|Year : 2015 | Volume
| Issue : 4 | Page : 531-535
Study on knowledge, experiences and barriers to mammography among working women from Delhi
Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
|Date of Web Publication||10-Mar-2016|
Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Mammography is not a popular screening tool for deducting breast cancer in India although regular screening is associated with reduced mortality from breast cancer. OBJECTIVE: The objective of this study is to find out knowledge, experiences and barriers to mammography among working women of Delhi. MATERIALS AND METHODS: Cross-sectional descriptive study was conducted from October 2012 to March 2013 among working women from Delhi, India. The study was conducted as a part of ongoing training workshops organized for women on early detection of breast cancer. Total of eight such programs were organized and were attended by a total of 439 women. Each participant got a self-administered questionnaire to fill. Data was entered in Microsoft Excel and analysis was done using Statistical product and service solutions (SPSS) version 21 (IBM). RESULTS: A total of 439 participants were included in the study. 230 (52.4%) of the women were more than 40 years of age. Only four participants (1%) had not heard about the term mammography before. Less than half (45.1%) of the participants knew correctly the purpose of a mammogram. Only 11.8% of the women knew correctly about the age of getting the first baseline mammogram. Knowledge of frequency of getting the mammogram was also low only 95 (21.6%) correctly knew about it. Only 59 (11.9%) correctly responded that one needs to go to an imaging facility located either in a hospital or elsewhere to get mammogram done. Main experience shared by the women regarding mammography was that 42 (95.45%) did not know anything about the procedure when they went for this investigation. Out of a total of 230 women over 40 years of age only 38 (16.5%) had ever got a mammogram carried out. There is a statistically significant association between education status and practice of mammography (P < 0.05). There were 18 women with family history of breast cancer out, of which 10 (55.5%) had got mammography carried out. 192 out of 230 (83.5%) women over 40 years of age had never got a mammogram done. Main reason 74 (38.5%) cited for this was that they did not know/were not aware they were supposed to go for mammography. CONCLUSION: As knowledge and utilization of mammography is low among women, there is a need to have a multipronged strategy to inform women about mammography and bring about a behavioral change along with having a formal national level screening guidelines for breast cancer early detection.
Keywords: Barriers to mammography, experiences, knowledge, mammography, working women
|How to cite this article:|
Khokhar A. Study on knowledge, experiences and barriers to mammography among working women from Delhi. Indian J Cancer 2015;52:531-5
| » Introduction|| |
Regular screening procedures are effective in substantially reducing cancer incidence and preventing many cancer-related deaths. Routine mammography can reduce breast cancer mortality by 40-45% among women between the ages of 40 and 69., The efficacy of mammography in breast cancer detection and mortality reduction is contingent upon repeat mammography behavior (i.e., adherence to screening guidelines). Although there have arguments and discussions regarding the appropriate age to have the first mammogram i. At 40 or 50 years, doctors from India are of the opinion that screening in India should start at the age of 40. Screening mammography - the all-important X-ray examination of breasts to check for cancer in a woman who is asymptomatic (shows no symptoms) - is abysmally low in India. According to World Health Organization's latest World Health Statistics (WHS), less than 5% women, aged between 50 and 69, underwent screening by mammography in India between 2000 and 2003. In India, where breast cancer is on the rise and most of women report when the disease is already in stage III or IV, it becomes essential to focus on screening procedures and early detection of the disease. As observed breast cancer screening is not popular in India we need to study the perception of women regarding screening and what could be the possible barriers to their getting screened. This study was planned against this backdrop to find out the existing knowledge of women regarding mammography, their experiences and barriers to mammography.
| » Materials and Methods|| |
The present cross-sectional descriptive study was conducted from October 2012 to March 2013 among working women from Delhi, India. The study was conducted as a part of ongoing training workshops organized for women on early detection of breast cancer. For the purpose of sample size estimation prevalence was assumed to be 50% with an absolute error of 5%. The size was calculated to be 400 with 80% and 95% confidence level. After seeking administrative approval from the various organizations where the women worked total of eight such programs were organized and were attended by a total of 439 women. Each of the sessions had attendance of about 60 participants. Each participant got a self-administered questionnaire to fill. Section one pertained to knowledge about mammography, section two was applicable to only those women who had ever undergone mammography because it dealt with experiences related to mammography and the third section was to be filled only by women more than 40 years of age as it had questions pertaining to barriers to mammography. Data was entered in Microsoft Excel and analysis was carried out using Statistical product and service solutions (SPSS) version 21 (IBM).
| » Results|| |
A total of 439 participants were included in this study. Age wise distribution of the subjects is as per [Table 1]. 230 (52.4%) of the women were more than 40 years of age [Table 1].
|Table 1: Age and education wise distribution of the participants (N=439)|
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Only four participants (1%) had not heard about the term mammography before. Less than half (45.1%) of the participants knew correctly the purpose of a mammogram. Only 11.8% of the women knew correctly about the age of getting the first baseline mammogram. Knowledge of frequency of getting the mammogram was also low only 95 (21.6%) correctly knew about it. Furthermore, there was confusion regarding whether mammography was same as ultrasonography as most either did not know the difference (61%) or thought they were same (10.4%). Regarding the time taken to conduct mammography some women, 32 (7.3%). Even replied, that it required hospitalization. Only 59 (11.9%) correctly responded that one needs to go to an imaging facility whether located in a hospital or elsewhere to get mammogram done. As low as 65 (14.9%) of the participants only correctly knew that mammography is performed under the supervision of a radiologist and not any other specialist [Table 2].
Out of a total of 44 women who had under gone mammography ever six were less than 40 years of age. Main experience shared by the women regarding mammography was that 42 (95.45%) did not know anything about the procedure when they went for this investigation. 05 (11.4%) of the women found the experience so unpleasant that they replied that they will tell others not to go for mammography [Table 3]. Out of a total of 230 women over 40 years of age only 38 (16.5%) had ever got a mammogram done. 5/67 (7.5%) of those with education less than graduation had undergone a mammography as against 33/130 (25.4%) of those either with graduation or a post-graduation degree. There is a statistically significant association between education status and practice of mammography (P < 0.05). Out of 44 only seven women had gone for a screening mammogram from their side as a part of an executive health package they had enrolled for others went because they had one or the other breast complaint.
There were 18 women with family history of breast cancer out of which 10 (55.5%) had got mammography done. Out of eight left who had not got the mammography done four were less than 40 years of age and four were more than 40 years of age. Those more than 40 years of the age stated that since they had no breast lump they did not feel any requirement of mammography.
A total of 230 women out of 439 were over 40 years of age and were asked if they had not undergone mammography what the barriers to it were. Out of 230, 192 (83.5%) women over 40 years of age had never got a mammogram done. Main reason cited for this was that they did not know/were not aware they were supposed to go for mammography; 74 (38.5%) [Table 4].
|Table 4: Women over 40 years of age according to reasons for not having undergone mammography ever (n=92)*|
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| » Discussion|| |
In the present study, 99.1% of the women had heard the word mammography before and only 45.1% correctly knew it is done for diagnosis of breast cancer. In another study among school teachers of Delhi by Khokhar, 67.1% had heard the term mammography. In another community based study by Puri et al. from North India on being inquired about what investigation the women would have to undergo to diagnose breast cancer only 27.3% mentioned mammography as the answer. In a study by Bari et al. from resettlement colony of Delhi only 6 women out of 333 interviewed knew of early detection by mammography. Although women may have heard of the term mammography, correct knowledge about the purpose of doing it is very low among the women from India. In another study from Iran by Montazeri et al. only 9% had heard of mammography. Only 11.8% women from the current study, knew that the first (baseline) mammogram should be performed at age 40 and 21.6% mentioned the correct frequency to be once a year, this parameter of knowledge about mammography is again low. Only 50% of the respondents from Malaysia  were aware of mammography and when asked about age of mammography screening 53.2% wrongly mentioned it to be 25 years. None of the school teachers from Delhi knew that first mammogram should be performed at the age of 40. In a study by Sadikoglu et al. 12.7% of the women from Turkey had no knowledge of mammography. In a study by Akinola et al. from Nigeria, only 40.5% of the women had heard about mammography, 31.4% had heard of mammographic screening and 39.5% were not aware it is used for diagnosis of breast. Only 20% knew how many times mammographic screening should be performed in a year. 36% of women from Malaysia  reported that frequency of mammographic screening is once a year and that it is needed for women above 40 years. In the current study, less than half of participants (45.1%) correctly mentioned that mammogram can detect breast cancer. Comparable proportion 48.8% of participants from Malaysia was aware that mammogram could detect breast cancer.
In the present study, 17.6% stated exposure to radiation as one of the side-effects of mammography. In the study from Nigeria  also a very low figure of 7.6% was aware of the fact that mammography was associated with side-effects like discomfort from compression of the breasts and exposure to radiation. 90% of the Malaysian  felt that mammogram was painful and associated with serious side-effects. Iranian women  also mentioned that exposure to radiation is a discouraging factor in getting a mammogram done. In the present study, 7.3% women thought mammography required hospitalization majority of the respondents from Malaysian also believed that, hospital admission is required to do the mammogram. People usually try hard to avoid being admitted into hospital. Hence, when they believed the need of hospitalization prior to mammography, the rate of women interested to utilize it will be affected. 78% of the women from the present study responded that mammogram can be availed at any hospital similar observation was also made among Malaysian women where 40.7% of the women also thought that it can be performed at any health center. 10.4% of the women confused ultrasound to be same as mammogram in the present study same observations were made in Nigeria (2.7%) and Mulago, Uganda. This throws light on the fact that women are not aware about the screening tests and investigations.
In our study, only 16.5% of women over 40 years of age had ever got a mammogram done. None of the teachers from Delhi went for regular screening mammography and only eight had ever gone for a mammogram that too because they had one or the breast problem. 68.05% of over 40-year-old Chinese women in Hong Kong had also never got a mammogram done according to Yan. Less than 5% of the respondents from Nigeria had got a mammography done. 89.3% of the Turkish women had also never got a mammogram done. From Iran, 44.3% women had under gone a mammogram. All these studies support that fact that mammography screening is not popular among women.
In the present study, 95.4% of the women who had undergone mammography they said that they knew nothing about the procedure when they had gone for the test as no one had told them or counseled about what was to be expected during the test. In a conducted at imaging centers in Philadelphia by Fine et al. only 12% of the women reported that their physician had explained the mammography procedure.
Embarrassment is a common emotion, which women from all across the globe feel while undergoing mammography. In our study, 68% of the participants felt embarrassed while getting the procedure done. In USA, 6.7% felt moderately or very embarrassed in telephonic surveys done by Peipins et al.
Anxiety about the test is also widely prevalent amongst women. In our study, 44% felt anxiety, 60% of the participants from Philadelphia study felt anxious during the test. 59% of our participants found the test to be painful and 41% to be discomforting similar observation was made by Peipins et al., they found 25% of their participants reported moderate to high level of pain during mammography and 15.8% reported being very nervous. It is very important that the first mammographic experience is not discomforting if not pleasant for them as it can influence their decision to have future screening and also influence other women. In the present study 16%, women mentioned that they will avoid getting it done again. 34% of subjects from Philadelphia also mentioned that their current experience of mammogram will affect their future plans of having another.
Only 6.8% of the women from the present study stated that they were not happy with the behavior of the technical staff this finding is similar to study from United States where 90% of the women found technician to be helpful and friendly.
In the present study 83.5% of women over 40 years of age had never got a mammogram done. 38.5% of our women did not know they were supposed to get it done. 12.7% participants from Turkey had not heard of mammography and 4.3% were unaware of its necessity.
In a study from Mulago, Uganda also majority reported they did not go for mammography because they had never heard of it and its use in investing breast cancer. Those who were aware of it complained of high cost of the procedure. Women from Iran also reported they do not feel any advantage of mammography along with anxiety, fear, embarrassment that is associated with it. Furthermore, lack of physician prescription was a reason why women from Iran probably did not go for mammography. In present study also1.6% stated doctor doesn't refer unless there is a breast problem. Women from government offices mentioned that under the Central Government Health Services scheme doctors at the dispensary do not automatically send women over 40 for screening. They want the women to go to a hospital and get the test written by a specialist as a result it is often left out. Contrary to this there were two women less than 40 years of age who have been getting annual mammogram since 35 years of age because it was a part of their executive health-care package they had enrolled for. Since government of India has not formalized any uniform screening guidelines for the country these disparities exist.
In the present study, 32.3% stated that mammography was not required as they did not have any breast related problem and same response was given by 25.3% of Turkish women. What this reflects is that women are not aware of concept of screening for a disease when they are asymptomatic.
From the present study, 25.5% of the women stated that the reason for not getting a mammogram to be the uncomfortable nature of the procedure. Nearly, 26.9% of the women from Singapore  also mentioned pain to be a deterrent.
This is how women attending radiology department at Mulagao Hospital, Uganda 14 described mammography:
“The pain you know…they squish it between the two slabs over
“I don’t think anybody is telling you the truth but I think that
the pain, the pressing your breast that people try to avoid it.”
Nearly, 25% of the subjects from current study mentioned that their doctor has never advised it mammography. 15.2% of Turkish women also mentioned the same. Also women from Singapore gave this to be a reason for not getting a mammogram done.
About 15.1% of our women stated they did not know where to go for the test. In Turkey, even those who were referred by a doctor 11.2% of those did not find a place to for mammogram. Not knowing where to go for a mammogram was also a reason stated by women from Singapore. This suggests that physicians and the media should focus on making women aware about this aspect of mammography.
Scared of finding a breast lump was a deterrent in 4.7% of the women from present study. 37.4% of the women from Turkey were also afraid to go for the test as it could reveal cancer. Women from Uganda were so scared that is what some had to say. “The very word cancer, I think that scares you. Some people say that I don't even care if it's at an early stage it can be cured, but the very thought of cancer you know makes you scared and you think no and you are gone now.” I don't want to see that cancer floor, you know, name and everything you know.”
In the present study, a statistically significant association was found between higher education qualification (graduation and post-graduation) and practice of mammography as has been reported from other studies also.,,
This indicates as the literacy rate and academic qualifications of women from India increase there is likely to improved rate of mammographic screening.
| » Conclusion|| |
Government of India needs to formalize and disseminate amongst all national guidelines pertaining to breast cancer screening. Since the disease is on the rise it should be considered as a top priority as early detection saves lives. Physicians need to be sensitized further regarding the need of mammographic screening so that they refer women for this test. Good quality mammographic facilities should be made available it would be worth the effort if mobile vans could be provided to go to worksites of women to do mammograms. Ask knowledge about mammography screening is low among women. Information, education and communication drive is required to make the masses aware about utility and availability of mammographic services and removes barriers that may be in their behavior in seeking such services.
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[Table 1], [Table 2], [Table 3], [Table 4]