Home visits to improve breast health knowledge and screening practices in a less privileged area in Jordan

Breast cancer is the leading cause of cancer death and the most common female cancer worldwide, accounting for 23% (1.4 million) of the total new cancer cases and 14% (458,400) of the total cancer deaths [1]. It is estimated that 1.7 million women will be diagnosed with breast cancer in year 2020, and the majority of these cases will be in low- and middle income countries (LMIC) [2]. Early detection of breast cancer is essential for LMIC, because breast cancer at early stages has a better prognosis with more cost-effective treatment [3].

Breast cancer is the most common cancer afflicting women in Jordan, comprising nearly 20% of all incident cancer cases and 37% of all female cancers [4]. In 2009, 43% of the cases diagnosed were in women aged 20-49 years and 36% in those aged 50 years and more; 3.0% of the cases were in stage 0 (in situ), 26% in stage I, 30% in stage II, 23% in stage III, and 10% in stage IV [4]. During the period from 1997 to 2002 the five-year survival rate of breast cancer in Jordan was 83% for stage I, 72% for stage II, 59% for stage III, and 35% for stage IV cancers [5]. Based on this data it was suggested that creating breast health awareness in addition to conducting targeted mammography screening interventions for women aged 40 years and above might lead to earlier detection of breast cancer and thus to higher survival rates [5].

The Jordan Breast Cancer Program (JBCP) was established in 2007 as a national initiative led by the King Hussein Cancer Foundation (KHCF) to improve public awareness about breast cancer and the benefits of early detection and to ensure the provision of quality screening services in Jordan [6]. The JBCP orchestrates the efforts of all the stakeholders in the different sectors to enhance women’s breast health awareness and their access to quality screening services [6]. The national guidelines for early detection of breast cancer promote breast health awareness, including monthly practice of breast self-examination (BSE) starting from the age of 20 years [6]. Clinical breast examination (CBE) is recommended once every 1-3 years in the age group 20-39 years and annually in women aged 40 years and older. Mammography is recommended once every 1-2 years for all women starting from age 40 years.

Women in Jordan, especially those who live in less privileged areas, might still face barriers that constrain them from adopting screening practices [6]. These barriers could include prioritizing the needs of the children and family above their own health, having fears about breast cancer and feeling safe and not at risk of the disease. To enhance women’s access to culturally appropriate information about breast cancer and to overcome possible barriers to their breast health practices, the JBCP in collaboration with the American Near East Refugees Aid (ANERA) and the Jordanian Women’s Union (JWU) conducted a home visits intervention to women in a Palestinian refugees’ camp in Jordan. The intervention included a home-based educational session and offered free mammography screening vouchers. This study aimed to assess the effect of this outreach home visits intervention on changing women’s breast health knowledge and screening practices for early detection of breast cancer.

In this intervention, 55% of the women who received the first visit were aged 40 years or more; 81% had low family income; 74% had no health insurance; 96% were housewives; 80% were married; 8.7% were illiterate; 44% had primary or secondary education; 10% of the women’s husbands were unemployed while 54% of them worked as handymen or drivers (Table 1). Women who were not revisited had similar characteristics as those who received the follow-up visit except for small differences with regard to age groups, woman’s occupation and attending a previous lecture about breast cancer. In addition, the proportion of women with a low knowledge score in the pre-test was higher among the women who were revisited than among women not revisited (45% vs. 37%; p = 0.001).

This home visits intervention significantly improved women’s breast health knowledge, their perceived BSE knowledge, BSE practice and mammography screening. At first visit a low proportion of women reported practicing breast health examinations. Their previous mammography screening was significantly associated with being aged 40 years or older, having higher breast health knowledge and having attended a previous lecture about breast cancer. Women who received a free voucher and had a pre-set follow up visit were more likely to have mammography screening. Being busy and having other priorities was the most reported barrier for women’s breast health practices in the post-test, followed by not feeling at risk.

The participants in this study had relatively low breast health practices at the baseline. The reported practices in the pre-test indicated that previous mammography screening was associated with older age, higher breast health knowledge score and attending a previous lecture about breast cancer. This is consistent with Jordan’s breast health national guidelines that promote mammography screening starting from the age 40 years [7]. Public awareness can contribute to earlier detection of breast cancer if it is culturally appropriate and tailored to the specific population [11]. Educational programs that enhance women’s perceived self-efficacy and perceived benefits can lead to significant improvement in breast health practices [12]. Based on the Revised Health Belief Model, women’s perceived seriousness and susceptibility to illness influence their perceived threat, while, perceived benefits from early detection and perceived barriers influence health-seeking behaviour. In addition, general health motivation, perceived self-efficacy and ability enhance health-seeking behaviours [13]. Similarly, the social cognitive theory indicates that self-efficacy positively influences health behaviour and should be considered an integral component of educational interventions [14]. Therefore, breast health educational interventions that provide balanced health information might empower women to take an informed and more active decision-making role than they initially intended [15].

In this intervention, the post-test showed a significant improvement in women’s retained breast health knowledge, perceived BSE self-efficacy, reported BSE practice and mammography screening. Due to the increase in availability of and quantity of health promotion messages, women might be selective in the messages they receive and retain in their minds. Thus, health communication interventions should be more tailored and responsive to the targeted audience [16]. In a review of the specific challenges and proven interventions to improve attendance in female cancer screening in lower socioeconomic groups, it was found that consistently successful strategies were to offer free tests, eliminate geographical barriers, and to adopt an individually tailored pro-active communication addressing the specific barriers [17]. Thus, home visits by local outreach workers, as in our study, has been proposed to be more effective within this specific context in changing beliefs and practices than other breast health promotion strategies [17], as individual concerns and barriers can be addressed directly.

Our results demonstrated a higher use of the free mammography screening vouchers among the women who received the pre-set follow-up visit from the LCOW. This is consistent with the social support theory [18] as perceived support from the women’s social network, such as the LCOWs, is assumed to influence their health practices. Social support can be classified into formal or informal support [18]. Formal support is offered by health providers through giving information, guidance and advice. Informal support can be affective, appraisal, and instrumental and is considered the more effective type of support. Affective support involves mutual trust and genuine concern. Appraisal support confirms the self-value and is often provided by co-workers or through social influence. Instrumental support includes symbolic or material and tangible aid usually provided by family [18]. Mauad et al [19] found that home visits by outreach workers, who were well known in the community, were effective in improving the number of women screened for breast and cervical cancer in a low-income setting. The effectiveness of communication is enhanced since these outreach workers might share similar socio-cultural context with the women [19, 20]. Our findings are also consistent with other studies, which have used local lay community workers to conduct educational sessions about breast cancer [21, 22] and cervical cancer [23, 24], which have shown significant increases in women’s screening participation rates.

Our study showed that receiving a voucher for free mammography screening increased the utilization of the screening facility. Out-of-pocket payments have been reported in literature as a barrier to screening [25]. Earp et al [21] described that an intervention including one-to-one conversations between lay community health advisors and women, use of culturally sensitive materials to promote breast cancer screening, increasing access to mammography by providing transportation and promoting lower charges, was more effective in increasing participation in mammography screening among lower income women than in the higher income group [21]. In a randomized trial by Stoner et al [26], vouchers for free mammography were distributed in two rural Minnesota counties and were significantly associated with increased participation in mammography screening [26]. In another intervention by Margolis et al [27], lay health advisors recruited women and offered screening appointments, resulting in a significant increased attendance in breast and cervical cancer screening [27].

In this study, being busy and having other priorities was the most reported barrier by women for their BSE, CBE and mammography screening practices. This is consistent with the findings of a qualitative study conducted by the same research team in Jordan [7], which indicated that Jordanian women were ambivalent to prioritize their own health and put children and family needs first. Lack of time and not feeling at risk have been reported also as common barriers for breast cancer screening among women in Asia [17, 28].

This study has some limitations including recruitment of a non-random sample. Thus, our results cannot be directly generalized to other women in less privileged settings in Jordan. Although this study assessed the retained knowledge and changes in breast health practices six months after the home visits educational intervention, there is still a need to assess the long-term sustainability and the cost-effectiveness of such an intervention. Another limitation was that the LCOWs had only 625 free mammography screening vouchers to offer, which was not enough for all women who met the inclusion criteria. Additionally, a few follow-up visits could not be conducted. More importantly, we do not have complete follow-up data for more than half of all women who received a free voucher, which somewhat reduces the possibilities to identify the most relevant barriers for non-adherence to the referral for screening.

The strengths of this study are in the relatively large sample who received the first home visit, in the design that used multifaceted breast health promotion strategies, in the assessment of retained breast health knowledge and practices in a sub-sample six months after the first home visit, and the opportunity to track the actual utilization of the free mammography vouchers at the assigned mammography unit. Following mammography screening, women had all the necessary further investigations including: extra X-ray views, ultrasound, ultrasound guided biopsy and stereotactic biopsy. Two women who never had previous mammography screening before this home visits intervention used their free mammography screening vouchers and were diagnosed with stage II breast cancer. They were referred for treatment in the public sector.

Evidence from this study suggests that home visits by trained LCOWs that incorporate tailored education about breast cancer and breast health, in addition to offering free mammography screening vouchers and a follow-up visit, were effective in improving women’s breast health knowledge and mammography screening in a less privileged area in Jordan. However, there is a need for further research to assess long-term sustainability and the cost-effectiveness of this type of intervention.