Knowledge, behaviour, attitudes and beliefs

Knowledge or awareness of breast and cervical cancers and their prophylaxis have been studied by many researchers and it has been noted that their lack may negatively influence the uptake of screening (Gronwald et al., 2006; Lyttle and Stadelman, 2006; Okobia et al., 2006; Paolino and Arrossi, 2011; Steven and Fitch, 2004). Other factors such as underlying attitudes, beliefs, perceptions and motivations towards health and disease, such as cancer, have been previously found to be related to the uptake of breast and cervical cancer screening programmes (Bowling, 1989; Sutton and Rutherford, 2005; Jepson et al., 2000) and could be at least partially explained by exploration of these factors on an individual level (Sutton and Rutherford, 2005). Women with positive attitudes showing intentions to take up breast screening were more likely to use those screening services (Jepson et al., 2000; Marcinkowska et al., 2006). Fylan (1998) and Waller et al. (2009) noted that women may think of cervical screening as unnecessary or not beneficial if they believe they are not at risk of developing cervical cancer (Waller et al., 2009; Fylan, 1998). Also embarrassment when attending cervical screening, as well being afraid of receiving referral for colpsocopy and other medical procedures can be considered barriers to screening uptake (Waller et al., 2009; Fylan, 1998). Another study amongst Swedish women confirmed Fylan’s findings as Eaker et al. (2001) found that non attendees did not think that cervical screening is beneficial (Eaker et al., 2001). A recent review of studies published between 2000 and 2008 confirmed that belief in the usefulness of screening was an important predictor of breast screening uptake (Vedel et al., 2011). Also higher likelihood of breast screening attendance was found among women that undertook breast screening in the past than those who have never been screened (Lechner et al., 1997). This could be due to lack of such possibility or a conscious decision not to attend. But attending once does not mean that the woman will decide to repeat the screening (Lechner et al., 1997). Jepson et al. (2000) found a similar association in cervical screening (Jepson et al., 2000).

A number of studies explored how knowledge of breast and/or cervical cancers and their prophylaxis was related to attendance (Wong et al., 2009; Okobia et al., 2006; Jokiel and Bielska-Lasota, 2005; Spaczyński et al., 2010). The studies looked not only at knowledge

amongst the general female population undergoing routine screening, or cancer patients but also amongst female healthcare professionals. For example a study conducted in Nigeria amongst community-dwelling women to assess their awareness, attitude and practice of breast cancer prophylaxis has shown that knowledge of the disease was very poor and only the minority practiced BSE or attended the clinics to have their breasts examined by a medical professional (Okobia et al., 2006). Similarly, another study among Malaysian women highlighted that many women believe that the purpose of the cervical smear test is detection of the existing cancers and that the lack of symptoms equalled to lack of need to undergo screening (Wong et al., 2009). Most of the women were not aware that the cancer could be prevented if changes were detected early (Wong et al., 2009).

Other studies examined the level of knowledge about both breast and cervical screening. Lyttle and Stadelman (2006) reported in a study in West Virginia that awareness of breast cancer issues was much higher than those relating to cervical cancer (Lyttle and Stadelman, 2006). The authors noted that many women based their knowledge on misconceptions that could have an unfavourable impact on the future uptake of cancer screening (Lyttle and Stadelman, 2006). Another study in Turkey examined knowledge of screening related topics amongst health professionals and found that health professionals may be insufficiently informed about screening and in particular about recommendations for cervical screening intervals and their dependence on the previous results. The study was conducted amongst a sample of nurses and found out that only 66.4% knew that if the repeated Pap smear tests were normal, screening could be done every 2–3 years (Yaren et al., 2008). Conversely, a study amongst health care professionals in the U.S.A. examining knowledge, perceptions and attitudes toward cervical screening found a good level of knowledge but noted that the educational resources for patients were insufficient (Tessaro et al., 1996). Paolino and Arrossi (2011) have shown that 49% of Argentinean women who had been screened and 73% of unscreened ones had inadequate levels of knowledge about Pap smears. Forty seven percent of screened and 30% of unscreened women had never heard about HPV. Having knowledge about cervical cancer screening was also positively linked to being screened in the previous three years (Paolino and Arrossi, 2011).

Limited Polish studies to date have examined the association between the levels of breast or cervical cancer screening uptake with knowledge, behaviours and attitudes towards either breast or cervical cancer or cancer screening (Jokiel and Bielska-Lasota, 2005; Spaczyński et al., 2010). One of the earlier studies conducted by Chojnacka-Szawłowska (1998) in the city of Gdańsk explored the psychological factors of knowledge of cancer symptoms in cancer patients in relation to that of the general population. The study was not specific to breast or cervical cancer but it included a number of patients (men and women) who were diagnosed with either of these cancers as well as healthy controls. Results have shown that approximately 21% of cancer patients and 53.8% of respondents from the general population were unable to name any cancer symptoms. Forty one per cent of cancer patients were able to name at least one and 27.7% two cancer symptoms versus 32.3% of general population having knowledge of one symptom and 13.7% two symptoms. Chojnacka-Szawłowska (1998) noted that the female patients who had better knowledge of cancer symptoms were younger and the level of fear of cancer was not related to knowledge of the symptoms (Chojnacka-Szawłowska, 1998). In a later study, Jokiel and Bielska-Lasota (2005), aiming to measure women’s knowledge about Pap test and their screening practices, involved nationally representative samples at 5 different time points between 1976 (N=1,035), 1986 (N=460), 1990 (N=455), 1998 (N=524), and 2002 (N=509). The results have shown at the last data collection point (2002) that 91% of women reported that they were aware of the importance of cervical screening and 88%, 75%, 65%, and 31% in 1998, 1990, 1986 and 1976, respectively. The highest knowledge levels were noted amongst women aged 25-39 or 40-49 with the highest educational level and living in cities. Also the number of women visiting their gynaecologist increased from 33% in 1976 to 46% in 2002 (p<0.001). The researchers also explored cancer registry data and found that the overall survival rate was 52.2% which one of the lowest amongst European countries. They also found that the relative excessive risk of death was related to progression in disease stages, delay in treatment and density of the population in the place of habitual residence (Jokiel and Bielska-Lasota, 2005).

Zych et al. (2006) on the other hand attempted to gain understanding of women’s (from South- East region of Poland, N=300) knowledge of breast cancer prevention and their familiarity

with its symptoms. They concluded that more than half of patients (51%) stated that they were aware of the need for BSE from the age of 20, 32% of women indicated that self-examination should be done beginning from the age of 30 and 6.9% pointed that the most appropriate period of women’s life falls during the menopause. Overall the results revealed that BSE and cancer symptoms were not well understood and women did not know when BSE should be done. Risk factors for breast cancer were known to most women but every second woman had trouble in naming at least four of them (Zych et al., 2006).

Nowicki et al. (2008) examined knowledge and health screening behaviours amongst women who were employed in the healthcare sector, compared to those that were not. They found that there were no significant differences between the two groups in knowledge or screening behaviours related to cervical cancer. However, they surveyed a convenience sample of a relatively small size (N=207) women in both of the studied groups (Nowicki et al., 2008).

Later Nita et al. (2010) conducted a survey amongst 109 visitors or mothers of children being hospitalised in the Orthopaedic and Traumatology Department of The Institute of Health of Mother Pole in Lodz and found that the women had inadequate levels of knowledge of both breast and cervical cancers. Authors of this hospital based study assessed that due to lack of knowledge of cancer and cancer prophylactic practices such as BSE (currently recommended in Poland) the knowledge amongst surveyed women was insufficient (Nita et al., 2010b).

Two other Polish studies confirmed the previous findings of inadequate knowledge of breast and cervical cancer and its prophylaxis and highlighted the role of media in the increasing women’s knowledge of female cancers and cancer screening initiatives (Gronwald et al., 2006; Ulman-Włodarz et al. 2011). Gronwald et al. approached Polish women from the Pomeranian region who attended genetic BRCA1/BRCA2 testing after they read an advertising article in the women’s popular press. The researchers followed a sample (N=198) of BRCA1 (the most common BRCA mutation in Poland) carriers and non-carriers after one year and questioned them about their knowledge on breast cancer and its prevention. The majority (81%) of the carriers responded that they had been adequately informed during counselling about cancer

screening) the satisfaction of undergoing the test was very high (98%). Gronwald et al. (2006) demonstrated also that carriers of BRCA1 followed the cancer prophylaxis more often than non-carriers (Gronwald et al., 2006). The researchers pointed out that Polish women at a high risk of breast cancer do not have the possibility to get genetically screened, due to high cost or lack of recognition by their health care providers (Gronwald et al., 2006). Therefore they remain unaware of their cancer predisposition. The second of the mentioned studies (Ulman- Włodarz and Nowosielski, 2011) questioned 250 patients who attended gynaecology clinics in Krakow and found that the majority of women (68%) assessed that they had medium level of knowledge on cervical cancer. Similarly like the women from the study conducted by Gronwald et al (2006), it was found that that the primary sources of knowledge was the women’s press (59%), television (47%) and internet (38%) (Ulman-Włodarz and Nowosielski, 2011). Only about a third of respondents gained their knowledge from their gynaecologist and as little as 3% attended following their personal screening invitation from the National Health Fund (Ulman-Włodarz and Nowosielski, 2011).