Do high socio-economic status (SES) women really pseudo-screen? High SES women’s attitudes, beliefs and behaviours to breast cancer and mammography
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 (SES) are at significantly increased risk of developing and dying from breast cancer.2,3
by Scott Walsberger, Val Tootell, Donna Perez, Margaret Hardy, Jill Sternfeld, Arthur Hung, Anita Dessaix
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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
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| 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.
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| 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.
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| 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.
References
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- NSW Central Cancer Registry. Breast Cancer – Age Standardised Incidence Rates, Females, 2003-2007 by Socio-economic Status www.statistics.cancerinstitute.org.au Accessed on 11 March 2010.
- NSW Central Cancer Registry. Breast Cancer – Age Standardised Mortality Rates, Females, 2003-2007 by Socio-economic Status www.statistics.cancerinstitute.org.au Accessed on 11 March 2010.
- Australian Institute of Health and Welfare & National Breast and Ovarian Cancer Centre 2009. Breast cancer in Australia: an overview, 2009. Cancer series no. 50. Cat. no. CAN 46. Canberra: AIHW.
- Taylor R, Ivanov O, Page A, Brotherton J, Achat H and Close G. Predictors of non-attendance from BreastScreen NSW in women who report current mammography screening. Australian and New Zealand Journal of Public Health 2003, 27, 6: 581-587.
- Esteva M, Ripoll J, Leiva A, Sanchez-Contador C and Collado F. Determinants of non attendance to mammography program in a region with high voluntary health insurance coverage. BMC Public Health 2008, 8:387.
- Donato F, Bollani A, Spiazzi R, Soldo M, Pasquale L, Manarca S, Lucini L and Nardi G. Factors associated with non-participation of women in a breast cancer screening programme in a town in northern Italy. Journal of Epidemiology and Community Health 1991, 45:59-64.
- Aro A, de Koning H, Absetz P and Schreck M. Two distinct groups of non-attenders in an organized mammography screening program. Breast Cancer Research and Treatment 2001, 70:145-153.
- Department of Health and Ageing. Medicare Benefits Schedule (MBS) Mammography Analysis Project. Canberra: Commonwealth of Australia, May 2009.
- Tracey E, Culjak G, Caballes M, Chen Y, Godding R. Determining priority LGAs to prevent breast cancer in NSW. Unpublished, 2009.
- Australian Institute of Health and Welfare 2009. BreastScreen Australia monitoring report 2005–2006. Cancer series no. 48. Cat. no. CAN 44. Canberra: AIHW.
- Centre for Epidemiology and Research. 2008 Report on Adult Health from the New South Wales Population Health Survey. Sydney: NSW Department of Health, 2009.
- Howard M, Agarwal G, Lytwyn A. Accuracy of self-reports of Pap and mammography screeningcompared to medical record: a meta-analysis. Cancer Causes Control 2009, 20:1–13.