| Abstract |
Introduction
Breast cancer is the most commonly diagnosed cancer among women and a leading
cause of death in both developed and developing countries. Although the use of
mammography seems to be effective in mortality reduction, and there is extensive
evidence on the importance of pre-symptomatic screening programmes, Greece has
no national breast cancer screening programme for women, except some isolated local
activities. Especially in primary health care (PHC), participation of women in these
programmes is low and there is no data available with regards to women undergoing
periodic mammography screening. Despite efforts to improve the knowledge and
skills of public health professionals in carrying out breast cancer screening preventive
programmes, the Greek reality remains far from the systematic implementation of
national guidelines for breast cancer screening. In Crete, to date, factors that
influence the use of mammography have not been investigated.
The aims of this study were the following:
1. To examine the attitudes, beliefs and knowledge of midlife women in Crete
about the use and value of mammography.
2. To investigate the degree to which the different social-economical factors
affect the knowledge, attitudes and practices of these women in the use of
mammography.
3. To present the most common reasons that women mention for refusing
mammography and what influences their views.
4. To set out the reasons that health professionals consider responsible for refusal
of mammography use and to which degree they are able to affect it.
5. To examine the degree to which physicians follow the international guidelines
about the use of mammography and what practices they should follow to
affect it.
6. To investigate the degree to which physicians inform women about the
benefits and risks from the use of mammography.
Methods
The study was conducted with semi-structured individual interviews. Two interview
schedules were used (one for physicians, and one for women). In addition, we used
the questionnaire “Cancer Control Practices” (CCP), developed in the USA, after it
was translated and validated according to international standards, and completed as a
self-administered survey to investigate physicians’ knowledge.
Setting
The study was conducted in the 14 primary health care centers (PHCCs) that serve the
rural population of Crete and in the outpatient clinics of University Hospital of
Heraklion, Crete.
Participants:
Primary Health Care Centres of Crete
16
A. Interviews
March to April 2004
· Thirty women 45-65 years of age, permanent residents of rural areas of Crete,
attending a regular check-up appointment with a GP or internist.
· Twenty-eight qualified primary care physicians serving this rural population,
selected at random and recruited on the morning shift for an interview.
B. Questionnaire
· All 106 general practitioners (n=91) and internists (n=15), employed as of
October 2004 and practicing at participating PHCCs were included. In
addition, we included a random sample of 45 trainee general practitioners
(GPs) from a total of 83 working at the 14 PHCCs of Crete.
University Hospital of Heraklion
A. Interviews
April 8 to June 28, 2005
· Thirty women 45 - 65 years of age, permanent residents of Heraklion, selected
at random and recruited from the list of regular appointments at hospital
clinics.
· Sixteen randomly selected physicians from the respective clinics of University
Hospital.
B. Questionnaire
· 8 physicians for pilot test
· All trainee GPs (19) for test, re-test
Results
A. Attitudes and practices of physicians and women
Of the 30 women in PHC settings, 15 had not used mammography, and very few of
them had made the decision after being informed adequately or being given a
recommendation by their physician. The principal barriers were: absence of
symptoms (9), fear of radiation (7), lack of physician recommendation (6), pain from
previous experience (5), fear of a serious diagnosis (4), lack of knowledge about the
benefits (2), lack of free time and family obligations (4), embarrassment (4), living far
away from the screening site (1) and the cost in private centers (2).
The majority of physicians (20) in PHC seemed to be well informed about
mammography and recognized the importance of their recommendation (16). Five
physicians mentioned lack of time for discussion with women due to a large number
of patients. Only eight physicians stated that they recommend it to all women
according to international guidelines. The factors affecting women’s use of
mammography were: socio-economic/demographic factors of women (23), lack of
appointments and problems with waiting times in public hospital (14), the distance for
elderly women (8), the cost in private centers (9), the absence of symptoms (12),
cancer diagnosis in a family member or loved one (6), embarrassment (3), lack of
time and family obligations (2), fear of diagnosis (4), fear of radiation (8), and
physician’s gender (16).
17
The results from University Hospital of Heraklion showed that out of 30 urban area
women, 28 had used mammography at least once, either due to a diagnosis or for
prevention. Of those 28, 6 had mammography regularly every year, 9 only once to
date, and 7 had done it after symptoms and mastectomy. Eleven women made the
decision alone or after encouragement from family or a friend or after a loved one had
been diagnosed with breast cancer. Seventeen had been encouraged by a doctor.
Factors affecting their attitude were the following: lack of recommendation or
encouragement by physician or others (17), fear of diagnosis (17), good physical
condition (lack of symptoms) (9), difficulties in access (appointments, waiting time,
transportation problems, distance from mammography center) (8), lack of information
(8), embarrassment (4), and family obligations (3).
In regards to hospital-based physicians, all were well informed about mammography
and considered it a very important exam. Factors affecting mammography use by
women according to physicians were: women’s sociodemographic characteristics
(13), lack of knowledge (6), negligence (5), difficulties in access related to waiting lists,
waiting time and distance from hospital (5),,radiation (5), pain caused by the procedure (4),
fear of diagnosis (2), cost at private centers (2), family obligations (2) and lack of symptoms
(1) .
B. Physicians’ knowledge
Our study demonstrates limited awareness of international guidelines on breast cancer
screening among primary care physicians in Crete, Greece. In general, the level of
physicians’ knowledge for each of the four items was low, with agreement ranging
from 31% to 58% for the individual breast screening items, indicating knowledge
gaps in regard to timing and frequency of breast screening. Overall, respondents
exhibited considerable variation in responses with just 4% answering all four items
correctly, 25% answering three out of four items correctly, and 14% failing to answer
any item correctly. No differences were noted between responses to the knowledge
items and demographic characteristics of physician respondents. The majority of them
(78%- 94%) did not discuss the benefits and the risks of the use of mammography
screening with women patients. Insufficient time (41%) to discuss mammography
screening and poor office organization (36%) were cited as the most important
barriers to recommending cancer-screening services.
Discussion - Conclusion
According to our study, rural women do not use mammography frequently, and they
are not as familiar with it as urban women. There is a difference between them in their
knowledge of the usefulness of mammography, despite the fact that a large number of
urban women had used it for diagnosis rather than prevention. Both groups of women
usually decided on the use of mammography on their own or after encouragement
from a friend or family member, or when they already had some symptoms. Most of
the women knew about mammography and were interested in having mammography
screening, but few women, especially in rural Crete, were able to take an adequately
informed decision about it.
Our study identified the subtle interplay of complex factors from both women and
physicians’ perspectives that affect the use of mammography; these concern women’s
attitudes, practices that physicians follow, and the country’s health care policy. Both
18
groups (women and physicians) mentioned barriers to the use of mammography.
Women most often identified the absence of symptoms, their good physical condition,
fear of diagnosis, negligence in regards to preventive health issues, embarrassment,
and family obligations. Other factors preventing mammography use were: physicians’
practices, such as not giving a recommendation and not informing women adequately,
difficulties gaining access to services, long waiting times for appointments, distance,
and the cost at private centers. It is worth mentioning how different socio-economic
factors as well as the recommendation by a physician influenced the use of
mammography. Another notable finding was the reported barriers to implementing
cancer control services in clinical practices such as lack of time and lack of office
organization. The majority of primary care physicians had limited awareness of
international guidelines on breast cancer screening.
This innovative study, the first of its kind in Crete, provides valuable information
about attitudes, knowledge and practices of both women and physicians regarding
mammography screening. Despite several methodological difficulties it focuses on
issues concerning the effective implementation of preventive breast cancer services.
These findings indicate that there are several barriers impacting on the decision–
making process, including clinicians’ awareness of guidelines for breast screening, as
well as those factors expected to influence the participation rate in the mammography
screening. The barriers revealed by our study underline the necessity for a national
pre-symptomatic screening programme for breast cancer prevention, implemented at a
regional level for all eligible women.
The study was designed to deliver data through which to inform health policy for a
serious public health issue. The study’s findings provide health care providers and
policy makers in Crete with evidence specific to their locality for the future
development of a preventive programme of mammography screening.
|
Στάσεις και πεποιθήσεις με την μαστογραφία γυναικών μέσης ηλικίας και γιατρών στην Κρήτη
