Who has regular mammograms? Effects of knowledge, beliefs, socioeconomic status, and health-related factors
Introduction
Breast cancer is responsible for the largest proportion of female deaths from any form of cancer in Australia [1] and has accounted for approximately 16% of all cancer-related deaths in recent years [2], [3]. While breast cancer mortality rates showed a downward trend in the 1990s [2], incidence rates, partly influenced by population screening [4], increased by 19% in the period from 1990 to 2000 [3]. In New South Wales (NSW), breast cancer is responsible for the largest proportion of new cancers that are reported [3], making up 29% of female cancers in 2000 [5]. These figures suggest that about 1 in 11 females would develop breast cancer by the age of 75 years [3].
Population-based studies have shown that mammography can be effective in early detection [6] and consequently significantly reduce breast cancer mortality [7], [8]. Mammograms without direct charge can be obtained from BSNSW by women who are 40 years or older or from private providers (paid for via Medicare, the government-funded universal health insurance scheme if the purpose is identified as diagnostic). BSNSW is a government-funded organization that recruits and offers women aged 50 to 69 years two yearly breast screening. Its aim is to reduce morbidity and mortality attributable to breast cancer [9] and the way to achieve this is to promote screening at recommended intervals. Identifying and understanding barriers to the recruitment of women into a regular screening program is therefore a key concern.
Although comparison of studies is difficult because of differences in access and availability of breast screening in different health systems, some predictors of mammographic screening have been consistent across studies. Two consistent findings are the positive associations of breast screening with high income [10], [11] and having a ‘usual’ or ‘regular’ source of medical care [12], [13]. Conflicting results have been reported regarding the effects of education [14], [15], age [14], [16], marital status [14], [17], and the presence of co-morbidities [17], [18].
Utilizing a BSNSW database, the present cross-sectional study aimed to examine how SES, beliefs and knowledge of women regarding breast cancer and mammography, health status, and health service utilization are associated with self-report of ever having a mammogram and mammography at regular intervals. An earlier report from this survey used BSNSW-defined mammography attendance to examine predictors of regular screening with BSNSW [19].
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Participants
With the approval of the NSW Department of Health Ethics Committee, women were selected from the BSNSW database (those who had had at least one mammogram at BSNSW) and from the NSW Electoral Roll (those who had never attended BSNSW for a mammogram). The sampling frame utilized BSNSW data (information on actual screening behavior) to provide a relatively unique data set enabling a better understanding of possible predictors of utilization of mammography.
The BSNSW database consists of women aged
Results
Inability to contact potential respondents by phone and insufficient English proficiency were the most common factors contributing to the 49% participation rate detailed elsewhere [23]. Of the 4381 eligible women telephoned to request their participation in the survey, 3106 completed the survey, resulting in a response rate of 71%. Two participants were excluded from the analyses because their screening status on the BSNSW register categorized them as ‘current screeners’ but they reported that
Discussion
We examined four mammography attendance status groups, defined according to self-reported utilization of mammography, comparing ever with never and recent with overdue mammography.
With the exception of an inverse association between the lowest-income category and mammography use, the present findings did not support previous reports of strong associations between SES indicators and mammography utilization [15], [27]. The relatively limited effect of SES indicators on mammography utilization,
Conclusion
A lack of knowledge and inaccurate beliefs about mammographic screening and poor health service utilization must be addressed if more women in their early 50s are to reap the benefits of early detection [53]. Women need to be reminded that mammography is an effective screening procedure and mammograms cannot be replaced by breast examination [54]. Recent debates on the effectiveness of mammograms [55] and population-based [56] versus high-risk individual [57] screening, necessitate reassurance
Acknowledgments
This study was funded in part by a grant from the Commonwealth Department of Health and Ageing.
We thank the following people for their assistance with the survey: Leendert Moerkerken, Rajah Supramaniam, Teresa Tomczyk, and Michelle Phillips.
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