of Preventive Breast Cancer Screening in Low-income Women
According to the National
Breast Cancer Foundation (2012), the most common cancer in women is breast
cancer and it is the second leading cause of death in women around the world as
one in eight women is likely to be diagnosed with cancer in their life time. Breast
cancer deaths are, however, preventable when detected early and treated.
Although, death from breast cancer has been declining since the 1990s due to
increased awareness, screening, early detection and improved treatment, it has
not been the case for low income women. My focus is on mammography as the most
effective preventive cancer screening tool, since, “Regular mammography is the best tool available
to detect breast cancer in its earliest stages, availing opportunities for
effective life-saving treatment,” (American Cancer Society, 2011). Studies
have shown that there exists an inaccurate knowledge of breast cancer screening
among low income women around the world which leads to low screening and
consequently high breast cancer deaths among low income women in the world.
A study done in Kenya
showed that rural and urban low-income women said that they saw no reason to
have one’s breasts checked if they looked healthy and not painful. And while
most of the urban middle-income women were able to describe early detection
measures such as self-breast exam, clinical breast exam, mammography in detail
and even had experienced them, most urban low-income and rural women had heard
vague knowledge that about breast cancer screening, (Muthoni & Miller,
2009). Another study conducted among low income Hispanics, native Americans and
Caucasians in Wyoming showed that they had a poor knowledge regarding breast
cancer screening and believed that
the absence of a family history of breast cancer implied a low risk for breast
cancer, therefore, no need to get a mammogram. Some of the women thought that
an “Inverted nipple” would be a sign for one to get a mammogram done, (Purtzer, 2012).
A hospital based cross
sectional study was conducted in Ibadan, Nigeria on the level of awareness of
mammography among 818 randomly selected women attending the General outpatient
clinic of the University College Hospital. Only 5% of the women had heard of
mammography and their knowledge of the procedure was poor. The women with no
college education were far less likely to be aware of mammography compared with
those college educated ones. The most common source of information regarding
mammography screening were newspapers and magazines, (Obajimi et al., 2013).
Inadequate health literacy
as a result of low level of education is strongly associated with lower
mammography screening as suggested by a study among Mexican American women in
Texas. Out of a sample of 722 women age 40 and above, only 44% had a mammogram
within the last one year. Participants in the survey were also given the Short
Test of Functional Health Literacy (STOFHLA) in either English or Spanish.
STOFHLA consisted of patient medical instructions for X-ray preparation and the
rights/responsibilities part of a Medicaid application form. Out of 36 questions,
50.42% scored below 22. This implied they had inadequate health literacy, and
consequently a lower mammography screening was demonstrated among the Hispanic
women residing in the Lower Rio Grande Valley of Texas, (Pegan et al., 2012).
status, inadequate health literacy related to low level of education, and old
age were associated with poor knowledge of mammography screening in low income
women. The studies examined supported that the above factors are interrelated
in contributing to the poor knowledge and use of mammography screening among
low income women. Breast cancer
screening knowledge and practices among women in southeast of Iran study showed
that overall knowledge of breast cancer screening was inadequate in 67.4% and
only 1.3% had a mammography throughout their life. Furthermore, about mammography, 72.7% had
poor knowledge, 24% had average knowledge and 3.4% had good knowledge. A
questionnaire was used that had demographic characteristics such as age,
educational level, socioeconomic status and knowledge of mammography.
Statistically, there was a significant relationship between the overall
knowledge of breast cancer screening and level of education. The lower the
level of education and socio-economic status, the lower the knowledge of breast
cancer screening. Also, statistically there was an inverse relationship between
knowledge of mammography with age. The older the women, the poorer the knowledge
of mammography. In older women of 40-49years of age, 94.4% had poor knowledge
while women 15-24, 66% had poor knowledge, (Heidari, Mahmoudzadeh-Sagheb
& Sakhavar, 2008).
Iran study above revealed that there is a stronger relationship between low level
of education and poor knowledge on mammography screening in low income women. There
is also poor knowledge among older women, but the educational factor is more
important and encompasses the age factor. It is imperative to say that low
income women with low level education have poor knowledge of mammography
screening for breast cancer leading to the higher rate of death from breast cancer
income women with either high school or no high school diploma have poor
knowledge of breast cancer screening and, therefore, need to be educated on
preventive breast cancer screening using mammography. Healthcare providers
should not only recommend mammography screening for low income women but teach
them that preventive breast cancer screening is important at age 40 and above,
whether or not risk factors and symptoms are present, in order to detect breast
cancer in its earliest stages. Nurses need to advocate for uneducated low-income
women by making sure that their providers follow up with them regarding preventive
breast cancer screening.
Primary care nurses need to
teach low income patients with only high school diploma or lower level of
education that at age 40 and above, women need to get mammogram screening for
breast cancer every 2 years. Community health nurses practicing in low income
neighborhoods need to educate community members and encourage them to get
mammogram screening every 2 years. Advanced practice nurses need to recognize that
low income women with no college degree are more likely to have a late presentation
of breast cancer, therefore, there is the need to refer them to get a mammogram
whether or not symptoms are present. Also, to provide resources such as breast
cancer clinic locations available for low income families.
an acute care nurse who also works in a Subacute, Rehab and Nursing home
facility, there are always educational resources regarding breast cancer
screening on the company’s educational website that could be handed over to
patients and families. In the near future when I become a primary care provider
at the forefront of health care, I would incorporate into my practice the habit
of teaching and encouraging my patients about breast cancer screening. When I
come across patients in teachable states, regardless of the healthcare setting,
it would be important to recognize these risk factors associated with poor knowledge
of mammography screening: Are they low income women? Is high school their
highest level of education? If the answer to my assessment is yes, then it
would be important to educate them on the use of mammography testing for breast
cancer after age 40, refer them to breast cancer clinics, follow up with them to
make sure it is done every 2 years. It is also important to bear in mind that some
among these population might not be insured. As a result, I would need to not
only teach them, but provide them with list of free or low-cost places for the
uninsured to get mammogram testing for breast cancer. When this is done, there
would be a decreased late presentation of cancer, increase survival chances,
hence, decrease in cancer death among low income women.
Ahmed, N., Ford, J., Fair, M., Samenya. K., & Haber,
G. (2009). Breast cancer knowledge and barriers to mammography in a low-income
managed care population. Journal of Cancer Education, 24 (4): 261-6. Retrieved
Cancer Society. (2012). Cancer Facts and Figures . Retrieved from http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/documdoc/acspc-031941.pdf
Davis, T. C.,
Arnold, C., Berkel, H. J., Nandy, I., Jackson R., & Glass, J. (1996).
Knowledge and attitude on screening mammography among low-literate, low-income
women. Cancer, 78, 1912-1920. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8909311
Eisner, J., Zook, G., Goodman, N., & Macario, E.
(2002). Knowledge, Attitudes and Behavior of Women Ages 65 and Older on
Mammography Screening and Medicare: Results of a National Survey. Women and
Health, 36,1. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12555798
Heidari, Z., Mahmoudzadeh-Sagheb, H., & Sakhavar.
N. (2008). Breast Cancer Screening Knowledge among Women in Southeast of Iran .
Acta Medica Iranica, 46(4): 321-328.
Pagán, J. A, Brown, C. J., Asch, D. A., Armstrong, K.,
Bastida, E., & Guerra, C. (2012). Health Literacy and Breast Cancer
Screening among Mexican American Women in South Texas. Journal of Cancer
Purtzer, M. (2012).
A Transformative Decision-Making Process for Mammography Screening Among Rural,
Low-Income Women. Public Health Nursing, (29),3. http://www.ncbi.nlm.nih.gov/pubmed/22512426
Muthoni, A. &
Miller, A. (2010). An Exploration of Rural and Urban Kenyan. Health Care for
Women International, 31, 801–816. Retrieved from http://www.tandfonline.com.libproxy.calvin.edu/doi/pdf/10.1080/07399331003628453
Cancer Foundation. (2012). Breast Cancer. Retrieved from
Obajim, M. O.,
Ajayi, O. I., Oluwasola, A. O., Adedokun, B. O., Adenike, T. A., Mosuro, O. A.,…Olupade,
O. I. (2013). Level of awareness of mammography among among women attending outpatient
clinics in a teaching hospital in Ibadan, South-West Nigeria . BMC Public
Health, 13,1471-2458. Retrieved from http://www.biomedcentral.com/1471-2458/13/40/