Mammography screening of Greek women and primary care physicians in Crete
- Reported, January 23, 2012
 Breast
cancer is the most commonly diagnosed cancer among women and a leading cause of
death from cancer in women in Europe. Although breast cancer incidence is on the
rise worldwide, breast cancer mortality over the past 25 years has been stable
or decreasing in some countries and a fall in breast cancer mortality rates in
most European countries in the 1990s was reported by several studies, in
contrast, in Greece have not reported these favourable trends. In Greece, the
age-standardised incidence and mortality rate for breast cancer per 100.000 in
2006 was 81,8 and 21,7 and although it is lower than most other countries in
Europe, the fall in breast cancer mortality that observed has not been as great
as in other European countries. There is no national strategy for screening in
this country. This study reports on the use of mammography among middle-aged
women in rural Crete and investigates barriers to mammography screening
encountered by women and their primary care physicians.
Design: Semi-structured individual interviews. Setting and participants: Thirty
women between 45–65 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 40–64 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: 45–50 years n = 6; 51–55 years n
= 3; 56 – 60 years n = 4; 61 to 65 years n = 2) and others 15 had never had
mammography (ages: 45–50 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
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WF Team
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