Introduction

Breast cancer is the most common cancer among women and that continues to stay at the top because of the 1.67 million new cases and 508.000 deaths worldwide [1]. In Turkey, it ranks first among cancers with high mortality rates (13.4 %) and 5-year prevalence (34 %) [1]. In 2013, it was reported that one of every four Turkish women had been diagnosed with breast cancer. Of these women, 45 % were between the ages of 50 and 69 and 40 % of were between 25 and 49 years [2]. Mammogram awareness and screening are fundamental for women to adopt and practice early detection of breast cancer [3], but low awareness and wrong beliefs can be a barrier. Health literacy is a dynamic part of individual capacities and has a shared definition used by different organizations as follows: skills of obtaining, processing, and understanding of basic health information to make appropriate health decisions [4, 5]. Health literacy is considered to be an important component in predicting women’s behaviors including knowledge, awareness, and willingness for cancer screening [6–8]. Indeed, low health literacy (LHL) remains a main hidden obstacle to increase cancer awareness and screening due to having limited health vocabulary [9]. However, most studies suggest that breast cancer awareness and screening were low in Turkish women [10, 11], but there is no evidence that health literacy may improve mammogram awareness and screening.

The purpose of this study was to assess the level of health literacy, mammogram awareness, and screening among tertiary hospital women patients.

Methods

A cross-sectional study was conducted from August 2015 to February 2016 in out-patient clinics of a tertiary hospital which was located in Çorum city, Middle Black Sea region of Turkey. Target population was women patients aged between 40 and 69. Patients were recruited from different women health clinics. In the course of registration to admission system, patients were screened carefully by ten trained female nursery students. The city is growing rapidly by immigration day by day so all patients were chosen with Turkish- speaking. Criteria for exclusion were incompleted survey, being in other age groups, being illiterate, having psychiatric, hearing and vision problems. Patients were asked to participate in a 10-min private face to face interview. Before interview, verbal and written study consent was taken in an interview room. Patients were told that we were studying what patients knew about breast cancer screening age and if ever they had a mammogram. As part of the study, we also told them to answer a list of medical reading test. Relevant and volunteer 519 women were included in the study. The record of enrolling was sequentially according to the waiting list at the clinics. A questionnaire form was prepared by the researcher according to literature. To try out the validity of questionnaire, a pilot study was based on 30 patients. Data obtained by the questionnaire included four parts: demographic characteristics (age, education, marital status, occupation, monthly income, self-perceived health) and health behaviors (smoking, using alcohol, physical activity, regular health screening), mammogram awareness and screening and health literacy tool.

Mammogram Awareness and Screening

The National Turkish Breast Cancer Screening Standard (NBCS) suggests that “mammogram screening should start at age 40 and women who are 40–69 years should be screened biennial” [12]. By respect to the national guide, for the purpose of mammogram awareness, patients were asked to “Should mammogram screening start at age 40”? The content validity of this question was assessed by experts on oncology.

In order to identify mammogram screening, the patients were asked with questions “Have you ever had a mammogram?” and, if they answered “yes”, “Have you had a mammogram within 2 years”?

Health Literacy Tool

To assess the health literacy level of patients, a health literacy tool was used, called as “The Rapid Estimate of Adult Literacy in Medicine (REALM)”. The REALM is defined as a robust test to measure health information (Cronbach α = 0.99) [13]. It asks participants to read a list of 66 medical terms. Level of health literacy varies according to scores which obtains by reading and pronunciation terms correctly. For each correct score, patients are given “1” point. Categories of health literacy are divided into three groups according to the total scores. Patients with a REALM score of 61–66 were classified as adequate health literacy while other with scores ranging from 0 to 44 and 45 to 60 were classified as inadequate and marginal health literacy, respectively [13]. The tool was translated into Turkish version by Ozdemir et al. [14]. Also in this study, the internal consistency of the REALM was found as good (Cronbach α = 0.96).

Statistical Analysis

Data was analyzed by using the SPSS Program 17.0. In analysis, means, standard deviation, chi-square test, and multivariable logistic regression analysis were used. In analyses, health literacy level was handled in two categories as “adequate” and “limited” (inadequate and marginal), p < 0.05 values were considered statistically significant.

Ethical Approval

The study protocol was conducted in accordance with the Helsinki Principles and approved by the Ethics Committee of Hitit University.

Results

The sample of study was consisted of 519 women patients. Table 1 shows characteristics and health literacy level of respondents. The average age was 50.6 ± 8.4 years. Of the study population, 55.1 % were between the age of 40 and 49 years, 69.2 % had less education than high school, 94.2 % were married, and 80.2 % were housewives. In response to the question: “Should mammogram screening start at age 40?”, 58.4 % of the patients reported “yes”. Only a small number of patients indicated that they had a mammogram before (23.1 %), and also all of those had a mammogram within the 2 years. Inadequate literacy and marginal health literacy were present in 44.7 % and in 49.3 % of patients, respectively. Adequate health literacy existed in 6 % of patients.

Table 1 Characteristics and health literacy level of patients
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The distribution of patient characteristics by health literacy level is shown in Table 2. Adequate health literacy was significantly higher in 40–49 years than compared with other age groups. Among patients, who had a university degree, employed individuals and individuals with high income and good self-perceived health adequate health literacy were found significantly more often. On the other hand, inadequate health literacy was significantly more frequent among housewives who are less educated and nonsmokers. Health care, mammogram awareness and screening also affected health literacy. Inadequate health literacy was consistently associated with mammogram awareness and screening.

Table 2 Patient characteristics by health literacy level
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Table 3 lists the factors associated with mammogram awareness and screening. Limited health literacy was significantly associated with lower mammogram awareness (OR 6.53; 95% CL 1.46–9.13) and screening (OR 1.12; 95% CL 0.45–2.80). The effects of other factors on mammogram awareness were not significant. Nonetheless, lower mammogram screening risk was 5.55 times higher in patients with poor self-reported health and 4.57 times higher with having low income.

Table 3 Logistic regression results to predict mammogram awareness and screening
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Discussion

In spite of the increase in breast cancer, mammogram screening rates were low among women in our country. Studies from different Turkish cities reported that mammogram screening rates were between 22.3 and 54 % [10, 11, 15]. In contrast to Turkey, a report by the Centers for Disease Prevention and Control (CDC) indicated that 66.8 % of women aged 40 or younger had had a mammogram within the past 2 years [16]. Also, studies from different countries reported a wide range of mammogram screening as 43–78 % [17–21]. In the present study, over half of the women were aware of the mammogram screening age, but surprisingly, mammogram screening was very low. These results seem to be consistent with national studies but lower than the international reports.

This study showed that majority of women patients (94 %) had REALM scores in the category of limited (marginal or inadequate) health literacy level. Prior studies showed similar findings that women patients had limited level of health literacy [22, 23]. A possible explanation for this might be that women were exposed to sexism in the field of education and occupation and health.

As mentioned in the several reports, the current study also confirmed significant association between health literacy level and socio-demographic features [22, 24, 25]. Adequate health literacy existed among younger, employed, high educated, patients with high income and good self-perception of health. Aging which leads to decline in functions is an inconvertible factor. Because of less formal education, individuals may have poor income and health. So, national intervention schemes should be made on formal education which establishes a social dignity in favor of women.

Investigating the obstacles for mammogram awareness and screening can be a pioneer to develop effective national interventions. This study identified a supportive evidence to these obstacles that health vliteracy levels were a determining factor on mammogram awareness and screening. Notably, lower mammogram awareness significantly associated with limited health literacy and this evidence has not previously been described. However, mammogram screening significantly associated with limited health literacy, lower income, and poor self-perceived health (Table 3). These results are consistent with those observed in earlier studies [7, 8, 23]. The next steps should involve public health framework to increase health literacy, breast cancer awareness, and screening. Public health workers can assume this valuable mission. In primary care, family health centers may be arranged as a meeting place and education environment because of intensive women population. Educations should be designed on health practice and national screening policy of breast cancer by researching women’s basic literacy and communication skills.

As a conclusion, this study provides noteworthy information by exploring impacts of health literacy level on mammogram awareness and screening in a sample of Turkish women. Limited health literacy was widespread among women and also mammogram awareness, and screening were associated with limited health literacy. Health literacy can be an advantageous opportunity on focal point of national cancer screening. Breast cancer education program and public health campaigns should be arranged according to women health literacy level.