estimates of the level of benefits and harms, the Panel relied mainly on findings from randomised trials of breast cancer screening that compared women invited to screening with controls not invited, but also reviewed evidence from observational studies. The Panel focused on the UK setting, where women aged 50-70 years are invited to screening every 3 years. In this Review, we provide a summary of the full report on the Panel's findings and conclusions. In a meta-analysis of 11 randomised trials, the relative risk of breast cancer mortality for women invited to screening compared with controls was 0·80 (95% CI 0·73-0·89), which is a relative risk reduction of 20%. The Panel considered the internal biases in the trials and whether these trials, which were done a long time ago, were still relevant; they concluded that 20% was still a reasonable estimate of the relative risk reduction. The more reliable and recent observational studies generally produced larger estimates of benefit, but these studies might be biased. The best estimates of overdiagnosis are from three trials in which women in the control group were not invited to be screened at the end of the active trial period. In a meta-analysis, estimates of the excess incidence were 11% (95% CI 9-12) when expressed as a proportion of cancers diagnosed in the invited group in the long term, and 19% (15-23) when expressed as a proportion of the cancers diagnosed during the active screening period. Results from observational studies support the occurrence of overdiagnosis, but estimates of its magnitude are unreliable. The Panel concludes that screening reduces breast cancer mortality but that some overdiagnosis occurs. Since the estimates provided are from studies with many limitations and whose relevance to present-day screening programmes can be questioned, they have substantial uncertainty and should be regarded only as an approximate guide. If these figures are used directly, for every 10,000 UK women aged 50 years invited to screening for the next 20 years, 43 deaths from breast cancer would be prevented and 129 cases of breast cancer, invasive and non-invasive, would be overdiagnosed; that is one breast cancer death prevented for about every three overdiagnosed cases identified and treated. Of the roughly 307,000 women aged 50-52 years who are invited to begin screening every year, just over 1% would have an overdiagnosed cancer in the next 20 years. Evidence from a focus group organised by Cancer Research UK and attended by some members of the Panel showed that many women feel that accepting the offer of breast screening is worthwhile, which agrees with the results of previous similar studies. Information should be made available in a transparent and objective way to women invited to screening so that they can make informed decisions. Copyright © 2012 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                Role: Formal analysisRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: SoftwareRole: Visualization
                Role: Data curation
                Role: ConceptualizationRole: Validation
                Role: ConceptualizationRole: Data curationRole: Writing – original draft
                Role: ConceptualizationRole: Supervision
                Role: ConceptualizationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLOS Glob Public Health
                PLOS Glob Public Health
                plos
                PLOS Global Public Health
                Public Library of Science (San Francisco, CA USA )
                2767-3375
                5 May 2023
                2023
                : 3
                : 5
                : e0001849
                Affiliations
                [1 ] Department of General Surgery, University of California, Los Angeles, Los Angeles, California, United States of America
                [2 ] School of Public Health, Yerevan State Medical University, Yerevan, Armenia
                [3 ] Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
                [4 ] Department of Neuroscience, University of California, Berkley, Berkley, California, United States of America
                [5 ] Department of Pediatric Surgery, University of California, Los Angeles, Los Angeles, California, United States of America
                Babcock University, NIGERIA
                Author notes

                The authors have declared that no competing interests exist.

                Author information
                https://orcid.org/0000-0003-2961-1270
                https://orcid.org/0000-0003-1795-1892
                https://orcid.org/0000-0002-8534-0121
                Article
                PGPH-D-22-02079
                10.1371/journal.pgph.0001849
                10162547
                37145984
                7ee9c956-f079-44f3-a4e1-b6325aa2b19c
                © 2023 Tupper et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 26 December 2022
                : 12 April 2023
                Page count
                Figures: 0, Tables: 4, Pages: 9
                Funding
                The authors received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Oncology
                Cancers and Neoplasms
                Breast Tumors
                Breast Cancer
                Medicine and Health Sciences
                Diagnostic Medicine
                Cancer Detection and Diagnosis
                Cancer Screening
                Medicine and Health Sciences
                Oncology
                Cancer Detection and Diagnosis
                Cancer Screening
                People and Places
                Population Groupings
                Ethnicities
                Asian People
                Armenian People
                Medicine and Health Sciences
                Public and Occupational Health
                Health Screening
                Medicine and Health Sciences
                Diagnostic Medicine
                Diagnostic Radiology
                Mammography
                Research and Analysis Methods
                Imaging Techniques
                Diagnostic Radiology
                Mammography
                Medicine and Health Sciences
                Radiology and Imaging
                Diagnostic Radiology
                Mammography
                Medicine and Health Sciences
                Public and Occupational Health
                Behavioral and Social Aspects of Health
                People and Places
                Geographical Locations
                Asia
                Armenia
                People and Places
                Geographical Locations
                Europe
                Armenia
                Research and Analysis Methods
                Research Design
                Survey Research
                Surveys
                Custom metadata
                The de-identified data is available in Supplemental S1 File.

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