1. 9. Supplementary information Abstract Background: Spouses can play a role in supporting and motivating their wives’ uptake of breast cancer screening. Methods: We first establish the reasons for mammography screening attendance in women with no history of breast cancer (n = 3,395) through a structured questionnaire. Focus group discussions (FGDs) were conducted with 19 husbands of women with no history of breast cancer. The FGD prompts included questions on husbands’ attitudes towards mammography screening, their roles in their wives’ health, and their opinions on risk-based screening. Four FGDs with 4 to 7 participants were transcribed, coded, and thematically analysed. Results: The analysis of the FGD’s revealed six key themes on husbands’ (median age 41 years) attitudes towards women’s breast cancer screening practices: Awareness of breast health, priorities, social support structures, fears, incentives, and attitudes towards risk-based screening, which were supported by the questionnaire data. Husbands were interested in their wives’ health and assisted in appointments. However, they lacked awareness towards breast health and screening, thus limiting their influence. There were themes identified in the questionnaire data that were not brought up in the FGDs, suggesting a possible lack of communication and sharing of health-related information between spouses. Husbands generally accepted breast cancer risk-based screening but highlighted some concerns including the frequency of testing and the interpretation of results. Conclusion: Extrinsic motivation from a spouse can play a crucial role in overcoming barriers, addressing fears or anxieties, and ultimately increasing the likelihood of the individual undergoing mammography screening. Keywords Breast cancer screening, mammography, screening attendance, spousal support and encouragement, husband, partner
2. 1. Background The attendance rates for mammography screening vary among the eligible population[1]. Several factors such as individual choices, accessibility of services, and societal influences contribute to this inconsistency [2]. Women who participate in mammography screening tend to have higher levels of social support compared to those who do not [3–5]. The Women's Health Initiative study of 55,278 post-menopausal women in the United States, revealed a connection between regular mammography screening and the presence of emotional/informative support and positive social interaction [6].
3. 1. 1. Marital status and preventive healthcare behaviour Marital status is an example of a potential source of social and emotional support that has been associated with preventive healthcare behaviours [7]. A retrospective population-based cohort study, encompassing 1,733,906 cancer patients, discovered that being married was linked to an increased chance of survival [8]. This study also attributed some of the reduction in breast cancer mortality to early disease diagnosis [8]. When a spouse encourages or supports their partner in undergoing mammography screening, it can serve as an external influence that motivates the individual to participate. Research has shown that the screening behaviours of spouses have a significant influence on the screening behaviours of their partners [9–11]. Additionally, it has been observed that women who do not have a partner tend to have the lowest attendance rates for screening [12].
4. 1. 2. The influence of family unit in Asian cultures In collectivistic cultures prevalent in many Asian countries, the family unit is highly valued, and decisions regarding health and well-being are often made collectively. Spousal and family support is thus an important factor related to screening behaviours in Asia. Cross-sectional studies in Malaysia and Saudi Arabia reported that husbands’ or family members’ knowledge of and support for breast cancer screening predicted uptake for clinical and breast self-examinations [13, 14]. An intervention study on married couples reported that women were twice as likely to have a mammogram after the intervention aimed at increasing spousal support [15].
5. 1. 3. The influence of spouses on women’s health-seeking behaviour in Singapore Despite the reported benefits of positive spousal relationships on mammography screening uptake, the specific mechanisms of spousal influence on mammography screening attendance have yet to be explored. This entails delving deeper into the influence of this social support network, encompassing emotional, informational, and practical assistance. Understanding the value and impact of spousal support on screening behaviour is crucial for developing effective intervention strategies aimed at enhancing breast cancer screening rates, particularly within the unique context of Singapore. Singapore exhibits a relatively high marriage rate, with 61.8% of Singaporeans above the age of 15 being married as of July 2022 [16]. Furthermore, the 2021 crude marriage rate (number of marriages in a population per 1,000 people) in Singapore (6.5 per 1,000) [17] surpasses those of the United States (6.0 per 1,000) [18], European Union countries (3.9 per 1,000) [19], developed countries in Asia such as Korea [20] (3.8 per 1,000), China (5.4 per 1,000) [21], Japan (4.1 per 1,000) [22], and is comparable to neighbouring country Malaysia (6.7 per 1,000) [23]. Instead of treating individuals in isolation, Singapore has embarked on a family health unit approach. Various programs in Singapore have been rolled out to encourage healthier lifestyles among families and couples. The "Korang OK?" campaign by the Health Promotion Board (HPB) aims to help individuals live healthier lives by taking small steps towards better well-being while emphasising the importance of loved ones in maintaining good health and fostering a more fulfilling and enjoyable life together. The campaign provides resources, tips, and support for various aspects of health, including healthier eating, mental well-being, health screening subsidies, and free physical activity events [24]. A strong emphasis on family and collective well-being is integral to Singapore's cultural fabric, which are reflected in health promotion initiatives. Thus, we can leverage this important social network in support of practices that can enhance breast cancer screening, including understanding how new approaches to breast cancer risk and prevention can be delivered in communities.