Understanding Fear of Breast Cancer Among Ghanaian Women via the Champion Breast Cancer Fear Scale

Abstract

Background:

Screening for breast cancer via mammography is underutilised in Ghana, with fear of the disease influencing women’s participation. However, little is known about the role fear of breast cancer plays in screening decisions, partly due to the lack of a Ghana-specific measure to assess this fear. There is a need for a valid and reliable measure to assess breast cancer-related fear among Ghanaian women.

Objectives:

To evaluate the construct validity and internal consistency reliability of the Champion Breast Cancer Fear Scale among Ghanaian women.

Design:

Cross-sectional research design.

Methods:

The participants were women (aged 18-78 years) recruited in the general population through convenience sampling. The total sample was randomly split into 2 equivalent subsamples to perform the construct validity analysis via exploratory factor analysis (n = 428) and confirmatory factor analysis (n = 427), along with internal consistency reliability testing using McDonald omega (ω) and Cronbach alpha (α).

Results:

The original one-factor structure of the Champion Breast Cancer Fear Scale was supported by both exploratory factor analysis and confirmatory factor analysis in the present study. Omega and alpha coefficients for the total sample (ω = .877; α = .876), subsample 1 (ω = .877; α = .875), and subsample 2 (ω = .879; α = .877), were found to be good. Overall, the confirmatory factor analysis found sound validity evidence, χ²(19) = 62.84, P < .001, comparative fit index = .971, root mean square error of approximation = .074, 90% confidence interval = [.05, .09], standardised root mean square residual = .031, for the use of the Champion Breast Cancer Fear Scale for assessing fear of breast cancer among Ghanaian women in the general population. Other results revealed that most of the participants reported a high fear of breast cancer, whereas a substantial number reported a moderate fear of breast cancer.

Conclusion:

The study confirms the Champion Breast Cancer Fear Scale as a valid and reliable measure for identifying women with a fear of breast cancer.

Keywords

Cancer mammography screening women mental health validity reliability

Introduction

Female breast cancer remains the most common cancer in Ghana, with an estimated 15 987 new cases and 9856 deaths reported in 2022.¹ According to the Global Cancer Observatory, the age-standardised breast cancer incidence and mortality rate per 100 000 women in Ghana in 2022 was 132.2% and 87.8%, respectively.¹ Breast cancer is therefore a leading cause of death among Ghanaian women, but numerous studies have shown that early detection through mammography can reduce morbidity and mortality.^2-8 This is because screening participation can lead to the detection of breast cancer tumours that are treatable. Awareness campaigns in Ghana have improved knowledge about breast cancer and mammography.^9,10 However, screening remains underutilised in Ghana.¹¹ For example, a study among 1672 women aged 18 to 60 years in Ghana found that while 84% knew about mammography, fewer than 10% had been screened.¹² Similarly, a breast cancer study among 385 female undergraduate students in Ghana found that 42.6% practised breast self-examination, 10.1% had a clinical breast examination, and only 2.3% had a mammogram in the past 3 years.¹³

Consequently, research has reported most Ghanaian women with breast cancer present late,^14-16 leading to poor prognosis and poor treatment outcomes.^17-19 A variety of factors has been identified to be impeding women’s participation in breast cancer screening and treatment in Ghana. They include cultural beliefs,²⁰ illness beliefs and fatalism,^21,22 misinterpretation of breast cancer symptoms and signs,²³ complementary and alternative medicine use,^19,24 negative attitudes of health care providers,²⁵ educational level,^11,26 inadequate screening facilities,^27-29 and high cost of breast cancer diagnosis and treatment.^30-32 Yet, to our knowledge, no survey research has specifically investigated how fear of breast cancer influences screening participation and treatment delays among Ghanaian women. This is partly because there is no specific measure for assessing fear of breast cancer in Ghana.

Considerable research has shown that fear of breast cancer and harms related to the screening process and diagnosis are real.^33-40 For this reason, it was noted by the World Health Organization that ‘irrespective of the type of setting, access to objective, evidence-based information about the benefits and harms of breast cancer screening is crucial for women’.⁴¹^(p26) Therefore, there is a need for an objective, valid, and reliable measure to assess the fear of breast cancer in a population-based survey in Ghana. A number of tools are available to measure fear of cancer, fear of recurrence, and cancer-related worry, such as the Fear of Cancer Recurrence Inventory, Fear of Recurrence Questionnaire, Cancer Worry Scale, and Cancer-related Worries Scale.⁴² These self-report tools are typically used with patient populations and often target a range of cancer types, including breast cancer, colorectal cancer, and lung cancer. A popular measure in the breast cancer literature that aligns closely with our research goal is the Champion Breast Cancer Fear Scale (CBCFS).⁴³ Thus, we selected the CBCFS because it was specifically developed to assess fear of breast cancer among people in the general population.

The CBCFS is an 8-item measure (hereinafter called CBCFS-8) for assessing generalised fear of breast cancer (eg, fear of mammography use, fear of positive screening outcomes) among healthy people in the general population. Fear of breast cancer has been conceptualised as a negative emotion characterised by intense arousal, triggered by a threat perceived to be significant and personally important.^43,44 The CBCFS-8 is a unidimensional measure developed using an American sample. Various researchers, working independently, have found good validity and reliability evidence for the CBCFS-8 among women in Spain,⁴⁵ Saudi Arabia,⁴⁶ the United States,^43,47 and Iran.⁴⁸ The good validity and reliability information on the CBCFS-8 coupled with its brevity and simple items suggest that it might potentially be a promising measure for investigating fear of breast cancer in population-based surveys in Ghana.

However, to date, the construct validity and reliability of the CBCFS-8 have not yet been examined in Ghana. Thus far, we know very little about how the CBCFS-8 will perform psychometrically in a novel cultural context like Ghana, despite the growing evidence of its utility in the cultural contexts of America, Spain, Iran, Turkey, and Saudi Arabia. Given that there are cultural differences between individuals in these social contexts and those in Ghana, where deference to authority, social embeddedness, interconnectedness, achievement of group goals, and traditional and religious beliefs about health and illness are held in high esteem,^49-51 there is a compelling need to examine the CBCFS-8’s utility within the context of Ghana. Taken together, the present study aimed to validate the CBCFS-8 for use among Ghanaian women in the general population. This study was needed to answer the following research questions: (1) What is the factorial validity of the CBCFS-8 in the context of Ghana? (2) What is the reliability of the CBCFS-8 in the context of Ghana? The present study used the classical test theory’s approaches of exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to answer these research questions.^52,53

Methods

Research design

This study used a cross-sectional research design, a type of observational design which enables the examination of survey data from a population at one specific point in time. Survey data for the present study were collected between April and May 2022.

Participants and procedure

The empirical data for the present analysis were collected as part of a substudy (ie, Screen4BC study) aimed at providing validity and reliability evidence on behavioural measures of breast cancer screening participation for use among women in the general population in Ghana. The main study investigated the experience of breast cancer and its treatment outcomes in a patient population.^14,17,19,54 Participants for the substudy were women recruited from the general population in the Greater Accra Region of Ghana. They were recruited via a convenience sampling method, described as a non-probability sampling technique that involves recruiting individuals who are available, easily accessible to the researcher, and are willing to participate in a research.^55,56 Methodologists have shown that the minimum sample size required for stable estimates in EFA and CFA using a variable-to-factor ratio of 4 or 7 was 30 cases in CFAs and 150 cases in EFAs.^57-59 The present study had a single factor with 8 indicators (ie, a variable-to-factor ratio of 8). Thus, the sample size of 857 exceeded the minimum requirement and was considered adequate for the current analysis. A total of 860 participants were recruited but 3 individuals declined participation for not having the time (see Figure 1).

Figure 1.

Flowchart of the study participants.

Potential participants were contacted in various community settings, including workplaces, corporate institutions, universities, and churches. They were invited to participate in the study, following a brief information session regarding the study’s objectives, data collection methods, confidentiality, anonymity, and informed consent. To be eligible, participants had to (1) be women, (2) be at least 18 years old, and (3) have the ability to read and write in English. Those to be excluded from the study were (1) women screened or diagnosed with breast cancer, (2) women under the age of 18 years, and (3) women who could not read or write in English, as the survey was conducted in that language. Individuals who met the inclusion criteria and showed interest were then recruited. The participants completed a paper-and-pencil survey in English. They provided informed consent before completing the survey. The reporting of this study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement/guidelines for reporting observational/cross-sectional studies.⁶⁰ The checklist was downloaded and completed (see Supplementary File).

Measure

Fear of breast cancer was assessed by the CBCFS-8.⁴³ The CBCFS-8 is a self-report measure (see Table 1). Scale items are rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). A total CBCFS-8 score is created by summing item scores (theoretical range = 8-40) with higher scores indicating a greater fear of breast cancer. The CBCFS-8 showed good internal consistency reliability in a US female sample (α = .91),⁴³ in an Iranian female sample (α = .95),⁴⁸ and in a Spanish female sample (α = .92).⁴⁵

Table 1.

Items, range, mean, standard deviation (SD), skewness, and kurtosis of Champion Breast Cancer Fear Scale^a (N = 857).

Item description	Range	Mean	SD	Skewness	Kurtosis
1. The thought of breast cancer scares me.	1-5	3.51	1.44	-0.51	-1.18
2. When I think about breast cancer, I feel nervous.	1-5	3.28	1.34	-0.21	-1.26
3. When I think about breast cancer, I get upset.	1-5	2.59	1.25	0.58	-0.72
4. When I think about breast cancer, I get depressed.	1-5	2.54	1.25	0.60	-0.68
5. When I think about breast cancer, I get jittery.	1-5	2.71	1.24	0.42	-0.83
6. When I think about breast cancer, my heart beats faster.	1-5	2.67	1.31	0.43	-0.98
7. When I think about breast cancer, I feel uneasy.	1-5	2.96	1.36	0.12	-1.29
8. When I think about breast cancer, I feel anxious.	1-5	2.93	1.38	0.12	-1.28

All of the items on the Champion Breast Cancer Fear Scale (CBCFS-8) are available in Champion et al.⁴³

Statistical analysis

SPSS software (v25) was used for data processing, descriptive analysis, and for checking item univariate and multivariate normality. The skewness and kurtosis values were acceptable (see Table 1) because they were below the cut-off criteria (skewness ± 2.00 and kurtosis ± 7.00).⁶¹ There were no significant floor and ceiling effects in the data because far less than 15% of the participants achieved the lowest score (8/40; n = 10, 1.2%) or highest score (40/40, n = 28, 3.3%) possible.⁶² Only 2 items were missing a data point each and missing value analysis via Little’s MCAR test showed that they were missing completely at random, χ²(14) = 17.46, P = .232.^63,64 To examine the factor structure and construct validity of the CBCFS, the split sample method was followed.^65,66 That is, the total sample size (N = 857) was randomly split into 2 equivalent subsamples via the SOLOMON method,⁶⁷ in FACTOR software (v12.04).⁶⁸ Because 2 items were missing one data point each, the SOLOMON method excluded them before splitting the data, reducing the total sample size from 857 to 855 (see Figure 1).

Exploratory factor analysis was performed on subsample 1 (n = 428) via JASP software (v0.19.1),^69,70 and CFA on subsample 2 (n = 427) via Mplus software (v7.0).⁷¹ Given that the CBCFS has 8 items, the subsample sizes were considered adequate for performing factor analysis because they exceeded the recommended participant-to-item ratio of 20:1.⁷² Exploratory factor analysis on subsample 1 was used to examine the factor structure of the CBCFS-8. The polychoric correlation matrix and the maximum likelihood extraction method were used.^72,73 Minimum factor loading and the number of factors to retain were determined via factor loadings (λ > .40) and parallel analysis, respectively.^74-76 Factor rotation was obtained via Direct Oblimin (oblique rotation).^77,78

Model fit for the CFA was assessed via the χ² statistic with degrees of freedom (which is known to be sensitive to large samples) together with the comparative fit index (CFI; >0.95 shows good model fit), root mean square error of approximation (RMSEA; <0.08 with 90% confidence interval [CI], shows good model fit), standardised root-mean-square residual (SRMR; ⩽.08 shows good model fit).^79,80 Internal consistency reliability analysis for the total sample (N = 857), subsample 1 (n = 428), and subsample 2 (n = 427) was performed via McDonald omega (ω) and Cronbach alpha (α).^81,82

Results

Sample characteristics

Participants were 857 women from the general population (M_age = 26.29; SD = 7.15, age range = 18-78 years). They were mostly never married (77.0%), not working (44.2%), recipients of tertiary education (88.9%), and Christians (92.4%). About half (46.4%) self-reported their average monthly household income to be less than Gh¢1,999 (USD128).

Percentage of participants agreeing with breast cancer fear scale items

Percentages of participants’ responses about the fear of breast cancer are summarised in Table 2. For ease of reading some response categories were combined. Table 2 shows that most of the participants got scared (60.4%) by the mere thought of breast cancer and became nervous (51.2%) when actively thinking about breast cancer. In addition, a sizeable number of participants felt uneasy (40.1%) and anxious (38.4%) when thinking about breast cancer. Moreover, the range of scores on the CBCFS-8 is 8 to 40. Using cut-off categories of low fear of breast cancer (score ⩽ 15), moderate fear of breast cancer (score 16-23), and high fear of breast cancer (score ⩾ 24) of Champion et al to classify the present sample revealed that most of the participants reported high fear of breast cancer (44.8%), whereas a substantial number reported moderate fear of breast cancer (39.8%). The fear score categories are presented in Table 2.

Table 2.

Percentage of participants agreeing with Champion Breast Cancer Fear Scale (CBCFS-8) items (N = 857).

Item description	N	Strongly agree or agree, n (%)	Neither agree nor disagree, n (%)	Strongly disagree or disagree, n (%)
1. The thought of breast cancer scares me.	857	518 (60.4)	77 (9.0)	262 (30.6)
2. When I think about breast cancer, I feel nervous.	857	439 (51.2)	113 (13.2)	305 (35.6)
3. When I think about breast cancer, I get upset.	857	213 (24.9)	144 (16.8)	500 (58.3)
4. When I think about breast cancer, I get depressed.	857	204 (23.8)	144 (16.8)	509 (59.4)
5. When I think about breast cancer, I get jittery.	857	230 (26.8)	187 (21.8)	440 (51.3)
6. When I think about breast cancer, my heart beats faster.^a	856	246 (28.7)	146 (17.0)	464 (54.1)
7. When I think about breast cancer, I feel uneasy.^a	856	344 (40.1)	118 (13.8)	394 (46.0)
8. When I think about breast cancer, I feel anxious.	857	329 (38.4)	142 (16.6)	386 (45.0)
Scale range 8-40^b (M_fear = 23.18, SD = 7.74)				n (%)
Low fear of breast cancer (score range 8-15)				132 (15.4)
Moderate fear of breast cancer (score range 16-23)				341 (39.8)
High fear of breast cancer (score range 24-40)				384 (44.8)

CBCFS items are rated from 1 (strongly disagree) to 5 (strongly agree) with totals between 8 and 40. Higher scores indicate greater fear of breast cancer. Values in parentheses are percentages. For ease of reading ‘strongly disagree’ and ‘disagree’ response categories were combined, whereas ‘agree’ and ‘strongly agree’ categories were combined.

Abbreviations: M = mean, SD = standard deviation.

Item missing one data point.

Higher scores on the CBCFS-8 indicate higher levels of fear of breast cancer.

Construct validity

Exploratory factor analysis

The Kaiser-Meyer-Olkin measure of sample adequacy value of .882 and Bartlett’s test of sphericity statistic of, χ²(28) = 1847.10, P < .001, revealed that the data were factorable. Combining factor loadings (λ > .40) with parallel analysis indicated that a one-factor solution was optimal (see Table 3). The loadings for the one-factor solution were adequate (|λ| = .564 to .808, Med_λ = .729), explaining a total variance of 52.5%.

Table 3.

Factor loadings of the Champion Breast Cancer Fear Scale (CBCFS-8) from EFA in subsample 1 (n = 428).

Item description	λ	δ
1. The thought of breast cancer scares me.	.672	.548
2. When I think about breast cancer, I feel nervous.	.735	.460
3. When I think about breast cancer, I get upset.	.564	.682
4. When I think about breast cancer, I get depressed.	.724	.476
5. When I think about breast cancer, I get jittery.	.723	.478
6. When I think about breast cancer, my heart beats faster.	.748	.440
7. When I think about breast cancer, I feel uneasy.	.808	.347
8. When I think about breast cancer, I feel anxious.	.792	.372
Eigenvalue		4.66
Total % of variance explained		52.5
McDonald omega (ω)		.877
Cronbach alpha (α)		.875

Abbreviations: EFA, exploratory factor analysis.λ = factor loadings, δ = item uniqueness, extraction method: maximum likelihood, rotation method: oblimin, number of factors to extract: parallel analysis.

Confirmatory factor analysis

The model fit of the initial CFA solution, except SRMR, was less than optimal, χ²(20) = 201.27, P < .001, CFI = .881, RMSEA = .146, 90% CI = [.13, .16], SRMR = .057. However, model modification indices indicated that model fit would improve if the error terms for item 1 and item 2 were correlated. Following this, the CFA was re-run with the correlated errors for item 1 and item 2. The CFA with correlated error showed that the one-factor model provided a good fit to the data, χ²(19) = 62.84, P < .001, CFI = .971, RMSEA = .074, 90% CI = [.05, .09], SRMR = .031 (see Table 4 and Figure 2). All of the standardised factor loadings were significant (P < .001) and acceptable (|λ| = .505 to .780, Med_λ = .715).

Table 4.

Model fit statistics for the confirmatory factor analysis model in subsample 2 (n = 427).

Model	χ²	df	CFI	SRMR	RMSEA [CI_90%]	ΔCFI	ΔSRMR	ΔRMSEA
1. Initial model	201.27***	20	.881	.057	.146 [.13, .16]	—	—	—
2. Revised model	62.84***	19	.971	.031	.074 [.05, .09]	+.09	−.026	−.072

Abbreviations: CFI, comparative fit index; CI, confidence interval; df, degrees of freedom; RMSEA, root mean square error of approximation; SRMR, standardised root mean square residual; Δ, change in the statistic.

***

P < .001.

Figure 2.

Confirmatory factor analysis model of the Champion Breast Cancer Fear Scale (CBCFS-8) in subsample 2 (n = 427).

Construct reliability

Internal consistency reliability coefficients on subsample 1 (n = 428; ω = .877, CI_95% = [.86, .89]; α = .875, CI_95% = [.86, 89]) and subsample 2 (n = 427; ω = .879, CI_95% = [.86, .90]; α = .877, CI_95% = [.86, 89]) were considered good. Moreover, the total sample (N = 857) showed adequate reliability (ω = .877, CI_95% = [.87, .89]; α = .876, CI_95% = [.86, 89]).

Discussion

In this study, the factor structure and psychometric properties of the CBCFS-8 have been evaluated among Ghanaian women recruited from the general population. Overall, the CBCFS-8 demonstrated sound validity and reliability, making it a promising measure for assessing the fear of breast cancer among women in the general population in Ghana. The original one-factor structure of the CBCFS-8 was supported by both EFA and CFA in the present study. Internal consistency reliability via McDonald omega and Cronbach alpha was found to be adequate in the present sample. The present results are consistent with those of previous work which reported a single-factor structure and a high internal consistency reliability for the CBCFS among African American and white women,^43,47 Saudi women,⁴⁶ Iranian women,⁴⁸ and among Spanish women.⁴⁵ Previous use of the CBCFS-8 also found it be reliable among Nigerian and Turkish women.^83-85

Thus, the present CFA results supported the postulated relations between the 8 indicators and their underlying factor to be psychometrically adequate for examining fear of breast cancer in the cultural context of Ghana. In other words, the CFA results demonstrate that the Ghanaian participants considered the measured items underlying the single, latent construct to be salient for assessing fear of breast cancer. Therefore, not only is this study the first to demonstrate the psychometric utility of the CBCFS-8 in Ghana, but also it is the first population-based survey to highlight how fear of breast cancer may be impeding breast cancer screening participation by women in Ghana. The study thus fills a gap in the breast cancer literature in Ghana by confirming the internal structure of the CBCFS-8.

Moreover, descriptive analysis of the number of participants agreeing with the items on the CBCFS-8 revealed that a greater majority of them were scared by the mere thought of breast cancer, whereas more than half of participants self-reported feeling nervous when thinking about breast cancer. Furthermore, an appreciable number of the participants also reported feelings of uneasiness and anxiety when thinking about breast cancer. It is possible that our participants’ fear of breast cancer emanates from their own illness beliefs or from social norms about the aetiology of breast cancer as well as media coverage of breast cancer cases. It is also possible that this intense fear of breast cancer as self-reported by our participants arises from the public health message framing about breast cancer in Ghana such as the use of fear appeals in breast cancer awareness campaigns (ie, socially learned fear).⁸⁶ For example, because breast cancer screening guidelines require that women be told about the benefits and harms, it is possible that the ‘harm’ aspect is over-emphasised in breast cancer awareness campaigns in Ghana. Fear appeals have long been identified to have deleterious effects on health behaviour change and health promotion by health behaviour scholars.^87-90

However, this study identified a wording effect in some items on the CBCFS-8. As noted in an earlier section of this work, model modification indices suggested that correlating the error terms between item 1 (‘The thought of breast cancer scares me’) and item 2 (‘When I think about breast cancer, I feel nervous’) would lead to improvement in model fit (which was done). Item analysis indicated that item 1 (‘The thought of breast cancer scares me’) seems to tap the latent construct in a somewhat ambiguous way (ie, lacks precision or specificity, eg, ‘the thought of . . .’ appears more general than ‘when I think about . . .’). It is also probable that the words ‘scare’ versus ‘nervous’ used in item 1 and item 2 are similar in meaning, tapping the same aspect of the latent construct and thereby rendering item 2 somewhat redundant (ie, item 2 provides little or no incremental information about the latent construct). This wording effect may arise from what the measurement literature refers to generally as rater effects, item characteristic effects, or item context effects.⁹¹ Consistent with the present results, previous research using the CBCFS-8 among women in Saudi Arabia and Iran also had to rely on correlated errors to achieve good model fit in their CFA results.^46,48 Earlier research argued that ‘. . . correlated errors are possible among items using similar wordings or appearing near to each other on the questionnaire’.^92(p310)

Implication of results

The present results have implications for practice, health policy, and research. For practice, by having a valid and reliable measure of fear, it is now possible for health care professionals in Ghana to use this psychological test to assess women’s fear of breast cancer screening at primary health care clinics to provide the basis for educating women about the need for screening. The administration of this brief test to potential women may help to identify those experiencing fear so that appropriate interventions can be provided. Because of its brevity, the CBCFS-8 can be administered and scored at Ghanaian primary health care facilities, community health centres, corporate organisations, government agencies, and higher education institutions to provide a point of reference for raising awareness and debunking myths and misconceptions about the disease.

For public health policy, the descriptive results revealed that most Ghanaian women experience fear of breast cancer screening participation. Therefore, there is a need to review Ghana’s health policy to include a national breast screening programme and a national awareness campaign. The policy could also incorporate free psychological counselling services for women who demonstrate extreme fear of breast cancer, and provide incentives such as transportation fees for women who wish to participate in screening. The policy could provide for a periodic training of health care professionals and media personnel in health communication or health message framing about breast cancer to enhance accurate information dissemination about the disease.

For future research, this study identified a wording effect among some items on the CBCFS-8. Because the CBCFS-8 was developed using only EFA, the developers could not identify this problem. Had we not used a CFA in the present study, we would not have identified this psychometric quality issue. Based on this finding, we suggest that future researchers should re-word item 1 using the same question stem as the remaining 7 items (eg, ‘When I think about breast cancer, I get scared’) or use the same question stem and replace the clause ‘I get scared’ with a similar synonym (eg, ‘When I think about breast cancer, I feel afraid’). In addition, future studies need to use a CFA or modern test theory such as Rasch analysis and network psychometrics to examine the data. Future research may also examine the CBCFS-8’s responsiveness, ease of use, and test-retest reliability.

Limitations

Although the present study made an important contribution to the breast cancer literature by extending the theoretical construct of fear of breast cancer to the context of Ghana via robust statistical analysis, it nevertheless had some limitations to note. The limitations of the present study included the use of convenience sampling, which limits the generalisability of research results. Another limitation is that the present study did not examine the CBCFS-8’s validity within its nomological network of theoretically related constructs. Readers should take these limitations into consideration in interpreting the results.

Conclusion

In this study, both EFA and CFA found sound validity and reliability evidence for the internal structure of the CBCFS-8. The current results suggest that the CBCFS-8 is a valid and reliable, unidimensional measure for assessing the fear of breast cancer among Ghanaian women in the general population. The present results showed that fear of breast cancer is an important mental health problem among Ghanaian women.

Supplemental Material

sj-docx-1-bcb-10.1177_11782234251353270 – Supplemental material for Understanding Fear of Breast Cancer Among Ghanaian Women via the Champion Breast Cancer Fear Scale

Supplemental material, sj-docx-1-bcb-10.1177_11782234251353270 for Understanding Fear of Breast Cancer Among Ghanaian Women via the Champion Breast Cancer Fear Scale by Enoch Teye-Kwadjo in Breast Cancer: Basic and Clinical Research

Footnotes

Acknowledgements

This work was generously supported by The Andrew W. Mellon Foundation through the BECHS-Africa residency programme. The author spent the residency at the American University in Cairo, Egypt. However, the opinions expressed and conclusions presented in this work are those of the author and are not to be attributed to The Andrew W. Mellon Foundation. The author also wishes to thank the Psychometrics Project Group for assisting in collecting the data.

ORCID iD

Enoch Teye-Kwadjo

Ethical Considerations

Ethics approval was granted by the Ethics Committee for the Humanities[ECH] (Protocol #: ECH104/16-17), University of Ghana. The ECH’s procedures are consistent with the principles of the 1964 Declaration of Helsinki and its later amendments.

Consent to Participate

Informed consent was obtained from all individual participants included in the study.

Consent for Publication

Consent for publication was obtained from all of the participants included in the study.

Author Contributions

Enoch Teye-Kwadjo: Conceptualisation; Data curation; Formal analysis; Investigation; Methodology; Writing – original draft; Writing – review & editing.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and/or analysed during the current study are available in the OSF repository at ().

Supplemental material

Supplemental material for this article is available online.

References

Ferlay

Ervik

Lam

, et al. Global cancer observatory: cancer today. 2024. https://gco.iarc.who.int/media/globocan/factsheets/populations/288-ghana-fact-sheet.pdf

Duffy

Tabár

Yen

AMF

, et al. Mammography screening reduces rates of advanced and fatal breast cancers: results in 549,091 women. Cancer. 2020;126:2971-2979.

Broeders

Moss

Nyström

, et al. The impact of mammographic screening on breast cancer mortality in Europe: a review of observational studies. J Med Screen. 2012;19:14-25.

Monticciolo

Newell

Hendrick

, et al. Breast cancer screening for average-risk women: recommendations from the ACR commission on breast imaging. J Am Coll Radiol. 2017;14:1137-1143.

Nicholson

Silverstein

Wong

, et al. Screening for breast cancer: US preventive services task force recommendation statement. JAMA. 2024;331:1918-1930.

Tabár

Yen

, et al. Insights from the breast cancer screening trials: how screening affects the natural history of breast cancer and implications for evaluating service screening programs. Breast J. 2015;21:13-20.

Tabar

Chen

Yen

, et al. Effect of mammography screening on mortality by histological grade. Cancer Epidemiol Biomarkers Prev. 2018;27:154-157.

Tabár

Dean

Chen

THH

, et al. The incidence of fatal breast cancer measures the increased effectiveness of therapy in women participating in mammography screening. Cancer. 2019;125:515-523.

Dadzi

Adam

. Assessment of knowledge and practice of breast self-examination among reproductive age women in Akatsi South district of Volta region of Ghana. Plos One. 2019;14:e0226925.

10.

Dzidzornu

Angmorterh

Aboagye

, et al. Communication channels of breast cancer ccreening awareness campaigns among women presenting for mammography in Ghana. J Am Coll Radiol. 2024;21:1201-1207.

11.

Anaba

Alor

Badzi

, et al. Drivers of breast cancer and cervical cancer screening among women of reproductive age: insights from the Ghana demographic and health survey. BMC Cancer. 2024;24:1-16.

12.

Shirazu

Mumuni

Mensah

, et al. Awareness and knowledge on breast cancer screening among reproductive aged women in some parts of Ghana. Health Technol (Berl). 2024;14:317-327.

13.

Osei-Afriyie

Addae

Oppong

Amu

Ampofo

Osei

. Breast cancer awareness, risk factors and screening practices among future health professionals in Ghana: a cross-sectional study. PLoS ONE. 2021;16:e0253373.

14.

Ofei

Teye-Kwadjo

Amankwah-Poku

, et al. Determinants of post-traumatic growth and quality of life in Ghanaian breast cancer survivors. Cancer Invest. 2023;41:379-393.

15.

Okifo

Tuoyire

Appiah

Debrah

Morna

Duda

. Breast cancer treatment and outcomes at Cape Coast teaching hospital, Ghana. Ghana Med J. 2021;55:190-197.

16.

Tagoe

Dwamena-Akoto

Nsaful

Aikins

Clegg-Lamptey

Quaye

. High atherogenic index of plasma and cardiovascular risk factors among Ghanaian breast cancer patients. Exp Biol Med (Maywood). 2020;245:1648-1655.

17.

Dadzie

HAN

Teye-Kwadjo

Oppong Asante

, et al. Psychological factors associated with mental adjustment to breast cancer: a hospital-based observational study. Illn Cris Loss. 2023;32:621-643. doi:10.1177/10541373231176018

18.

Teye-Kwadjo

Goka

Health

. Unpacking the psychological and physical well-being of Ghanaian patients with breast cancer. Dialogues Heal. 2022;1:100060. Accessed October 25, 2022. https://www.sciencedirect.com/science/article/pii/S2772653322000600

19.

Teye-Kwadjo

Goka

Ussher

YAA

. Complementary and alternative medicine use by Ghanaian patients with breast cancer. Trends Psychol. Published online August 29, 2023. doi:10.1007/s43076-023-00327-2

20.

Afaya

Anaba

Bam

, et al. Socio-cultural beliefs and perceptions influencing diagnosis and treatment of breast cancer among women in Ghana: a systematic review. BMC Womens Health. 2024;24:1-10.

21.

Kugbey

Oppong Asante

Meyer-Weitz

. Illness perception and coping among women living with breast cancer in Ghana: an exploratory qualitative study. BMJ Open. 2020;10:e033019.

22.

Salisu

Mirlashari

Seylani

Varaei

Thorne

. Fatalism, distrust, and breast cancer treatment refusal in Ghana. Can Oncol Nurs J. 2022;32:198-205.

23.

Agbokey

Kudzawu

Dzodzomenyo

Ae-Ngibise

Owusu-Agyei

Asante

. Knowledge and health seeking behaviour of breast cancer patients in Ghana. Int J Breast Cancer. 2019;2019:5239840.

24.

Mburu

Boamah Mensah

Virnig

, et al. Pathways to breast cancer diagnosis and treatment among women in Ghana: a qualitative study. Womens Health Rep (New Rochelle). 2021;2:234-244.

25.

Sanuade

Ayettey

Hewlett

, et al. Understanding the causes of breast cancer treatment delays at a teaching hospital in Ghana. J Health Psychol. 2018;26:357-366.

26.

Wuur

Duodu

Tarkang

. Factors that influence breast cancer screening among women of reproductive age in the Nandom Municipality, Ghana. BMC Womens Health. 2022;22:1-8.

27.

Asobayire

Barley

. Women’s cultural perceptions and attitudes towards breast cancer: northern Ghana. Health Promot Int. 2015;30:647-657.

28.

Boamah Mensah

Mensah

Aborigo

, et al. Breast cancer screening pathways in Ghana: applying an exploratory single case study methodology with cross-case analysis. Heliyon. 2022;8:e11413. doi:10.1016/j.heliyon.2022.e11413

29.

Price

Mali

Dedey

, et al. Mammography and breast ultrasonography services in Ghana, availability, and geographic access. JCO Glob Oncol. 2024;10:e2400218. doi:10.1200/GO.24.00218

30.

Adanu

Bansah

Adedia

Aikins

. Household treatment cost of breast cancer and cost coping strategies from a tertiary facility in Ghana. PLOS Glob Public Health. 2022;2:e0000268. doi:10.1371/JOURNAL.PGPH.0000268

31.

Clegg-Lamptey

Dakubo

Attobra

. Why do breast cancer patients report late or abscond during treatment in Ghana? a pilot study. Ghana Med J. 2009;43:127-131.

32.

Kudjawu

Agyeman-Yeboah

. Experiences of women with breast cancer undergoing chemotherapy: a study at Ho teaching hospital, Ghana. Nurs Open. 2021;8:3161-3169.

33.

Burugu

Salvatore

. Exploring breast cancer screening fear through a psychosocial lens. Eur J Cancer Prev. 2024;34:76-80. doi:10.1097/CEJ.0000000000000895

34.

Orji

Kanu

Adelodun

Brown

. Factors that influence mammography use for breast cancer screening among African American women. J Natl Med Assoc. 2020;112:578-592.

35.

Peek

Sayad

Markwardt

. Fear, fatalism and breast cancer screening in low-income African-American women: the role of clinicians and the health care system. J Gen Intern Med. 2008;23:1847-1853.

36.

CDC. Screening for breast cancer. 2024. https://www.cdc.gov/breast-cancer/screening/index.html

37.

Grimm

Avery

Hendrick

Baker

. Benefits and risks of mammography screening in women ages 40 to 49 years. J Prim Care Community Health. 2022;13:21501327211058322. doi:10.1177/21501327211058322

38.

Migowski

Nadanovsky

Manso

Mello Vianna

. Harms and benefits of mammographic screening for breast cancer in Brazil. PLoS ONE. 2024;19:e0297048.

39.

Myers

Moorman

Gierisch

, et al. Benefits and harms of breast cancer screening: a systematic review. JAMA. 2015;314:1615-1634.

40.

Pace

Keating

. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014;311:1327-1335.

41.

WHO. WHO position paper on mammography screening. 2014. https://www.ncbi.nlm.nih.gov/books/NBK269545/

42.

Thewes

Butow

Zachariae

Christensen

Simard

Gotay

. Fear of cancer recurrence: a systematic literature review of self-report measures. Psychooncology. 2012;21:571-587.

43.

Champion

Skinner

Menon

, et al. A breast cancer fear scale: psychometric development. J Health Psychol. 2004;9:753-762.

44.

Witte

. Putting the fear back into fear appeals: the extended parallel process model. Commun Monogr. 1992;59:329-349.

45.

Aguirre-Camacho

Hidalgo

González-Cuevas

. Fear of breast cancer among young Spanish women: factor structure and psychometric properties of the Champion breast cancer fear scale. PLoS ONE. 2021;16:e0249562.

46.

Alyami

Al-Sharef

Al-Aseri

, et al. Mammography self-efficacy scale and breast cancer fear scale: psychometric properties of the Arabic versions among Saudi women. Cancer Nurs. 2021;44:163-170.

47.

Champion

Monahan

Springston

, et al. Measuring mammography and breast cancer beliefs in African American women. J Health Psychol. 2008;13:827-837.

48.

Moshki

Shahgheibi

Taymoori

, et al. Psychometric properties of the mammography self-efficacy and fear of breast cancer scales in Iranian women. BMC Public Health. 2017;17:1-9.

49.

Kenin

Dzokoto

Osei-Tutu

, et al. Ghanaian values in motion: a content analysis of slogans on commercial vehicles in Accra. J Cult Res. 2024;28:378-392. doi:10.1080/14797585.2024.2364636

50.

Marbell

Grolnick

. Correlates of parental control and autonomy support in an interdependent culture: a look at Ghana. Motiv Emot. 2013;37:79-92.

51.

Schwartz

. A theory of cultural value orientations: explication and applications. Comp Sociol. 2006;5:136-182.

52.

Raykov

Marcoulides

. On the relationship between classical test theory and item response theory: from one to the other and back. Educ Psychol Meas. 2016;76:325-338.

53.

Schmitt

. Current methodological considerations in exploratory and confirmatory factor analysis. J Psychoeduc Assess. 2011;29:304-321.

54.

Teye-Kwadjo

Goka

Ussher

YAA

. Unpacking the psychological and physical well-being of Ghanaian patients with breast cancer. Dialogues Health. 2022;1:100060.

55.

Andrade

. The inconvenient truth about convenience and purposive samples. Indian J Psychol Med. 2021;43:86-88.

56.

Stratton

. Population research: convenience sampling strategies. Prehosp Disaster Med. 2021;36:373-374.

57.

MacCallum

Widaman

Zhang

, et al. Sample size in factor analysis. Psychol Methods. 1999;4:84-99.

58.

Mundfrom

Shaw

. Minimum sample size recommendations for conducting factor analyses. Int J Test. 2005;5:159-168.

59.

Wolf

Harrington

Clark

Miller

. Sample size requirements for structural equation models: an evaluation of power, bias, and solution propriety. Educ Psychol Meas. 2013;76:913-934.

60.

von Elm

Altman

Egger

, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453-1457.

61.

West

Finch

Curran

. Structural equation models with non-normal variables-problems and remedies. In: Hoyle

, ed. Structural Equation Modeling: Concepts, Issues, and Applications. Sage Publications; 1995;56-75.

62.

Lim

Harris

Dawson

, et al. Floor and ceiling effects in the OHS: an analysis of the NHS PROMs data set. BMJ Open. 2015;5:e007765.

63.

. Little’s test of missing completely at random. Stata J. 2013;13:795-809.

64.

Little

RJA

. A test of missing completely at random for multivariate data with missing values. J Am Stat Assoc. 1988;83:1198-1202.

65.

Lam

Kwong

. Development and validation of a questionnaire on Chinese parents’ beliefs in parental roles and responsibilities. Appl Res Qual Life. 2020;15:693-712.

66.

Teye-Kwadjo

. The perceived social support for job search activity scale (PSS-JSAS): a psychometric evaluation in the context of Ghana. Curr Psychol. 2023;42:8997-9005.

67.

Lorenzo-Seva

. SOLOMON: a method for splitting a sample into equivalent subsamples in factor analysis. Behav Res Methods. 2022;54:2665-2677.

68.

Lorenzo-Seva

Ferrando

. FACTOR: a computer program to fit the exploratory factor analysis model. Behav Res Methods. 2006;38:88-91.

69.

MacDougall

. A user’s guide for JASP. 2024. https://jasp-stats.org/wp-content/uploads/2024/08/MacDougall-Users-Guide-for-JASP-v-2.0.pdf

70.

Rogers

. Best practices for your confirmatory factor analysis: a JASP and lavaan tutorial. Behav Res Methods. 2024;56:6634-6654.

71.

Muthén

. Mplus User’s Guide. 8th ed. Muthén & Muthén; 2017. https://www.google.com/search?ei=KqjVW5SlAcSdsgHrlI4Q&q=Mplus+User’s+Guide+%288th+ed.%29.+&oq=Mplus+User’s+Guide+%288th+ed.%29.+&gs_l=psy-ab.3. . .19482.19482.0.20004.1.1.0.0.0.0.472.472.4-1.1.0. . . .0. . .1c.1.64.psy-ab..0.0.0. . . .0.xK3r9wR7Zgo

72.

Carpenter

. Ten steps in scale development and reporting: a guide for researchers. Commun Methods Meas. 2018;12:25-44.

73.

Holgado-Tello

Chacón-Moscoso

Barbero-García

, et al. Polychoric versus Pearson correlations in exploratory and confirmatory factor analysis of ordinal variables. Qual Quant. 2010;44:153-166.

74.

Gaskin

Happell

. On exploratory factor analysis: a review of recent evidence, an assessment of current practice, and recommendations for future use. Int J Nurs Stud. 2014;51:511-521.

75.

Howard

. A review of exploratory factor analysis decisions and overview of current practices: what we are doing and how can we improve? Int J Hum Comput Interact. 2016;32:51-62.

76.

Ledesma

Ferrando

Trógolo

, et al. Exploratory factor analysis in transportation research: current practices and recommendations. Transp Res Part F Traffic Psychol Behav. 2021;78:340-352.

77.

Costello

Osborne

. Best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. Pract Assessment Res Eval. 2005;10:7.

78.

Watkins

. Exploratory factor analysis: a guide to best practice. J Black Psychol. 2018;44:219-246.

79.

West

Taylor

. Model fit and model selection in structural equation modeling. In: Hoyle

, ed. Handbook of Structural Equation Modeling. Guilford Press; 2012;209-231.

80.

West

McNeish

, et al. Model fit in structural equation modeling. In: Hoyle

, ed. Handbook of Structural Equation Modeling. 2023; Guilford Press:185-205.

81.

Hayes

Coutts

. Use omega rather than Cronbach’s alpha for estimating reliability. But. . . . Commun Methods Meas. 2020;14:1-24.

82.

Raykov

Marcoulides

. Thanks coefficient alpha, we still need you! Educ Psychol Meas. 2019;79:200-210.

83.

Ezema

Igbokwe

Iwuagwu

, et al. Association of sociodemographic factors, breast cancer fear, and perceived self-efficacy with breast cancer screening behaviors among middle-aged Nigerian women. Breast Cancer. 2021;15:11782234211043651. doi:10.1177/11782234211043651

84.

Kissal

Vural

Ersin

, et al. The effect of women’s breast cancer fear and social support perceptions on the process of participating in screening. Glob Health Promot. 2017;25:52-59.

85.

Secginli

. Mammography self-efficacy scale and breast cancer fear scale: psychometric testing of the Turkish versions. Cancer Nurs. 2012;35:365-373.

86.

Olsson

Nearing

Phelps

. Learning fears by observing others: the neural systems of social fear transmission. Soc Cogn Affect Neurosci. 2007;2:3-11.

87.

Gallagher

Updegraff

. Health message framing effects on attitudes, intentions, and behavior: a meta-analytic review. Ann Behav Med. 2012;43:101-116.

88.

Kok

Peters

Kessels

LTE

Ten Hoor

Ruiter

RAC

. Ignoring theory and misinterpreting evidence: the false belief in fear appeals. Health Psychol Rev. 2018;12:111-125.

89.

Ruiter

Kessels

Peters

Kok

. Sixty years of fear appeal research: current state of the evidence. Int J Psychol. 2014;49:63-70.

90.

Teye-Kwadjo

. How can we better frame COVID-19 public health messages? Discov Psychol. 2022;2:30-35.

91.

Podsakoff

MacKenzie

Lee

Podsakoff

. Common method biases in behavioral research: a critical review of the literature and recommended remedies. J Appl Psychol. 2003;88:879-903.

92.

Bollen

Lennox

. Conventional wisdom on measurement: a structural equation perspective. Psychol Bull. 1991;110:305-314.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.03 MB