Knowledge and attitude towards screening mammography among 400 women in the eastern province of saudi arabia.

OBJECTIVE: Assess knowledge and attitude of Saudi females towards screening mammography.
MATERIAL AND METHODS: A sample of four hundred Saudi females were interviewed using a structured questionnaire.
RESULTS: Positive family history of breast cancer was the most significant factor that was positively associated with individual knowledge and attitude towards screening mammography (p<0.00001). There was no significant association with the level of education. Poor knowledge and attitude were observed among 41.8% of all participants, especially in relation to not having mammography done or not wishing to have it done. There were 51 (12.8%) participants who had not had mammography done, but wished to have it, 25 (6.3%) participants who were undecided about having mammography done in the future, while 67 (16.8%) wished to have it done every one to two years.
CONCLUSION: This study showed that there has been deficient knowledge and attitude towards screening mammography even among the highly educated, and stressed the need for health education on the importance of screening.

INTRODUCTION

Screening mammography (SM) is an important tool for detecting early breast cancer. SM refers to x-ray examination of the breast for women who are asymptomatic, that is, have no apparent breast problems.1 Estimates of SM sensitivity range from 75 to 90%, with specificity ranging from 90 to 95%.2

The positive predictive value of SM for breast cancer ranges from 20% in women under the age of 50 years, to 60 and up to 80% in women aged 50-69 years. Randomized clinical trials have demonstrated a 30% reduction in breast cancer mortality in women 50-69 years who are screened annually or biannually with mammograms. The data on women under age 50 years are less clear.2 Conclusions on the value of SM in these women have been hampered by inadequately designed studies, including the failure of randomization and inadequate sample size, low compliance in the intervention group, and high screening rates (cross-over) in the control groups.34 A few studies have suggested adverse effects on mortality in the early years after screening implementation, but both the occurrence and potential etiology of these effects are poorly understood.45

In many countries, screening programs are mandatory for women over 50 years of age. This is due to the higher incidence of breast cancer in older women there, consideration of cost-benefit ratio, and past fears about radiation risks in younger women.67 One review discounts the last factor, indicating that even in women as young as 25, the benefits of mammographic screening far outweigh any risks.8 Given the fact that the majority of breast cancer patients in Saudi Arabia are younger than those in the West, mainly because of the nature of the population pyramid of Saudi Arabia, the right population for screening needs to be defined and access to specialized medical services must be assured.9 The lack of public knowledge about cancer is a potential barrier preventing people from participating in such studies and in cancer control activities.1011 The aim of this study is to assess the knowledge and attitude of Saudi females about SM as the first step towards the early detection of breast cancer.

MATERIAL AND METHODS

This study was conducted in the period January-to-June, 2000. The study population was women in the 30-65 year age group working in schools in the Eastern province. The total number of women was about 2000, and was composed of teachers, clerks, and those in administrative and miscellaneous jobs. A simple random sampling approach was adopted and a 25% target sample size was set. Thus, the estimated sample size was 500 women. Participants were interviewed using a structured questionnaire, consisting of the “yes” or “no”, and “uncertain” question format.

The variables in the questionnaire concerned: marital status, number of children, level of education, occupation, history of previous mammography, family history of breast cancer, number of mammography tests done, who made the decision about mammography, motive for doing mammography, reasons for not doing mammography, sources of knowledge about mammography, and a series of seven questions describing the positive, or negative attitude towards mammography screening.

The data was analyzed using the Statistical Package for Social Sciences (SPSS PC). Frequency distribution tables were generated and a chi-squared test was done to assess the significance of differences between categories. Significant variables were further analyzed using multiple logistic regression with the attitude towards screening mammography as the dependent variable. A p-value of 0.05 or less was considered as indicative of statistical significance.

RESULTS

The total number of females who participated in the study was 500, with a response rate of 80.0%. The reasons for non-response were that 100 women were excluded from the study: 75 had not heard about SM, 15 were below the age of 30, and 10 with incomplete questionnaires were rejected.

The mean age of the sample was 35.9 ± 5.7 years, with a range of 30-65 years. The majority of participants (92.8%) were within the age groups 30-44 years. Schoolteachers constituted 74.5% of the sample, while housewives, university teachers and others formed 14.5%, 2,5% and 8.5%, respectively. The majority of participants (90.5%) were married (Table 1).

Table 1

Socio-demographic variables

Regarding experience with mammography, 58 (14.5%) women had previous experience with mammography. Of these, 36 (62.1%) had had it done once, 18 (31.0%) two times, and 4 (6.9%) three times. The decision for mammography had been made by 28 (48.3%) of the participants themselves, while for the remaining number the decision had been made by others.

A total of 89 (22.3%) participants were motivated to have mammography done, 56 (62.9%) of whom had it done for fear of cancer and 14 (15.7%) because they knew of people who had cancer.

However, 371 (92.8%) participants had had no motivation for mammography. The reasons for non-motivation were that they had had no breast problems (66.9%), were afraid of discovering that they had cancer (13.2%), or were too busy (10.0%). Among the rest, the reasons were that they were not old enough, could not afford the cost, were afraid of radiological hazards, or uncertain of its benefits.

On the source of knowledge about mammography, 128 (32.0%) of the participants stated the source of their knowledge. The sources consisted of the mass media (31.3%), private doctors (16.4%), personal knowledge and conviction (40.6%), husband (7.0%), and another relative (4.7%) (Table 2).

Table 2

Experience with mammography

Table 3 shows the attitude towards SM. Almost half of the sample had a positive attitude towards mammography. This attitude was expressed in the wish to have mammography done, having had mammography done before and the desire to have it done every 1-2 years. The other half who had a negative attitude towards mammography stated that they had not had mammography done and had no wish to have it done, were not decided what to do in the future, or would discuss the matter first with the doctor.

Table 3

Attitude towards mammography

On the effect of variables on participants’ attitudes, significantly more younger participants had a positive attitude than older ones (P<0.01). Also, significantly more participants with a positive family history of breast cancer displayed a positive attitude than those with a negative family history (P< 0.0001). However, no significant relationship was observed on the positive attitude towards SM with any of the other variables studied (Table 4). Multiple logistic regression analysis revealed that the only variable that was significantly and positively associated with a positive attitude towards mammography was a positive family history of breast cancer (P < 0.00001).

Table 4

Variables affecting attitudes towards mammography

DISCUSSION

Mammography, a screening procedure, is an x-ray examination of the breast that has decreased the risk of death from breast cancer by 25 to 30%. It can detect breast cancer or carcinoma in situ at 5 to 10 mm in diameter. Most physicians cannot reliably detect lesions smaller than 10 mm on physical examination, and patients generally seek medical attention for lesions that are 25 mm or larger.12

Early breast cancer is potentially curable; in Saudi Arabia it is the most common cancer in women. However, our experience indicates that the pattern of the disease is different than that reported in the literature.913 Published data from the Saudi National Cancer Registry indicate that breast cancer is the most frequent malignancy in adult women, accounting for 18% of the total. A review of studies on the relationship of age to the incidence of breast cancer in North America and Europe shows that the incidence in women younger than 40 years ranges from 8 to 15%, as compared with the 35% observed in King Faisal Specialist Hospital. The low frequency of early stage disease reflects delayed presentation and referral, and is a cause for serious concern. The delay may be due to ignorance of the disease, little education and/or the inaccessability of specialized medical care.9

The evaluation of public awareness and misperception about cancer is of fundamental importance for the successful implementation of activities on cancer control.1014

This study shows that there is poor knowledge and considerable negative attitude towards mammography in all identified age groups, and on all educational levels. Little work has been done by the media or private doctors on community education for disease prevention. Participants with personal or family experience with cancer were more aware of the importance of screening for the disease. The data also suggest that for effective cancer control in Saudi Arabia there should be comprehensive cancer health education.

A joint effort by the primary care physician and community oncologist in this task will be necessary and the development of more widespread screening and educational programs will be of benefit to the women of the Kingdom. The development and implementation of a comprehensive Breast Cancer Program in which additional resources are allocated towards its control would be an important first step towards raising the national consciousness on this disease.