RELATIONSHIP OF WOMEN'S HEALTH BELIEFS ABOUT MAMMOGRAPHY AND ITS PERFORMANCE

	Dr Maryam Nooritajer Ph.D. Assistant Professor of Nursing & Midwifery School /Iran University of Medical Sciences and Health services, Dr Hossein Ghaffari MD. Manager of Secretariat specialized Medical Education Council Ministry health and treatment and Medical education of Iran
	Dr Maryam Nooritajer Ph.D Iran University of Medical Science, Rashid-yasami Street. Valiasr venue, Tehran Tel: + 982188773073; Fax: 8793805 E-mail: maryamnoorytajer@yahoo.com Dr Hossein Ghaffari MD E-mail: ghaffari79@yahoo.com

ABSTRACT Background: Breast cancer is one of the life threatening problems in women's lives. One of its early diagnostic methods is mammography which determines masses even less than 0.5 cm in diameter. In order to encourage women to have mammography performed, we have to change their attitude and behaviour, so knowledge about health beliefs is an important issue to be considered. Objective: To determine the relationship of health beliefs about mammography and its performance. Methodology: this was a comparative cross sectional study. Data collection tool was a questionnaire, with questions that were on the basis of health belief model about four issues: (benefits and barriers of mammography performing) and (severity and susceptibility to breast cancer). Two communities were studied. The first contained Iranian women above 35 years old, who attended the hospitals, that had been considered for research. For mammography performing, the second study group contained Iranian women above 35 years old who came to the above-mentioned hospitals for performing, other kinds of Para clinical services, except mammography. Sample: 360 people that were classified into two groups (180 with mammography and 180 without mammography) were studied. The sampling method in both groups was non-probability and continuous. The number of samples in every hospital was dependent on the number of mammography investigations performed in that hospital. Acceptance standard was negative history of mammography and elimination standards were being affected by cancer and other difficult to cure disease, chemotherapy and drug-taking because of mental illness. Results: Findings showed a significant statistical difference (P<0.0001) between women's health beliefs, about (benefits and barriers of mammography performing) and (severity and susceptibility to breast cancer) in two groups (with mammography and without mammography). Conclusion: Research findings indicated a relationship between health belief and performance of mammography. Results also showed that occupation, level of education and marital status had a relationship with susceptibility to breast cancer. As self-breast examination is one of the early diagnostic methods in detection of breast cancer, it is recommended that further research be done in relation to heath beliefs and self-breast examination.

Key words: Heath belief, mammography, breast cancer

INTRODUCTION

Health is an undeniable right of humans who should not be deprived of it, and all efforts must be made to deliver appropriate healthcare for all people.(1) Health is not motionless but is an active and changeable phenomenon. Human health is always influenced by many diseases.(2) One of the important problems that threatens the health, specially in nowadays, is cancer. Breast cancer is still the most frequently diagnosed cancer in women in the western world and the cause of a large amount of suffering. (4) 21600 women are newly diagnosed with breast cancer each year and 19,000 die of their disease. The incidence rate continues to rise and an increasing number of young women are affected. (5)
Breast cancer is the third most prevalent cancer in Iranian women, hence one of the leading causes of death. What makes it different in Iran is the early onset of the disease. Breast cancer starts earlier in Iranian women and it takes longer for them to seek medical treatment (3).

Screening for breast cancer has been show to reduce breast cancer mortality by approximately 35% for participants in randomized studies. Thus screening has the largest overall effect of any intervention on mortality from this frequent disease. Mammography is the only screening method that has been thoroughly evaluated and shown to have positive results.(6)

Mammography screening for breast cancer is a well established method with a body of evidence and experience supporting it.(7)

Mammography screening not only leads to a reduction in breast cancer mortality,
It also contributes to a shift towards earlier breast cancer stages upon presentation. Breast cancers detected by screening will be smaller and mostly node - negative (8).

As breast cancer has a high incidence and because of specifity of mammography for breast cancer diagnosis, encouragement of women to mammography performing is necessary. But fto encouragement of women to use mammography, their attitude and behavioral trends must alter, as well as alteration of behavioral trends, about health and disease. The Potter & Perry's health belief model contains four components:

1. benefits of a health behavior being performed
   
2. barriers of a health behavior being performed
   
3. susceptibility to a disease
   
4. Severity of a disease (Glanz & colleagues)

By having knowledge about women's health beliefs, nurses are able to use methods for correct education and if necessary with desired change in these beliefs, they promote level of women's health.

According to significant role of beliefs in women's functions and because of the importance of mammography in women above 35 years old,as the most effective and available method for early diagnosis of breast cancer, and the direct relationship between early diagnosis and women's health, it is necessary to explore women's beliefs, who have jhad mammography performed and those of women who have not had mammographyperformed. Because of the above-mentioned causes, the researcher decided to inspect women's health beliefs about mammography. Consequently, this research was done to determine the relationship of women's health beliefs about mammography and it's performance in women who came to hospitals, related to medical universities, in Tehran.
The hypotheses of this research comprised of:

1. Women's health beliefs about mammography in relation to its performance.
   
2. Women's health beliefs about barriers against having mammographyperformed.
   
3. Women's health beliefs about severity of breast cancer have in relation tomammography performance.
   
4. Women's health beliefs about susceptibility of breast cancer in relation to mammography performance.

MATERIALS AND METHODS

This research was a comparative cross sectional study that the researcher conducted between women's health beliefs about mammography with its performance in two groups, With having mammography performed and without having mammography performed). The research society contained Iranian women above 35 years of age who came to the hospital, under consideration for this researchd, for mammography performance or for receiving other kinds of pre-clinical services except mammography.

For data collection, the researcher came to the above mentioned hospitals (the hospitals related to medical universities in Tehran) and used continuously for sampling. In this research 360 people that were classified into two groups 180 with mammography performed and 180 without it) were selected. Data collection tool was a questionnaire, containing two parts. The first part contained questions about individual, social and economical characteristics, for example age, marital status, level of education occupation, level of income, and history of breast cancer. In the group with mammography having been performed, The percentage of ages between 34-35, were more than other ages (44%) and in the group without mammography performed percentage of ages between 35-45 was 76.7%. Average age in the group with mammography performed was 47.41 ± 7.57 and in another group was 42.34 ± 6.95. In the group with mammography performed the biggst percentage of level of education was respectively 28.3 in diploma holders and 20.6 in women who study in guidance school. In the group without mammography performed the percentage of diploma holders was 35 and the percentage of women with bachelor's degree and higher was 20.6. From the viewpoint of income, 51.7% in the group of mammography performed and 53.3% in another group had an income between 600000- 1449000 Rials. More than 50% of women were housewives in the both groups, with the percentage of 57.8 in the group with mammography performeds and 59.7 in the other group. Also in both of groups, the age of the first pregnancy in the majority of women was between 13-20 , with average and standard deviation of 20.98 ± 40.4 in the group with mammography performed and 21.54± 4.02 in the other group. Regarding familial history of breast cancer 7.2% of women in the group with mammography performed had a grandmother, affected by cancer and 5.6% of women in the other group had an aunt affected. In both groups, familial history of breast cancer was positive in the majority of women.

The second part of the questionnaire contained questions about women's health beliefs about performance of mammography, were based on four issues: benefits of mammography performing, barriers of mammography performing, severity of breast cancer and susceptibility to breast cancer. The questions about health belief were on the basis of Potter & Perry's health belief model and Five choices on the scale of Likert. Those choices were : completely agreeing, without viewpoint , opposed and completely opposed. In the questions, related to health belief components about mammography, excluding questions about barriers, all answers of completely agreeing, had a score of 5 and completely opposed had a score of 1. In the questions about barriers, answer of, completely agreeing , had a score of 1 and completely opposed had a score of 5.

For determining of scientific credibility of data collection tool, content credibility manner, and for determining it's scientific reliance, renewed trial methods were used for doing the aforesaidreseach, the researcher at first selected women who came tothe hospital and were according to acceptance standards, informed of the research goals, method of questionnaire filling and of keeping thewritten information confidential After their agreement for participating in the research, the questionnaires were given to them. In this study, the data collection method was self- reporting. Because 13.9% of women were illiterate and 25% were only able to read and write, the questionnaires of these groups were filled out by the interviewers. All of questionnaires were filled out during official working hours, over 2 months.

In order to analyse the information from this research, SPSS statistical program was used. For inspecting of people's characteristics and describing them, descriptive statistical methods contained, tables, charts, central and variance indexes, in this study. For inspecting of homogeneity between the two groups k2 , and fissure free tests were used. For analysis of dates, related to health belief components, Manwitney nonparameterial test was used. Relationship between health belief grades and variables of occupation, level of education and marital status, was studied using valis croscal analysis test. Mentel-henzel test was used for inspecting interventional variables, in this study.

RESULTS

About the first special goal of study " determining and comparing women's health beliefs about benefits of mammography performing in the group with mammography performing and in the group without performing it, on the basis of age, level of education and marital status," information of table fig.1 shows that, regarding grade of health belief about benefits of mammography performing, the two groups had a meaningful statistical difference, (Z:9.066 & P<0.0001), in such a manner that, the average of grades of health belief about benefits of mammography performed in the group with mammography performed (= 27.19) was more than the average number in the group without performing it, (= 23.52). Therefore, performance of mammography has a relation with health belief grades. It seems that, the women of the group with mammography performed, accepted that, this method was an early diagnostic method of breast cancer and they had faith in this belief. Those women believed more in the advantages of mammography- performing.

The result obtained from Lager Lund and colleague's research (9). And according to their research, women's knowledge about advantages of mammography is one of the most important factors for it's performance.(9) Also according to their research, increasing the level of women's information about mammography was a very important and effective factor for forming their beliefs.

About the second special goal of research "determining and comparing women's health beliefs about barriers of mammography performing in the group with mammography performing and in the group without performing it on the basis of occupation, level of education and marital status", information of table fig.2 show that, regarding the grade of health-belief about barriers of mammography performing, the two groups had a meaningful statistical difference (z=6.862 & p>0.0001), in such a manner that the average of grades of health-belief about barriers of mammography performing in the group with mammography performing (= 28.24) was more than the average of them in the group without mammography performing (= 24.99). It seems that the higher grade is because of women's higher information about barriers of performing this method in the group with mammography performing as compared with the group without performing it. Therefore the women's health beliefs about barriers of mammography had a relationship to its performance.

The results of this table's information show that the women's health beliefs about barriers of mammography have a relationship with its performance. In tmoststudies, a reversed relationship between having aperception about barriers of mammography, with it's performance, has been shown, in such a manner that, according to Champion & colleague's study(10), the women, who consider more barriers for performing of mammography, don't have tendency for performing it.(11) Also, Frank & colleagues wrote: women's health beliefs about barriers of mammography has a reversed relation with it's performance.(11) The women, who believe there are less barriers for mammography, perform it less than the others. These barriers include: pain, worry, fear of X-ray, needlessness of performing mammography if there is no sign of breast-cancer and , shortage of knowledge about indications for it. With determining of these barriers, the health and care framework, are able to better program for participating women in mammography performing, better.

About the third special goal of research " determining and comparing of women's health beliefs about severity of breast cancer, in the group with mammography performing and in the group without performing it , on the basis of occupation, level of education and marital status "informations of table fig.3 show that, regarding grade of health belief about severity of breast cancer, the two groups had a meaningful statistical difference (Z= 7.431 & P<0.0001), in such a manner that the average of grades of health belief about severity of breast cancer in the group with mammography performing (= 33.68) was more than the average of those in the group without performing it (= 28.62) , therefore women's, health beliefs about severity of breast cancer had a relationship with performance of mammography. According to Smith & Maurer's work (11): "when we talk about a severe disease or damage, people's tendency to follow medical orders and cares, and engaging in preventive effortsincreases". Therefore on the basis of Lagerland & colleague's statement (9), "stronger women's - beliefs about the severity of breast cancer and when they believe that the breast cancer is incurable or has no possibility of cure, their participating in the mammography performing program decreases. The results of this study confirm the results of Lagerland's research.

Regarding the fourth special goal of research " determining and comparing of women's health - beliefs about susceptibility to breast cancer in the group with mammography performing and in the group without performing it, on the basis of occupation, level of education and marital status, the information in table fig.4 shows that, regarding grade of health belief about susceptibility to breast cancer, the two groups had a meaningful statistical difference (Z= 6.034 & P< 0.0001), in such a manner that the average of grades of women's health beliefs about susceptibility to breast cancer in the group with mammography performing (= 21.89) was more than the average of them in the group without performing it (= 19.49). This result shows performance of mammography has a relationship with grade of health belief about susceptibility to breast cancer. It seems that, the women in the group with mammography performing considered themselves more susceptible to breast cancer and, they had more information about predisposing factors of breast cancer, for example age, marital status and positive familial history. According to Alken's work (13), women's health beliefs about susceptibility to breast cancer have a direct direct relationship with acceptance of mammography performing. Because of having a greater perception of susceptibility to breast cancer, the women, who have a mother or sister affected by breast cancer, or the women , who have a history of benign breast mass, have more tendency toward mammography performance.(12) According to the work of Clanz & colleagues's " if people feel themselves exposed to a severe disease and believe that there is a way for decreasing entanglement and severity of diseases , they participate in health programs.(13)

CONCLUSION

At last, after access to research goals, the results, obtained from this research, discuss our research hypotheses.

The first hypothesis in this research was " women's health beliefs about benefits of mammography has a relationship with it's performance; the results of research showed that the average grades of health beliefs about benefits of mammography performing had a meaningful statistical difference (P<0.0001) between the group with mammography performing and the group without performing it. It means that mammography performing, had a relationship with grades of women's health beliefs about benefits of mammography . On the basis of Walsh's belief, recognition of benefits of a health behaviour, encourage people to do that behaviour.(14)
About the second hypothesis, mooted in this research, " women's health beliefs about barriers of mammography has a relationship with it's performance," the results of research showed that the averages grades of women's health beliefs had a meaningful statistical difference between the group with mammography performing and the group without performing it. (P<0.0001). It means that women's health beliefs about barriers to mammography had a relationship with performing it.

According to Champion & colleagues's statement (10), women , who consider more barriers for mammography performing, don't have a tendency to usethis method. About the third hypothesismooted, in this research, "women's health beliefs about severity of breast cancer has a relationship with mammography performing", the results of our research showed that, the averages grades of health belief about severity of breast cancer had a meaningful statistical difference (p<0.0001) between the group with mammography performing and the group without performing it. It means that, women's health beliefs about the severity of breast cancer had a relationship with mammography performing, so that, obtaining higher grade in the group with mammography performing in comparison with the group without it, and confirms that issue.
According to the work of Smith & colleagues's [11] when an issue like a severe disease or perilous damage is mooted, people will have more tendency to follow medical orders and advice, and the performing of preventive efforts. About the fourth hypothesis of research " women's health beliefs about susceptibility to breast cancer has relation with mammography performing", the results of this research showed that, the averages grades of health belief about susceptibility to breast cancer had a meaningful statistical difference (P<0.0001) between the group with mammography performing and the group without mammography performing , in such a manner that the grade of health belief in the group with mammography performing was more than the other group and this issue confirms an existing relationship between women's health belief about susceptibility to breast cancer and the performance of mammography.
According to gGanz & colleague's belief, when people feel themselves exposed to a severe disease and believe that there is a way to decrease the entanglement or to decrease the severity of diseases, they participate in health programs.(13)

The results of this research, to access the main goal of the research, "determining relationship of women's health beliefs about mammography with it's performance in women, who came to hospitals related to the medical universities of Tehran" showed that the group with mammography performing and the group without mammography performing are different in women's health beliefs about performance of mammography. This difference in beliefs, has led to performance of mammography (health behaviour) in one group and no performance of mammography in another group. According to Bolander's work about the above mentioned issue, in order to execute health behaviors, people in addition to having knowledge about these behaviors and the manner of executing them, must believe that health behaviors, lead to their better health and protection from diseases.(14)

Education is an important part of nursing duties. A nurse can work as a health counselor, and can teach people health-issues iondividually or via participation in health education classes as a teacher. The nurses are able to intervene in all primary and secondary prevention of diseases related to breast cancer, and they can teach women about early diagnosis of breast-cancer. This matter causes elimination of incorrect women's beliefs and informs them about their health needs. Therefore accorregarding the important role of nurses in the field of education, it is recommended that they consider higher importance for education and consultation of women because, the most prevalent cancer in Iranian women is breast cancer, and it is recommended that, the importance of early diagnosis of this disease becomes mentioned in mass media. (TV- radio- newspapers and scientific magazines can introduce the topic of mammography to women of society as the best method for early diagnosis of breast cancer.

The researcher, by using the health belief model, could inspect women's beliefs about mammography as a diagnostic method for breast cancer. But, because self- examination of breast is a simple and nonexpenditure method for early diagnosis of breast cancer performing other research on the grounds of "inspection of relation between women's health beliefs about self- examination of breast and it's performance in women above 20 years is recommended.

The table fig 1: Distribution of frequency and grade percentage of health belief about benefits of mammography performing in the group with mammography performing and in the group without doing it. Tehran

Grade of health belief  about benefits of mammography performing	Women with mammography performing number (%)	Women without Mammography performing number (%)
6-13	1(0.6)	6(3.3)
14-22	11(6.1)	68(37.8)
23-30	168(93.3)	106(58.9)
± SD	27.19±3.28	23.25±4.53
The result of Manwitney test	P<0.0001 and	Z= 9.066

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