Knowledge, attitude and uptake of mammography among female health workers in two tertiary health facilities of Sokoto state, Nigeria

INTRODUCTION

Globally, breast cancer is the most common cancer in women, and is the second leading cause of cancer deaths among females; after lung cancer.^1-3 There is an estimated 1,384, 155 new cases worldwide and over 459,000 related deaths annually.⁴ Since 2008, estimates of the World Health Organization (WHO) showed that, worldwide, the incidence of breast cancer has increased by more than 20%, and mortality has increased by 14%.²

If discovered early breast cancer can usually be cured, as such, primary prevention is the best strategy to decrease breast cancer related morbidity and mortality, and early detection remains the cornerstone of breast cancer control in terms of outcome and survival.³ Currently the only breast cancer screening method that has proven to be effective is mammography.² Screening for breast cancer with mammography aims at detecting breast cancer at an early, curable stage.⁵ A mammogram is an x-ray of the breast that uses a very small amount of radiation. A screening mammogram is used to look for breast diseases in women who have no present indication for breast problems.² Combined results from randomized screening trials suggest that mammography reduces the risk of mortality from breast cancer by 15% to 20%.^5,6 Annual mammography remains the gold standard of asymptomatic breast cancer screening for women starting at the age of 40.^1,2,5 The recommended interval between two screens varies from 1-3 years.⁵ The high cost of mammography, fear or irradiation, difficulty accessing health care services generally are some of the reasons that prevents large scale screening in most countries.⁷

Studies have shown that recommendation by a physician is a very strong incentive for women to obtain screening mammography.^3,8-10 Female health care workers have the potential to disseminate accurate information and knowledge on mammography to the general public. This is because as frontline healthcare providers, they often come in contact with patients and their relatives. Female HCW have a role to play as health educators on mammography as well as advocates for early presentation to hospital. It has also been observed that for health workers to be effective as educators they must possess the appropriate knowledge, attitude and beliefs concerning the health behaviour being promoted.^3,8-10 Studies from developed countries show that attitude and orientation of healthcare providers are important determinants of use of breast screening program.^8-10

This study aimed to assess the knowledge, attitude and uptake of mammography among female health care workers working in 2 health care institutions in Sokoto, Nigeria.

METHODS

The study was carried out between May and August 2016 at 2 tertiary hospitals located in Sokoto metropolis; Usmanu Danfodiyo University Teaching Hospital (UDUTH) and Specialist Hospital Sokoto. UDUTH is a tertiary health care facility, it renders preventive, curative and rehabilitative services including mammography services. It has over 650 bed capacity with staff strength of 1,705 including 362 female health workers.

Specialist Hospital Sokoto also offers preventive, curative and rehabilitative services, with a bed capacity of 520 and staff strength of 1,654 including 251 female health workers.The study was cross sectional in nature. Using formula for estimating sample size for cross-sectional studies, with a prevalence of 0.876 (prevalence of knowledge of mammography) 8 and correction of non-response of 20% a sample size of 209 was obtained.

Inclusion criteria

All female health professionals (doctors, nurses, medical laboratory scientist, pharmacist) employed by the hospitals were eligible to participate in the study.

Exclusion criteria

Health care workers who had spent less than 6 months at place of work were excluded from participating in the study.

After obtaining the list of the female health workers from their respective departments/units systematic sampling was used to recruit them into the study. A semi-structured, self-administered questionnaire was used for data collection. The questionnaire had sections that assessed socio-demographic and professional characteristics, respondents’ mammography related knowledge, mammography related attitude and respondents’ uptake of mammography. Informed consent was obtained from individual respondents and ethical approval for the study was obtained from the ethics committee of Usmanu Danfodiyo University Teaching Hospital, Sokoto. The questionnaires were distributed and retrieved by trained research assistants (medical students). The retrieved questionnaires were manually checked for completeness. Mammography related knowledge of respondents was obtained by calculating the percentage of questions answered correctly, each question answered correctly attracted a score of 1 and any question wrongly answered attracted a score of zero, the total score was divided by the total number of questions and multiplied by 100. For each respondent, a score of 50% and above was regarded as good mammography related knowledge, while a score of less than 50% was regarded as poor mammography related knowledge.

Data was subsequently entered into IBM statistical software package version 20. Data editing and cleaning were performed, and data was only analysed after it was confirmed to be clean. Descriptive analysis was performed using frequency and percentages for categorical data and means and standard deviation for quantitative data. Chi-square analysis was performed to determine factors associated with mammography related knowledge of respondents. All statistical tests were carried out using 2 tailed test with alpha set at 0.05.

RESULTS

The study participants comprise of Hausas (29.7%), Ibo (25.8%), Yoruba (22%), Fulani (15.8%). Majority (77.5%) of the study participants were less than 40 years old and Islam was the predominant religion (60.3%). Majority of the respondents had ever married (85.5%). Nurses were the predominant profession (83.2%), followed by doctors (11.5%), laboratory scientist (3.4%) and pharmacists (1.9%). Few (21.2%) of the respondents had been practicing for more than 10 years (Table 1).

Only 2 (1%) of the respondents reported having been diagnosed with breast cancer, 22 (10.6%) of the respondents reported having a family member with breast cancer, 13 (6.3%) had a friend with breast cancer (Table 2).

Majority of the respondents (83.4%) knew that a woman who is forty years or more should go for a mammography, 86.2% knew that a woman less than forty years who has a family history of breast cancer should go for a mammography, majority also knew that mammography can be used to diagnose breast cancer (95.6%). Less than a fifth of the respondents knew the age screening mammography end if no breast problem is detected, less than half (44.4%) of the respondents knew how frequent a screening mammography be obtained after the age of 40 years (Table 3).

More than half (55.2%) of the respondents would undergo a mammography if the need arises, majority (70%) do not think that going for a screening mammography is inconvenient, more than half (53.7%) of the respondents think that the possibility of physical discomfort during mammography will not discourage them from accessing the procedure, majority of the respondents (76.3%) feel that possibility of pain during the procedure would not discourage them from assessing mammography, while lack of time to go to the hospital would not discourage 83.7% of the respondents (Table 4).

Less than a tenth (7.9%) of the respondents had ever had mammography done (Figure 1).

Reasons respondents gave for not going for a mammography include but not limited to; nothing is wrong with me (30.1%), I feel healthy (27.8%), my doctor did not refer me for one (10.2%) among other reasons (Table 5).

Respondents with in-adequate knowledge were more likely to be less than 40 years (OR=1.5), this was not statistically significant (p=0.276). Most of the respondents who had adequate knowledge were nurses (81%), there was no statistically significant relationship between cadre and mammography related knowledge. Respondents with in-adequate knowledge of mammography were more likely to have had only basic education (OR=1.63), this was not statistically significant. Respondents that had in-adequate knowledge of mammography were more likely to have less than 10 years’ duration of practice (OR= 1.24). Respondents with negative mammography related attitude were 6.7 times more likely to have in-adequate mammography knowledge. Respondents with in-adequate mammography related knowledge were less likely to have ever performed a mammography (OR=0.26), this was not statistically significant (p=1.00) (Table 6).

DISCUSSION

Female health workers having good mammography related knowledge is encouraged as it impacts the quality of information given to woman who assess health care services since health care facilities is an important source of health related information. Most of our study participants knew that a woman who is forty years or more should go for a mammography, majority knew that a woman less than forty years who has a family history of breast cancer should go for a mammography. Most of them also knew that mammography can be used to diagnose breast cancer (95.6%). This is similar to findings from a previous study which reported that 80.7% of respondents knew that mammography can be used to diagnose breast cancer.³ However, less than a fifth of the respondents knew the age screening mammography should end if no breast problem is detected, less than half (44.4%) of the respondents knew how frequent a screening mammography be obtained after the age of 40 years. Low level of knowledge of mammography among female health care workers (who are in the best position to provide health education) may lead to provision of wrong mammography information to women who may require mammography and this in turn may lead to low or non-utilization of mammography.

Most of our study participants demonstrated positive attitude towards mammography as more than half reported willingness to undergo a mammography, majority do not think that going for a screening mammography is inconvenient, more than half of the respondents think that the possibility of physical discomfort and or pain during mammography will not discourage them from accessing the procedure. This is in consonance with a study conducted in Malaysia which also reported positive attitude among respondents to mammography.¹¹

Less than a tenth (7.9%) of the respondents had previously had mammography done. This is comparable to previous studies which noted that few study respondents reported having undergone a mammography and low level of mammography uptake among female health care workers.^3,8,12-16 However, a previous study conducted among health personnel in Malaysia reported a much higher rate of 80.3%.¹⁷ The high rate of mammography screening in the study was ascribed to the wellness program domiciled in the study site.

My doctor did not refer me for one was also found to be an important reason for not performing a mammography, some studies suggest that a major reason for the underutilization of mammography is the failure of physicians to recommend that it be done, as studies have revealed that physician recommendation was significantly associated with having mammogram.^13,18-20 Another study however reported that a clear recommendation to undergo a mammography is helpful but 48% of women given this recommendation did not follow through to obtain the mammogram.²¹ The test is expensive is another reason giving for not utilizing mammography services, some studies have reported cost as a barrier to the uptake of mammography.^1,11 The issue of cost can be reduced if mammography is incorporated into social health insurance schemes. Other studies found that cost was not a barrier to uptake of mammography as breast cancer screening was free or covered by health insurance.^22,23

Other reasons respondents gave for not going for a mammographic examination include but not limited to; nothing is wrong with me, I feel healthy. There is need to do more to encourage women to undergo mammography. Perhaps, influencing women's values and beliefs regarding mammography could be part of the solution. Health education and mammography campaigns may be an important way of improving response to mammography. According to health belief model, a woman must believe that she is personally susceptible to the disease; that the disease itself would substantially affect her life and that taking action now would be beneficial without excessive cost, inconvenience and pain.²⁴ Perceived susceptibility to breast cancer was significant with mammography uptake among hospital workers in Turkey.^25,26

Respondents less than 40 years were 1.5 times more likely to have in-adequate mammography knowledge compared with those that were 40 or above. It is possible that as women become older, they may gain more information about health challenges that occur in that age group, this may be the reason why the older study participants had more knowledge about mammography compared with the younger ones. A previous study reported lower level of knowledge among older women, although this study was not carried out among health care workers.¹⁵

Respondents with in-adequate knowledge of mammography were 1.63 times more likely to have had only basic education, however, this was not statistically significant. This finding is in consonant with previous studies that also reported strong association between education and mammography knowledge.^27,28

This study was conducted in 2 tertiary hospitals, thus the findings of this study may not be generalizable to female health workers in Sokoto state.

CONCLUSION

Majority of our study participants had good overall mammography related knowledge, although most of them did not know the frequency a screening mammography should be obtained after the age of 40 and the age screening mammography end if no breast problem is detected. Most of them demonstrated positive attitude towards mammography, the uptake of mammography in our study population was very low. Incorporating mammography into Continuous professional development programs of health workers (with emphasis on the important role of early detection of breast tumours) may go a long way in increasing uptake of mammography among female health workers. Further research such as a qualitative study on the barriers towards obtaining mammography may provide more in-depth understanding of these barriers.

ACKNOWLEDGEMENTS

We wish to appreciate the management of Usmanu Danfodiyo University Teaching hospital and Specialist hospital Sokoto for allowing us use their facilities for data collection.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of Sokoto State Ministry of Health

REFERENCES

1. 1. Choridah L, Icanervilia AV, de Wit MJM, van Asselt ADI, Kurniawan WT, Fahmi YI, et al. Knowledge and acceptance towards mammography as breast cancer screening tool among Yogyakarta women and health care providers (mammography screening in Indonesia). J Cancer Educ. 2019;3(1):1-6.
2. 2. Nazzal Z, Sholi H, Sholi S, Sholi M, Lahaseh R. Mammography screening uptake among female health care workers in primary health care centers in Palestine- motivators and barriers. Asian Pac J Cancer Prev. 2016;17(5):2549-54.
3. 3. Akhigbe A, Omuemu V. Knowledge, attitudes and practice of breast cancer screening among female health workers in a Nigerian urban city. BMC Cancer. 2009;9(203):1-9.
4. 4. Amin S, Ewunonu H, Oguntebi E, Liman I. Breast cancer mortality in a resource‐poor country: A 10‐year experience in a tertiary institution. Sahel Med J. 2017;20:93-7.
5. 5. Loberg M, Lousdal M, Bretthauer M, Kalager M. Benefits and harms of mammography screening. Breast Cancer Research. 2015;17(63):1-12.
6. 6. Pace L, Keating N. A systematic assessment of bene ts and risks to guide breast cancer screening decisions. JAMA. 2014;311:1327-35.
7. 7. Marinho LAB, Cecatti JG, OsisII MJD, Gurgel MSC. Knowledge, attitude and practice of mammography among women users of public health services. Rev Saúde Pública. 2008;42(2).
8. 8. Odusanya OO. Breast cancer knowledge, attitude and practice of female schoolteachers in Lagos, Nigeria. Breast J. 2001;7(3):171-5.
9. 9. Seah M, Tan SM. Am I breast cancer smart? Assessing breast cancer knowledge among healthcare professionals. Singapore Med J. 2007;48(2):158-62.
10. 10. Chong PN, Krishnan M, Hong CY, Swah TS. Knowledge and practice of breast cancer screening amongst public health nurses in Singapore. Singapore Med J. 2002;43(10).
11. 11. Al-Naggar RA, Bobryshev YV. Practice and barriers of mammography among Malaysian women in the general population. Asian Pacific J Cancer Prev. 2012;13:3595-600.
12. 12. Schwartz K, Fakhouri M, Bartoces M, Monsur J, Younis A. Mammography screening among Arab American women in metropolitan Detroit. J Immigr Minor Health. 2008;10(6):541-9.
13. 13. Rosmawati N. The usage and knowledge of Mammogram among women in suburban area in Terengganu, Malaysia. Asian Pac J Cancer Prev. 2010;11:767-71.
14. 14. Dündar P, Özmen D, Öztürk B. The knowledge and attitudes of breast self-examination and mammography in a group of women in a rural area in western Turkey. BMC Cancer. 2006;6:43-9.
15. 15. Ibrahim NA, Odusanya OO. Knowledge of risk factors, beliefs and practices of female healthcare professionals towards breast cancer in a tertiary institution in Lagos, Nigeria. BMC Cancer. 2009;9(76).
16. 16. Obajimi MO, Ajayi IO, Oluwasola AO, Adedokun BO, Adeniji-Sofoluwe AT, Mosuro OA. Level of awareness of mammography among women attending outpatient clinics in a teaching hospital in Ibadan, South-West Nigeria. BMC Public Health. 2013;13(40).
17. 17. Abdullah N, Abd Aziz N, Rampal S, Al-Sadat N. Mammography screening uptake among hospital personnel in Kuala Lumpur tertiary hospital. Asian Pac J Cancer Prev. 2011;12:2643-7.
18. 18. Rimer BK, Keintz MK, Kessler HB, Engstrom PF, Rosan JR. Why women resist screening mammography: Patient-related behaviours. Radiology. 1999;172:243-6.
19. 19. Zapka JG, Stoddard AM, Costanza ME, HL G. Breast cancer screening by mammography, utilization and associated factors. Am J Public Health. 1999;79:1499-502.
20. 20. Silva IT, Griep RH, Rotenberg L. Social support and cervical and breast cancer screening practices among nurses. Rev Latino-am Emfermagem Julho-agosto. 2009;17:514-21.
21. 21. Taplin SH, Montano DE. Attitudes, age, and participation in Mammographic screening: a prospective analysis. J Am Board Fam Pract. 1993;6:13-23.
22. 22. Amin T, Al Mulhim A. Breast cancer knowledge, risk factors and screening among adult Saudi women in a primary health care setting. Asian Pac J Cancer Prev. 2009;10:133-8.
23. 23. Bener A, El Ayoubi H, Moore M. Bener A, El Ayoubi H, Moore M, et al. Do we need to maximize the breast cancer screening awareness? Experience with an endogamous society with high fertility. Asian Pac J Cancer Prev. 2009;10:1-6.
24. 24. Hammond JMS, Stewart M. Female patient's attitudes to mammogrpahy screening. Canadian Fam Phys. 1994;40:451-5.
25. 25. Canbulat N, Uzun O. Health beliefs and breast cancer screening behaviours among female health workers in Turkey. Eur J Oncol Nurs. 2009;12:148-56.
26. 26. Parsa P, Kandiah M. Predictors of adherence to clinical breast examination and mammography screening among Malaysian women. Asian Pac J Cancer Prev. 2010;11:681-8.
27. 27. Akinola R, Wright K, Osunfidiya O, Orogbemi O, Akinola O. Mammography and mammography screening: are female patients at a teaching hospital in Lagos, Nigeria, aware of these procedures? Diagn Interv Radiol. 2011;17(2):125-9.
28. 28. Lee K, Lim HT, Park SM. Factors associated with use of breast cancer screening services by women aged >40 years in Korea: The Third Korea National Health and Nutrition Examination Survey 2005 (KNHANES III). BMC Cancer. 2010;10(144).