The prevention of breast and cervical cancer in a rural population of Crete:Inadequacies and perspectives in primary health care

 
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PhD thesis (EN)

2010 (EN)
Η πρόληψη του καρκίνου του μαστού και του τραχήλου της μήτρας σε ένα αγροτικό πληθυσμό της Κρήτης: Ελλείψεις και δυνατότητες στην πρωτοβάθμια φροντίδα υγείας
The prevention of breast and cervical cancer in a rural population of Crete:Inadequacies and perspectives in primary health care

Παναγουλοπούλου, Ευαγγελία

Μακρυγιαννάκης, Α
Σανιδάς, Ηλίας
Φιλαλήθης, Αναστάσιος

Οι Γενικοί Γιατροί Πρωτοβάθμιας Φροντίδας Υγείας (ΠΦΥ) έχουν ιδιαίτερο ρόλο στην προαγωγή της έγκαιρης διάγνωσης του καρκίνου με εξέταση Παπανικολάου και μαστογραφία, αφού η διαλογή (screening) με οργανωμένα προγράμματα στον πληθυσμό, μπορεί να οδηγήσει σε σημαντική μείωση της θνητότητας. Στην παρούσα μελέτη, ερευνώνται οι πρακτικές πρόληψης των γυναικών ενός αγροτικού πληθυσμού σχετικά με τον καρκίνο του μαστού και του τραχήλου της μήτρας. Θα εκτιμηθούν οι παράγοντες που επιδρούν στη συμπεριφορά πρόληψης, με έμφαση στο ρόλο των Γενικών Γιατρών ΠΦΥ. Η έρευνα είναι μια "έρευνα πεδίου", που πραγματοποιήθηκε το 2006 σε τυχαίο δείγμα 120 γυναικών που κατοικούν μόνιμα στο Δήμο Γοργολαΐνη το νομού Ηρακλείου. Η διεξαγωγή έγινε μέσω προσωπικών συνεντεύξεων, βασισμένες σε Ερωτηματολόγιο με 65 προ-κωδικοποιημένες ερωτήσεις. Οι ορισμοί για την "ορθή πρόληψη" τέθηκαν σύμφωνα με τις οδηγίες της Αμερικανικής Εταιρείας Καρκίνου 2003. Η στατιστική ανάλυση έγινε με απλή και πολλαπλή λογιστική παλινδρόμηση, με το SPSS 17.0. Στη διάρκεια των έξη προηγούμενων ετών, 40,8%, 17,5% και 13,0% του δείγματος εξετάζονταν σύμφωνα με τις οδηγίες (ορθή πρόληψη) με τεστ ΠΑΠ, κλινική εξέταση μαστών και μαστογραφία, αντίστοιχα. Η ορθή πρόληψη για τον καρκίνο του τραχήλου συσχετίζεται αρνητικά με την ηλικία >55 ετών (OR=0,13, 95%CI: 0,05-0,40), ενώ επηρεάζεται θετικά από το ιστορικό με γυναικολογικά συμπτώματα (OR=11,27, 95%CI: 3,35-37,97) και την ενημέρωση από γιατρό για την HPV λοίμωξη (OR=14,24, 95%CI: 1,25-162,60). Οι γυναίκες που έκαναν ορθή πρόληψη για τον καρκίνο του μαστού έχουν αυξημένη πιθανότητα να είναι ≤55 ετών (OR=0,005, 95%CI: 0,01-0,31), να έχουν διδαχθεί την αυτοεξέταση μαστών (OR=7,69, 95%CI: 1,36-43,49) και να έχουν ρωτηθεί από γιατρό σχετικά με το οικογενειακό ιστορικό καρκίνου (OR=8,02, 95%CI: 1,92-33,51). Καμιά παράμετρος σχετιζόμενη με τις επισκέψεις στην ΠΦΥ δεν επηρέασε τις πρακτικές πρόληψης. Συμπερασματικά, η πρόληψη του καρκίνου στον πληθυσμό εφαρμόζεται κυρίως ευκαιριακά. Δεν παρατηρούνται ανισότητες ως προς την οικονομική κατάσταση ή το επίπεδο εκπαίδευσης, ωστόσο, οι γυναίκες μεγαλύτερης ηλικίας εμφανίζουν χαμηλότερα ποσοστά screening. Αν και ο ρόλος των Γενικών Γιατρών ΠΦΥ στην προαγωγή της έγκαιρης διάγνωσης είναι περιορισμένος, οι γυναίκες που είχαν συγκεκριμένη προσέγγιση από γιατρό σχετικά με την πρόληψη, εμφανίζουν σημαντικά καλύτερη συμμόρφωση προς τις κατευθυντήριες οδηγίες. (EL)
Prevention exercise with the application of public health strategies in the community is at the first line of human defense against the expected increase in cancer incidence in the 21st century. For breast and cervical cancer, the early detection through organized screening with mammography and Papanicolaou smear can result in a decline of mortality rates by up to 30% and 60%, respectively. General Practitioners (GPs) in Primary Health Care (PHC) have a great role in promoting cancer screening, since they are the first to contact the patients in most health care systems and, additionally, they manage most of people’s health problems on a long- term basis. In Greece, however, Pap testing and mammography are recommended opportunistically, while a full-development of PHC is limited by several financial and organizational impediments. In this context, the present study aims to explore the cancer prevention practices of Greek women in a rural population within the period of the previous six years, as well as to evaluate the factors which determine the women’s screening-related behavior, with emphasis on the impact of GPs. Previous studies in literature have shown that the benefits from the early detection of breast and cervical cancer do not equally concern all social groups; low income, a low educational level or the lack of insurance coverage are negatively associated with screening practices. In contrast, attendance in Primary Care, a GP’s referral and the use of reminder systems in primary care practices have been pointed out among the strongest predictors of women’s compliance with the recommendations for cervical and mammographic screening. The present study is a field survey which took place in 2006 in a random sample of 120 women 35-75 years who live in Gorgolaini Municipality, a rural region of Cretan island. The Response Rate was 97.5%. The survey was conducted through personal interviews with a 65-item-questionnaire with pre-coded answers, that was formed based on previously validated tools for the purpose of the present study. The collected data were about the women’s screening practices with Pap smear, clinical breast exam and mammography within the previous six years (dependent variables), as well as the women’s demographic characteristics, use of PHC in the area, medical history and knowledge about cancer prevention (independent variables). The definitions for the opportunistic or adequate screening were put according to the IX guidelines of the American Cancer Society 2003. For data analysis the women were divided into two age groups based on the mid-point of the sample (>55 and ≤55yrs). Crude and adjusted Odds Ratios with 95% Confidence Intervals (CIs) were estimated by using single and multiple logistic regression analysis. SPSS 17.0 was used for statistical analysis and the significance level was set at 5%. The majority of the women in the sample are primary school graduates (60.8%), and work/have worked in farming activities (68.3%), while the total have insurance coverage. Less than half of the sample (38.3%) have visited the PHC practices for prevention uptake within the previous year. Regarding cervical cancer screening, 73.3% of the women have at least once had a Pap smear and 40.8% were adequately screened within the last six years. In terms of breast cancer prevention, 55.8% and 50.0% of the women have at least once been screened with clinical breast exam and mammography respectively, while 17.5% and 13.0% were adequately screened with a clinical breast exam or a mammogram during the previous six years, respectively. The majority of the women who have never got screened considered the absence of any relevant symptoms as the major reason for noncompliance. On the other hand, the women in the younger age group, compared with those >55years, have a greater likelihood of giving correct answers at the questions of knowledge about cancer prevention. The women’s cancer screening behavior is not influenced by any of the variables related to the use of the Primary Care services in the area (health visits for prevention, chronic diseases or emergencies, the availability of a doctor to consult regularly, etc). The results of the multiple regression analysis show that Pap screening based on guidelines within the previous six years is negatively associated with age >55years (OR=0.13, 95%CI:0.05-0.40) and positively related to a history of gynecological symptoms (OR=11.27, 95%CI: 3.35-37.97) and a knowledge acquired by a physician about the HPV infection (OR=14.24, 95%CI: 1.25-162.60). On the other hand, women who got screened opportunistically, in comparison with those who never got screened, are more likely to be younger (OR=0.13, 95%CI: 0.02-0.88), married (OR=6.97, 95%CI: 1.00-48.47) with a history of gynecological symptoms (OR=3.46, 95%CI: 1.01-11.88) and a good knowledge score about cervical cancer prevention (OR=1.49, 95%CI: 1.09-2.02). In regard to breast cancer, having ever been screened is related to a knowledge acquired by a physician about how to do a breast self exam (OR=5.90, 95%CI: 2.19-15.88) and a good knowledge score about breast X cancer prevention (OR=1.44, 95%CI: 1.18-1.76). Finally, the women in the younger age group, those who were shown by a physician how to do a breast self exam and those who were questioned by a doctor about a family history of cancer are more likely to adhere in the breast screening guidelines with clinical breast exam and mammography (OR=0.05, 95%CI: 0.01-0.31, OR=7.69, 95%CI: 1.36-43.49, OR=8.02, 95%CI: 1.92-33.51, respectively). In conclusion, cancer prevention in women is mostly practiced on an opportunistic basis, without compliance to screening recommendations. GPs in Primary care have a limited role in promoting cancer early detection. Although no screening-related disparities are observed regarding the women’s main occupation, income or educational level, women >55 years have a decreased likelihood of getting regularly screened with a Pap smear, a clinical breast exam or a mammogram. Women ≤55 years have an above average level of knowledge in regard to cancer prevention, however, the majority of the sample have not sufficiently understood the preventive (and non diagnostic) role of screening. Nevertheless, the women who had a gender –specific preventive approach by a physician have a better compliance to regular screening for both breast and cervical cancer. A multi-level planning is needed for the creation of a Cancer Registry and the establishment of a nation-wide organized screening program for the early detection of cancer in Greece. GPs’ training in prevention exercise as well as the development of sufficient infrastructure in Primary Care are necessary for the effective implementation of screening interventions in the community. (EN)

Τύπος Εργασίας--Διδακτορικές διατριβές
text

Prevention
Primary health care
Gynecology
Καρκίνος τραχήλου
Πρωτοβάθμια φροντίδα υγείας
Καρκίνος μαστού
Breast cancer
Γυναικολογία
Cervical cancer
Πρόληψη

Πανεπιστήμιο Κρήτης (EL)
University of Crete (EN)

Greek

2010-07-20


Σχολή/Τμήμα--Ιατρική Σχολή--Τμήμα Ιατρικής--Διδακτορικές διατριβές



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