Delay in seeking medical evaluations and predictors of self-efficacy among women with newly diagnosed breast cancer: A longitudinal study
Introduction
The crisis level in the worldwide breast cancer incident rate is indicative of a severe problem. Breast cancer has been recognized as the most commonly diagnosed cancer in the U.S. and the second leading cause of cancer deaths (American Cancer Society, 2007). Similarly, in Taiwan, breast cancer has been ranked as the fourth leading cause of cancer-related deaths. Twenty-two women are diagnosed and 5 women die of breast cancer every day in Taiwan (Bureau of Health Promotion, 2009).
The enormous psychological impact of suspicious signs of breast cancer in women has been extensively explored. A series of examinations including mammography, fine-needle biopsy, and core-needle biopsy are performed and require approximately 1–2 weeks in Taiwan's healthcare system. Once the physician has confirmed the breast cancer diagnosis and stage, further surgery is scheduled, and the treatment regimen is arranged. However, fear of painful or invasive procedures, high anxiety and distorted perceptions are barriers to the completion of mammography for women with breast abnormalities (Wujcik and Fair, 2008).
The international definition of health care “delay” is not consistent; Unger-Saldana and Infante-Castaneda (2009) categorized conceptual definitions and reasons presented in prior studies including delay by patients and delay by providers. Diagnostic delay was defined as the elapsed time interval between the first symptom and the medical diagnosis. Patient delay in seeking a cancer diagnosis, which describes patients who wait to obtain medical care between the time the breast abnormality was identified and the time initial care was sought, is the focus of the present study.
Fear of finding cancer has been mentioned by both breast cancer survivors and cervical cancer survivors as a significant barrier to seeking diagnostic care (Ashing-Giwa et al., 2010). The average delay in breast cancer diagnosis between the first visit for breast cancer-related symptoms and the time of diagnosis was 27.8 days in a sample from central Taiwan (Shieh et al., 2013). However, few studies have addressed the factors affecting the delay in seeking diagnostic evaluation from the first medical visit to the confirmation of cancer stage.
Approximately 84% of Taiwan's women with a breast lump or suspicion of breast cancer discovered by mammography are married (Liao et al., 2008). Women with confirmed breast cancer in Taiwan think about their significant others first (Fang et al., 2011) and believe that fate is predetermined with the principle of maintaining harmony between personal and family needs. Before seeking medical care, the obligations of childbearing and family care must be maintained, as married women view themselves as a member of their spouse's family (Kagawa-Singer and Wellisch, 2003). As such opinions of others are crucial considerations and may contribute to the ambivalence that many women with suspected breast care in Taiwan have about whether and when to seek diagnostic evaluation.
Although numerous studies have addressed the diagnostic delay among women with breast cancer, most have aimed to examine the factors related to diagnostic delay, including pathological, psychological and personal attributes, using cross-sectional designs. Relatively little research has explored specific factors related to delay in seeking cancer evaluation using a longitudinal design. In those studies that do explore specific factors, diagnosis delay has been associated with older age, milder symptoms, fear of informing anyone, negative attitudes toward medical practitioners (Bish et al., 2005), positive lymph nodes, high incidence of late-stage and metastatic disease (Ermiah et al., 2012), and less knowledge or education (Eaker et al., 2009). Therefore, the earlier the cancer is detected, the better the prognosis and the higher the survival.
A comprehensive review (Wujcik and Fair, 2008) noted that most studies are descriptive and retrospective in design and that the reasons for delay are varied and extensively focused on patient domain. Furthermore, there were no definitions of predictor variables, limiting the ability to make comparison and draw conclusions. Further refining the definition of delay and predictive studies identifying which women are at risk for delayed follow-up was recommended (Wujcik and Fair, 2008). Prior studies have applied a three-month delay cut-off, reporting that a delay to diagnosis directly and positively impacts survival (Duijm et al., 2009, Gullatte et al., 2010). Therefore, it is necessary to identify specific factors relating to delay in seeking breast cancer evaluation and to compare subsamples of delayers and non-delayers.
Cultural differences between Asian and Western countries influence health belief and the experience of seeking professional help. Chinese cancer patients view a cancer diagnosis as taboo and feel stigmatized by illness. Prior studies have found that poor insight due to the lack of knowledge, avoidance of physician examinations, and beliefs that the situation was not urgent or had a supernatural cause also results in a healthcare delay (Lin, 2005). However, fatalistic attitudes toward cancer may be a significant and common barrier cross-culturally; African American women with self-detected breast symptoms also believe that death is inevitable, attribute a breast abnormality to the actions of God and delay the follow-up of screening mammograms (Gullatte et al., 2010). Although spirituality and personality are potential factors in healthcare decisions, such factors have been understudied, particularly among women with suspected breast cancer. To identify the relationship between spiritual belief and delay in seeking cancer evaluation is necessary to improve culturally competent care.
Prior studies have determined that self-efficacy plays a key role in increased participation in cancer screening programs, adjustments to cancer diagnoses (Lev, 1997), and greater influences women's intention to undergo mammography (Secginli, 2012). Studies have also demonstrated that enhanced capabilities and health beliefs sustain cancer patients through the disease trajectory (Tien et al., 2007). Therefore, understanding the change in self-efficacy and the factors associated with self-efficacy from the first physician visit to the confirmation of cancer is critical for helping patients cope with breast cancer.
According to Bandura (1997), self-efficacy is a set of beliefs that operates as a cognitive mediator of performance and helps a person better cope with stressful situations. Way of creating and strengthening self-beliefs of efficacy are through mastery experiences, vicarious experiences provided by social models, social persuasion and reduce people's negative emotion caused by stress as well as alter their and misinterpretations of their physical states.
The stronger the perceived self-efficacy, the higher the confidence with which women advocate for their health and the higher a priority timely self-care becomes in the initial care sought and throughout the duration of the illness. Although cross-sectional studies have addressed the causal mechanism of self-efficacy in a wide range of health behaviors, most studies have examined associations of self-efficacy with specific variables only. Certain factors have validated the negative association or predictive relationship between self-efficacy and anxiety, fear or depression (Allen et al., 2008, Boehmer et al., 2007, Cunningham et al., 1991, Maciejewski et al., 2000, Mystakidou et al., 2010), whereas other factors have been positively correlated with self-efficacy, such as hope (Duggleby et al., 2009, Snyder, 2000), and exhibit a demonstrated positive effect on quality of life (Northouse et al., 2002).
The dynamic between self-efficacy, depression and anxiety is complex (Bandura, 1997), and a patient's emotions can fluctuate when the patient is given a positive cancer biopsy diagnosis by a physician. Therefore, the relationship between negative/positive psychological factors and self-efficacy should be identified not only at the time that care is sought but also at the time the diagnosis confirmed. A longitudinal study of Taiwanese women with newly diagnosed breast cancer determined that higher perceived self-efficacy and lower anxiety before surgery contributed to a positive change in quality of life (Cheng et al., 2011). However, time and other positive psychological factors that can interact with or affect the change in self-efficacy must be considered. Additionally, there is a dearth of literature exploring the psychological factors of personality, anxiety, depression or hope, which occur simultaneously, in the prediction of self-efficacy among the subsamples of delayers and non-delayers.
Therefore, the aims of the present study were to (1) identify the differences in demographics, cancer and psychological variables between the delayers and non-delayers at the time of care sought, (2) explore any change in self-efficacy or psychological responses over the two months following breast cancer diagnostic evaluation, (3) examine the correlates of delay time and self-efficacy over that period and (4) identify the key factors that can predict any change in self-efficacy. We hypothesized that greater self-efficacy will be associated with lower psychological distress and higher hope. We anticipated that hope would play a significant role in predicting self-efficacy in newly diagnosed women with breast cancer.
Section snippets
Theoretical framework
The theoretical framework was guided by a synthesis of the information-seeking model (Johnson, 1997) and Bandura's (1997) self-efficacy theory to provide insight into how women's beliefs in their abilities to maintain quality of life following the diagnoses-seeking period. To identify the influences on delays in seeking a cancer evaluation, we examined how the demographics, spiritual support and psychological factors affected the perceived self-efficacy in coping with cancer among the delayers
Design
A two-group, repeated measure, prospective longitudinal study was conducted to identify the predictors of change in self-efficacy from the time of the first physician visit to the date the diagnosis of breast cancer was confirmed. Data were collected at three time points: upon the first physician visit (T1) as well as at one week (T2) and two months after the first visit (T3).
The delay in seeking breast cancer evaluation was calculated as the elapsed time between patients receiving the breast
Sample characteristics
The sample was characterized by a mean age of 49 years (SD = 9), ranging from 35 to 71 years. Most subjects were younger than 50 years old and were single (n = 42, 63%), divorced or widowed (n = 51, 76%); half of the women had at least a senior high school education and were employed. Over 90% of the women (n = 61) did not have a family history of breast cancer.
The mean delay in seeking diagnostic evaluation was 187 days, ranging from 4 to 1463 days in the total sample. The difference in the time from
Discussion
This longitudinal study aimed to explore what influences the delay in seeking a cancer diagnosis, changes in self-efficacy and related factors in Taiwanese patients with breast cancer during the first two months of cancer evaluation. Overall, the period between the initial discovery of breast abnormalities and the time care was sought was approximately 6 months in the present study. Compared with previous studies, the patient delay in seeking medical advice was longer in the current sample than
Conclusion
Spiritual support and personality traits were key variables in Taiwanese women's delay in confirming a breast cancer abnormality. The longer the delay to clinical evaluation, the more severe the cancer stage. Changes in self-efficacy occur among women undergoing breast cancer diagnoses. Women who delay a breast cancer evaluation exhibit decreased self-efficacy after surgery, whereas women who do not delay exhibit increased self-efficacy after surgery. Hope at the first clinical visit is a key
Limitations
The findings are limited by the bias inherent in a purposive sample, which resulted in a narrow are range; therefore, a relationship between age and delay could not be established. The reasons and correlates of women choosing to delay seeking diagnoses, especially the mechanism by which spiritual support affected the decision to seek medical help, were not investigated and may be dependent on unexplored factors. Alternatively, a change in self-efficacy may have been difficult to identify in the
Conflict of interest
None declared.
Ethical approval
The study has been approved by the Institutional Review Board of National Cheng Kung University Hospital.
Funding
Funding was supported from the National Science Council, Taiwan, R.O.C. (NSC96-2413-H006-008-MY2).
Authors’ contribution
Study design: M-F L, W-X C, E C-L L; data collection and analysis: M-F L, W-X C, Y-Y T; manuscript preparation: M-F L, H-J C, S F.
Acknowledgements
We acknowledge funding support from the National Science Council, Taiwan, R.O.C. (NSC96-2413-H006-008-MY2) and assistance from participants and the breast cancer care team of National Cheng Kung University Hospital in Taiwan.
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