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Dr.
Layla A. Al-Alaboud, M.B.B.S., FFCM
(KFU)**
Dr. Nabil Y. Kurashi, M.B.B.S., FFCM
(KFU)**
**Department of Family
and Community Medicine
College of Medicine and Medical Sciences
KING FAISAL UNIVERSITY
Dammam, Saudi Arabia
Correspondence to:
Dr. Nabil Y. Kurashi
Associate Professor
Department of Family and Community
Medicine
College of Medicine and Medical Sciences
KING FAISAL UNIVERSITY
P.O . Box 2114 Dammam, Saudi Arabia
Email: dr_nabil_kurashi@yahoo.com
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ABSTRACT
Introduction:
While breast cancer is a serious health
problem to countries as well, breast
cancer screening remains underutilized
because of many barriers such as costs,
pain due to mammogram procedures,
lack of knowledge about the benefits
of early screening, and many other
barriers such as cultural or social
factors. But fighting breast cancer
means educating women on the importance
of early breast screening and detection
for prevention as well as for management.
In order to educate the general population
on the benefits of breast cancer,
the present study was done to identify
and describe barriers to early detection
of breast cancer.
Methodology:
This is a survey of 75 female PHC
physicians who responded out of the
total 79 available female physicians
in 43 Primary Health Centers in Al
Khobar, Al Dammam, and Al Qatif, Saudi
Arabia in 2004 regarding the barriers
in implementing of breast cancer screening
programs using a specially designed
questionnaire which divided into two
parts (demographic data, and items
regarding barriers in implementing
breast cancer screening programs).
Results and Discussions:
Most of the female physicians were
Saudi (65%) with mean age of 35.93
± 7.23 in years from PHHCs
in Al Khobar, Al Dammam, and Al Qatif.
The average mean duration of work
as physician is 8.82 years and the
average duration of work a PHC physician
is 8.2 years. 95% of physicians in
the study did not undergo post graduate
training as compared to literature.
The 2 physicians (5%) in the study
did not have graduate degrees in family
and community medicine but had master's
degree in pediatrics (3), obstetrics
(1), and gynecology (1).
The physicians reported
the different barriers which have
prevented them from practicing screening
programs in PHHCs with the main barrier
given as: there was no national screening
program (56 physicians), time pressure
(55 physicians), physician's lack
of training (48 physicians), lack
of good communication between physician
and patients (46 physicians), there
were not enough facilities in the
PHHCs (42 physicians), lack of women
cooperation and trust (33 physicians),
walk-in clinic (4 physicians), and
social and cultural reasons (4 physicians).
Costs and unavailability of mammography
are the main barriers in other countries
including the United States of America.
Such is not the case in Saudi Arabia
since mammography is usually given
free to Saudi citizens or is part
of the patient's insurance coverage.
It was found out that physicians who
thought that BC screening is important
tended to advice patients to undergo
BC screening. Physicians with low
scores in BC epidemiology in Saudi
Arabia claimed Saudi women are not
at risk of BC (p=0.04).
Conclusion: The
main barrier of the BC screening program
which may be instituted by PHCs female
physicians was unavailability of a
national screening program. Other
barriers include time pressure, lack
of training on the part of the physician,
lack of good communication, there
were not enough facilities in the
PHHCs, lack of women cooperation and
trust, walk-in clinic, and social
and cultural reasons.
Recommendation:
Development and institutionalization
of breast cancer screening program,
massive educational program on breast
cancer using multi-media tools and
strategies, training and intervention
program for PHC physicians on breast
cancer including screening and early
detection, and inclusion of breast
cancer education on the medical curriculum
are some of the recommendations arising
from the study's results.
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Key words: Barriers
of breast cancer screening and early detection
Breast
cancer can tremendously affect the women's
quality of life. While breast cancer is
one of the leading causes of cancer and
cancer death among women in the U.S., screening
mammography remains underutilized, particularly
by women from low-income families. Studies
show about one in four women 40 and older
have not had a mammogram within the last
two years. Nearly 40 percent of low income
women have never had a mammogram. Barriers
to screening have been often studied, with
cost identified as a dominant factor in
women's screening decision.[1] But fighting
breast cancer means educating women on the
importance of early breast screening and
detection for prevention as well as for
management. Primary care physicians are
critical for the recommendation of mammography
and clinical breast examinations to their
patients.[2]
In a experimental
study of an intervention program designed
to study the effects of academic detailing
in New York's Manhattan and South Bronx
primary care physicians' screening recommendation
to patients , results showed a statistically
significant intervention effect on the recommendation
of mammography and clinical breast examination
(according to medical audit) by female patients
age 40 and over. Intervention group physicians
correctly identified significantly more
risk factors for breast cancer, and significantly
fewer barriers to practice, than did comparison
physicians. [2]
In Brunswick,
Canada a survey yielded results which showed
that physicians had great influence on mammography
screening of patients. Having mammography
at recommended intervals and clinical breast
examinations (CBEs) yearly were significantly
associated with having had a physician recommend
the procedures (P < .001). Rates of screening
differed sharply by whether a family physician
was physically practicing in the community
or not (P < .05, odds ratio 2.68, 95%
CI 1.14 to 6.29).[3]
While breast
cancer screening in rural America remains
underutilized, barriers to screening mammography
in poor, rural areas are marked by significant
racial disparities, according to a new study.
These barriers include poor knowledge about
breast cancer and screening, difficulty
accessing facilities, and lack of encouragement
and funds to get screened. These factors
are particularly striking among Native Americans.[4]
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The findings
of the study of 1,247 women of Hispanic,
Chinese, Japanese, and white women on their
utilization of breast cancer screening indicated
that language barriers that hinder a woman's
access to pap smears, mammograms and clinical
breast exams create disparities in screening
rates.[5]
The independent Task Force
on Community Preventive Services recommends
strategies which address particular barriers
to screening such as client-related (e.g.,
knowledge or attitudinal) barriers to screening,
access barriers, or provider and system
barriers. Some of these strategies are:
strong patient reminders, multi-component
using media, education, and enhanced access,
reducing structural barriers, client incentives,
reduced out-of-pocket expense, group education,
one-on-one education, and use of mass media.[6]
Older women, in general, have
been found to underestimate their risk of
these cancers. Fear of cancer diagnosis,
or discomfort from or embarrassment during
the screening procedures, and other factors,
serve as barriers for many women. The first
step toward addressing these and other barriers
is to recognize that they exist. The importance
of physician's recommendation in patient
screening decisions was also found. Physician
advice and recommendations were the most
frequently cited reasons for having had
a screening test. In addition, lack of understanding
of the need for asymptomatic screening,
misconceptions such as the belief that injuries
cause breast cancer and limited recognition
of the importance of age as a risk factor
are some barriers from breast screening
use. Physician interventions alone will
not be adequate to address these issues.
Culturally relevant community outreach and
education projects are also necessary.[7]
The objective of the
study was to identify and describe barriers
to early detection of breast cancer.
This is
a survey of 75 female PHC physicians who
responded out of the total 79 available
female physicians in 43 Primary Health Centers
in Al Khobar, Al Dammam, and Al Qatif, Saudi
Arabia in 2004 regarding the barriers in
implementing of breast cancer screening
programs.
A specially designed questionnaire
divided into two parts (demographic data,
and items regarding barriers in implementing
breast cancer screening programs) was used
as data gathering tool.
A pilot study was conducted
using the tools of data collection to assess
the reliability of the research tool which
was found to be highly reliable (Cronbach
a coefficient of 0.77). Face validity and
content validity were also established with
the aid of experts on the field in Saudi
Arabia. The Statistical Package for Social
Science (SPSS) version 10 was used for data
entry and analysis and decided to use a
p value of <0.05 level of significance
(with 95% confidence interval). The study
followed strict ethical considerations.
Selected
demographic variables of the respondents
were shown in Table 1. Most of the physicians
were Saudi (65%) with mean age of 35.93
± 7.23 years old. It indicates that
female young Saudi physicians are working
in PHCs in the 3 cities of Al Khobar, Al
Dammam, and Al Qatif. The average mean duration
of work as physician is 8.82 years and the
average duration of work a PHC physician
is 8.2 years. The respondents' mean ages,
duration of medical practices in general
and PHCCs in particular, are lower than
what is in literature. 8,9,10,11 Most of
the physicians in the study (95%) did not
undergo post graduate training as compared
to literature wherein 46% are family physicians.
The 2 physicians (5%) in the study who had
master's degree in pediatrics (3), obstetrics
(1), and gynecology (1) were also working
as general physicians.
The physicians indicated the
different barriers which may prevent doctors
from practicing screening programs in PHHCs.
The main barrier given was that there was
no national screening program (56 physicians),
time pressure (55 physicians), physician's
lack of training (48 physicians), lack of
good communication between physician and
patients (46 physicians), there were not
enough facilities in the PHHCs (42 physicians),
lack of women cooperation and trust (33
physicians), walk-in clinic (4 physicians),
and social and cultural reasons (4 physicians).
Some studies found in literature have common
barriers to the present findings, such as:
fear of diagnosis (lack of trust), tests
as unnecessary, lack of cooperation, and
social and cultural beliefs, lack of knowledge
of breast cancer. Some other studies indicated
logistics or costs1 and pain to the patients7,
geographic area, education level, and health
status, infrequent clinical breast examinations
as part of regular care, unavailability
of mammography services, and lack of time
for patients from their jobs are some of
the barriers for recommending mammography
and screening.6,14-20 Costs and unavailability
of mammography are the main barriers in
other countries including the United States
of America. Such is not the case in Saudi
Arabia since mammography is usually given
free to Saudi citizens or is part of the
patient's insurance coverage
The reason for majority of
the physicians (68%) to advice patients
to do BC screening comes from their knowledge
of the importance of BC screening. The physicians
who did not advice their patients to do
BC screening (32%) gave the lack of national
screening program on breast cancer (n=24)
as the main reason for not doing so; a not
good enough reason to prevent physicians
from trying to educate the women about BC
or advice them to do breast cancer screening
wherever they can access it. Other reasons
were the same as reported in the literature.
Those who were found to have low scores
in epidemiology in Saudi Arabia claimed
Saudi women are not at risk of BC (p=0.04).
Only 6 (25%) reported that women do not
come for breast problems.
The results
of the study give the following conclusions:
The main barrier of the BC
screening program which may be instituted
by PHCs female physicians was unavailability
of a national screening program. Other barriers
include time pressure, lack of training
on the part of the physician, lack of good
communication, there were not enough facilities
in the PHHCs, lack of women cooperation
and trust, walk-in clinic, and social and
cultural reasons.
Based on the conclusions of
the study, the following are recommended:
- Development
and institutionalization of breast cancer
screening program
- Massive educational program
on breast cancer using multi-media tools
and strategies for the mass media.
- Training and intervention
program for PHC physicians on breast cancer
including screening and early detection.
- Inclusion of breast cancer
education on the medical curriculum.
- Availability of enough
breast cancer screening utilities and
machines for the use of women
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