Knowledge , attitude and practice of mammography among women users of public health services

OBJECTIVE: To evaluate knowledge, attitude and practice related to mammography among women users of local health services, identifying barriers to its performance. METHODS: A total of 663 women were interviewed at 13 local health centers in a city of Southeastern Brazil, in 2001. Interviewees were randomly selected at each center and they were representative from different socioeconomic conditions. The number of interviewees at each center was proportional to monthly mean appointments. For data analysis, answers were described as knowledge, attitude, practice and their respective adequacies and then they were correlated with control variables through the chi-square test. RESULTS: Only 7.4% of the interviewees had adequate knowledge on mammography, while 97.1% of women had an adequate attitude. The same was seen for the practice of mammography that was adequate in 35.7% of the cases. The main barrier to mammography was lack of referral by physicians working at the health center (81.8%). There was an association between adequacy of attitude and fi ve years or more of education and being married. There was also an association between adequacy of mammography practice and being employed and family income up to four minimum wages. CONCLUSIONS: Women users of local health services had no adequate knowledge and practice related to mammography despite having an adequate attitude about this exam. DESCRIPTORS: Mammography. Health Knowledge, Attitudes, Practice. Breast Neoplasms, prevention & control. Women’s Health Services. Women’s Health. 201 Rev Saúde Pública 2008;42(2):200-7 Breast cancer is the second most common neoplasia and the fi rst leading cause of cancer death among Brazilian women. There were 48,930 new cases in Brazil in 2006, a standardized incidence rate of 52 per 100,000 women.a Primary randomized controlled trials (RCT) have showed the importance of mammography for early diagnosis of breast cancer in asymptomatic women. It has been the most effi cient resource for decreasing disease mortality, especially in women aged 50 to 69 years,6,12,19,22 with reductions of 20% to 35%. However, breast cancer screening in community practices may be different from that in RCT.6 Mammography high cost prevents large-scale screening in many countries.3 Studies showed that low-income women have also more diffi cult access to mammography.1,8 Besides the economic issue, there are other RESUMO OBJETIVO: Avaliar o conhecimento, a atitude e a prática do exame de mamografia entre as mulheres usuárias do serviço médico municipal, identifi cando as barreiras para seu acesso à realização do procedimento. MÉTODOS: Foram entrevistadas 663 mulheres de 13 centros de saúde municipais de Campinas, SP, em 2001. As entrevistadas foram incluídas de forma aleatória, representando diferentes estratos sociais. O número de entrevistas em cada centro de saúde foi proporcional ao número médio mensal de mulheres atendidas. As respostas foram descritas quanto ao conhecimento, atitude e prática e suas respectivas adequações. A adequação foi correlacionada com variáveis de controle utilizando o teste qui-quadrado. RESULTADOS: Apenas 7,4% das entrevistadas tinham conhecimento adequado sobre o exame de mamografi a, embora a atitude frente a este procedimento tenha sido adequada em 97,1% das mulheres e a prática adequada em 35,7% das entrevistadas. A principal barreira para a realização da mamografi a foi a não solicitação por parte dos médicos dos centros de saúde (81,8%). A adequação da atitude esteve relacionada à escolaridade igual ou superior a cinco anos e ser casada. A prática adequada da mamografi a associou-se com o trabalho fora de casa e renda familiar igual ou superior a cinco salários mínimos. CONCLUSÕES: O conhecimento e a prática da mamografi a entre as usuárias do serviço médico municipal foi inadequada, apesar da atitude adequada em relação ao procedimento. DESCRITORES: Mamografi a. Conhecimentos, Atitudes e Prática em Saúde. Neoplasias Mamárias, prevenção & controle. Serviços de Saúde da Mulher. Saúde da Mulher.

Breast cancer is the second most common neoplasia and the fi rst leading cause of cancer death among Brazilian women.There were 48,930 new cases in Brazil in 2006, a standardized incidence rate of 52 per 100,000 women.a Primary randomized controlled trials (RCT) have showed the importance of mammography for early diagnosis of breast cancer in asymptomatic women.It has been the most effi cient resource for decreasing disease mortality, especially in women aged 50 to 69 years, 6,12,19,22 with reductions of 20% to 35%.However, breast cancer screening in community practices may be different from that in RCT. 6mmography high cost prevents large-scale screening in many countries. 3Studies showed that low-income women have also more diffi cult access to mammography. 1,8Besides the economic issue, there are other RESUMO OBJETIVO: Avaliar o conhecimento, a atitude e a prática do exame de mamografia entre as mulheres usuárias do serviço médico municipal, identifi cando as barreiras para seu acesso à realização do procedimento.

CONCLUSÕES:
O conhecimento e a prática da mamografi a entre as usuárias do serviço médico municipal foi inadequada, apesar da atitude adequada em relação ao procedimento.diffi culties: fear of irradiation, obstacles of public services, 15,17 and pain, discomfort, and anxiety about the screening. 6rst diffi culties to screening mammography should be identifi ed and then community health care authorities should establish strategies to overcome them.It is essential to have comprehensive knowledge, attitude and practice of mammography in the target population, stressing the importance of implementing it as a routine and preventive measure for early diagnosis of breast cancer.
The objective of the present study was to evaluate knowledge, attitude and practice of women towards mammography and to identifying potential barriers to screening among women users of health centers.

METHODS
Descriptive, observational study of knowledge, attitude and practice (KAP) 24 carried out in 13 municipal health centers in Campinas, Southeastern Brazil.A total of 663 women attending medical visits at internal medicine, gynecology and nursing care units were interviewed between August 2000 and March 2001.Health centers were randomly selected from the 43 existing in the city and users were representative from different socioeconomic conditions.A questionnaire previously tested in other units was used to evaluate KAP on mammography and to identify barriers to screening.
Health centers were selected according to socioeconomic conditions (better-off and deprived areas) taking into account the number of public schools in the corresponding area and whether or not there was a water supply system.A random stratifi cation process was used to select 13 health centers including a wide range of socioeconomic characteristics.
The sample size was based on the average number of women assisted in the fi rst semester of 1998 and a stratifi ed random sampling described by Scheaffer et al. 21The estimated sample size was 663 women, corresponding to a sample fraction of about 1.1%, proportional to care fl ow at each health center.
Women aged 40 and older enrolled in the health center for at least six months were included in the study.Those with a personal history of breast cancer or who had other medical insurance were excluded.Interviews were performed by previously trained nursing assistant staff from the same health centers while women waited for their appointment at internal medicine, gynecology or nursing care units.One in every fi ve women meeting the inclusion criteria was asked to participate in the study.When a woman refused to be interviewed, the next one was asked, and so forth.Refusal rate to participate was very low.
Adequate knowledge on mammography was defi ned when interviewees provided correct statements about the availability and use of the exam and how it is practiced.Examples of questions and correct answers were as follows: "Have you heard anything about an exam called mammography?" "When have you fi rst heard about mammography?During educational activities at the health center?On the radio or television?In conversations with friends or neighbors?"If women considered correct the following statement: "It's a special X-ray to detect lumps in your breasts / It's a procedure to detect any problem in your breasts / It's an important procedure that should be carried out along with clinical and breast self-examination." Women's attitude towards mammography was considered appropriate when they expressed a favorable opinion and consistently supported it.Some examples of questions and correct answers were: "How necessary do you think a mammography is? Very necessary?Fairly necessary?Not necessary?Why?" "I think this exam is very necessary because: It's the best one to detect breast conditions./ This exam can detect early breast cancer.Sometimes the diagnosis of breast cancer comes late." The practice of mammography was considered adequate when women reported undergoing it following medical prescription or their own will and when the time interval between two mammography exams was not greater than two years.As for those subjects who had not had mammography, the main reason given for that was analyzed.
The questionnaires were reviewed for information quality and legitimacy, and corrections were made as needed.The data were through cleanliness and consistency tests and variable frequency analysis and entered into EpiInfo 6.1 program.Associations between sociodemographic characteristics (age, education, paid job, marital status, family income and length of time being assisted at the health center) and adequacy of KAP of mammography was evaluated according to the interviewees' answers using a two-sided chi-square test, with a 5% signifi cance level.
Correct and consistent answers, regarding the value of mammography was considered adequate knowledge.An attitude was considered adequate when interviewees were positive on the value of mammography and supported their answer with statements that imparted consistency to their previous answer.Practice was considered adequate when interviewees correctly answered the questions regarding the method and desired frequency of mammography.
The study was approved by the institution's Research Ethics Committee and followed the principles of the Declaration of Helsinki.

RESULTS
Most interviewees were over 50 years of age (67.9%), had lower education (80.6%), no active participation in the labor market (70.1%) and low family income up to four minimum wages (67.1%).More than half of the interviewees reported four pregnancies or more (56.1%)and over 80% had attended the health center for more than two years (Table 1).
Users showed knowledge about mammography (93.5%) and their health centers were the main instrument to promote this knowledge (56.0%).Nevertheless, few interviewees (7.4%) had adequate knowledge about mammography.Similarly, they showed a positive attitude towards mammography and most had an adequate attitude (97.1%) (Table 2).
Half of the women seeking medical care at the health centers reported they had not been referred to mammography (50.7%).Among those who had had mammography exams, their main indication was age (Table 3).
Of those who were supposed to have a mammography every 24 months, only 38% underwent the exam and the adequacy rate was low (35.7%).Among those who did not have the exam, no medical referral was the main barrier (81.8%) (Table 4).
There was not found an association between sociodemographic variables and adequacy of knowledge.There was an association between adequate attitude and higher education and the status of being married as well as an association between adequate practice and having a paid job and family income higher than fi ve minimum wages (Table 5).

DISCUSSION
Low education and socioeconomic conditions are major factors for diagnosis delay, response to treatment and survival rates in several cancers, including breast cancer. 1,2,13,16In the present study most women studied had a low educational level and low socioeconomic condition which certainly contributed to the study fi ndings.Most interviewees had inadequate knowledge (92.6%) and the health service was their main source of information (56%).In a recent study in Goiania, Midwestern Brazil, including 531 women, television was reported as the main source of information about breast cancer (26.5%). 9though many of them had a favorable attitude towards mammography, in the present study only one-third of them (35.7%) have had it routinely and adequately performed.
In a recent similar study conducted in 1,012 Chinese women from Hong Kong, 58% had never heard of mammography screening.Lack of time and costs were the most frequently reported reasons for their reluctance to participate in clinical breast examinations or mammography screenings. 4r a successful fi ght against breast cancer it is necessary to promote a behavior change in both women and health professionals, especially those providing care to the poor and improve women's knowledge, attitude and practice regarding screening mammography.
Since the most famous study on mammography screening was published, mammography has been defi nitively incorporated into the early diagnosis of breast tumors. 5,6,22,23though mammography and clinical breast examination are widely used in breast cancer screening, their benefi cial impact remains controversial.A systematic review of Cochrane Library reviewed the main RCTs on the practice of screening mammography developed in the past decades and the authors questioned some results of previous studies, mainly concerning randomization.They concluded there is not enough evidence to support that mammography screening reduces deaths rate of breast cancer. 20However, despite some biases found in these trials, other studies concluded they are not suffi ciently relevant to invalidate the effi cacy of mammography screening found in RCTs. 6,12t breast cancer screening in community health care may not be as effective as that suggested by RCTs, performed under ideal circumstances.There is a need to further explore the effects of current screening practices in the general population. 11A recent casecontrol study conducted in six health plans in the United States showed that screening history was not associated with reduced breast cancer mortality and suggested that mammography screening might be effective only among women who are at increased risk for breast cancer. 7cost-effectiveness analysis in Switzerland compared a mammography screening program (MSP) with an opportunistic screening strategy (OS) based on clinical practice. 18This economic analysis showed incremental costs per life-year gained for MSP were about twice those found for OS and it was concluded that MSP enables a signifi cant reduction of breast cancer mortality compared with OS.
Notwithstanding, investments are made to improving mammography techniques (especially digital mammography) or other forms of screening (magnetic resonance imaging) based on the belief of its actual benefi t to women. 6,14 Brazil, the fi rst offi cial data on mammography utilization comes from a household survey by the The data of the present study should be analyzed from two different aspects.First, there is a need for an ongoing program for early detection of breast cancer.Women The results of the present study are in agreement with another Brazilian study that found a similar proportion of no mammography referrals in both public and private health services (84.3% and 46%, respectively).They also found that about 30% of women seen in public services did not undergo mammography because the health professionals considered it unnecessary. 10Apparently there is greater medical resistance than women's regarding mammography in asymptomatic patients.
The lack of programs for early detection of breast tumors -a responsibility of health authorities -ends up negatively affecting patients who have their chances of cure reduced, experience greater mutilation and cause more suffering during treatment and to their family.In addition, there are further losses to the public sector with increased costs to treat cases that could have been early diagnosed.The implementation of an educational program targeting women's health and more specifically focusing on early diagnosis of breast cancer is the only action that could change the current situation.
Unfortunately, due to operational issues, this study could not be extended to all health centers in the city of Campinas, which would have allowed to gathering data that would either ratify or rectify the results obtained in the present study.It is suggested further investigation of health insured women.Combined to the data of the present study, both could provide better understanding of the barriers faced by women when trying to gain access to a procedure of greater complexity such as mammography.
In conclusion, users of local health services in Campinas had inadequate knowledge and practice concerning screening mammography, although they show an adequate attitude towards the exam.The main barrier to mammography is related to the public health system: patients did not undergo the exam because they were not referred by their doctors.
Instituto Nacional do Câncer (INCA -Brazilian National Cancer Institute).It comprised 2,525 women aged 50 to 69 years between 2002 and 2003 in 15 capitals plus the Federal District.It showed that 54% of the women studied had a mammography in the prior two years, one third of them in public health services and the remaining in health insurance covered or private services.a

Table 1 .
Distribution of women users of local health services according to sociodemographic characteristics.Campinas, Southeastern Brazil, 2000-2001.(N=663)

Table 2 .
Knowledge, its sources and adequacy, and attitude of women users of health services regarding screening mammography.Campinas, Southeastern Brazil, 2000-2001.

Table 3 .
Distribution of women users of local health care centers according to mammography requested by the health center doctor, indication and other variables.Campinas, Southeastern Brazil, 2000-2001.

Table 4 .
Distribution of women users of local health care centers according to characteristics regarding the practice of mammography.Campinas, Southeastern Brazil, 2000-2001.

Table 5 .
Assessment of adequacy of knowledge, attitude and practice of mammography according to sociodemographic variables of women users of local health care centers.Campinas, Southeastern Brazil, 2000-2001.