Current knowledge, attitudes and practices of women on breast cancer and mammography at Mulago Hospital.

Background Breast cancer is the third commonest cancer in Ugandan women. Women present late for breast cancer management which leads to high mortality rates. The objective of the study was to assess the knowledge, attitudes and practices of Ugandan women concerning breast cancer and mammography. Methods This was a descriptive cross-sectional study where 100 women reporting to the Radiology department were interviewed. We used consecutive sampling. Interviewer-administered questionnaires were used to collect opinions of the participants. For data analysis, answers were described as knowledge, attitude, practice and they were correlated with control variables through the chi-square. Bivariate and logistic regression analyses were also used. Results Most of the women (71%) had no idea about mammography. More than 50% did not know about risk factors for breast cancer. The attitude towards mammography was generally negative. Regarding seeking for mammography; level of literacy, occupation and marital status were significant on bivariate analysis, however only level of literacy and employment remained the significant independent variables on logistic regression analysis. The main barrier to mammography was mainly lack of information. Conclusion Women in this study had inadequate knowledge and inappropriate practice related to mammography as a procedure for breast cancer investigation.

Despite breast cancer being one of the few cancers that can be detected early before seeing symptoms using mammography, mammography is still only performed on a low proportion of the women population in Uganda. Despite the wealth of literature available globally documenting knowledge, attitudes and practices of women about breast cancer and mammography, there is still paucity of literature on the African experience in this area. The aforementioned gaps form the basis of the present study. Hindrances to accessing mammography services not only in Uganda or Africa, but also globally should be identified and then health care authorities should establish strategies to overcome them.
The purpose of this study therefore, was to assess the knowledge, attitudes and practices of women about cancer and mammography as well as identify potential barriers hindering women from accessing mammography services. Hopefully, findings from this study will provide a starting point for health authorities to raise awareness amongst women about breast cancer and the role of mammography in breast cancer investigation. Due to operational costs, this study could neither be extended to all women reporting to the hospital nor to women elsewhere in Uganda. This coupled with no focus group discussions conducted with the study participants are potential limitations of the study. We could not conduct focus group discussions since all women in the study were outpatients and just trickle in the Radiology department it would be difficult to gather them. We suggest more similar studies to be conducted with other groups of women from other areas. Combined with the data from this study, it could provide a better understanding of the barriers faced by women when accessing a procedure such as mammography.

Methods
The study was conducted at Mulago Hospital which is Uganda´s National Referral Hospital. It also acts as the teaching hospital for the College of Health Sciences, Makerere University. The hospital is located in the northern part of Kampala City, Uganda's capital and has a bed capacity of 1,500.
It was a descriptive cross-sectional study using interviewer-administered questionnaires. The questionnaires were administered in English and Luganda (a local language) covering the following domains: Demographics (age, marital status, education, employment etc), knowledge, attitudes and practice (KAP) of women on breast cancer and mammography. To ensure validity and reliability of the data collected, the questionnaire was reviewed for information quality and legitimacy and any corrections arising were made. It was then pre-tested before the survey. Questions asked sought knowledge, attitudes and practices on breast cancer, use of mammography, BSE as well as CBE. Women above 30 years of age reporting to the Radiology department during the study period and had consented were included in the study. Additionally, all women who reported to the radiology department specifically for mammography examination were also excluded because they already had some information about mammography. Correct and consistent answers regarding the value of mammography were considered adequate knowledge. Attitude was considered adequate if women were positive about mammography and supported their statements consistently. Practice was considered satisfactory if women correctly answered questions regarding the use of mammography and the desire of doing it. For women who had not had a mammogram, the main reasons for that were also sought.
100 women reporting to the Radiology department during the study period were involved in the study. Consecutive sampling was used. This was done in order to give an opportunity to every woman who meets the inclusion criteria to participate in the study without any bias.
A quiet place was chosen for the interviews. Responses were compiled, entered in the computer and stored on flash disks and kept securely in a locked place. Only the investigators had access to this information. Information in the computer was protected using passwords.
Data was both quantitative and qualitative. Thematic analysis was used for qualitative data. It involved content analysis to extract the meanings of the participants, and also transcription. Raw data was proof-read and coded into categories of similar meaning. Categories were established, resulting into content themes. These themes summarized the meaning of the data which addressed the purpose of the study. Quantitative data went through cleanliness and consistency tests, frequency analysis and entered into SPSS version 10.0 statistical program. Age of participants was

Attitudes
All women generally reported a negative attitude towards mammography. The limited knowledge about mammography probably contributed to the negative attitude since they did not know its exact role. However, the participants expressed willingness to change their attitude towards mammography provided they got adequate information regarding its role. This is partly due to the wide campaign about breast cancer and its effects not only in Uganda, but globally as well. Therefore, being an investigative procedure to detect breast cancer is probably the main reason for women having acceptance for it provided they get to know its benefits. Majority of women (75%) in this study feared that breast ultrasound would pose a potential risk to cancer. Conversely, Aylin et al found out in their study that majority of the women (72.5%) were comfortable with breast ultrasound without any fear [45]. This shows that the women in Uganda and probably in many developing societies confuse breast ultrasound with mammography. In support of these findings, an earlier study done by Mubuuke et al (46) again with Ugandan women showed that women think ultrasound can cause cancer. This unveils a huge knowledge gap as far as breast ultrasound is concerned probably in all developing societies and therefore calls for more sensitization and education of society regarding the issues raised by the health workers.
Some women who had done CBE reported embarrassment especially when being examined by a male doctor which changed their attitude towards breast screening procedures. This finding was also reported by Dibble et al [4] and Saint-Germain [20]. Although women in this study had not done any mammography, the procedure of carrying out the mammogram may turn out to be embarrassing as well. Women in the Ugandan society have a much closed culture and a traditional, conservative and male-dominated life style. The theory of reasoned action suggests that the intention to participate in mammography for breast cancer is determined primarily by 2 factors: the woman's attitude toward the procedures and the social normative influence of the people, who are important in her life, most notably spouses [4]. Educational programs and sensitization campaigns about mammography can be accomplished in a culturally sensitive manner by considering these points. Husbands should be included in the breast cancer sensitization programs. They cannot only support their wives and prevail on them to change their attitude towards mammography, but can also reduce their own risk of breast cancer morbidity and mortality [8,24].

Practices
Majority of the women frequently practiced BSE and occasionally sought for CBE, but did not go for mammography. It is thought that BSE makes women more aware of their breasts which in turn may lead to an earlier diagnosis of breast cancer [21]. The rationale behind extending BSE practice as a screening test is the fact that breast cancer is frequently detected by women themselves without any other symptoms. A metaanalysis of studies investigating the possible benefits of BSE has shown that regular practice increases the probability of detecting breast cancer at an early stage [5]. This study revealed the finding that many participants had practiced BSE. Most of the women in this study were from diverse backgrounds and mainly from lower social status. This means that these women may not have ready access to mammography and CBE. In their study, Siahpush & Singh also reported a similar finding with women from non-metropolitan backgrounds [21]. ACS no longer recommends BSE (30). However, in developing societies like Uganda, BSE should still be encouraged because access to CBE and most importantly mammography is extremely limited. Some health facilities are not easily accessible and mammography is very expensive for the majority, yet BSE can still help to some extent.
There may be several reasons for not undergoing mammography. The cost of mammography in Uganda and probably globally is high, particularly for a woman who does not have social security like most of the participants in this study. Although Dibble et al [4] have reported factors like mammography-induced pain and discomfort plus the effects of the radiation received during a mammogram, as a barrier, this cannot apply to this study as all the women interviewed had not undergone any single mammogram. This means that there is something more than pain or the fear of radiation that hinders these women from seeking mammography. The lack of information about mammography and the high costs for the few who know about it may be the biggest hindering factors especially in low-resourced settings. Focused educational programs are urgently needed to address this issue. Programs for women, especially those who have low education levels, do not work and spend most of their time at home, should be encouraged. For this purpose, the media (local written and oral, radio, television, soap operas, newspapers etc.) could be used. Through such programs, awareness of breast cancer, the importance of its early diagnosis, and prompt treatment can significantly increase.

Conclusion
Participants in this study lacked adequate knowledge had poor attitude and inappropriate practice about mammography. The main barrier to mammography was lack of information about its role in early detection of breast cancer which improves survival. Awareness campaigns and subsidizing the costs for mammography by Ministry of Health would improve survival from breast cancer. Involving men as well in this awareness will also greatly improve the current situation. All this should be coupled with acquisition of mammography machines by regional referral hospitals to ease access to the service.

Competing interests
The authors declared that they have no competing interests Tables   Table 1: Socio-demographic characteristics of participants     Healthy women should have control mammography at certain intervals 15 (15%) There is an age limit for mammography 10 (10%)