Cancer-related beliefs and behaviour in low-, middle- and high-income countries

1. Cancer-related beliefs and behaviourin low-, middle- and high-income countries

2. Overview • Survey development and methodology • Participating countries • Risk factor behaviour • Screening and diagnosis • Cancer prevention beliefs • Risk factors and prevention beliefs

3. Why do a population survey? • Beliefs influence lifestyle choices, participation in screening and treatment decisions • Cancer prevention programmes need to be informed by local population data to design programmes and evaluate progress • Aims: • Enhance collection of comparable population survey data about cancer beliefs and behaviours across countries where there are UICC member organizations • Develop capacity in UICC member organizations to use such survey data to develop population-based cancer control programmes and policies and evaluate their impact

4. Survey development • The UICC partnered with Roy Morgan Research Company and Gallup International • Technical advisory group to advise on survey development and reporting: • Dr Melanie Wakefield, Australia • Dr Sharon Campbell, Canada • Dr Michael Stefanek, USA • Dr Jane Wardle, Britain • Dr Hein de Vries, Netherlands

5. Survey methodology • Data collection commenced in October 2007 • The same survey questions were asked, regardless of administration method, in the language/s spoken by the majority of each country’s population • Randomly selected population sample • Administered face to face or by phone, depending on the country’s infrastructure • Often as part of Gallup affiliate omnibus survey to defray costs • For the information presented in the subsequent slides, the margin of error is ± 1.32%

6. Standard set of questions • Personal characteristics (age, sex, employment status, occupation, religion, personal cancer experience, family cancer experience) • Risk factor behaviour (smoking, alcohol use, physical activity, sun protection, body mass index) • Screening participation • Beliefs about treatment • Beliefs about risk factors for cancer

7. Australia (1272) Austria (920) Bolivia (1296) Canada (1070) China (1000) Czech Republic (500) Dominican Republic (500) Georgia (1000) Greece (500) Guatemala (500) Indonesia (1081) Israel (992) Kenya (500) Lebanon (500) Mexico (518) New Zealand (858) Nigeria (5021) Panama (502) Peru (1206) Philippines (1000) Romania (947) Serbia (1004) Spain (1000) Turkey (2019) Ukraine (1137) United Kingdom (691) United States of America (855) Uruguay (500) Venezuela (1036) First 29 countries participating in survey

8. Categorization of these countries: World Bank income groups

9. 12 additional countries (awaiting data) • Albania • Algeria • Belgium • Ethiopia • Finland • Germany • Ghana • India • Italy • Ivory Coast • Pakistan • Switzerland

10. Categorization of all 41 countries: World Bank income groups

11. Risk factor behaviour • Smoking status • Alcohol consumption • Level of physical activity • Weight • Sun exposure

12. Prevalence of tobacco use • Tobacco use was determined by asking “In the last 12 months have you used any tobacco products…” • If respondents indicated that they had used cigarettes, roll your own tobacco, pipe, cigars, chewing tobacco, snuff or bidis they were classified as a tobacco user • If respondents replied “no, none” they were classified as not being a tobacco user • As illustrated in the next figure, there was a large difference in the prevalence of tobacco users in low-income countries in comparison to tobacco users in middle- and high-income countries

13. Prevalence of tobacco use

14. Prevalence of tobacco use • Tobacco use was determined by asking “In the last 12 months have you used any tobacco products…” • If respondents indicated that they had used cigarettes, roll-your-own tobacco, pipe, cigars, chewing tobacco, snuff or bidis they were classified as a tobacco user • If respondents replied “no, none” they were classified as not using tobacco • As illustrated in the next figure, across income categories, tobacco use is more prevalent amongst males than females • This gender difference is most pronounced in the low-income category, where males are 11 times more likely than females to use tobacco

15. Prevalence of tobacco use

16. Alcohol consumption • Alcohol consumption was determined by asking “In the last 12 months have you had an alcoholic drink of any kind? If yes, about how often do you have an alcoholic drink?” • If respondents replied “most days” or “5 or 6 days a week” they were classified as a frequent consumer • If they replied “3 or 4 days a week” or “once a week” they were classified as a moderate consumer • If respondents replied “2 or 3 times a month” “once a month” “less often” or “rarely” they were classified as an occasional consumer • Individuals who responded “no, never, or don’t drink” were classified as never consuming alcohol. The majority of respondents in low-income countries do not drink alcohol • Respondents in high-income countries were nearly three times more likely to identify that they were frequent alcohol consumers

17. Alcohol consumption

18. Vigorous physical activity • Physical activity was assessed by asking “How often do you do hard physical or vigorous activity…” in three contexts: work; home; or at a gym, sports place or somewhere else • Based on National Physical Activity Guidelines for Australians,a recommended level of physical activity was engaging in activity “most days”, “5 or 6 days a week” • Less than recommended was engaging in physical activity “3 or 4 days a week” “once a week”, “2 or 3 times a month”, “once a month”, “less often”, “rarely” or “never” • In low- and high-income countries, more physical activity was occurring at home than at work or at a gym • Those in high-income countries appear to engage in higher overall physical activity than others

19. Vigorous physical activity

20. Body mass index • Estimates of height and weight were used to calculate BMI • Respondents were then classified as being either of an acceptable/healthy weight or as overweight/obese based on WHO weight recommendations • Those in middle-income countries were the only group where the majority of respondents were of a healthy weight • Note: Question not asked of respondents in Austria and Israel

21. Body mass index

22. Sun exposure • Sun exposure was determined by asking, “In the last 12 months have you been sunburnt? By sunburnt I mean any reddening of the skin after being outside in the sun?” • As illustrated in the figure, the majority of respondents did not report being sunburnt in the last 12 months. However, a greater percentage of those in high-income countries reported being sunburnt than others

23. Sun exposure

24. Screening and diagnosis • Cancer screening • Individual and immediate family cancer diagnosis • Beliefs about a cure for cancer following diagnosis • Expectations about medical treatment decision-making

25. Cancer screening • Individuals were asked “Have you ever had a cancer screening test, blood test, or some other test for cancer?” • If respondents replied yes, they were asked, “Which, if any, of the following cancer tests have you had? Bowel or colon cancer check; Skin cancer check; Lung cancer check; (if female) pap test or pap smear; (if female) mammogram or breast x-ray; (if male) prostate check; other check” • In low- and middle-income countries, over 80% of respondents reported not being screened for cancer • Those in high-income countries were 4.9 times more likely (and middle-income respondents were 1.7 times more likely) to report being screened for cancer than those in low-income countries

26. Cancer screening

27. Previous cancer screening • Individuals were asked “Have you ever had a cancer screening test, blood test, or some other test for cancer?” • If respondents replied yes they were asked “Which, if any, of the following cancer tests have you had? Bowel or colon cancer check; Skin cancer check; Lung cancer check; (if female) pap test or pap smear; (if female) mammogram or breast x-ray; (if male) prostate check; other check” • In low-income countries, screening experience did not vary by age, but it increased with age in other countries • In high-income countries, 65% of respondents aged 40+ reported previous screening for cancer, compared with 30% and 11% respectively of those in middle- and low-income countries

28. Previous cancer screening

29. Previous cancer screening • Males were asked “Have you ever had a cancer screening test, blood test, or some other test for cancer?” • If respondents replied yes, they were asked, “Which, if any, of the following cancer tests have you had?Bowel or colon cancer check; Skin cancer check; Lung cancer check; prostate check; other check” • Within low- and middle-income countries, over 85% of males reported not being previously screened for cancer • In high-income countries, 56% of males had not been previously screened

30. Previous cancer screening

31. Previous cancer screening • Males were asked “Have you ever had a cancer screening test, blood test, or some other test for cancer?” • If respondents replied yes they were asked, “Which, if any, of the following cancer tests have you had? Bowel or colon cancer check; Skin cancer check; Lung cancer check; prostate check; other check” • In the middle-income category, over one third of men aged 60+ reported screening, compared with over two-thirds of men aged 60+ in high income countries • Screening increased with age in both middle- and high-income countries, but not in low-income countries

32. Previous cancer screening

33. Previous cancer screening • Females were asked “Have you ever had a cancer screening test, blood test, or some other test for cancer?” • If respondents replied yes they were asked “Which, if any, of the following cancer tests have you had? • Bowel or colon cancer check; Skin cancer check; Lung cancer check; pap test or pap smear; mammogram or breast x-ray; other check” • Only within the high-income category did the majority of females report being previously screened for cancer

34. Previous cancer screening

35. Previous cancer screening • Females were asked “Have you ever had a cancer screening test, blood test, or some other test for cancer?” • If respondents replied yes they were asked “Which, if any, of the following cancer tests have you had? Bowel or colon cancer check; Skin cancer check; Lung cancer check; pap test or pap smear; mammogram or breast x-ray; other check” • Screening gradually increases with age in middle-income countries but not in low-income countries • In high-income countries, screening rates doubled between the age categories of 18-29 years and 40-49 years

36. Previous cancer screening

37. Previous cancer screening • Females were asked “Have you ever had a cancer screening test, blood test, or some other test for cancer?” • If respondents replied yes they were asked if they had previously had a pap test or pap smear • In high-income countries, 48% of women reported having a pap smear, compared with 16% and 3% respectively in middle- and low-income countries • Women in high-income countries are 16 times more likely (and women in middle-income countries are 5.3 times more likely) to report having had a pap test than women in low-income countries

38. Previous cancer screening

39. Previous cancer screening • Females were asked “Have you ever had a cancer screening test, blood test, or some other test for cancer?” • If respondents replied yes, they were asked if they had previously had a pap test or pap smear • Less than 5% of each age group of women in the low-income countries reported having had a pap test • In high-income countries, there was a sharp increase in the number of women reporting a previous pap test after the age of 30, in comparison to women aged 18-29 • This trend was less marked, but still apparent, in middle-income countries

40. Previous cancer screening

41. Previous cancer screening • Females were asked “Have you ever had a cancer screening test, blood test, or some other test for cancer?” • If respondents replied yes, they were asked if they had previously had a mammogram or breast x-ray • Women from high-income countries were 8.8 times more likely than women from low-income countries to have reported having a mammogram • Additionally, women in middle-income countries were twice as likely to have had a mammogram than women in low-income countries

42. Previous cancer screening

43. Previous cancer screening • Females were asked “Have you ever had a cancer screening test, blood test, or some other test for cancer?” • If respondents replied yes, they were asked if they had previously had a mammogram or breast x-ray • In high-income countries, two-thirds of women aged 50+ report having had a mammogram, as do half of those aged 40-49 years • Mammograms are infrequent in low-income countries, whereas in middle-income countries, just under one-quarter of those aged 50+ report having had one

44. Previous cancer screening

45. Cancer diagnosis • Individuals were asked “Have you ever been diagnosed with cancer?” and responded either “Yes”, “No”, “Don’t know” or “Refused” (to respond) • In high-income countries, 10% had been diagnosed with cancer, in comparison to 1% of other respondents • A further 7% of respondents in low-income countries did not know if they had been diagnosed with cancer

46. Cancer diagnosis

47. Cancer diagnosis • Individuals were asked “Has anyone in your immediate family ever been diagnosed with cancer?” and responded either “Yes”, “No”, “Don’t know” or “Refused” (to respond) • In low- and middle-income countries, the majority did not report a diagnosis in their immediate family • In contrast, half of high-income respondents indicated that an immediate family member had been diagnosed with cancer

48. Cancer diagnosis

49. Beliefs about a cancer cure • To assess beliefs about a cure for cancer, individuals were asked, “Some people believe once a person has cancer not much can be done to cure it - do you agree or disagree with that?” • Individuals then indicated agreement, disagreement or whether they were undecided • Items were reverse scored for reporting • More of those in high-income countries believed much could be done to cure cancer than those in middle- and low-income countries • When they become available, cancer screening programmes in low- and middle-income countries will need to overcome these low expectations of the success of cancer treatment, which serve as a barrier to screening participation

50. Beliefs about a cancer cure