Breast cancer (BC) is the most commonly diagnosed cancer among women, impacting
over 1.5 million women each year, and also the second leading cause of cancer-related
deaths in women throughout the world 1,2. In Iran also, the disease accounts for 24.4% of all cancers and its
incidence has been estimated to be 17.81%, which
has increased dramatically in recent years 3. Unfortunately, because of resource and infrastructure
constraints and diagnosing at later stages of breast cancer in low-income
countries, there is an enormous difference in BC survival rates worldwide, with
an estimated 5-year survival of 80% in developed countries to below 40% for
developing countries 4,5.

Delayed diagnosis in developing countries is related, at least
partly, to poor breast cancer awareness, especially low level of awareness
about early warning signs and symptoms of BS 6,7. Increasing breast cancer awareness is widely accepted as the
first step in the battle against BS, especially in countries that do not have
ongoing organized population-based screening 8,9. Previous studies have shown that the increased women’s awareness
about early diagnosis and screening of BS can change people’s screening
health-seeking behavior 6,10,11 and self-examination rather than clinical-breast examination lead to
earlier BS diagnosis 8. Therefore, there is an urgent need for
improving great BS awareness and its early detection measures among women 12.

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A vital first
step into addressing this need is valid instruments for measuring and
monitoring levels of BS awareness, and examining its associated risk factors 7,9. Only with such standardized instruments can design appropriate
interventions 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/or
methodological limitations and are not fully validated. Cancer Research United
Kingdom (UK) developed and did attempt to fully validate their instrument, the
Breast Cancer Awareness Measure (BCAM) in 2010 7. It is a self-completed questionnaire for assessing knowledge of
breast cancer symptoms and age-related risk, and reported frequency of breast
checking 7. In UK populations, the readability of the BCAM was reported high
and construct validity was supported by significant differences between the
levels of BS awareness among cancer experts compared to non-medical academics 7,13. However, the BCAM was developed and validated for western populations
where etiologic factors and health policy of BS differ considerably from Asian
developing countries 9. In addition, cross-cultural and language differences routinely
introduce 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 is
predominant and majority of BS patients are diagnosed at advanced stages of
disease 6, there is an urgent need for developing and validating an
instrument to assess BS awareness. To the best of our knowledge, there is no
accepted and validated instrument for assessing BS awareness in Iran. This
study aimed to investigate the validity, language appropriateness and
psychometric properties of the BCAM scale among Iranian women. Understanding Iranian
women’s BS awareness will help healthcare professionals and policy makers to
design and implement health education interventions in order to promote
awareness of BS.

Methods and Materials

Study Design and Participants

This cross-sectional study (methodological research) was conducted from July 2016
through November 2017. Participants were Iranian women living in Isfahan, a
city in central Iran. Nearly one thousand women
were selected from different parts of Isfahan city (such as shopping canters,
recreational places, kindergartens, health canters and different streets of the
city) to participate in the study. To be eligible for participation in this
study, 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 not
answer to main questions were excluded. Eligible women were invited to
participate in the study by face-to-face invitation. Interviews were performed
by trained interviewers. After getting oral consent to participate in the
study, participants were requested to complete the BCAM questionnaire. The
study was approved by the ethics committee of the Isfahan University of Medical
Sciences (Project Number: 194126).

The Breast Cancer Awareness Measure (BCAM)

Cancer Research UK developed and validated an awareness measure specific to BS
awareness which called BCAM
7. The team
generated questionnaire items through a review of the literature on the
existing BS awareness measures, a review of the ‘grey’ literature and the
team’s experience during researches on breast cancer patients. It includes
items on knowledge of
breast cancer symptoms, knowledge of age-related risk, and reported frequency
of breast checking. In the current
study, this instrument was selected based on its appropriate validity,
reliability and readability, and also its simplicity and generalizability. In
UK populations, the readability of the BCAM was reported high and over 90% of women found it acceptable. The
analyses of test– retest reliability of the BCAM showed moderate to good
reliability for most items. Good construct validity was approved by significant differences between the levels of BS awareness among cancer
experts compared to non-medical academics (50% versus 6%, p = 0.001) 7,13. We also
added questions about age, education level, marital status, job status, personal
history of breast problems, family history of breast cancer and sources of
acquiring awareness into the questionnaire.

Translation and cross-cultural adaptation

The “forward–backward” procedure was
applied to translate the BCAM questionnaire from English into Persian (Iranian
language), after seeking permission from the initial developer (Louise Linsell,
Kings College London, London, UK). Forward translation of the BCAM from English
to Persian was independently performed by two professional translators fluent
in both languages. The researchers and two forward translators then compared
the two translated versions with the original question­naire and reached a
consensus about the first draft of the Persian version of the BCAM. The Persian
adapted version was backward translated into English by a bilingual translator. The translated English version was compared
with the original one with respect to conceptual equivalence by research­ers
and an expert committee. Finally, after a
careful 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 on
50 women aged 18 years old and over who volun­teered to participate in the
study. They were asked to express any difficulty to understand any word or
sentences in the questionnaire. According to the participants’ feedback,
the trans­lation quality simplicity, and clarity of the questionnaire were
verified by most pilot study volunteers. Then, the researchers make final
adjustments in response to this feedback, and the final Persian version of BCAM
was developed.

Assessment of psychometric properties

In this study, psychometric characteristics
include reliabil­ity (test-retest reliability and in­ternal consistency),
validity (construct validity, face validity, criterion
(discriminant) validity and content validity).


In this study, we investigated two aspects
of 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 days
with a 7-day interval between both periods. Test–retest reliability was
assessed 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 reflects the extent to which several items in a questionnaire assess different aspects of 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 indicating acceptable (>0.7), good (>0.8), and excel­lent (>0.9) internal
consistency. Data collected in the first administration of the BCAM
questionnaire was used to evaluate internal consistency. 


Face validity

The face validity was assessed,
as mentioned above, by recruiting 50 women to participant in the pilot study to
evaluate whether the questions in the BCAM question­naire were understandable,
simple, and clear.

Construct validity

In accordance
with 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 latent
class analysis (LCA). In the other words, the level of “knowledge” about breast cancer warning
signs was
considered as a latent construct and it was evaluated based on having knowledge
or lack of knowledge about each item using LCA. This model examines the pattern
of relations among a set of observed categorical variables and classifies
similar individuals into latent classes. We fitted various LCA models with
different latent classes. The adequacy of fitted models was guided through
comparing the Bayesian Information Criterion (BIC), the Akaike information
criterion (AIC) and entropy indices across models. A model with lower “BIC and
AIC” and higher “entropy” values indicate better fitting and class separation,

Criterion (Discriminant)

Criterion validity was assessed based on
the BCAM ability to discriminant between general women and medical/clinical
experts. The validity of the measure is supported if distribution of the BCAM
items be significantly different across two groups. We distributed the BCAM
questionnaire to 965 general women and 113 medical/clinical experts and
compared their responses. We tested the difference in the proportion or scores
of 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 to
gauge the ability of the BCAM subscale of awareness level about warning signs
of breast cancer to discriminate between general women and medical/clinical

Other statistical analysis

In this paper, quantitative and qualitative
variables were expressed as mean (SD) and number (precent), respectively. The
determinants 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 latent
class of the level of “awareness” is obtained by multinomial regression of
latent class variable on independent variables. Data analyses were performed
using Statistical Package for Social Sciences version 21 (SPSS Inc., Chicago,
IL, USA) and … software. 


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