Breast cancer (BC) is the most commonly diagnosed cancer among women, impactingover 1.5 million women each year, and also the second leading cause of cancer-relateddeaths in women throughout the world 1,2. In Iran also, the disease accounts for 24.4% of all cancers and itsincidence has been estimated to be 17.81%, whichhas increased dramatically in recent years 3. Unfortunately, because of resource and infrastructureconstraints and diagnosing at later stages of breast cancer in low-incomecountries, there is an enormous difference in BC survival rates worldwide, withan estimated 5-year survival of 80% in developed countries to below 40% fordeveloping countries 4,5.

Delayed diagnosis in developing countries is related, at leastpartly, to poor breast cancer awareness, especially low level of awarenessabout early warning signs and symptoms of BS 6,7. Increasing breast cancer awareness is widely accepted as thefirst step in the battle against BS, especially in countries that do not haveongoing organized population-based screening 8,9. Previous studies have shown that the increased women’s awarenessabout early diagnosis and screening of BS can change people’s screeninghealth-seeking behavior 6,10,11 and self-examination rather than clinical-breast examination lead toearlier BS diagnosis 8.

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Therefore, there is an urgent need forimproving great BS awareness and its early detection measures among women 12.A vital firststep into addressing this need is valid instruments for measuring andmonitoring levels of BS awareness, and examining its associated risk factors 7,9. Only with such standardized instruments can design appropriateinterventions in order to promote BS awareness 7,9. Several BS awareness instruments have been proposed 7–9,12–17. However, some of these instruments contain design and/ormethodological limitations and are not fully validated. Cancer Research UnitedKingdom (UK) developed and did attempt to fully validate their instrument, theBreast Cancer Awareness Measure (BCAM) in 2010 7. It is a self-completed questionnaire for assessing knowledge ofbreast cancer symptoms and age-related risk, and reported frequency of breastchecking 7. In UK populations, the readability of the BCAM was reported highand construct validity was supported by significant differences between thelevels of BS awareness among cancer experts compared to non-medical academics 7,13.

However, the BCAM was developed and validated for western populationswhere etiologic factors and health policy of BS differ considerably from Asiandeveloping countries 9. In addition, cross-cultural and language differences routinelyintroduce measurement biases which affect the quality of data collected 13,18. These limitations reduce its usefulness outside the UK setting. In a developing community such as Iran where late presentation ispredominant and majority of BS patients are diagnosed at advanced stages ofdisease 6, there is an urgent need for developing and validating aninstrument to assess BS awareness. To the best of our knowledge, there is noaccepted and validated instrument for assessing BS awareness in Iran. Thisstudy aimed to investigate the validity, language appropriateness andpsychometric properties of the BCAM scale among Iranian women. Understanding Iranianwomen’s BS awareness will help healthcare professionals and policy makers todesign and implement health education interventions in order to promoteawareness of BS. Methods and MaterialsStudy Design and Participants This cross-sectional study (methodological research) was conducted from July 2016through November 2017.

Participants were Iranian women living in Isfahan, acity in central Iran. Nearly one thousand womenwere selected from different parts of Isfahan city (such as shopping canters,recreational places, kindergartens, health canters and different streets of thecity) to participate in the study. To be eligible for participation in thisstudy, women had to be at least 18 years old, able to read and write Persian,and should be permanent resident of Isfahan. The participants who did notanswer to main questions were excluded. Eligible women were invited toparticipate in the study by face-to-face invitation. Interviews were performedby trained interviewers.

After getting oral consent to participate in thestudy, participants were requested to complete the BCAM questionnaire. Thestudy was approved by the ethics committee of the Isfahan University of MedicalSciences (Project Number: 194126).The Breast Cancer Awareness Measure (BCAM)Cancer Research UK developed and validated an awareness measure specific to BSawareness which called BCAM7. The teamgenerated questionnaire items through a review of the literature on theexisting BS awareness measures, a review of the ‘grey’ literature and theteam’s experience during researches on breast cancer patients. It includesitems on knowledge ofbreast cancer symptoms, knowledge of age-related risk, and reported frequencyof breast checking.

In the currentstudy, this instrument was selected based on its appropriate validity,reliability and readability, and also its simplicity and generalizability. InUK populations, the readability of the BCAM was reported high and over 90% of women found it acceptable. Theanalyses of test– retest reliability of the BCAM showed moderate to goodreliability for most items.

Good construct validity was approved by significant differences between the levels of BS awareness among cancerexperts compared to non-medical academics (50% versus 6%, p = 0.001) 7,13. We alsoadded questions about age, education level, marital status, job status, personalhistory of breast problems, family history of breast cancer and sources ofacquiring awareness into the questionnaire.Translation and cross-cultural adaptation The “forward–backward” procedure wasapplied to translate the BCAM questionnaire from English into Persian (Iranianlanguage), after seeking permission from the initial developer (Louise Linsell,Kings College London, London, UK). Forward translation of the BCAM from Englishto Persian was independently performed by two professional translators fluentin both languages. The researchers and two forward translators then comparedthe two translated versions with the original question­naire and reached aconsensus about the first draft of the Persian version of the BCAM. The Persianadapted version was backward translated into English by a bilingual translator.

The translated English version was comparedwith the original one with respect to conceptual equivalence by research­ersand an expert committee. Finally, after acareful review and cultural adaptation process, necessary changes were made,and the provisional Persian version of the BCAM questionnaire was provided. This pre-final Persian BCAM questionnaire was then piloted on50 women aged 18 years old and over who volun­teered to participate in thestudy. They were asked to express any difficulty to understand any word orsentences in the questionnaire. According to the participants’ feedback,the trans­lation quality simplicity, and clarity of the questionnaire wereverified by most pilot study volunteers.

Then, the researchers make finaladjustments in response to this feedback, and the final Persian version of BCAMwas developed.Assessment of psychometric propertiesIn this study, psychometric characteristicsinclude reliabil­ity (test-retest reliability and in­ternal consistency),validity (construct validity, face validity, criterion(discriminant) validity and content validity). ReliabilityIn this study, we investigated two aspectsof reliability as test-retest reliability and in­ternal consistency. To test the extent to which the measure was repeatable (the stabil­ity of the measurement over time), we recruited 50 women aged 18 years old and over.

The women were asked to complete the BCAM questionnaire at two separate dayswith a 7-day interval between both periods. Test–retest reliability wasassessed separately for each item using the unweighted kappa statistic(<0.20: poor, 0.21- 0.40: fair, 0.41- 0.

60: moderate, 0.61- 0.80: good,0.81- 1.00: very good). In addition, Intra class correlation coefficient (ICC)was used to evaluate the relative reliability for the total score of items.

ICC? 0.70 was considered as the evidence of excel­lent stability. Internal consistency reliability reflectsthe extent to which several items in a questionnaire assess different aspectsof the same general construct. Cronbach’s ? coefficient was used for the whole questionnaire and ‘warning signs’section to measure internal consistency with pre-established val­ues indicatingacceptable (>0.7), good (>0.

8), and excel­lent (>0.9) internalconsistency. Data collected in the first administration of the BCAMquestionnaire was used to evaluate internal consistency.  ValidityFace validityThe face validity was assessed,as mentioned above, by recruiting 50 women to participant in the pilot study toevaluate whether the questions in the BCAM question­naire were understandable,simple, and clear. Construct validityIn accordancewith the scale of the items of the BCAM subscale of breast cancer warning signs(i.e. “yes-no” questions), the construct validity was investigated by using latentclass analysis (LCA). In the other words, the level of “knowledge” about breast cancer warningsigns wasconsidered as a latent construct and it was evaluated based on having knowledgeor lack of knowledge about each item using LCA.

This model examines the patternof relations among a set of observed categorical variables and classifiessimilar individuals into latent classes. We fitted various LCA models withdifferent latent classes. The adequacy of fitted models was guided throughcomparing the Bayesian Information Criterion (BIC), the Akaike informationcriterion (AIC) and entropy indices across models.

A model with lower “BIC andAIC” and higher “entropy” values indicate better fitting and class separation,respectively.Criterion (Discriminant)validityCriterion validity was assessed based onthe BCAM ability to discriminant between general women and medical/clinicalexperts. The validity of the measure is supported if distribution of the BCAMitems be significantly different across two groups. We distributed the BCAMquestionnaire to 965 general women and 113 medical/clinical experts andcompared their responses. We tested the difference in the proportion or scoresof items between two groups using Chi?square test or independent Student’s t?test. In addition, Receiver operating characteristic(ROC) curve along with the sensitivity and specificity values, were used togauge the ability of the BCAM subscale of awareness level about warning signsof breast cancer to discriminate between general women and medical/clinicalexperts.

Other statistical analysisIn this paper, quantitative and qualitativevariables were expressed as mean (SD) and number (precent), respectively. Thedeterminants of the level of “awareness” about breast cancer warning signs were evaluated using “latent class regression”analysis (LCR). In the other words, the prediction of membership into latentclass of the level of “awareness” is obtained by multinomial regression oflatent class variable on independent variables. Data analyses were performedusing Statistical Package for Social Sciences version 21 (SPSS Inc., Chicago,IL, USA) and … software.



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