Fighting breast cancer - Qatar research program: From secondary to primary prevention

1. Fighting breast cancer - Qatar research program: From secondary to primary prevention Professor Tam Truong Donnelly Saumur, France Oct 9-12, 2013

2. Acknowledgement Funded by the Qatar National Research Fund, National Priorities Research Program, in Collaboration with the University of Calgary-Qatar, Hamad Medical Corporation, Qatar Primary Health Care, Qatar Supreme Council of Health, Qatar University, University of East Anglia.

3. Research Key Investigators Tam Truong Donnelly Al-Hareth Al-Khater Mohamed Ghaith Al-Kuwari Nabila Al-Meer Salha Bujassoum Al-Bader Mariam A Malik Rajvir Singh

4. Research Key Investigators Sheikha Al-Anoud bint Mohammad Al-Thani Kathleen Benjamin Kim Critchley Mohamed Ahmedna Tak Shing Fung Ailsa Welch Kevin Teather

6. Background Qatar Statistics Authority, 2010 • Population: 1,696,563 • Qatari citizens represent 24.4% of the population • Qatari female citizens represent 36.7% of the female population • GDP per capita: More than $88,000 for 2010 (http://www.forbes.com)

7. Background • Breast cancer is the most common cancer in Qatar for women • 20% cancer cases receiving treatment in 2007 at Al Amal Hospital in Doha (Now Qatar Centre for Cancer Care and Research), were breast cancer

8. Most frequent cancers for women in Qatar in 2008 (IARC, WHO 2008)

9. IARC International Agency for Research Cancer, WHO. World cancer report 2008 and Global cancer statistics. [http://globocan.iarc.fr/factsheet.asp]

10. Age-adjusted incidence and mortality rates of Breast Cancer among selected countries Data from GLOBOCAN 2008 (IARC).

11. Background • Arabic women are often diagnosed at advanced stages of breast cancer • Qatar National Cancer Society and Hamad Medical Corporation recommend BSE for all women, yearly CBE for women 35 +, and mammography every two years for women 40-69 unless otherwise advise by physicians. • Among Qatari women, 24% do BSE, 23% have had CBE, and 23% have had a mammography (Bener et al., 2009). • Low rate of screening suggest that Arab women in Qatar are at risk for lack of early detection and treatment of breast cancer in its early stages.

12. Research Goal • To develop, implement, and sustain an intervention program that will raise awareness of breast cancer and increase women’s participation in breast cancer screening activities and therefore reducing breast cancer’s morbidity and mortality for Arab women living in the State of Qatar

13. Ecological Conceptual Framework • Individuals and their physical and socio-cultural environment of individuals • Health care behaviour and the physical environmental variables, intrapersonal, and other social determinants of health • Health promotion and interventions should occur at multiple social, cultural, and environmental levels

14. Kleinman’s Explanatory Model • Individuals’ explanatory models are derived from their knowledge and values, which are informed by their specific socio-cultural backgrounds • Providing effective health care requires that providers be able to elicit and recognize clients’ beliefs and values with respect to their understandings of illnesses and treatments, and to negotiate these differing perspectives.

15. Study 1 • Cross-sectional Community -Based Survey of Breast Cancer Screening Practices Amongst Arabic Women Living in the State of Qatar

16. Study 1: Research Questions • What is the participation rate of Arabic women on breast self examination, clinical breast examination, and mammogram? 2. To what extent are Arabic women’s cultural knowledge and values, knowledge of breast cancer and its screening, socioeconomic status, and social support networks, associated with their breast cancer screening behaviours?

17. Methodology Study 1 • Sites: Doha, Al Wakrah (S), Al Khor (N) Study sample size calculation based on Cochran’s formula for sample size • Sample: convenience 1063 (87.5% response rate) Arabic women aged 35+ various healthcare settings, live in Qatar for at least 10 years • Data collection: structured survey-face to face • Data analysis: SPSS version 19

18. Results of the survey

20. BCS Awareness is significantly related to the following factors • Age (40-49 years old) • Marital Status (married) • Living area (mammogram - urban) • Education Levels – participants & husbands • Employment status (mammogram – employed) • Having an understandable doctor who talked about breast cancer with participant • Receiving BCS information from any source: family/friend, doctor, media or other HCP.

21. BCS Practice is significantly related to the following socio-economic factors • Being 40-49 years old, and married with 1-5 children • Higher education levels (participant & husband) • Higher income levels • Having BSE, CBE or mammogram awareness

22. BCS Practice is significantly related to the following beliefs • Having self-perceived Good – Excellent health • Believing cancer can be prevented and may be caused by heredity. • Believing cancer is not due to God’s punishment, bad luck or being contagious. • Significant predictors of CBE or Mammogram non-compliance : fear, embarrassment.

23. BCS Practice is significantly related to the following social or HCP factors • Having a doctor who talked to her about breast cancer • Understanding her doctor • Trusting her doctor (CBE) • Not having a gender preference for her HCP when it comes to clinical breast examinations (BSE, CBE). • Having received BCS information from any of a variety of sources: Doctor, Family/Friend, Media, or other HCP.

24. Study 2 – Methods

25. Study 2 • Aims/Research Questions: • How do Arab women participate in BCS programs? • How do contextual factors, such as social, cultural, historical, and economic influence Arab women’s BCS practices? • What would be culturally and socially appropriate and effective intervention strategies for increasing Arab women’s participation in BCS activities? • Data was collected from qualitative interviews conducted from October 2011 to May 2012 with a sample of 29 HCP, 56 women and 50 men living in Qatar.

26. Study 2 Results

27. Overall Study 2 Results • BCS practice is influenced by the following basic factors by general themes: • Cultural • Religious • Social • Educational, and • Economical factors.

28. Specific BCS Barriers Mentioned • Fear of cancer, cancer stigma, lack of concern for one’s health, embarrassment or shyness, • Overall lack of awareness of BCS among men and women, lack of encouragement or permission to get BCS from husbands/family, • High workload for doctors and lack of time with patients, lack of doctor recommendations, lack of delegation of BCS-related services to nurses, • Transportation and language issues, and a public health care system that is opportunistic with cancer screenings.

29. Specific BCS Facilitators mentioned • Fear of cancer, high concern for one’s health, socially active and influential women, • Religious beliefs that promote health and treatment, • Higher education levels (especially for younger generation of men and women), increasing awareness and willingness to learn more about cancer and BCS, media-savvy population, • Free/affordable health care in Qatar, and expanding health care services/facilities. • Value health and individual responsibility to keep oneself healthy; men are quite supportive of women BCS activities.

30. Recommendations Given • Establish population-based BCS programs • Expand health care services and the role of HCPs: • Increase doctor-patient time by reducing HCP workload • Increase mammogram facilities in public and private facilities • Mental health facilities and counseling services must be made available for cancer patients (these services must comply with religious and social context of Qatar)

31. Recommendations (cont’d) • Raise awareness of BCS with men and women • HCPs -Doctors must discuss BCS with and give recommendations to patients; must discuss the benefits of early detection with every adult female and male patient • To help reduce fear of cancer : • Emphasize gender-appropriate HCPs and facilities are available • Religious messages must be utilized for public health/early detection awareness campaign, along with cooperation with religious/community leaders • Media campaign must address benefits of BCS and early detection

32. Recommendations (cont’d) • Health centers must have readily available brochures, posters, workshops, lectures, videos to display/distribute • More health lectures on cancer, especially for males • Pamphlets are useful for those who are too shy to bring up BCS • Videos on cancer prevention and early detection should be played in health centers/hospitals for patients to watch during wait time.

33. Recommendations (cont’d) • Other • Schools/universities should raise awareness of health promotion, cancer and screening among younger generations • Utilize media and SMS messages to send reminders and cover importance of BCS and early detection. • Mobile clinics and mammograms clinic at the malls can reach more people.

34. Fostering Active Living and Healthy Eating Through Understanding of the PhysicalActivity and Dietary Behaviours of Arabic-Speaking Adults Living in Qatar

35. Background • Association between breast cancer and physical inactivity and high fat diet. • In 2006, in the State of Qatar, nearly 50% of young adults 18 to 19 years of age had insufficient levels of physical activity; 75% of people 60-69 years of age had inadequate levels of physical activity. • 2006 World Health Survey : 24% of the people surveyed in Qatar were of normal weight, 39% were overweight, and nearly 29% were obese. Factors contributing to obesity in the Middle East and United Arab Emirates (UAE) included unhealthy diets that is high in carbohydrates and fats, and physical inactivity.

36. Objectives 1. To determine the physical activity levels andfood habitsof Arabic-speaking adults, 18 years of age and older, in Qatar;  2. To assess the attitudinal, normative, and control beliefs of Arabic-speaking adults in Qatar regarding physical activity and healthy diet; 3. To determine significant predictors of Arabic-speaking adults’ intentions to engage in physical activity and healthy eating; 4. To gain an in-depth understanding of factors (e.g., environmental, social, cultural, policy) that influence the physical activities and eating behaviours of Arabic-speaking adults in Qatar ; 5. To identify tailored health promoting strategies to increase active living and healthy diets for Arabic-speaking adults in Qatar.

37. Phase1: cross sectional survey, quantitative research design Goals • Determine participants’ Physical Activity (PA) levels and food habits • Assess participants attitudinal, normative and control beliefs regarding PA and healthy diet • Determine predictors of participants’ intentions to engage in PA and healthy eating

38. Tasks Completed Year 1Recruitment and Data Collection • Recruit 42 participants for the elicitation study- (6 focus groups) • Recruit 24 people for pilot testing • Finalize survey items • Recruit 1565 participants for the main survey • Data collection/analyses ongoing • Begin writing articles on the quantitative results

39. Phase 2-Qualitative Goals • Gain in depth understanding of the influencing factors related to PA and healthy diet • Identify health promoting strategies to foster active living and healthy diets.

40. Tasks Completed Year 2Recruitment and Data Collection • Recruit 42 participants for pilot testing-(6 focus groups) • Finalize focus group questions and protocols • Pilot testing • Recruit 168 participants for 24 focus groups • Data collection /analyses ongoing • Recruit 24 participants (2 focus groups for member checking) • Complete data analyses • Begin writing articles on the qualitative results

41. Tasks Completed Year Three – Dissemination • Presentation of the findings at local, regional, international conferences and/or workshops • Submission of articles to international and national peer-reviewed journals • Preparation of final progress report

42. Anticipated OutcomesKnowledge Development and Awareness Raising -Year Three • Identification of participants’ salient beliefs about PA and healthy diet • Identification of significant predictors of participants’ intentions to engage in PA and healthy diet • Development of recommendations for health policy, health care delivery, and future research • Development of an Arabic survey to assess people’s attitudinal, normative, and control beliefs regarding their intentions to engage in PA and healthy eating. • Raise international awareness of the research activities related to active living and healthy diet in Qatar

43. Thank you