Attitudes, beliefs and behaviours to breast cancer and mammography
Do high socio-economic status women really pseudo-screen?
Breast cancer is the most common cancer in NSW females. In 2007
there were 4,196 new cases of breast cancers in NSW, affecting one
in nine women.1 Women of high socio-economic status are
at significantly increased risk of developing and dying from breast
cancer.2,3
In 2005-06 high SES women aged 50-69 years were significantly
less likely than all women in this age group to participate in the
BreastScreen Australia program, 55 per cent compared to 57 per
cent.4 A
finding consistent with other Australian and international
research. 5,6,7,8
At the same time, high SES women were significantly more likely
than all women to have a Medicare Benefits Schedule (MBS) funded
mammogram, 7.7 per cent annually compared to 6.7 per cent.9
Average Annual Attendance through BreastScreen
Australia
and MBS Mammography by Socioeconomic Status
(Australian Women Aged 50-69 Years, 2001-2005)
 |
| Source: Department of Health and Ageing, Medicare Benefits
Schedule (MBS) Mammography Analysis Project, 2009. |
The evidence therefore suggests that women of high SES are more
likely to pseudo-screen either through MBS funded services or out
of pocket private screening.
Summary
The purpose of this paper is to explore factors that may be
impacting on participation in breast screening among women of high
SES. It also aims to determine the significance of the role of
pseudo-screening.
An analysis conducted by the Cancer Institute to identify high
priority local government areas (LGAs) for breast screening has
assisted in highlighting areas of higher risk. The analysis used
breast cancer risk factor data specific to LGAs in NSW, including
socio-demographics, mortality, incidence, distant metastases,
fertility and obesity, and participation in BreastScreen NSW. LGAs
were ranked highest to lowest priority according to these factors
and six of the top ten were areas of 'least disadvantage'.10 Attendance of
MBS-funded mammogram services however was not included in the
rankings. Despite this, the results suggest that even if
women in these LGAs were pseudo-screening via diagnostic services
or privately screening at their own expense, improved cancer
outcomes, such as decreased mortality and/or decreased distant
metastases, are not being realised.
To gain a better understanding of mammography screening
behaviours among women of high SES, the paper will draw on data and
information collected through population surveys, and a research
project undertaken by the BreastScreen NSW South Eastern Sydney
Illawarra Screening and Assessment Service in collaboration with
the Cancer Institute NSW.
Method
A survey undertaken to assess awareness, knowledge, attitudes
and behaviours in relation to breast cancer and screening
(conducted as part of the evaluation of the Breast Screening
Campaign) was used as the primary data source. Results from the
telephone survey of 1,000 NSW women aged 40-69 years in 2008 and
2009 were analysed to identify any differences by SES (using
individual and area based measures).
A face-to-face intercept survey was also conducted in two of the
high priority LGAs (Woollahra and Waverly) to assess why women in
these LGAs were not screening with BreastScreen NSW. The survey was
conducted with 100 women aged 45-69 years who had never had a
screening mammogram or had had a screening mammogram done
privately, whether exclusively private or in addition to using
BreastScreen NSW.
Results
Survey results reveal that women of high SES are more aware of
mammography as a method for early detection and have higher levels
of knowledge in relation to some screening particulars. Nearly nine
in ten women of 'least disadvantage' (86%) spontaneously mentioned
mammography as a method of early detection compared to 80 per cent
overall.
Unprompted Awareness of Mammography by Socioeconomic
Status
(NSW Women Aged 40-69 Years)
 |
| Source: Breast Cancer and Screening: Women's Awareness,
Knowledge, Attitudes and Behaviour in NSW Survey 2009. |
In relation to screening particulars, education and income are
related to women's likelihood to correctly identify 50 years as the
recommended age to commence screening. Women with a Bachelor's
degree or higher (51.1%) or with a household income greater than or
equal to $60,000 (52.9%) were significantly more likely to identify
50 years than women who did not complete secondary school (42.6%)
or with an income less than $60,000 (42.7%).
Interestingly, women with a lower household income (79.3% less
than $20,000 and 76.6% $20,000 to less than $40,000) were more
likely to correctly identify every two years as the recommended
frequency of screening mammograms compared to women with a higher
household income (65.8% $100,000 or greater). However, it is
unclear whether women with higher household incomes over or under
estimate the recommended frequency of screening mammograms, and
whether this is linked to screening behaviour.
Despite the higher levels of screening awareness and knowledge
among women of high SES, BreastScreen Australia participation data
shows women of high SES are significantly less likely to attend the
service, 55.0 per cent in the least disadvantaged group and 55.4
per cent in the second least disadvantaged group compared to 56.9
per cent of all women.11 This is the reverse of what is observed
in surveys based on self report. According to the 2008 NSW
Population Health Survey, women of least disadvantage (82.2%) are
significantly more likely to self-report having had a screening
mammogram within the last two years than the state average
(76.2%).12
Self-reported behaviour is known to be less accurate than observed
behaviour, particularly in regards to screening frequency.13
Survey results also reveal differences by SES in relation to
screening attitudes. Women with a household income of $100,000 or
greater were significantly less likely to agree with the statement
"It's better to have regular breast screen mammograms at
BreastScreen NSW rather than at a private radiology practice" than
women with a household income of less than $20,000, 32.1 per cent
compared to 45.6 per cent. This supports local evidence from the
intercept survey which found the majority (83%) of women in
Sydney's Eastern Suburbs had previously had a mammogram through
private services. Of these women, only just over a quarter (28%)
had also previously used BreastScreen NSW services in addition to
private services.
Agreement with "It is better to have regular breast screen
mammograms
at BreastScreen NSW rather than a private radiology
practice"
by Income (NSW Women Aged 40-69 Years)
 |
| Source: Breast Cancer and Screening: Women's Awareness,
Knowledge, Attitudes and Behaviour in NSW Survey 2009. |
Whilst it is difficult to determine the range of factors
influencing high SES women's attitudes and behaviours in regards to
their preference for private screening. Results indicate general
practitioners are a key influencer in women's screening behaviours,
particularly in initiating screening. Twenty-two per cent of survey
respondents identified encouragement by a doctor as a reason for
having their first mammogram, second only to finding a lump or
abnormality during self examination (28%). The intercept survey
also found that general practitioners were the primary influencing
factor in women's decision to have a mammogram at a private service
instead of/or in addition to BreastScreen NSW.
Conclusion
Findings from recent surveys indicate a number of factors may be
impacting on participation in breast screening among women of high
SES. Women of high SES tend to be more aware of mammography and
screening particulars; however this does not tend to translate into
behaviour. Perceptions regarding private screening, in addition to
prompting by a GP, seem to be influencing women to pseudo-screen.
However, while self-reported behaviour and higher usage of MBS
funded services suggest that high SES women have regular mammograms
at or above rates of other women, improved cancer outcomes haven't
been realised.
These results support the need for further exploration of
awareness, knowledge, attitudes and behaviours in relation to
screening behaviours of high SES women. And to identify a better
way of measuring and monitoring private or pseudo screening.
It is important to note that conclusions based on the survey
findings are limited by analysis of awareness, attitudes and
behaviours by SES. Attitudes and behaviours in relation to
screening mammography are complex and are strongly influenced by
other factors such as age and previous screening patterns. Further
analysis and additional research is required to better understand
the relationship between SES and screening mammography.
Note: Measures of socioeconomic status (SES) are a
combination of area based measures (SEIFA) and individual based
measures (annual household income and level of education). SEIFA is
the Socio-Economic Indexes for Areas based on the Index of Relative
Socioeconomic Disadvantage (IRSD). Women have been placed into
categories based on the socioeconomic index of their home postcode.
The first quintile corresponds to the highest level of
socioeconomic status and the fifth to the lowest. Reference to
"high SES women" or "women of least disadvantage" is based on the
first quintile using SEIFA unless specific individual based
measures are noted.
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