Abstract
In this study authors aimed to investigate the barriers to participation of a sample of Jamaican women in mammography screening. The data were obtained from a previous survey that was conducted in Jamaica from June to August 2013 in the four parishes (Hanover, St. James, Trelawny, and Westmoreland) served by the Western Regional Health Authority (WRHA). WRHA served four hospitals, five non-randomized health centers, and five sites of community events. The sample consisted of women ranging in age between 35 and 83 years, with the mean age of 50.2 (SD = 10.6). The authors used a logistic regression to determine the extent to which variables were associated with breast cancer screening. The level of significace was 0.1 for the bivariate and multivariable analysis. The main factors associated with the lack of breast cancer screening among the women were: being less than 50 years old, single, never thought about breast cancer screening, in need of childcare, and having more than three children. We identified significant barriers to participation in mammography screening experienced by a sample of Jamaican women. Our results suggest that it is necessary to increase the awareness of the importance of breast screening importance among the women who may never have thought about mammography.
Keywords: Barriers, breast cancer, Jamaican women, mammography
Breast cancer mortality incidence ratio for less developed regions is 0.37, compared with 0.20 for more developed regions(Ferlay et al. 2014). In 2012 1.67 million new cancer cases and 0.52 million cancer-related deaths were reported worldwide. Of these, 43.4% was the global incidence rate of breast cancer, 31.3% of breast cancer cases occurred in less developed countries (LDCs), and 46.1% of breast cancer occurred in the Caribbean. Breast cancer incidence rates in the Caribbean are considered intermediate between those of North America and Europe and those of the Far East. Within the Caribbean, Jamaica has been shown to have one of the highest rates of breast cancer (Lerner-Ellis et al. 2017).
The burden and mortality rates from breast cancer remain high in Jamaica as a result of low screening level and lack of early detection (C. P. Anakwenze, Coronado-Interis, Aung, & Jolly, 2015; Chin et al. 2014). Authors reported that less than five percent of Jamaican women eligible for mammography screening have mammograms (Soares et al. 2007). To reduce the mortality rate from breast cancer we need successful interventions aimed at early dedection, but the adoption of breast cancer screening among Jamaican women has been slow. Researchers reveal that a study which was conducted in poor and rural province in Eastern Canada found that the important breast screening prompt was social support (Miedema and Tatemichi 2003).
Many factors can affect participation in mammography. Health belief, socio-economic status, educational level, and knowledge about breast cancer screening have been associated with breast cancer screening usage (Cruz-Castillo et al. 2015). Researchers reveal different factors that could be barriers to participation in mammography screening. The most consistent barriers were cost of the procedure, lack of knowledge, lack of healthcare provider recommendation, fear of the results, and belief that mammography is recommended when the women have breast cancer symptoms only. Women from less educated and low-income groups were less likely to be screened (Berry et al. 2015). Fear, pain during mammography, subjective indifference, inertia and reliance on physician referrals were identified as barriers to complying with mammographic screening among Jamaican women (Soares et al. 2009).
The Jamaica Association of Radiologists (JAR) raised an alarm over what it says is the absence of any functioning mammography machines in the entire public health system in Jamaica. The President of the Jamaica Association of Radiologists, Dr. Derrin Cornwall, drew attention to the lack of a working mammography machine in the public health system in Jamaica (Cornwall 2015).
Mammography screening is currently the most effective method to detect early breast cancer and reduce breast cancer mortality with current estimates of the magnitude of mortality reduction ranging from 10% to 25% (Kalager et al. 2010). The U.S. Preventive Services Task Force (USPSTF) guidelines for breast cancer screening recommend that women should start mammography screening at age 50.
In Jamaica, according to the Jamaica Cancer Society recommendation women should have one mammogram between age 35 and 39 and one every year from age 40 and older (Chidinma P. Anakwenze et al. 2014). Several risk factors associated with breast cancer, include nulliparity, early menarche, late menopause, and late age at first childbirth, along with genetic background. Because of high mortality rate from breast cancer and the absence of the national screening program for breast cancer in Jamaica, it is important to create educational interventions to increase public awareness (Ragin et al. 2018).
Methods
Study design and variables definition
We performed a retrospective analysis of collected data from a survey that was conducted in Jamaica from June to August 2013 in the four parishes served by the Western Regional Health Authority (WRHA). The WRHA provides free healthcare through a network of four hospitals and 84 health centers. The inclusion criteria were women who resided in the areas served by the WRHA, had no breast complaints, had or never had a mammogram in the past 5 years, aged 35 years and older. These women were eligible to participate in this study if they gave written informed consent and they were 35 years old or more. Women who expressed willingness to participate in the study were asked to read the informed consent form and to ask any questions they had. They were asked to sign the consent form after their questions were answered and they were satisfied that they wanted to participate. The participants gave the research team permission to involve them in the research and they acknowledged that their data would be fully anonymized. The minimum age required to participate was set according to the Jamaica Cancer Society recommendation.
The total sample size was 255 women who resided in the areas served by the WRHA. Three women were excluded because they did not meet the age inclusion criteria. Two hundred and forty-seven women met the inclusion criteria and were enrolled in the study, with the aim of obtaining a sample of participants that reflected the proportion of the overall population of each parish served by WRHA. The study protocol was approved by the Institutional Review Board of the University of Alabama at Birmingham, the Advisory Panel of Ethics and Medico-Legal Affairs in the Jamaican Ministry of Health, and the Western Regional Health Authority of Jamaica (Chidinma P. Anakwenze et al. 2014).
The sample consisted of 247 women ranging in age between 35 to 83 years, with a mean age of 50.2 (SD = 10.6). Authors state that 88.63% of the women reported never having a breast cancer screening, 40.82% reported that they have never thought of getting a mammography screening for breast cancer.
The survey included questions on socio-demographic characteristic (age, employment status, marital status, number of children, need for a childcare during breast exam, time available to screen, time to the nearest clinic or hospital, and educational status).
The survey also included questions on participants’ possible perceptions (mammography is painful, mammography is embarrassing, heard about breast cancer screening from healthcare provider, media, or others, such as friends, partner, or family), participants’ awareness of screening location, and knowledge about breast cancer screening. A total of 21 questions about breast cancer screening knowledge where used to calculate a knowledge score (Table 1). Participants who answered less than or equal to 10 correct questions, were classified in the poor knowledge group, those who answered more than or equal to 11 correct questions, were classified in the good knowledge group.
Table 1.
Knowledge score questions.
| Choose YES or NO for each question: |
|---|
| DO you believe the following may increase a woman’s chances of getting breast cancer Being older in age Being obese after menopause Using deodorants and roll-on Smoking Not exercising regularly Having family members with breast cancer Breastfeeding Others, specify |
| Do you believe the following signs would make you suspect you may have breast cancer Lump in breast or underarm area Breast pain Change in breast texture Discharge from nipple Nipple turned inward into the breast Others, specify |
| Do you believe the following may lower your risk of getting breast cancer? Get a mammogram screening Avoid smoking and limit the alcohol you drink Control your weight Breastfeed Limit amount of hormone therapy Exercise Others, specify |
The exposure variables are the associated factors that could prevent the women from having breast cancer screening based on mammography screening history. The outcome variable is whether the women had a breast cancer screening in the past 5 years or not. All the continuous exposure variables were recoded into categorical variables.
Statistical analysis
Authors categorized the participants into two groups. Group 1 for women who never had breast cancer screening. Group 2 for women who had breast cancer screening. Bivariate analysis were performed using the chi-square test for categorical variables. P-values were reported from Fisher’s Exact Test for categorical variables. In the description of subjects, categorical data were expressed as percentages.
A logistic regression was used to determine the extent to which variables predicted breast cancer screening. Results are presented based on univariable and multivariable adjusted models. Investigators reviewed a list of potential confounding variables and identified which variables were associated with breast cancer screening (p < 0.1). Variables associated with breast cancer screening were included in multivariable models: age, marital status, self-reported embarrassment of breast cancer screening, self-reported pain during breast cancer screening, preexisting knowledge of breast cancer screening, awareness of a screening location, whether awareness was driven by media or healthcare provider, self-reported need for a childcare, and number of children. Multivariable models were assessed in terms of concordance (C)-statistics. A C-statistic measures the probability that a model will assign higher likelihood of breast cancer screening to a participant who did undergo breast cancer screening versus a participant who did not undergo breast cancer screening. The level of significance was 0.1 for all analyses.
Results
Descriptive characteristic
The sample consisted of 247 women ranging in age between 35 and 83 years, with the mean age of 50.2 (SD = 10.6). Majority of the participants did not get a mammography in the past 5 years (88.26%). Half the participants were aged less than 51 years old. Most of the participants were single (46.31%), 43.03% were married or living with male partner, and 10.66% were divorced, separated, or widower. Almost half of the women reported secondary school as their highest educational level, 33.88% had none or a primary education, and 17.14% had a vocational, college, or higher education. Majority of the women were employed (53.97%) and the majority had more than three children (65.59%). Ninety-eight percent of the women reported that they had time for screening. Ninety-five percent of the women reported that they needed a childcare for their children if they decided to go for breast cancer screening. Seventy-one percent of the women needed less than 30 minutes to get the screening location. In addition, 40.82% of the women reported they never thought about breast cancer screening.
Among the women who never had a mammography screening the majority were less than 51 years old (p 0.05); 93.81% were single (p 0.03), and 83.53% had more than three children (pvalue 0.09). The majority stated that they needed childcare to be able to go for screening (pvalue 0.01) (Table 2). Eighty-one percent of the women stated that they had not thought of having a breast cancer screening (p <0.001). Eighty-four percent of the participants never heard about breast cancer screening from health care providers (p 0.01), and 70% of the women never heard about it from the media (p 0.01) (Table 3).
Table 2.
Percent and frequency of reported breast cancer screening behaviors, n = 247a (%).
| Had a mammography | |||
|---|---|---|---|
| Characteristic | Yes 29 (11.74) | No 218 (88.26) | p-valueb |
| Parish | .28 | ||
| St James | 13 (11.02) | 105 (88.98) | |
| Hanover | 4 (8.33) | 44 (91.67) | |
| Westmoreland | 7 (22.58) | 24 (77.42) | |
| Trelawny | 5 (10.00) | 45 (90.00) | |
| Age (years) | .05 | ||
| 10 (7.81) | 118 (92.19) | ||
| 19 (15.87) | 100 (84.03) | ||
| Highest Education Level | .42 | ||
| Primary or less | 12 (14.46) | 71 (85.54) | |
| Secondary | 11 (9.17) | 109 (90.83) | |
| Vocational/College/Higher | 6 (14.29) | 36 (85.71) | |
| Employment status | .2 | ||
| Unemployed | 16 (14.55) | 94 (85.45) | |
| Employed | 11 (8.53) | 118 (91.47) | |
| Marital status | .03 | ||
| Single | 7 (6.19) | 106 (93.81) | |
| Married/Living together | 16 (15.24) | 89 (84.76) | |
| Separated/Divorced/widower | 5 (19.23) | 21 (80.77) | |
| Number of children | .09 | ||
| ≤ 3 | 14 (16.47) | 71 (83.53) | |
| > 3 | 15 (9.26) | 147 (90.74) | |
| Have time to screen | .60 | ||
| Yes | 28 (11.67) | 212 (88.33) | |
| No | 1 (20.00) | 4 (80.00) | |
| Travel distance | .21 | ||
| ≤ 30 minutes | 17 (9.83) | 156 (90.17) | |
| >30 minutes | 11(15.49) | 60 (84.52) | |
| Childcare needed | .01 | ||
| Yes | 24 (10.30) | 209 (89.70) | |
| No | 5 (38.46) | 8 (61.54) | |
Numbers may not always sum to total due to missing observations
P-value estimated from Fisher exact test, threshold of .1
Table 3.
Participants’ perceptions and knowledge about breast screening, n = 247 (%)a.
| Had a mammography | |||
|---|---|---|---|
| Variables | Yes 29 (11.37) | No 226 (88.63) | p-valueb |
| Mammography is embarrassing | .37 | ||
| Yes | 0 (0.00) | 13 (100.00) | |
| No/Not sure | 29 (12.39) | 205 (87.61) | |
| Mammography is painful | .42 | ||
| Yes | 15 (13.76) | 94 (86.24) | |
| No/Not sure | 14 (10.14) | 124 (89.86) | |
| Ever thought about screening | <.001 | ||
| Yes | 27 (18.62) | 118 (81.38) | |
| No | 1 (1.00) | 99 (99.00) | |
| Heard about breast screening from friends/family/partner | .83 | ||
| Yes | 22 (12.57) | 153 (87.43) | |
| No | 7 (10.61) | 59 (89.39) | |
| Heard about screening from media | 0.1 | ||
| Yes | 3 (30.00) | 7 (70.00) | |
| No | 26 (11.21) | 206 (88.79) | |
| Heard about screening from a healthcare provider | .01 | ||
| Yes | 24 (16.11) | 125 (83.89) | |
| No | 5 (5.38) | 88 (94.62) | |
| Aware of a screening location | .07 | ||
| Yes | 20 (51.15) | 112 (84.85) | |
| No | 8 (7.27) | 102 (92.73) | |
| Knowledge score | .52 | ||
| Poor | 19 (10.86) | 156 (89.14) | |
| Good | 10 (13.89) | 62 (86.11) | |
Numbers may not always sum to total due to missing observations
P-value estimated from Fisher exact test, threshold of .1
Factors associated with breast cancer screening
Our possible confounders based on p threshold of 0.1 were: age, marital status, having more than three children, in need for a childcare while screening, never thought about breast cancer screening, never heard about screening from health care providers or media, and not aware of a screening location. The multivariable logistic regression model had a C-statistic of 0.885. After adjusting the regression analysis for possible confounders, we found that women who were less or equal 50 years old were almost 4 times more likely not to have a mammogram compared to women who were older than 50 years old (adjusted OR 3.77, CI: 1.31–10.67). Participants who had more than three children were 3 times more likely not to have a mammography compared to women who had less or equal to three children (adjusted OR 3.02, CI: 1.07–8.54). Women who were in need of childcare were 18 times more likely not to have a mammogram compared to women who did not need childcare or who had someone to take care of their children (adjusted OR 17.79, CI: 2.93–108.04). Women who never thought about breast cancer screening were 24 times more likely not to have a mammogram compared to women who thought about breast cancer screening (adjusted OR 23.58, CI: 2.82–197.01). Single women were 4 times more likely not to have a mammogram compared to married women (adjusted OR 4.00, CI: 1.25–−12.83). (Table 4).
Table 4.
Crude and adjusted odds ratios (ORs)a and associated 95% confidence interval (CIs) for the association between women who never had a mammography and odds factors of interest.
| Crude odds ratio (95% CI) | Adjusted odds ratiob (95% CI) | |
|---|---|---|
| Age of ≤ 50 | 2.24 (0.99–5.04) | 3.73 (1.31–10.67) |
| Marital status | ||
| Married/Living together | Referent | Referent |
| Separated/Divorced/widower | 0.75 (0.25–2.29) | 0.67 (0.17–2.75) |
| fSingle | 2.72 (1.07–6.91) | 4.00 (1.25–12.83) |
| Number of children is 3 < | 1.93 (0.89 – 4.22) | 3.02 (1.07–8.54) |
| In need for Childcare | 5.45 (1.65 – 17.97) | 17.79 (2.93–108.04) |
| Never thought about mammography | 22.65 (3.02–169.64) | 23.58 (2.82 – 197.01) |
| Never heard about screening from a healthcare provider | 3.38 (1.24–9.19) | 2.45 (0.70–8.58) |
| Never heard about screening from media | 3.39 (0.82–13.95) | 2.37 (0.41–13.73) |
| Not aware of a screening location | 2.28 (0.96–5.39) | 2.53 (0.83–7.72) |
Estimated using logistic regression
Adjusted for age, marital status, breast cancer screening is embarrassing, breast cancer screening is painful, thought about breast cancer screening, aware of a screening location, heard about screening from media, heard about breast cancer screening from healthcare provider, in need for a childcare, and number of children.
The main associated factors with breast cancer screening barriers by mammography history in this sample of Jamaican women were: being less than 50 years old, single, never thought about breast cancer screening, in need of childcare, and having more than three children.
Discussion
Authors stated that 88.63% of the women had never gotten a mammogram. The percent is very high compared to other studies. For example, Soares et, al. reported that of 147 women attending the breast imaging units at the University Hospital of the West Indies and 127 attending Radiology West in Kingston, 32% were having a mammogram for the first time (Soares et al. 2009). The lower rate of prior mammography reported in our study may be attributed to the lack screening site for the detection and prevention of breast cancer that included mammography. The Jamaica Association of Radiologists reported on the absence of any functioning mammography machines in the entire public health system. No public facilities offer screening and the screening cost is very high. Only two private facilities offered screening in western Jamaica (Williams 2015).
Authors stated that women who were less than or equal to 50 years old were less likely to have a mammogram. Medical Oncologist at the University Hospital of the West Indies (UHWI), Dr. Sheray Chin, told JIS News that “About 60% of the breast cancer that we diagnose in Jamaica is among women between the ages of 25 and 59, while about 25% is over the age of 60”. Dr. Chin pointed out that the burden of breast cancer in Jamaica is high. It is the most common cancer diagnosed in Jamaican women, and we have quite a high mortality rate compared to other countries in the world, so not only are we diagnosing many women, unfortunately, we are diagnosing them at a late stage in which cure or long-term survival is not always possible, she explained (Hodges 2018). There should be an awareness programs to teach young Jamaican women that breast cancer can occur in young women. Educational campaigns are recommended to increase awareness among young Jamaican women who are under age of 50.
A main barrier that women never thought about breast cancer screening (adjusted OR 23.58, CI: 2.82–197.01) suggest that simple intervention such as public education to increase awareness and providing reminders may enhance mammography screening among women in Jamaica. Physician recommendation is very important cue to cancer screening. Physicians play a key role in informing women of the benefits of Screening (DuBenske et al. 2017).
To our knowledge this is the first study to describe the need of childcare among Jamaican women as a barrier for breast cancer screening. Since 2013 to 2020 this is the first paper that focused on different barriers for mammography screening.Women who had more than three children and women who need childcare while screening may potentially be helped through more support from family, increasing the number and awareness of mobile mammography services, and providing childcare services while screening to increase convenience for women to undergo screening.
This sample of Jamaican women had good knowledge about mammography and breast cancer. Surprisingly, knowledge was not a significant factor in this study despite being so in other studies (Rosmawati 2010). The limited access to the mammography screening and a need of childcare could play a more important role in lack of screening than having good knowledge.
A limitation in this study is the small sample size. In addition, incomplete surveys and missing data further reduced our sample size. Self-reported data might have been biased due to social desirability. Missing important variables from the survey, such as family history of breast cancer, income, and insurance type would improve this study.
In conclusion, few researchers have investigated the associated factors that motivate women to have a breast cancer screening in Jamaica. The low number of Jamaican women who had a breast cancer screening in this study is a concern and suggest that there is a need to increase the awareness of breast cancer screening. Minimizing the barriers would increase the access to the breast cancer screening. This was a self-selected and small sample study so that the findings may not be generalizableed to all Jamaican women. Longitudinal studies are needed to investigate the associated factors that motivate women to have a breast cancer screening.
Footnotes
Disclosure statement
No potential conflict of interest was reported by the author(s).
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