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Mammography screening of Greek women and primary care physicians in Crete
– Reported, January 23, 2012
Design: Semi-structured individual interviews. Setting and participants: Thirty women between 4565 years of age, with a mean age of 54,6 years, and standard deviation 6,8 from rural areas of Crete and 28 qualified primary care physicians, with a mean age of 44,7 years and standard deviation 7,0 serving this rural population. Main outcome measure: Qualitative thematic analysis.
Most women identified several reasons for not using mammography. These included poor knowledge of the benefits and indications for mammography screening, fear of pain during the procedure, fear of a serious diagnosis, embarrassment, stress while anticipating the results, cost and lack of physician recommendation. Physicians identified difficulties in scheduling an appointment as one reason women did not use mammography and both women and physicians identified distance from the screening site, transportation problems and the absence of symptoms as reasons for non-use.
Women are inhibited from participating in mammography screening in rural Crete. The provision of more accessible screening services may improve this. However physician recommendation is important in overcoming women’s inhibitions. Primary care physicians serving rural areas need to be aware of barriers preventing women from attending mammography screening and provide women with information and advice in a sensitive way so women can make informed decisions regarding breast caner screening.
Among women, breast cancer is the most commonly diagnosed cancer both in the developed and developing world and a serious cause of mortality and morbidity . There is evidence from many countries that breast screening with mammography can reduce mortality from breast cancer and mammography screening has been recommended in Europe for over a decade . In 2006 in Greece, the age-standardised incidence and mortality rate (ASRs, European Standard) for breast cancer per 100.000 was 81,8 and 21,7. Although this is lower than most other countries in Europe, the fall in breast cancer mortality observed in most European countries over the last decade has not been as great in Greece . During the 1990s, the observed incidence of female breast cancers increased in Europe, accompanied by a significant decrease in breast cancer mortality . Many European countries, including the Scandinavian countries, Germany, Poland, the Czech Republic, Austria, Switzerland, Italy and Spain have shown an appreciable reduction in mortality rates (between 8% and 19% in the last 5 years), which has been attributed to earlier detection and improved treatment . Reductions in mortality rates have been lower in Greece , where delayed diagnosis seems to be a key issue. There is no nationally formulated strategy for early detection of breast cancer, and mammography screening programmes have yet to be established in the Greek mixed public-private health care system. There have been local initiatives such as a pilot study by the Hellenic Society of Oncology for early detection af breast cancer. In this pilot study in Ilia and Messinia in the Peloponesos, in Southern Greece women aged 4064 years were invited for screening and a participation rate of 52,48% was reported . The establishment a mobile mammography unit to cover rural population health needs has been proposed and is currently being set up. Although there is free access for all to health care services through the social insurance system , use of the private sector, including private diagnostic centres, is on the increase but it is mostly people with higher education and income levels that use these centres . Where mammography screening has been promoted, for example through primary care, participation rates have been low . Debate on health care reform in contemporary Greece is focused on primary care enhancement and health promotion, including the encouragement of appropriate mammography breast screening . However, Greek general practitioners report that heavy workloads and lack of time make it difficult for them to engage in prevention and health promotion activities . Little is known about how women in Greece perceive mammography breast screening. This study explores the knowledge, attitudes and perceived practices of both primary care physicians and women in relation to mammography breast screening on the island of Crete in Greece. The study was led by a research team in Crete, building on earlier work in the UK . It forms part of a wider programme of research undertaken in Crete to identify the key components of a regional policy for breast cancer screening.
Mammography screening participation in differing health care systems
Studies of mammography screening participation rates and reasons for participation or non-participation have been undertaken in many countries with diverse health care systems and screening programmes. In the UK, where there is a well-established population-based screening programme with invitations sent to eligible women every three years, women find mammography screening an uncomfortable experience, but they perceive attendance as a social obligation . No such scheme exists in Greece, where women must seek advice and care on their own initiative. This paper therefore briefly reviews only studies undertaken with women in health care systems similar to the Greek mixed public-private model. Similarly, it reviews studies of physicians’ attitudes to mammography screening undertaken in countries with a mixed health economy.
In Europe, studies in France and Spain show participation to be higher among women of higher income and higher educational attainment. In North America, similar trends are found both in the USA and Canada . Where studies have asked women why they participate or not, a range of reasons has been found. For example, reasons given for non-participation by Spanish women included fear of finding a serious problem and the difficulty of making and keeping an appointment . In the US, non-participating women perceived the test to be unnecessary in the absence of symptoms and believed that they were not themselves at risk of cancer. Other concerns included inconvenience, discomfort, embarrassment and pain . A study with non-participating Canadian women identified similar issues, with the addition of rurality reducing participation. In the US, rural women were less likely to receive mammography screening at recommended intervals . Several studies indicate that older women may be unaware that they run a greater risk of developing breast cancer than younger women. Furthermore, it would appear that they perceive mammography to be unnecessary in the absence of symptoms . Older women have been found to be more negative about the outcome of cancer; their failure to attend screening is related to knowledge and information barriers .As a result, they undergo fewer early-detection examinations than younger women .
In countries such as the UK, a woman’s personal physician is not involved in arranging mammography screening. However, studies have shown that in countries with a mixed health economy, recommendation by a physician is one of the most powerful incentives for women to attend mammography regardless of age, socioeconomic status or ethnic group . A study in Cyprus found that physician recommendation and women’s sense of self-effectiveness were the most important predictors for the decision to undergo screening . Studies with physicians report difficulties concerning implementation of preventive care; the most important barriers reported were lack of time , lack of patient compliance with advice , heavy workload and no reimbursement . Conflicting professional recommendations for screening older women, leaving older women out of clinical trials of screening efficacy, and possible negative attitudes held by physicians and patients all contribute to lower screening rates among older women . Physicians’ practices and attitudes in recommending screening vary according to age, years of training, speciality and gender . Some studies have also demonstrated a higher rate of referral among women physicians .
The aims and design of our study were underpinned by a model of transcultural health care utilization previously tested in rural and urban Crete, where biomedical and indigenous knowledge systems co-exist . This model identifies a series of factors that interact with utilization to varying degrees. On the individual level, the model includes predisposing factors such as socio-demographic characteristics (age, education, work status, marital status), psycho-social characteristics (attitudes towards health care, knowledge and practices) and enabling factors (income of household, socio-economic status, financial cost). These all influence the possibility of using health care at the individual level. On the medical system level, factors such as geographical and financial accessibility affect the influence of the medical system on the choice of type of health care. Our study aimed to determine what influences the uptake of mammography screening in rural Crete at both the individual and medical system level. The model guided the selection of questions for the interviews with both physicians and women.
This research questions were as follows
a) What attitudes do middle-aged women in Crete have towards the use of mammography screening, and what do they know about it?
b) What factors influence the women to attend mammography screening?
c) What are the views of physicians in Crete concerning women’s participation in mammography screening?
d) Do physicians follow guidelines on mammography screening when they advise women?
The study focused on women in rural Crete, and explored the perspectives of physicians working in publicly funded rural health centres on the island, since it was undertaken to assist in the development of a regional policy for breast screening in Crete. As the aim was to explore the approach women and physicians take to mammography screening, data was collected by means of qualitative interviews.
Of the 30 women who participated in the interviews (mean age of 54,6 years; SD 6,8), 15 women had undergone mammography (ages: 4550 years n = 6; 5155 years n = 3; 56 60 years n = 4; 61 to 65 years n = 2) and others 15 had never had mammography (ages: 4550 years n = 5; 51 to 55 years n = 2; 56 60 years n = 2; 61 to 65 years n = 6). The socio-demographic characteristics of the women interviewees and use of mammography as reported during the interviews. Most of the women had low income and limited final education levels. The reported use of mammography does not distinguish between mammography screening and mammography undertaken as part of a process of diagnosis of a breast abnormality.
This study provides valuable insights into women’s knowledge, attitudes and use of mammography screening and the knowledge, attitudes and use of mammography screening by primary health care physicians in rural Crete. The study was designed to deliver data through which to inform health policy, prioritizing qualitative data collection, methods and analysis and listening to women’s voices. The study’s findings build upon previous research in other settings but uniquely, 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. Barriers to the implementation of a mammography screening programme may be similar across different geographical and national contexts, but demonstrating both the specific factors involved and the distinct local way in which such factors interact, is necessary for the development of robust and appropriate regional policy.
Credits: Maria Trigoni, Frances Griffiths, Dimitris Tsiftsis, Eugenios Koumantakis, Eileen Green and Christos Lionis
More Information at: http://www.biomedcentral.com/1472-6874/8/20
– WF Team