Family Practice Vol. 16, No. 1, 60-65
© Oxford University Press 1999
Breast screening: GPs' beliefs, attitudes and practices
Psychology and Genetics Research Group, UMDS, Guy's Campus, London SE1 9RT and
a Well Woman Centre, The United Elizabeth Garrett Anderson Hospital and Hospital for Women, Soho, 144 Euston Road, London NW1 2AP, UK.
Prof. TM Marteau, as above.
Bekker H, Morrison L and Marteau TM. Breast screening: GPs' beliefs, attitudes and practices. Family Practice 1999; 16: 60–65.
Received 9 February 1998; Revised 22 June 1998; Accepted 7 October 1998.
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Abstract |
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 Top Abstract IntroductionMethodAnalysesResultsDiscussionAppendix IReferences |
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Objectives. We aimed to describe GPs' knowledge, beliefs and attitudes towards breast screening, and their association with practice-based organizations of breast screening.
Method. A stratified randomized sample of 158 GPs from within the North-East and North-West Thames Health Regions were interviewed.
Results. Sixty-five per cent of GPs report checking the accuracy of invitation lists, and differ from those who do not, in having more knowledge about risk factors for breast cancer. Thirty-seven per cent of GPs report a policy of following up non-attendees for screening and differ from those who do not in three ways: a greater perception of the threat of breast cancer; a greater belief in the importance of GPs' role in increasing attendance of women for breast screening; and, a less-negative attitude towards breast screening.
Conclusion. Women's attendance for breast screening may be increased by raising GPs' perceptions of the threat of breast cancer, addressing their concerns about breast screening and enhancing their views of the importance of the role of primary care in a national screening programme.
Keywords. Breast cancer screening, GPs' attitudes, knowledge and behaviour..
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Introduction |
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TopAbstractIntroductionMethodAnalysesResultsDiscussionAppendix IReferences |
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The efficacy of population-based breast screening by mammography to reduce morbidity and mortality from breast cancer is dependent upon the high attendance of women.1 However, not all health regions achieved the optimal figure for mammography uptake of 70%.2 Most studies have investigated factors related to women when seeking to develop interventions to increase attendance rates. Marital status,3–4 social class,5 and women's beliefs about and attitudes towards breast cancer screening6 have been associated with screening attendance. These ‘women-targeted’ interventions have only been partially successful in developing interventions to increase attendance.
In an effort to improve the effectiveness of interventions, some studies suggest that a promising target may be to explore the role of GPs in influencing women's breast screening attendance.7–17 The majority of studies investigating predictors of breast screening behaviour have been carried out in North America and Australia, where breast screening referral is organized directly by the doctor. Within the UK, breast screening is run independently by the National Breast Screening Programme (NBSP). Although there is some evidence to suggest that targeting doctors' involvement in screening is associated with an increase in breast and cervical screening attendance,16–17 little empirical work has established the role of the GP in women's attendance for mammography.
The NBSP suggests two practice-based organizational behaviours that may be associated with increased attendance:18–19 mentioning breast screening to women opportunistically during routine consultations; and, ensuring the NBSP is efficiently organized within their own practices. The latter can be done by checking the accuracy of prior notification lists (names and addresses of women presumed eligible for mammography screening), and maintaining a policy of contacting women who do not attend for breast screening. Psychological models suggest that attitudes and beliefs of GPs will be associated with their organization of the NBSP within practices.20 The current study seeks to describe the predictors of these GP practice-based behaviours.
The study aims are:
- (i) to describe the beliefs, knowledge, attitudes and practice organization of GPs towards breast screening;
(ii) to determine the extent to which GPs' beliefs, knowledge and attitudes towards breast screening predict their organization of the National Breast Screening Programme within their practices.
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Method |
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TopAbstractIntroductionMethodAnalysesResultsDiscussionAppendix IReferences |
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Design
The design was cross-sectional, assessing GPs' attitudes and behaviours at one point in time.
Sampling
Participants were a random selection of GPs from rural and urban practices within the North-East and North-West Thames Health Regions during 1993–1994.
A stratified random sampling technique was employed in order to obtain an equal representation of practices with low (lowest quartile 22–37%), medium (midpoints of central quartiles 46–61%) and high (upper quartile 70–85%) breast screening uptake rates. The number of GPs within a practice was used as a crude measure of funding, as not all FHSAs had complete deprivation indices information for their practices.
A computer random number generator facility was employed to select practices for the study from the list of 1261 practices provided by the NBSP and FHSAs. In total, GPs from 116/155 (75%) invited practices agreed to take part in the study: 38 ‘low’, 38 ‘medium’ and ‘40’ with ‘high’ uptake rates.
Measures
A semi-structured interview was developed for the study with reference to the literature on social cognition models20 and pilot interviews with ten GPs:
- Breast screening organization within the practice: as the NBSP attendance rate figures by GP were incomplete at the time of data collection (NBSP correspondence) and were regarded as an imprecise guide to actual attendance,21–22 the following self-report measures of practice organization were assessed: whether GPs checked the accuracy of the NBSP notification lists; and, whether there was a policy for re-contacting women who did not attend for breast screening.
- Beliefs about and attitudes towards screening: following factor analysis of 19 items assessing attitudes to breast cancer and screening, six factors were used in subsequent analyses: positive attitude towards breast cancer screening; questioning attitude towards population-based screening programmes; confidence in the results of clinical trials; familiarity with breast screening trials; attitudes towards GPs' role in screening; and perceived limitations of the NBSP (Appendix I). Additionally, four belief items (four-point scales) were incorporated to reflect the perceived usefulness of cervical, breast, cholesterol and hypertension screening programmes in reducing mortality.
- Perceived threat of breast cancer: GPs' perceptions of the threat of breast cancer to women were assessed: ‘What are the two main health threats to women aged 50 years and over?’; and, ‘Do you perceive the risk of breast cancer to be low, medium or high?’
- Knowledge of risk factors for breast cancer: GPs were asked to identify the risk factors for breast cancer from a list of 16 items (Table 3
). The list was taken from the information pack supplied by the NBSP which is sent out routinely to all general practices. Correctly stating that each of the factors was or was not a risk factor obtained a score of one (range 0–16).
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Procedure
All GPs within the selected practices were informed of the study by letter. One of the GPs within each practice was randomly selected and telephoned. If the selected GP declined to be interviewed, the practice was recorded as having declined to participate. GPs agreeing to take part were interviewed at their surgeries at their convenience. Only those partners practising on the day on which the researcher visited the surgery and who were not on a rota for home visits were interviewed. Interviews lasted approximately 20 minutes. All interviews were audiotaped and transcribed.
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Analyses |
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TopAbstractIntroductionMethodAnalysesResultsDiscussionAppendix IReferences |
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The dependant variables assessed were: GPs self-reports for checking prior notification lists and follow-up of women who did not attend for screening. The independent variables were: attitudes towards breast screening; perceptions of the threat of breast cancer; knowledge of risk factors for breast cancer; and GPs' age and gender. Univariate analyses were applied to assess the association between GPs' practice-based organization of the NBSP with women's uptake of screening and GP demographics (T-test and chi-square statistics). Logistic regression analyses were conducted to determine the predictors of GPs' organization of the NBSP.
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Results |
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TopAbstractIntroductionMethodAnalysesResultsDiscussionAppendix IReferences |
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Participants
In total, 158/171 (92%) GPs approached agreed to be interviewed. Participation was unrelated to GPs' patients' uptake rates for breast screening. Thirty-four per cent (n = 53) of participants were female; and 66% (n = 105) were male. The mean age of participants was 46.7 years (s.d. = 9.5).
Practice organization of breast screening programme
Sixty-five per cent (n = 103) of GPs reported checking the NBSP prior-notification lists. Thirty-seven per cent (n = 58) of GPs reported that there was a policy in their practice for re-contacting women who had not attended for breast screening appointments. There was a trend for those who reported checking prior notification lists to be more likely to follow up women who did not attend for screening (42%; 43/58), compared with GPs who did not check prior notification lists (27%; 15/55) (chi-square = 3.2, d.f. = 1; P = 0.07).
Attitudes towards breast screening
The majority of GPs saw more advantages to breast cancer screening than disadvantages. The most frequently named advantages were: early detection of lesions (71%), reducing mortality (24%) and reassurance for women (18%). None the less, all GPs considered breast screening to have some disadvantages. The main disadvantages described were: false positives (39%); pain or discomfort of mammography (39%); and false reassurance (20%). However, 32% of participants did not consider breast screening to be useful in reducing mortality from the disease (Table 1). Following modification of the scale to a dichotomous score, analysis suggested that GPs perceived breast cancer screening to be less useful than cervical screening, more useful than cholesterol screening and equivalent to hypertension screening in reducing mortality (chi-square = 5.8, d.f. = 1, P = 0.02, chi-square = 14.4, d.f. = 1, P < 0.001; chi-square = 2.3, d.f. = 1, not significant, respectively).
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Perceived threat of breast cancer
Sixty per cent (n = 95) of GPs considered breast cancer to be one of the two main health threats to women aged 50 and over. Fifty-eight per cent (n = 92) perceived the population risk of breast cancer to be high, 36% (n = 57) as medium, and 6% (n = 9) as low.
Knowledge of risk factors for breast cancer
The proportions of GPs correctly identifying whether or not an item is a risk factor are shown in Table 2. The median knowledge of GPs was 10 (range of scores 5–14).
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Practice organization of the NBSP and uptake rates
GPs who reported checking their prior notification lists tended to have higher uptake rates than those who did not (57 versus 51% uptake, t = 1.72, d.f. = 156, P < 0.09). There was no association between having a practice policy for following up women who did not attend for breast cancer screening and uptake rates (those followed up: mean uptake = 52%; those not followed up: mean uptake = 56% t = –1.20, d.f. = 156, P = 0.23).
Practice organization of the NBSP and practitioner age and gender
There was no variation in checking of prior notification lists by age of GP (those checked: mean = 46.4 (9.7); those not checked: mean = 47.3 (9.3), t = –0.58, d.f. = 156, not significant) or gender of GP (those checked (f); 34%; those not checked (f): 33%, chi-square = 0.03, d.f. = 1, not significant). Reported follow-up of women who failed to attend was associated with age of GP (those followed up: mean = 50.0 (9.0); those not followed up: mean = 45.1 (9.5), t = 2.93, d.f. = 156, P = 0.004) but not gender of GP (those followed up (f): 38%; those not followed up (f): 31%, chi-square = 0.80, d.f. = 1, not significant). It was beyond the scope of this study to explore adequately the association between GP's age, practice organization and possible mediating variables. However, the GP's age was included within the multivariate analysis for predictors of a practice policy for follow-up of non-attendees.
Predictors of practice organization
Checking of prior notification lists was predicted by knowledge of risk factors for breast cancer: GPs who reported checking prior notification lists had greater knowledge of risk factors for breast cancer (Table 3
).
The presence of a practice policy for following up women who fail to attend a screening invitation was predicted by two variables: a greater perception of the threat of breast cancer in women aged between 50 and 64 years; and a greater perceived role for GPs in breast cancer screening. However, there was a tendency towards significance for two more variables: a less-negative attitude towards breast cancer screening and being an ‘older’ GP (Table 4).
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Discussion |
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TopAbstractIntroductionMethodAnalysesResultsDiscussionAppendix IReferences |
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The results of this study illustrate variation in the organization of the NBSP within GP practices. Two-thirds of GPs reported that the accuracy of lists of women invited for screening were checked, whereas only just over one-third reported a practice policy for following up women who did not accept screening invitations. Checking the accuracy of invitation lists was predicted by GPs' having more knowledge about risk factors for breast cancer. GPs' reporting that their practice had a policy to follow up non-attendees for screening were more likely to perceive breast cancer to be a serious threat to the health of women aged over 50 and had a stronger belief in the efficacy of GPs' encouragement on women's screening attendance. Also, although most GPs saw more advantages to breast screening than disadvantages, there was a tendency for those with a less-negative attitude towards breast screening to report a follow-up practice policy. This study found little association between practice-based organization self-report measures and women's attendance rates for breast screening. However, other, larger studies do demonstrate a relationship between following up women who do not attend for breast screening and increased women's attendance.16,19,23–24
The predictors of organizational behaviour from this study indicate that the relationship between implementation of NBSP recommendations and uptake by health professionals is more complex than the usual, simple knowledge-deficit explanation. Evidence from psychological research has demonstrated that in order to achieve behaviour change, underlying beliefs and attitudes have to be understood and addressed. By using the characteristics identified within this study, a number of interventions may be designed in an effort to increase adherence to NBSP recommendations and subsequent attendance of women for breast screening.
GPs are more likely to hear the negative screening experiences from their patients rather than the national benefits of reduced mortality. An intervention aimed at emphasizing the effectiveness of breast screening may assuage some GPs' doubts. Additionally, giving GPs evidence of the impact of their behaviour on their female patients' attendance and the importance of their role in promoting breast screening may be a worthwhile intervention.
The low attrition rate of this random sample suggests good representativeness of GPs within the two health regions. The main limitation of the study was the cross-sectional design so limiting the interpretation of findings. However, previous theoretically driven research suggests that GPs' beliefs and attitudes are causally linked with their behaviour. Therefore the evidence-based interventions proposed within this discussion ought to be associated with subsequent changes in the practice organization of the NBSP. Evaluations of such interventions need to include measures of practice organization, women's attendance rates and cost-effectiveness of encouraging a more active involvement of primary care teams within a screening programme that offers one of the few known ways of reducing mortality from a major threat to the lives of middle-aged women in the UK.
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Appendix I |
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TopAbstractIntroductionMethodAnalysesResultsDiscussionAppendix IReferences |
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Acknowledgments |
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This work was supported by a grant from the Cancer Research Campaign. Theresa Marteau is supported by The Wellcome Trust.
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References |
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TopAbstractIntroductionMethodAnalysesResultsDiscussionAppendix IReferences |
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