Breast Cancer Screening Knowledge and Sentiments in Singaporean Women: Mixed Methods Study Using Topic Modeling, Sentiment Analysis, and Structured Questionnaire Data

Background: Mammography screening uptake in Singapore remains below 40% despite campaigns and subsidies. Natural language processing (NLP) can extract nuanced attitudes from free text that fixed response options miss, revealing latent factors influencing breast cancer (BC) screening behavior. Objective: This study characterized women’s attitudes toward mammography using mixed methods data, examined associations between BC awareness and screening willingness, and identified barriers and facilitators through NLP of free-text responses. Methods: We conducted a cross-sectional study within the multicenter cohort in Singapore (October 2021-December 2023). In total, 4169 women aged 35‐59 years (median 48, IQR 43‐54) were recruited via convenience sampling (3 hospitals and 2 polyclinics). Participants completed online structured questionnaires on demographics and screening history, then a BC education quiz with feedback. Participants answering >80% correctly were classified as “BC-aware.” Posteducation, participants reported screening willingness (motivated or neutral) with optional free-text explanations. Logistic regression models (adjusted for study site, age, ethnicity, marital status, housing, and education) examined the associations with willingness. For 3819 English-language respondents, biterm topic modeling identified themes and sentiment analysis quantified emotional tone. Statistical significance: =.05. Results: Overall, 79% (3287/4169) were BC-aware, and 94% (3908/4169) reported increased motivation posteducation. BC-aware women had higher screening motivation than BC-unaware women (adjusted odds ratio [aOR] 2.88, 95% CI 2.19‐3.80; <.001). Motivation was higher among those with larger public housing (OR 1.81, 95% CI 1.30‐2.50; <.001) and private housing vs 1‐3 room units (OR 2.69, 95% CI 1.75‐4.13; <.001), married vs not separated, divorced, or widowed (OR 2.38 [inverse of 0.42], 95% CI 1.75‐3.13; <.001), and prior screening attendance (OR 3.49, 95% CI 2.71‐4.50; <.001). Women who disagreed that mammography was expensive had higher motivation (aOR 1.94, 95% CI 1.50‐2.50; <.001). Among 3819 English respondents, 94% (3579/3819) were motivated and 6% (240/3819) neutral. Free-text responses came from 34% (1220/3579) of motivated and 64% (153/240) of neutral participants. Biterm topic modeling revealed motivated participants emphasized early detection benefits, health awareness, BC risk, and logistics; neutral participants focused on mammography pain experiences and cost barriers. Mean sentiment was 0.207 (range: −1.00 to 1.65), with motivated participants displaying more positive sentiments than neutral participants (linear regression, <.001). Identical words carried different emotional tones across subgroups: “health” had positive sentiment among motivated participants (mean difference, Welch tests <.05) but negative sentiment among neutral participants. Word frequency analysis showed motivated participants used positive-sentiment words (“better,” “cure,” and “prevention”). Neutral participants emphasized negative words (“painful” and “uncomfortable”). Conclusions: Integrating quantitative surveys with NLP revealed that the same screening concepts are emotionally framed differently by motivated vs neutral women, a finding missed by knowledge- or intent-focused approaches alone. In practice, these findings support the need for emotionally tailored BC education and prevention strategies.