Women’s satisfaction ofThe National Breast Screening Programme

DM Attard 1,2,3, J Curtis 2, VA Marmara` 3

1 Malta National Breast Screening Programme2 Kingston University and St. George’s, University of London

3 University of Stirling, UK

Introduction� Breast cancer accounts for 32% of female cancers in the UK1, 23%

worldwide2 and over 32% locally with the highest incident rate in Europe3.

� Since the opening of the National Breast Screening Programme inOctober 2009, local women born in 1950-1959 have been invited to undergo mammography screening every three years.

� A large body of evidence has demonstrated that the physical, psychological and social aspects associated with and resulting from the screening process increase or decrease client satisfaction4-5.

� Although such studies have been undertaken in other European countries, local factors had not been explored since the local programme’s inception.

� To holistically evaluate women’s satisfaction of the Maltese Breast Screening Programme in its prevalent call – NATIONWIDE study

� To identify principal factors that enhance and decrease satisfaction by analyzing:� Client experiences;� Clients’ expectations of the service;

� To appraise clients’ perception of care and communication skills employed by radiographers and other employees;

� To quantify and identify the reasons of those who prefer undertaking future mammography elsewhere;

� To identify correlations between socio-demographic / socio-economic factors and client satisfaction;

� To share new knowledge with policy planners and screening management for future age extensions.

Aims and Objectives

4

� Client experiences

The Five Emergent Themes

Factors, Variables, Themes and Holistic Meaning to the study

Results� Screening appointment, care perception and overall programme - very

positive:

� Good (31.3%); Excellent (68.7%). � Environment - All clients were very satisfied.

� Accessibility:� A minority of participants (29.74%) faced difficulties to access the unit,

due to a ‘busy road’, ‘no bus access’, ‘non-central location’ and ‘limited parking’, resulting in less programme satisfaction.

� Pain and Discomfort:� Those who found mammography ‘severely uncomfortable’ also found it

‘severely painful’, which had a less excellent result on client satisfaction.

� Women related pain negatively to:� Radiographers’ confidence, care and communication.

� Anxiety prior to mammography (56.3%) vs Anxiety when recalled (92.3%);

� Biopsied women less satisfied than non-biopsied women.

8

Mammography� The Mammogram: “Excellent” - 98.7% of participants; “Good” - 0.8%; “Poor” - 0.5%

“The radiographer was very professional in her ways of communication, her care and competence” (Client 222).

� Privacy (99.2%): “It was just the two of us”.� Minimal waiting time (95.8%).

� Pain and Discomfort:

� Pain : The absolute majority (56.1%) found the test ‘not at all painful’; ‘severely painful’(8.4%) – “I just wanted it to end quickly. It’s painful!” (Cl ient 163).

� Severely painful – rated the standard of care less e xcellent!� Discomfort: The absolute client majority felt that the mammogram was ‘slightly

uncomfortable’ (51.1%); ‘severely uncomfortable’ (9.7%).

� Those who found mammography ‘severely uncomfortable’ also found it ‘severely painful’(67.6%), which had a less excellent result on client satisfaction.

� Those eliciting that the mammogram was severely uncomfortable (10.8%) are doubtful of re-attendance and 2.7% would not re-attend.

� Women related pain negatively to the radiographers’ confidence, care and communication”“She hurt me”.

Pain and Re-attendance

10

The EVIDENCE:� In a study involving women aged 50-62 ---- 46% of women found previous mammography painful and declined a subsequent screen (Elwood et al., 1998).

� A Norwegian study of 550 patients revealed that physical and psychological discomfort negatively impacted on repeat adherence(Loeken et al.,1996).

The mammography examination is that unique opportunity for mammographers where clients‘

concerns and misconceptions can be addressed and psychological distress is reduced.

Anxiety� More than half of participants experienced anxiety prior to mammography

(56.3%) and higher anxiety when recalled (92.3%);

� Reasons for higher anxiety prior mammography: ‘fear of the result’ and ‘its impact on the self and their family’ .

� Reasons for higher anxiety when recalled:“Implications for family”, “sexuality” and “mortality ”.

� Biopsied women less satisfied than non-biopsied women, though they were still satisfied with the programme and would recommend screening to others.

The Radiographer� In this study, the most important constituents

of a radiographer were found to be: communication, gender and care.

� The radiographer’s communication and care were rated very positively.

� If male radiographer - 68.9% would not undergo the test.

“The radiographer’s professionalism and effective communication were her best factors. These communic ated

care and confidence in my eyes”(Client 127).

Radiographer’s touch and gender

“With a woman, you feel more comfortable. If you go to a male for an eye test, it's not a problem, but not for a breast check.

It's all about touch of such an intimate and personal body part” (Client 310).

“These are the most intimate female parts where greater care can only be provided by the same sex due to the amount of touch. This is different to gynae examinations” (Client 271).

“I felt at ease with the radiographer. I was not embarrassed ”(Client 123).

14

....The Radiographers

Thousands of women attend for breast screening each year with preconceived notions, seeking‘compassion’, ‘reassurance’, ‘professionalism’,

‘education’, and ‘counselling’.

“The 'contact' with the Radiographer made all the difference” (Client 370).

“It's overwhelming and empowering to see so much support. The people taking care of me really do

care about me” (Client 02: 20.02.2010).15

Comments for Improvement

“Better directions” (6.58%) – bus numbers, map, information leaflet, door sign.

“Improved parking facility” (5.79%).

“Age extension and reduced screening interval” (5%).

“Shorter results’ waiting time” (4.47%).

16

Improvement in Information

17

Conclusions� The majority - ready to re-attend and recommend the programme;� No socio-demographic or socio-economic variables proved to cause

inequalities in healthcare;� External factors – No influence on care perception, though a minority

faced difficulties with accessibility;� The internal non-clinical, pleasant setting - increased satisfaction;

� The female radiographer + competence, care and communication -impacting factors for positive experience:

� Results concur with earlier studies :- NHS Humberside service; - Norway (91% - sample of 393 women).� This study contributes to a holistic approach of cl ient

satisfaction at the MBSP and will assist the implementation of subsequent screening cycles and age extensions .

Conclusions� Results consistent with other findings6-7 – ACCEPTABILITY is one of the

basis for the programme‘s success8. � Strong association between discomfort and pain since a large proportion

of respondents who found mammography ‘severely uncomfortable’ also found it ‘severely painful’ and vice versa.

� Bad experiences may deter women from re-attendance, further resulting in a reluctancy to recommend the examination.

� The impact of discomfort on client satisfaction was not often examined in other studies, as most studies focused on either discomfort or satisfaction9. In this study, the level of discomfort was one of the factors why not all clients rated the programme as ‘excellent’.

� Those who read the leaflet rated the overall programme satisfaction as more positive than those who did not. This shows that pre-procedural information may have positively influenced women’s perception of the whole setup/organisation.

Recommendations� Improve external signage;� Importance of minimizing pain and

discomfort;� Pre-procedural information – recommended

to minimize anxiety;

� Investigate reasons for non-attendance (since compliance rate at the time of data collection was 55.9% – gap between high satisfaction and relatively low attendance rates).

Contact

AcknowledgementsThe author would also like to thank the original authors of the Breast Screening Client Satisfaction Survey, Quality Assurance Reference Centre at the North East, Yorkshire and The Humber. Funding for this work was from STEPS – the Strategic Educational Pathways Scholarship Scheme (ESF 1.25).

The Scholarship was part-financed by the European Union Operational Programme II – Cohesion Policy 2007-2013, Empowering People for More Jobs and a Better Quality of Life, European Social Fund.

Danika Attard BSc (Hons.) (Melit.), MSc (Lond.), MLJ

ALCM. ATCL, LLCM, ABRSM, LRSMPostgraduate Researcher (Stir.)Cancer Care Research Centre (UK)

attard.danika@gmail.com