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Promoting Breast Screen to Melbourne Chinese women using ethnic-specific health promotion strategies

Elizabeth Y.-L. Kung, Ah-Choy Chan, Yuh-Shyan Chong, Trang Pham, Bridget H.-H. Hsu-Hage*

Abstract

Asian migrant women have the lowest participation rate in breast screening services of all ethnic groups in Australia. This is in spite of evidence that the incidence of breast cancer is increasing in certain subgroups of Asian female immigrants, such as ethnic Chinese women in whom breast cancer incidence is intermediate between that of the Australia and those in their country of birth. The aims of this study are to increase awareness of the rising incidence of breast cancer among Chinese women in Australia and to encourage women over 40 years of age to participate in breast screening. A survey was designed to examine the participation of Chinese women in breast screening services and to identify factors which may affect their attitude towards breast cancer or participation in screening. A total of 151 Chinese women were interviewed over the phone, by mail and in a shopping centre. The mass media and health promotion workshops were used to educate Chinese women about breast screening. 50% of respondents reported previous participation in breast screening. Compared to the 1989-90 national survey which reported a participation of 10% amongst Asian women, this study showed a much greater participation in breast screen. This increase may be attributable to the establishment of the "Breast Screen" program in 1991. Nonetheless, the participation rate among Chinese women remains inadequate at 50%. The major factors associated with the low participation rate were English language skills and the length of stay in Australia. It was reported that families are the most important support for women coping with breast cancer. This study indicates that the use of the mass media and language-specific workshops are appropriate when health promotion is directed at the ethnic populations.

Introduction

Breast cancer is the commonest cause of death from cancer in women (1,2). It accounted for 19% of all female cancer deaths in Australia in 1993 (1). Breast screening (or mammography) is one of the most effective methods of early detection of breast cancer (3). In Australia, a national breast cancer screening program was established in 1991. This program provides free mammograms for all women over the age of 50 and for women aged between 40-49 years upon request.

In recent years, over 40% of Australia's intake of immigration was from Asia (4,5). By 1986, 17% of newly-arrived immigrants in Australia were Asian born (5,6). Although Asian migrants constitute about one-fifth of Australia's overseas-born population, the participation of Asian migrants in government health care services remains the lowest of all migrant groups (7,8). Asian born women were less likely to have had a mammogram than other groups. 49% of Asian born women have never heard of breast screening and only 10% had attended the service in the 1989-90 National Health Survey (9).

Chinese women are reported to be at a low risk of developing breast cancer (10,11,12,13,14,15,16,17,18). However, a recent study of cancer incidence amongst Asian migrants to NSW, Australia, shows that breast cancer incidence in ethnic Chinese varies markedly according to birthplace (5). Women born in Vietnam, China and Taiwan have a significantly lower breast cancer incidence than Australian women, whilst women born in Hong Kong and Malaysia/Singapore have a rate approaching that of the Australian average. This observation supports the notion that diet and lifestyle factors are important in the etiology of breast cancer (19,20,21,22,23,24,25,26,27,28,29,30,31). Women born in Hong Kong or Malaysia/Singapore are more acculturated to the Australian way of life and exhibit equal or even increased breast cancer incidence compared to Caucasian Australians. Although breast cancer incidence in migrants from China or Taiwan is intermediate between that of Australia and their country of birth, their risk of developing breast cancer is increased 2 to 5 fold compared with women in China and Taiwan (5).

Aims

The study aims to increase awareness of the increasing incidence of breast cancer amongst ethnic Chinese women in Australia and, through community health promotion activities, to encourage active participation in the breast screening program. This study also investigated health related behaviour, knowledge of breast cancer and screening, and the factors associated with the low participation rate in breast screening services amongst Chinese women. The aim is to develop culture-specific strategies to improve participation in health services.

Method

This study was granted ethics approval by the Monash University Ethics Committee as a student project for the Health Promotion Course. Prior to the study, we consulted Chinese community groups in Melbourne to develop appropriate strategies and methods. The study consisted of a cross-sectional random survey and language-specific health promotion workshops. Cantonese and Mandarin, the most frequently spoken Chinese dialects in the Melbourne Chinese community, were used in mass media campaigns. Videos (in Cantonese and Mandarin) documenting Chinese women's experience with breast screening and breast cancer were produced and used as part of the educational material at the workshops. The project was carried out between August and September of 1995. The target population was women of Chinese ethnicity aged 40 years and over.

Cross-sectional survey questionnaires

The aims of the cross-sectional survey were to establish base-line information covering: (i) knowledge of breast screening, (ii) attitudes towards breast disease prevention and control, and (iii) participation in government funded breast screening and other health services. The interviews were carried out primarily in Cantonese and Mandarin. English and Vietnamese were also used where appropriate. The questionnaire was written in Chinese (later translated into English) and covered the following parameters: age, length of residence in Australia, English language skills (poor, limited, good), knowledge of and attitudes towards breast cancer and screening, participation in breast screening and other health services, and opinion of the importance of support structure during illness (including family, community and support groups). Study subjects were randomly obtained from (i) Chinese households through random telephone surveys using a sampling method developed for use in the Melbourne Chinese population (32), (ii) shoppers at a predominantly Asian shopping centre, the Box Hill Shopping Centre; (iii) members of two Chinese women's associations. On two occasions (surveys), shoppers near the food court area of Box Hill Shopping were approached, their self-imposed ethnic identity was confirmed, and they were interviewed. Members of two Chinese women's associations were randomly selected from membership lists and sent questionnaire. A total of 151 women (47 from telephone random survey, 46 shoppers, 58 from the two women's association) completed the questionnaire.

Mass media campaigns

Mass media, including radio broadcasts and newspapers in Chinese language, were used to promote breast disease awareness and screening services. A press release with background information about breast cancer and the proposed breast screening promotion activities/programs was issued to a local newspaper (the Melbourne Chinese Post). This was followed by two radio interviews with the Special Broadcast Services (SBS) radio Cantonese and Mandarin programs. The ten-minute pre-recorded interviews aimed to raise awareness of breast cancer risk factors, prevention and control, and eligibility for screening services. The interviews also allowed for audience feedback sessions off the air. A number of breast cancer patients responded to the radio interviews. The overwhelming audience response following the radio interviews indicated potentially under-recognised health concerns amongst members of the Chinese community.

Documenting women's experience with breast screening and cancer

Four Cantonese and four Mandarin speaking women, who either had had breast screening experience, a family history of breast cancer or were breast disease sufferers, were interviewed (EK and Y-SC). The participation of these women was entirely voluntary. All the women agreed to have the interview filmed and made into a video for use at future community health promotion workshops.

The video aimed to encourage women to talk about and share stories about their life and health experiences. Traditionally, Chinese women have had opportunities to share knowledge on health related issues through family- or their social network. After immigration to Australia, due to cultural differences, language and transport problems, many confine their contacts to nuclear family members with whom women's health issues are often inappropriate to discuss. The use of a video such as this one may not replace the traditional social network but it nonetheless provides an avenue for sharing their life and health experiences.

Health promotion workshops

Two Chinese women's associations in Melbourne, representing Cantonese and Mandarin speaking groups respectively, were identified and approached to participate in a health workshop aiming for community empowerment. At the workshops, facts about breast cancer and screening were presented (with overheads in Chinese). This was followed by a viewing of the video concerning women's experiences with breast screening and cancer, followed by a short discussion.

Workshop evaluation

At the conclusion of the workshops, an evaluation questionnaire was distributed to all workshop participants. The aim of the evaluation was to assess the effectiveness of the workshops. The questionnaire tested knowledge of breast cancer and screening, provided feedback on the workshops, enquired about women's attitudes towards health care access and willingness to participate in breast screening services.

Statistics

Rates and proportions were used to report the women's response to the questionnaire. Where appropriate the rates and proportions were divided according to dialect groups. Mantel-Haenszel Chi-square statistics were used to test the hypothesis that English language skills are independent of (i) knowledge about breast cancer and screening, (ii) participation in breast screening, and (iii) perceived importance of moral support during illness. The significance level was set at 5 per cent.

Results

Cross-sectional survey

A total of 151 Chinese women were interviewed in the cross-sectional study. 44.4% of the interviews were conducted in Cantonese, 43% in Mandarin and 12.6% in English. Table 1 shows the characteristics of the subjects who participated in this study.

Table 1: Characteristics of study subjects in the cross-sectional study (n=151) Age (Years) <40 11.3 % 40-44 28.5 % 45-49 26.5 % 50-54 17.2 % 55-59 7.3 % >=60 9.3 % Length of stay in Australia (Years) <5 33.8 % 5-10 35.8 % 10-15 15.2 % 15-20 9.9 % >=20 5.3 % Competency in English Poor 16.6 % Limited 50.3 % Good 33.1 %

Baseline data

Knowledge of breast cancer and screening: Table 2 shows the level of knowledge of the interviewees of breast cancer and screening. Regardless of English language skills, 93.4% had heard of breast cancer whilst 71.5% knew that breast cancer is the commonest cause of cancer death in Australian women. 85.4% had heard of breast screening but only 80.7% knew that breast screening is free for women over 50 years old. Among those who had heard of breast screening, 59.4% learnt of it through TV, newspaper or magazines, compared with 40.6% from family doctors and 38.3% from family and friends. Only 22.6% knew posters and pamphlets had been used.

Table 2: Respondents' response to questions concerning their knowledge of breast cancer and screening, and source where information is obtained in the cross-sectional study (n=151) Knowledge about breast cancer and screeing Ever heard of breast cancer 93.4 % Knew breast cancer is a major killer 71.5 % Ever heard of breast screening 85.4 % Knew that breast screening is free for women over 50 80.7 % Source of screening availability TV, newspaper and magazine 59.4 % Posters and pamphlets 22.6 % Family and friends 38.3 % Family doctors 40.6 %

Participation in breast screen service: Compared with pap smears and breast examination by doctors, mammography is the least frequently used screening service (Table 3). Only 50% of the interviewees had had mammograms. The reasons for this were: (i) referral from family doctors, (ii) suggestion from family or friends, or (iii) fear of breast cancer. Among those interviewees who had not had mammograms, 22.1% said that they did not know how to apply, 14.5% mentioned that they did not think they would have breast cancer, 6.5% were afraid to go because they were unsure of what to expect and 7.8% were ashamed to expose their bodies.

Table 3: Characteristics of respondents' participation in breast screening and pap smears in the cross-sectional study (n=151) Ever had asked for breast examination by doctors 54.7 % mammogram 50.0 % pap test 83.9 % Reasons for having the mammogram done arranged by the family doctor 57.3 % influenced by family and friends 18.9 % believed to have breast cancer 8.0 % Reasons for not having the mammogram done don't know how to apply 22.1 % believed not to have breast cancer 14.5 % shouldn't expose the body 7.8 % afraid to go, because not sure about the procedure 6.5 % afraid of the side effects of X-ray 5.2 % afraid to find out breast cancer 2.6 % not supported by the family 1.3 %

Breast disease and screening related support services: All the interviewees agreed that education was useful in minimising fear and apprehension of breast screening (Table 4). It was also reported that many supports were important in helping to cope with the diagnosis of breast cancer. In particular, family support was regarded as the most essential, followed by cancer support groups and community supports.

Table 4: Support from service provider, family, friends or community as an importance factor in helping cope with the diagnosis of breast cancer in the cross-sectional study (n=151) % Agreed Support from breast screening service provider 100.0 Breast cancer support from family 85.9 Breast cancer support from other women 75.4 Breast cancer support from community 65.5

Factors associated with breast screening

Age: Age of the interviewees ranged from 33 to 80. Age was found to be one of the more important factors that influence the participation of Chinese women in breast screening. There was a positive correlation between age and breast screening participation (p<0.004). Older women (over 50 years old) were more likely to participate in breast screening.

Length of residence in Australia: Length of residence was also significantly associated with the breast screening participation; the longer the residency, the higher the participation rate. Those who had lived in Australia for more than 10 years were 2.5 times more likely to attend breast screening compared to the newly arrived.

English language skills: English language skills were positively correlated to knowledge of breast disease and screening. Chinese women with poor English language skills were the least likely to know that breast cancer is the commonest cause of cancer deaths in women, and that breast screening is free for women over 50 (Table 5). They were the least likely to present to their doctors for pap smears and breast examinations. All believed that family support would be important to them if they were diagnosed with having breast cancer (p=0.001). On the other hand, women with poor English skills placed less value on support from the Chinese community (58.3%, p=0.025).

Table 5: English language skills as a factor which may affect the knowledge of breast disease, participation in breast screening and the expectation of support in helping cope with the illness in the cross-sectional study Knowledge   English language competency n (%) X2MHC p Heard of breast cancer Poor 15 60.0 17.6 0.000 Limited 66 86.6     Good 48 96.0     Know breast cancer is a major killer Poor 14 56.0 4.54 0.0032 Limited 54 71.1     Good 40 80.0     Know breast screening is free for women over 50 Poor 16 64.0 5.52 0.019 Limited 61 81.3     Good 44 88     Practice   English language competency n (%) X2MHC p Breast examination by doctors Poor 9 36.0 6.67 0.009 Limited 40 52.6     Good 33 67.4     Breast Screen Poor 5 20.0 8.16 0.004 Limited 41 54,0     Good 29 59.2     Pap test Poor 15 71.4 5.35 0.021 Limited 30 83.3     Good 33 94.3     Source of support   English language competency n (%) X2MHC p Family Poor 24 100.00 10.6 0.001 Limited 66 89.2     Good 32 72.7     Community Poor 14 58.3 7.34 0.0025 Limited 56 75.7     Good 23 52.3

Health promotion workshops evaluation

Forty seven (47) women, aged 25 to 63 years attended the workshops (27.7% aged less than 40 years; 34% aged 40-44; 10.6% aged 45-49; 4.3% aged 50-54; and 2.1% aged 55-59). Data from the workshop evaluation survey showed that 40.9% of the participants had had breast screening prior to the workshop. Among those who had never had mammograms, 81.5% took part in a group booking for breast screening conducted through the workshops (Table 6). Their reasons for signing up included realising the importance of breast screening through the workshop and enjoying the company of other women at the breast screen clinic. The quality of the workshops as a whole was generally rated 'high' (Table 7).

Table 6: Participation in breast screening prior to the workshops   Cantonese (n=26) % Mandarin (n=20) % Total (n=46) % Ever had breast screening 45.8 35.0 40.9 Never been to breast screening, but going to have it done 100 61.5 81.5 Reasons for taking part in the screening after the worshops recogonized the importance of breast screening 71.4 33.3 56.5 have other women's accompany 7.7 22.2 13.6

Table 7: Feedback from the participants after the workshop   Cantonese (n=26) % Mandarin (n=20) % Total (n=46) % Understand more about breast cancer and screening [true] 88.5 90 89.1 Is the topic/material interesting? Breast cancer [true] 23.1 65.0 41.3 Free breast screening [true] 42.3 15.0 30.4 Video (interviews) [true] 53.8 15.0 37.0 Small group discussion [true] 23.1 30.0 26.1 Ratings of the workshops as a whole High 96.2 70.0 84.8 Average 0.0 30.0 13.0 Low 0.0 0.0 0.0 The workshop content as a whole Very detail 50.0 30.0 41.3 Just right 50.0 55.0 52.2 Not enough 0.0 15.0 6.5 Workshop presentation Very clear 100 94.7 97.8 Not very good 0.0 5.3 2.2 Poorly presented 0.0 0.0 0.0

89.1% reported that they understood more about breast cancer and screening after the workshops. The Mandarin dialect group tended to be most interested in the seminar topic 'breast cancer', whilst Cantonese dialect group rated the video (interview) as the 'preferred topic'. 89% of women stated that they had acquired at least a 'Good' level of knowledge about breast cancer and screening after the workshops (Table 8). Only 17.4% of the participants responded correctly that 'breast screening cannot prevent but can provide early detection of breast diseases'.

Table 8: Knowledge about breast disease and screening at the end of the workshop (correct answer to the question) Questions Cantonese (n=26) % Mandarin (n=20) % Total (n=46) % Breast cancer is the 1st killer of Victorian women 88.5 100 93.5 There is an incresing no. of breast cancer among the Chinese migrants in Australia 84.6 90.0 87.0 Women over 40 are eligible for free breast screening service 96.2 100 97.8 Breast screening cannot prevent breast cancer 11.5 25.0 17.4 Application of breast screening services don't need doctors' referral 76.9 65.0 71.7 Interpretors are available for non-English speaking women 92.3 90.0 91.3

On questioning about possible topics for future workshops, the women rated 'menopausal health' (78%), 'Medicare' (53.7%), 'pap smears' (47.5%), and 'heart disease risk factors' (41.5%) and 'diabetes' (41.5%) as most important (Table 9).

Table 9: Health topics that participants would like to acquire at a future workshop Topic Cantonese (n=26) % Mandarin (n=20) % Total (n=46) % Menopausal Health 75.0 82.4 78.0 Medicare 45.8 64.7 53.7 Pap Smears 45.8 50.0 47.5 Heart Disease Risk Factors 62.5 11.8 41.5 Diabetes 45.8 35.3 41.5 Immunisation 37.5 17.6 29.3 STD/AIDS 25.0 5.9 17.1 Cot Death - SIDS 8.3 5.9 7.3 Royal District Nursing Service 4.2 5.9 4.9

Discussions

Investigating the use by ethnic women of screening services, such as breast screening, is of great importance, not only in identifying obstacles against participation in the service, but also to guide the development of future health promotion programs. In this study of Chinese women's participation in breast screening, we employed the following media: (i) ethnic radio which promoted breast screening and cancer awareness on a national scale, and (ii) local Chinese newspaper which covered selected Melbourne metropolitan areas. The cross-sectional survey and health promotion workshops were confined to the north-eastern suburbs of Melbourne. The impact of mass media campaigns on breast screening participation could not be evaluated due to the time-frame of this project. The radio interviews did however encourage discussion of the issue amongst the listeners, as was evident from the overwhelming response that occurred immediately after the broadcast. Print media, such as newspapers and pamphlets, reached only the small proportion of the target population who were literate and read the material. On the other hand, the ethnic radio only targeted that particular language group who tuned into the program at the time of the broadcast. Like the cross-sectional survey and health promotion workshops, the subjects were self-selected and thus not representative of the Chinese female community of Australia or Melbourne. Nonetheless, the study was the first of its kind in that it employed a range of media and developed population-specific health promotion strategies which allowed maximum interaction between the health professionals and participants in their nature language.

Factors affecting knowledge, participation and attitudes towards breast cancer and screening

There is discrepancy between a subject's knowledge of and actual participation in breast screening that is evident from one other study (33). In our study, among those who had heard of the breast screening service (85.4% of the total), 88.4% knew that breast screening is free for women over 50, whilst only 57.8% actually had a mammogram done. Language, cultural and economic barriers have been reported as factors contributing to ethnic women's low participation rate (8,14,34,35,36). In this study, by far the most important obstacle to access to health care services was the language barrier. Women with poor English language skills had the lowest knowledge of breast screening and cancer and were the least likely to take part in breast screening or present for pap smears. This group tended to rely on their family as a major source of support (Table 5). Poor English language skills also contributed to the perception that breast screening is time-consuming because it is performed outside the doctors' surgery. Our study confirmed the positive correlation between English language skills and women's knowledge of breast cancer, and their participation in screening (35). Women who speak only Mandarin or Cantonese are often unaware of the cancer detection and prevention services (14). Women who speak fluent English (who tend to have higher levels of education) are more likely to absorb health information from the mainstream mass media.

Although cultural beliefs and attitudes might impede participation in screening programs (35,37,38,39,40), women with good English skills are more likely to adapt to the host environment and its cultural practices. In contrast, due to communication problems, women with poor English language skills tended to associate with Chinese friends, who share the traditional belief that the well-being of a person is determined prior to birth and cannot be changed. Because of their sense of modesty, they are reluctant to touch their bodies or have their bodies touched by strangers (14,41). Due to these strong cultural beliefs, Chinese women in America have been reported to refuse breast screening and cancer treatment. Cultural barriers, while being present, were not the only contributors to low participation rates amongst Chinese women in Melbourne (Table 3).

Length of residence in Australia was positively correlated to English language skills and participation in the breast screening service. Increasing length of residence in Australia not only improves English skills (possibly through migrant language programs) but also enlarges the social network of immigrants. These factors together enhance the knowledge of and participation in the screening services. Language skills, social network and the length of residence in Australia are the three key factors affecting the access to mainstream health services by the study population in question.

Importance of social supports in the ethnic Chinese community

An adequate social support network is regarded as beneficial for cancer patients. The Chinese community in Taiwan however perceived family members is the most important support (42). 50% of Chinese-American women would include work or school associates in their support network and they tend to believe that an ill or aged family member deserves care and respect, a belief commonly held by all Chinese (14). It is thus not surprising that 85.9% of Melbourne Chinese women also place great importance on family support (Table 4), especially those with poor English language skills of whom 100% stated that family support as important (Table 5). Of note, women with limited English language skills recognised the existence and importance of community support. Women with better English language skills tended to be more independent and likely to seek community supports.

Pre-menopausal breast cancer in ethnic Chinese women

During the course of this study, we identified ten (10) Chinese women with previously diagnosed breast cancer; all of them whom in their early 40's. It has been reported that regardless of ethnicity, 25% of breast cancer deaths occur in pre-menopausal women (43). To this date, no single trial has been carried out to test the efficacy of mammographic screening in women aged 40-49 years (3,44,45). It is, however, important to recognise that pre-menopausal Chinese women may have an equal risk of developing breast cancer to post-menopausal women of other ethnic groups.

Breast screening in ethnic Chinese women

Since the establishment of Breast Screen in 1991, there has been an increasing number of Asian women attending the service (9). However, this participation remains inadequate. Our study confirms these observations. 85.4% of our respondents reported having heard of breast screen service compared with 49% in the 1989-90 national health survey, and 50% had had a mammogram compared with 10% in the 1989-90 national health survey. Melbourne Chinese women derived breast screening information from a variety of sources, ranging from the mass media (TV, newspapers or magazines, 59.4%) to social networks (family doctors, 40.6%; family members and friends, 38.3%). Posters and pamphlets were the least used resources. No particular media seemed to predominate and thus the use of a variety of promotional strategies is required to ensured coverage of the wider Chinese community.

Although there are pamphlets written on breast screening service in Chinese, only 22.6% of women who had had breast screening had learnt of these posters or pamphlets. Doctors can also play a role in improving breast screening participation. Some women avoid seeking medical care unless they are ill (46) and may only trust Chinese or alternative medicine. Improvement in breast screening participation can only be achieved if women are convinced of the importance of screening and encouraged by their doctors to participate (47,48). Active involvement with medical professionals, especially Chinese speaking doctors, may improve participation in breast screening, as it did with pap smears (84% of Melbourne Chinese women had had a pap smear, compared with 50% who had had mammography).

Language specific health promotion strategies

The language specific health promotion workshops performed in this study resulted in 81.5% of eligible participants signing a group booking form for breast screening. Breast cancer seminars and video interviews were reported the two most popular sections. Workshops offer an informal approach to public education and give the audience the opportunity to ask questions. In this study, we demonstrated acceptance of the language specific workshop approach. To promote breast screening and other health service participation amongst Chinese women, workshops could be conducted in other geographic areas. The use of video is also useful for women who are not accustomed to seminars. The video could also be offered to women who cannot attend the workshops. Small group discussion is an informal approach which also encourages social contacts. Similar workshops on menopausal health, Medicare and pap smears have been requested by our participants.

Conclusion

The low utilisation of government funded breast screening by ethnic Chinese women is underreported and underestimated, despite rising breast cancer incidence in subgroups of ethnic Chinese women. Through this study we have identified a possible high prevalence of breast cancer in the young Chinese women, as most of the sufferers we identified were diagnosed in their late 30's and early 40s. Women who had inadequate English language skills or were newly arrived in Australia had greater difficulty accessing breast screening because of their smaller knowledge base. Screening services increase early detection of cancer, but not cancer prevention. For the government funded "Breast Screen" to be effective, it is important to consider socio-demographic differences among populations at risk and to address the socio-cultural barriers which impede access to the service. For ethnic Chinese, this may include appropriate use of a variety of ethnic media, provision of language specific breast screening education programs, and use of Chinese dialects-speaking health service providers.

Acknowledgments

The authors would like to thank Ms. Wai-Lin Galbraith, Drs. Tony Chow and Vivian Lin, Ms. Doris Leung, Ms. May Hu, Mrs. Chie Lan Chang, Mr. Eddi Lei, the Chinese Health Foundation of Australia, the Chinese Community Service Centre, the Melbourne Chinese Women's Association, Breast Screen Victoria, the Melbourne Chinese Post, the SBS Radio Station and the Monash Teaching Service Unit for their assistance in the study, and also the Chinese women who participated in the study, who shared their experiences in the video interviews. In particular, we wish to thank Mrs. Isabel Lin and Ms. Sheut Yu Ho for revealing their very personal experiences. Mrs. Isabel Lin sadly passed away on 15 December 1996, aged 42 years. We wish to dedicate this article to Isabel for she is an inspiration for our determination to get this article published. The problem won't go away unless it is resolved.

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