Attitudes of Healthcare Workers Regarding National Breast Cancer Screening in Croatia

Introduction: National preventive screening program, such as mammography for women aged 50–69 years, are essential for detecting malignancies at the earliest stage and improving cure rates. Healthcare workers are the most effective promoters of public health prevention programmes. This study examines the response of healthcare workers in Croatia to the program they help promote.

Materials and Methods: The study involved 102 female healthcare workers aged 50–72 years in Istria County (Croatia). This study was conducted using a 13-question questionnaire created using Google Form. The data were processed using Microsoft Excel and Statistics 14.0.0.15, adhering to ethical principles and maintaining respondent privacy.

Results: The study showed a response rate of 92% among healthcare workers who had received an invitation to undergo mammography screening. The response rate was significantly higher than the average response rate of 60% among the general population of women in Croatia. The main reasons for non-response were practical reasons such as acute illness, lack of information, and working hours. Long-term health education and promotion, better information and advertising, and more flexible working hours have been suggested to increase response rates.

Conclusion: Healthcare workers showed higher participation in mammography screening than the general population, reflecting a strong awareness of prevention. Removing practical barriers and improving information could enhance healthcare workers’ motivation to promote these programs and increase their participation in the general population.

Introduction

According to the World Health Organization (WHO), chronic non-communicable diseases, including physical and mental illness, unintentional injuries, violence, and disability, currently represent the greatest burden of disease [1]–[3]. Among these, malignant diseases rank second in both the Republic of Croatia and globally in terms of burden and mortality. Great efforts are being made to raise public awareness and improve the response to the National Prevention Program (NPP) [4]. According to the latest published data from the Croatian Cancer Registry, there were 3,088 registered cases of breast cancer in 2022 (incidence rate: 154.78 per 100,000), and 707 women died from it in 2023 (mortality rate: 35.5/100,000) [5]. The NPP has been implemented for approximately 15 years, but the participation rate is still unsatisfactory [5], [6]. Breast cancer in women and colorectal cancer in both sexes are the main causes of mortality and disability in the Republic of Croatia [7], [8]. Although breast cancer can be detected relatively early and therefore treated more successfully, a large number of women are still diagnosed at an advanced stage, when treatment outcomes are less favourable and quality of life is reduced, which also carries a significant economic burden [9], [10]. The target group for NPP was women aged between 50 and 69 years. The screening method is mammography, which is performed every two years and should cover at least 70% of the general population [11]. Every year, approximately 150,000 mammograms are carried out as part of the program, with a participation rate of approximately 67%. In total, 8,304 new cases of breast cancer were detected in the first six cycles of the screening program [5].

Healthcare workers play a particularly important role in breast cancer prevention and health promotion. Their task is to encourage citizens to participate in the national screening programs (NPP) to ensure the greatest possible coverage. In addition to promoting these programs, they are also actively involved as patients themselves. Theoretical models based on the Health Belief Model and the Theory of Planned Behaviour have been used to investigate the behaviour of health professionals and their dual roles, as shown by Bahri et al. and Ritchie et al. in their studies [12], [13]. These models enable the analysis of professional norms in relation to perceived barriers, susceptibility, and self-efficacy as important elements in the promotion of public health interventions [14], [15]. Wang et al. investigated the prediction of women’s intention to participate in breast cancer screening programs and concluded that integrating both models has higher predictive power than using each model individually [16]. Integrating these models helps to identify key barriers in promoting breast cancer screening programs, including fear of uncomfortable screening, and to develop targeted interventions to increase participation. Based on previous research, this study aimed to determine the response rate of healthcare workers in the screening programs they promote, and the reasons for their non-participation, hypothesising that the response rate would be similar to that of the general population, and that the main reason for non-participation would be fear of an unpleasant examination.

Materials and Methods

Participants

The study was conducted between April and June 2024. A total of 102 female healthcare workers employed in health centers in Istria County (Croatia) were included in the study. The study included people over the age of 18 who had not previously been diagnosed with breast cancer and were willing to participate in the study. The exclusion criteria included participants who had already been diagnosed with or treated for breast cancer.

Procedure and Materials

Data were collected using a questionnaire developed exclusively for this study. The questionnaire was created using Google Forms and sent by email to employees of health centres in Istria County. It contained a total of 13 questions: the first five addressed the respondents’ socio-demographic data, three concerned personal and family history of breast cancer, and the remaining five focused on participation in the NPP. The questionnaire took approximately 10 minutes to complete. Statistical software Statistica 14.0.0.15 (TIBCO Software Inc.) was used for data analysis. Statistical significance was defined at a p-value < 0.05.

Ethical Considerations

The study complied with international ethical standards. In addition, the study strictly adhered to the principles of the Declaration of Helsinki. The participants were thoroughly informed about the purpose, procedures, potential risks, and benefits of the study before agreeing to participate. After completing the questionnaire, participants unequivocally agreed to participate. Participants’ anonymity was strictly preserved by not collecting any personally identifiable information. The study was authorized by the Istrian Health Authority.

Results

The sample consisted of 102 respondents, with an average age of 57.71 years. Their basic socio-demographic characteristics are listed in Table I. More than 50% of the respondents in the sample were nurses (51.0%), and more than a quarter were doctors (28.4%). The remainder (21%) of the sample comprised physiotherapists, laboratory technicians, sanitary technicians, radiologists, and pharmacists. Most of the respondents had completed higher education, while only 39.2% of respondents had secondary school education. In the vast majority of cases, the respondents lived with their immediate family (spouse and/or children). The proportion of respondents living alone was 16.7%. The majority of the respondents lived in the city (59.8%), with the fewest (15.7%), living in the countryside (Table I).

Table I. Basic Socio-Demographic Characteristics of the Sample

	N	%
Age (years)
50–59	67	65.7
60 years and older	35	34.3
Current level of education
Secondary school	40	39.2
Undergraduate University Study	16	15.7
Graduate University Study	18	17.6
Graduate University Study (Doctor)	17	16.7
Specialist Graduate Professional Study	11	10.8
Do you live...?
Alone	17	16.7
With immediate family (spouse and/or children)	73	71.6
With the extended family (parents, children, with grandchildren)	9	8.8
Other	3	2.9
Do you live...?
In the city	61	59.8
In a suburban neighbourhood	25	24.5
In the countryside	16	15.7

Of the 102 respondents, 94 (92%) responded to the invitation for NPP breast cancer screening. Only 14.7% of the participants had never given birth. Three-quarters of respondents were breastfed. Almost a quarter of the respondents (23.5%) reported a family history of malignant breast disease. Fig. 1 illustrates the main reasons for non-participation in the national breast cancer screening program. Most respondents (41.2%) did not take part in the examination because they were acutely ill on the day of the examination, and one in three respondents (33.3%) did not attend the examination because they were not sufficiently informed. The fewest respondents did not attend the examination because they were afraid of suffering from a malignant breast disease, because the examination was unpleasant, or for family reasons (Fig. 1).

Fig. 1. Percentage of respondents citing this reason for non-attendance.

The study allowed participants to suggest possible improvements to the organization of the NPP to maximise engagement. The responses are shown in Fig. 2. Of the respondents who made their suggestions, 45% saw room for an increase in responses, particularly in long-term work with young people through health education. Greater information and advertising in the public information media would increase the response rate, according to 16.3% of respondents, while 7.5% are in favour of mammography being carried out as part of regular systematic examinations, but also to create a system of sanctions for non-response (Fig. 2).

Fig. 2. Percentage of respondents’ answers to the question: “What do you think should be done to increase the utilisation of preventive medical check-ups?”.

The influence of various factors on screening attendance was examined by using a binary logistic regression model (Table II). According to the model, a statistically significant association was found between attendance and the following predictors: discomfort with the examination (OR = 0.039, p = 0.049), concern about being diagnosed with a malignant disease (OR = 0.023, p = 0.047), and age (OR = 1.353, p = 0.002). All calculations were made considering acute illness as the reason for absence. Fear of an uncomfortable examination and the possibility of facing a malignant breast disease decreases the likelihood that a patient will attend screening, while the likelihood increases with the respondent’s age. The results showed that the model fit the data significantly better than the null model, χ²(6) = 19.461, p = 0.003. The Hosmer-Lemeshow test for model assessment indicated a good model fit (p = 0.315). The model classified the cases well, with a predictive accuracy of 87.3%. This study also demonstrated a statistically significant correlation between response to NPP invitations and reasons for non-attendance at preventive screening (rpb = 0.476, p = 0.001).

Table II. Parameters of the Logit Model

Parameter		OR (95% CI)	p-value
Dependent variable: Response to screening (reference: Yes)	B
Reasons for absenteeism (reference: acute illness)
Working time	−0.948	0.388 (0.076–1.971)	0.253
Family reason	18.965	172290760.9 (0)	1.000
Inconvenience of the examination	−3.232	0.039 (0.002–0.994)	0.049
Lack of information	−0.817	0.442 (0.103–1.893)	0.271
Concern	−3.751	0.023 (0.001–0.950)	0.047
Age	0.303	1.353 (1.114–1.644)	0.002
Constant	−14.403	0.001	0.007

Discussion

The study revealed that 92% of healthcare workers responded to the invitation, a figure substantially exceeding the national average in the Republic of Croatia, which is estimated to be around 60%. Prior research has consistently underscored the pivotal role of healthcare workers in promoting preventive program, as demonstrated by Alissa et al. and Ramot et al. [17], [18]. Even when healthcare workers are not directly responsible for referring patients to breast cancer screening, they have a considerable influence by fostering an environment conducive to preventive behaviour. Several studies further indicate that a professional attitude and a preventive orientation have a decisive influence on participation in breast cancer screening programs, as shown by Haas et al. in their multicentre study in the United States and Bekker et al. in the United Kingdom [19], [20]. Importantly, for healthcare workers to act effectively as educators and advocates, they must possess adequate knowledge, positive attitudes, and well-founded beliefs regarding the health behaviours they promote [21].

These results underline the need to complement professional skills with an awareness of the structural and demographic framework of screening programs to achieve meaningful participation. In Croatia, the National Program for the Early Detection of Breast Cancer targets women aged 50–69 years. Evidence suggests that this focus has contributed to a reduction in breast cancer mortality in this age group [22]. Nevertheless, ongoing debates question the relevance and cost-effectiveness of extending such preventive strategies to younger cohorts [22], [23]. Public health initiatives promoting breast self-examination could play a valuable role in addressing this gap, as emphasized by Hijrah et al. [24]. Within this framework, healthcare workers are uniquely positioned to lead by example, and act as the main promoters of public health prevention initiatives. Nevertheless, even with their key role in health promotion, healthcare workers may face individual or knowledge-based barriers that prevent full participation in preventive programs. This study identified acute illness at the time of the scheduled examination and insufficient awareness among healthcare workers as the predominant reasons for non-participation in the NPP. These findings highlight the necessity for thorough preparatory measures when implementing screening programs. Furthermore, analysis using the proposed model demonstrated a statistically significant association between attendance and two factors: discomfort experienced during the examination and concern about receiving a diagnosis of a malignant disease. Population-based studies in Croatia have also shown that educational level and socioeconomic status are strong predictors of participation in NPP [25]. These results suggest that higher levels of education and socioeconomic status are associated with greater participation and less fear of screening, which was identified as one of the most common reasons for non-participation in the NPP. Women with these characteristics are not only more likely to participate in the program but are also more likely to undergo preventive mammography independently [25]. The lack of transportation has emerged as a substantial barrier, particularly in rural areas. This is partly attributable to the programme’s initial concentration in urban health centers, where fixed appointment schedules posed logistical challenges for women living in remote regions. In addition, refusal to attend without specifying a reason, or citing fear of the disease, was reported by between 8% and 40% of the respondents. These observations, consistent with our findings, point to the need for comprehensive educational outreach as an integral part of NPP implementation [20]. Finally, the views expressed by participants reinforce this conclusion: they identified intensified health education and more robust promotion of public health programs as the primary avenues for improving participation in the NPP for the early detection of breast cancer.

Limitations of the Study

The limitations of this study include the recruitment of participants from only one healthcare institution and a relatively small sample size, which limits the interpretability and generalizability of the results to other population groups. Furthermore, given that the study relied on questionnaires, potential subjective bias and the tendency to provide socially desirable responses may have also influenced the results. Socioeconomic factors, previous experience, and educational background may also have contributed to the participation patterns. Therefore, future studies should include a larger number of participants and employ a longitudinal approach, and conduct sensitivity analyses to assess the impact of these biases on the results.

Conclusion

The study conducted in Istria County (Croatia) demonstrated encouraging trends in healthcare workers’ participation in the national breast cancer screening program. Several factors contributing to non-attendance were identified, including logistical challenges and insufficient information. Practical measures, such as increasing appointment flexibility and expanding service locations, can enhance accessibility. Targeted education campaigns and clear communication about the benefits of the program can further improve participation, which may ultimately facilitate earlier diagnoses and improve treatment outcomes.