Risk perception and barriers to utilization of mammogram for breast cancer screening among female healthcare professionals in a tertiary health institution, Benin City, Nigeria

Background: For the effective functioning of health workers as promoters of breast cancer prevention through early detection, the need for relevant knowledge about the disease and its early detection is crucial. Objective: This study assessed the risk perceptions and barriers to use mammograms for breast cancer screening among female healthcare professionals in a tertiary health institution in Benin City, Nigeria. Materials and Methods: The quantitative approach was utilized in this study as it is a systematic process that helps to describe and test relationships among variables without bias. In line with this, a descriptive cross-sectional study was conducted with a sample of 255 female healthcare professionals from April 2023 to July 2023, using the multistage and convenience sampling method. A structured questionnaire was used to collect data with a reliability of 0.781. Data were analyzed using Statistical Package for Social Science (SPSS) version 22.0 and presented in words and frequency distribution tables. Hypotheses were tested with chi-square at a 5% level of significance. Results: A total of 225 nurses (88.2%) and 30 doctors (11.8%) participated in the study. The mean age was 45.69 ± 5.814 years (nurses = 45.55 ± 5.679 years; doctors 46.73 ± 6.757 years). Overall, 223 (87.5%) showed a positive risk perception of breast cancer with a mean of 2.74 ± 0.966. Only 35 (13.7%) respondents had a mammogram in the last 24 months before the study. Mean ± SD = 1.15 ±.376. Utilization was not associated with risk perception (P = 0.409), but there was a significant difference (P = 0.001) in the utilization of mammograms between nurses (10.7%) and doctors (36.7%). Perceived barriers to utilization of mammogram include cost 190 (86.4%), preference for other screening methods 210 (95.5%), fear of abnormal findings 189 (85.9%), and busy work schedule 200 (90.9%). Conclusion: There is a high positive risk perception of breast cancer but poor utilization of mammography. Therefore, it is recommended to sensitize female healthcare professionals on the need for mammography breast screening through training and re-training.

Keywords: Barriers to utilization of mammograms; breast cancer; healthcare professionals; risk perception

INTRODUCTION

Breast cancer continues to be a threat to women's lives, with a damaging impact on society's health, commonly linked to a lack of awareness and inadequate screening practices,[[1]] and this knowledge gap affects both developed and developing nations.[[2]] The precise etiology of the disorder has remained uncertain,[[3]] but studies have shown that cancer-related morbidity and mortality in women can be reduced through screening.[[4]] The report has shown that breast cancer is responsible for 30.2% with two-third of all cancer deaths seen among women[[5]]

According to the International Agency for Research on Cancer (GLOBOCAN) (2018), more than 1.2 million women worldwide are diagnosed with breast cancer every year, and 460,000 of them will die from it.[[6]] Recent statistics from the World Health Organization (WHO) in Nigeria show that the incidence of breast cancer has surpassed that of cervical cancer and currently accounts for 27% of cancer-related deaths in Nigerian women.[[6]]Nigeria presently lacks thorough cancer prevention and control plans and strategies while having a few population-based cancer registries and a disorganized cancer feedback system.[[6]]

The most excellent way to reduce breast cancer is by early detection through screening, which is acknowledged as a critical strategy for attaining sustainability and global health.[[7]] Increased public knowledge of the condition, improvements in breast imaging, and other variables, which include self-inspection and clinical assessment of the breast, have led to positive results in the identification and screening of breast cancer and could lead to its detection in its advanced stages even though it is now a global problem.[[8]]

The increasing number of breast cancer cases, many of whom did not utilize the available screening process in the institution of study, necessitated the need to carry out this study.

The primary aim of this study was to assess risk perception and barriers to using mammograms for breast cancer screening among female healthcare professionals in a tertiary health institution in Benin City, Nigeria. The secondary objectives are to help build on the existing knowledge of breast cancer screening and establish the reason for noncompliance with screening.

Healthcare practitioners play an essential role in the promotion of health and prevention of diseases, as they are in a great position to inform the general public with particular reference to women of all ages; however, findings have indicated that they have a poor screening uptake as well as a low perception of the risk of breast cancer.[[9]],[[10]] Given the significance of breast screening as an essential tool for the prevention of breast cancer, this study assessed the risk perception and barriers to mammography usage among female healthcare professionals in a tertiary health institution in Benin City, Nigeria.

MATERIALS AND METHODS

The quantitative research utilizing the cross-sectional descriptive design was conducted from April 2023 to July 2023. the target population comprised 255 female health practitioners (nurses and doctors), and the setting was the University of Benin Teaching Hospital, a tertiary health institution in Nigeria.

Sample size determination

Multistage sampling techniques were used in the study since the population is heterogeneous. A stratified proportionate sampling method was used in the assortment for an appropriate sample size from each stratum (nurses and doctors). Then, participants were recruited using a convenience sampling approach, as this sampling method was preferred due to the nature of the professionals involved in the study. It would not have been easy to assemble them for a random selection. The studied sample was calculated from the study population using the Taro Yamane equation.[[11]] The Yamane formula is given by n = N/ (1 + Ne2), where N = population size and e = alpha level, that is, e = 0.05 at a confidence interval of 95% with a population of 589 and an addition of 10% for attrition or nonresponses rate with a sample size of 262 respondents.

Inclusion criteria included a female healthcare professional (nurse or doctor) practicing in the study hospital, aged ≥ 40 years, present during the data collection period, and willing to participate in the study. Those with breast disease and those diagnosed with breast cancer were excluded from the study.

The face and content validity of the research instrument (structured questionnaire), including participants' sociodemographic characteristics and questions on risk perception, utilization, and barriers to mammogram utilization, was validated by experts in the area. The questions were closed, open-ended, and a four-point Likert scale.

Method of data analysis

Data was collected with the assistance of two female nurses and a female doctor from Monday to Friday for 4 weeks until the desired sample size was obtained. The raw data retrieved was coded and imputed into a computer for easy analysis using Statistical Package for Social Science (SPSS) version 22.0. Descriptive data were expressed as percentages, frequency counts, and mean ± standard deviation and presented in words and frequency distribution tables. Hypotheses were tested using Pearson chi-square at a 5% level of significance. P < 0.05 was considered the level of significance for all measured variables.

Ethical consideration

A request for ethical clearance was submitted to the Ethics Committee of the University of Benin Teaching Hospital in Benin City, Nigeria, and received approval under protocol number ADM/E 70 22/A/VOL.VII1417351200. Throughout this research study, strict adherence was maintained to the ethical principles governing the involvement of human participants in research.

RESULTS

[Table 1] shows that 225 nurses (88.2%) of the respondents and 30 doctors (11.8%) of the respondents participated in the study. Respondents within the age of 40–44 years were 145 (56.9%) followed by the age of 55–59 years who were 47 (18.4%) and 45–49 years who were 43 (16.9%), while those within 50–54 years were 20 (7.8%). The mean age of the respondent was 45.69 ± 5.814 years. In terms of academic qualification, 50 (19.6%) had RN/RM, 141 (55.3%) had a first degree, 31 (12.2%) had a second degree, and 30 (11.8%) had MBBS. Seventeen (6.7%) had 6–10 years of work experience, 111 (43.5%) had 11–15 years, and 127 (49.8%) had above 15 years of work experience. The mean years of work experience was 16.75 ± 6.516 years. Only 6 (2.4%) were single, 240 (94.1%) were married, 7 (2.7%) were widowed, and 2 (.8%) were separated. About 237 (92.9%) had 1–3 children while 18 (7.1%) had more than three children.{Table 1}

Level of risk perception of breast cancer among female healthcare professionals

[Table 2] revealed that 223 (87.5%) demonstrated positive risk perception of breast cancer while 32 (12.5%) demonstrated negative risk perception with an overall mean risk perception of 2.74 ± 0.966.{Table 2}

Level of utilization of mammogram for breast cancer screening

[Table 3] shows that only 35 (13.7%) of the respondents have ever done mammography; 18 (51.4%) were based on medical recommendations, and 11 (31.4%) were based on a voluntary routine check. In comparison, 6 (17.2%) ruled out an observed breast changes. Thirty-three (94.3%) of the investigation revealed normal findings while 2 (5.7%) were abnormal findings. All the abnormal cases were followed up with appropriate actions. The mean mammography uptake among the respondents was 1.83 ± 1.248 while the mean age at first uptake was 43.57 ± 14.351 years. In the last 24 months preceding the study, 10 (28.6%) did the procedure once, while only 2 (5.7%) did it twice or more. Mean ± SD = 1.15 ±.376. Three (8.6%) have been medically advised to undergo regular mammography.{Table 3}

Perceived barriers to utilization of mammogram for breast cancer screening

[Table 4] showed that perceived barriers to utilization of mammograms for breast cancer screening among the respondents include the cost of the procedure 190 (86.4%), preference for other breast cancer screening methods 210 (95.5%), fear of abnormal findings 189 (85.9%) and busy work schedule 200 (90.9%). 78{Table 4}

Test of Hypotheses

H1: There is no significant relationship between the level of risk perception of breast cancer and mammogram utilization among female healthcare professionals in a tertiary health institution in Benin City, Nigeria.

Since the computed χ2 = 0.780 at the degree of freedom (df) = 1 is less than the critical value of 3.841 at a 0.05 significance level, there is statistically significant evidence not to reject the null hypothesis (H). This means there's no statistically meaningful relationship (P = 0.409) between the position of threat perception of breast cancer and the application of mammograms among female healthcare professionals at the University of Benin Teaching Hospital, Benin City, Nigeria [Table 5].{Table 5}

H2: There's no significant difference in the application of mammograms between female nurses and doctors in a tertiary health institution in Benin City, Nigeria.

Since the computed χ2 = 15.111 at the degree of freedom (df) = 1 is greater than the critical value of 3.841 at a 0.05 significance level, there is statistically significant evidence to reject the null hypothesis (H). This means there is a statistically significant difference (P = 0.001) in the utilization of mammograms between female nurses (10.7%) and doctors (36.7%) at the University of Benin Teaching Hospital, Edo State [Table 6].{Table 6}

DISCUSSION

Breast cancer is the highest-occurring malignancy among females in Nigeria[[12]] However, its impact can be significantly minimized by adopting well-organized screening programs such as mammography, Brest self-examination (BSE), and clinical breast examination (CBE), critical requirements for reducing disease mortality and morbidity.

The female healthcare professionals in this study were nurses and doctors, unlike the study conducted in Sokoto State, Nigeria.[[12]] which involved nurses, doctors, laboratory scientists, and pharmacists. However, both studies were similar in the predominance of nurses in that the present study recorded 88.2% nurses vs. 11.2% doctors, while the Sokoto study recorded 83.2% nurses vs. 11.5% doctors which is also similar to another report 45.2% nurses vs. 20.0% doctors.[[9]]

This is in keeping with the global trends on the numerical dominance of nurses as the largest population of healthcare professionals in institutional healthcare settings in almost all countries. In the present study, the mean age of 45.69 ± 5.814 years is at variance with the findings of 31.17 ± 7.77 years reported from North Africa.[[13]] Most of the respondents in the present study were within the age range of 40–44 years, which differs from another finding with a predominant age range of 33–42 years.[[2]] Again, the difference can be attributed to the fact that this study was done among women of ≥40 years, while the above studies were not.

Risk perception of breast cancer

Risk perception is recognized as a strong driving force for women to engage in preventive and screening behaviors. Yet, previous studies suggest that most women incorrectly perceive their breast cancer risk.[[14]],[[15]] Women who do not perceive themselves as being vulnerable to breast cancer may not care much about the use of early diagnostic methods such as mammography.[[15]],[[16]] The present study recorded over two-thirds (87.5%) positive breast cancer risk perception among the participants. This figure is unsurprising among nurses and doctors in a tertiary health center where undergraduate nursing and medical professional courses are undertaken. Their level of high perception might also be that the majority of the respondents were 40 years and above when the risk of breast cancer was high. However, this finding contrasts with previous Nigeria studies.[[14]],[[17]]

Despite the high level of personal risk perception, the study also revealed some (12.5%) negative risk perceptions. However, this level of negative risk perception is lower than 59.3%[[14]] It is, however, surprising that healthcare professionals, with their wealth of knowledge and experience, would express poor risk perception of breast cancer. These groups of women may be basing that judgment, in part, on their family history of the disease without considering other important risk factors that may influence the disease's development, which may negatively influence their screening behavior.

Utilization of mammogram for breast cancer screening

The American Cancer Society (2023)[[18]] recommends mammography in women aged 40. In the present study, only 13.7% of the respondents have ever done mammography, with a mean age at first uptake of 43.57 ± 14.351 years. Such similar poor uptake abounds in literature, even among healthcare professionals. 5.4% was reported among community pharmacists in Jordan,[[10]] 1.9% among health professionals in Nnewi, Nigeria,[[13]] and 18.7% among female healthcare workers of King Fahad Medical City (KFMC).[[19]] But a few studies reported an average number of respondent agreed to use mammogram for breast cancer screening, 51.7%[[20]] and 58.8 %[[2]] respectively. In a national survey of female health workers, a mammography screening utilization rate of 15.4% was reported,[[21]] whereas a mammogram utilization rate of 75% was reported in Australia and 83% in Scotland.[[22]] Although the level of utilization was poor, the analysis in the present study revealed a significant difference (P = 0.001) in the utilization of mammograms between the nurses (10.7%) and the doctors (36.7%). A similar finding was reported from Saudi Arabia[[9]] and Eastern India.[[17]] This may be because doctors better understand the benefit of early cancer detection partly because of specialization in oncology.

On the contrary, this study found a surprisingly inverse relationship between risk perception and mammography screening uptake (P = 0.409). A similar observation was reported concerning risk perception and screening uptake for cervical cancer among women in Northern Ghana and postulated that fear of the unknown could deter women who think they are likely to be positive from accessing screening services.[[23]] This finding implies that the high-level risk perception did not translate into proactive cancer screening health-seeking behavior, which was statistically confirmed in the hypothesis (P = 0.409). This is problematic for a group of healthcare professionals who, by their profession, are familiar with the benefit of cancer screening for early detection of cancer diseases. More worrisome is that 83 (51.4%) of those who had undergone the procedure were based on a medical recommendation, while only (31.4%) were based on a voluntary routine check. Such attitude toward voluntary cancer screening could be responsible for the increasing incidences of the advanced stage of cancer at presentations across healthcare facilities in Nigeria.[[24]] The disparity in the utilization of mammograms in Nigeria (Africa), Middle Eastern countries, and developed nations is attributable to a lack of knowledge, poor financing, and health preventive programs in these poor resource countries.[[14]]

In the present study, one perceived barrier to mammogram utilization for breast cancer screening is busy work schedule 20 (9.1%). In an earlier study among female healthcare workers in Primary Health Care Centers in Palestine, a busy schedule (46.7%) was reported to be a barrier to mammogram utilization.[[25]] This could be due to reduced healthcare professional populations in Nigeria and other developing countries. Other notable barriers reported in this study were the cost of the procedure 30 (13.6%) and preference for other breast cancer screening methods 10 (4.5%). Some studies have reported cost as a barrier to mammography uptake.[[12]],[[26]] The cost issue can be reduced if mammography is incorporated into social health insurance schemes with full coverage.

CONCLUSION

This research emphasizes the necessity of encouraging the use of mammograms for breast cancer screening among both female healthcare professionals and the general female population. Doing so can significantly lower the heightened risks and fatalities linked to breast cancer. The study uncovered that although participants perceived high risk, this perception didn't translate into proactive health-seeking behavior for cancer screening, confirming the hypothesis statistically. This poses a significant issue, especially among healthcare professionals who possess knowledge about the benefits of early cancer detection but don't regularly utilize available screening facilities at their workplaces. Addressing this requires comprehensive awareness campaigns, continuous training, and mandating routine checks among female healthcare professionals. This effort should also encompass promoting regular self-breast examinations.

Limitations of the study

The information provided by the respondents might be influenced by the already existing knowledge among them, which may lead to bias or prejudice in their response.

Delimitation of the study

The study was conducted among female nurses and doctors aged 40 years practicing at the University of Benin Teaching Hospital (UBTH), Benin City, Nigeria.

Significance of the study

·Early detection of any breast abnormality.

·Enhance preventive measures that will help reduce the mortality and morbidity associated with breast cancer.

·Makes treatment easy.

·Reduces costs associated with the treatment of breast cancer.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.